Landscape of Urban Health Financing and Governance in Bangladesh

LANDSCAPE OF URBAN HEALTH
FINANCING AND GOVERNANCE
IN BANGLADESH
June 2016
This publication was produced for review by the United States Agency for International Development.
It was prepared by (Syed Abdul Hamid, Muhammod Abdus Sabur) for the Health Finance and Governance Project.

The Health Finance and Governance Project
USAID’s Health Finance and Governance (HFG) project helps to improve health in developing countries by
expanding people’s access to health care. Led by Abt Associates, the project team works with partner
countries to increase their domestic resources for health, manage those precious resources more effectively,
and make wise purchasing decisions. The five-year, $209 million global project is intended to increase the use
of both primary and priority health services, including HIV/AIDS, tuberculosis, malaria, and reproductive health
services. Designed to fundamentally strengthen health systems, HFG supports countries as they navigate the
economic transitions needed to achieve universal health care.
June 2016
Cooperative Agreement No: AID-OAA-A-12-00080
Submitted to: Scott Stewart, AOR
Office of Health Systems
Bureau for Global Health
Recommended Citation: Syed Abdul Hamid1, Muhammod Abdus Sabur2. June 2016. Landscape of Urban
Health Financing and Governance in Bangladesh. Bethesda, MD: Health Finance & Governance Project,
Abt Associates.
Cover top picture: A woman holds her child a slum of Barisal, Bangladesh. © 2013 Mahmudul Hasan,
Courtesy of Photoshare
Cover bottom picture: A pregnant woman receives antenatal care from a provider at a community clinic
in Nilphamari, Bangladesh.© 2015 Asad Rassel, Courtesy of Photoshare
Abt Associates | 4550 Montgomery Avenue, Suite 800 North | Bethesda, Maryland 20814
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| RTI International | Training Resources Group, Inc. (TRG)
1 Syed Abdul Hamid is a Professor at the Institute of Health Economics, University of Dhaka.
2 Muhammod Abdus Sabur is a Health Sector expert.

LANDSCAPE OF URBAN HEALTH
FINANCING AND GOVERNANCE
IN BANGLADESH
DISCLAIMER
The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency
for International Development (USAID) or the United States Government.

i
CONTENTS
Acronyms ..............................................................................................................iii
Executive Summary ..............................................................................................v
1.1 Introduction.......................................................................................................................v
1.2 Findings................................................................................................................................v
1.3 Financing and Governance of the Institutions Providing Urban Health ..............vi
1.4 Conclusions......................................................................................................................vii
2. Introduction....................................................................................................1
2.1 Background ........................................................................................................................1
2.2 Scope and Objectives of Study ......................................................................................2
2.3 Methodology......................................................................................................................2
2.4 Report Organization........................................................................................................2
3. An Overview of Urban Primary Health Services Delivery institutions
in Bangladesh .........................................................................................................3
3.1 Private Health Facilities ...................................................................................................4
3.2 Ministry of Health and Family Welfare and Other Ministries.................................5
3.3 Urban Local Bodies ..........................................................................................................6
3.4 Urban Primary Health Care Services Delivery Project............................................7
3.5 NGO Health Service Delivery Project ........................................................................8
3.6 International NGOs .........................................................................................................9
3.7 Local NGO-, CBO-, and SBO-Based Providers ..................................................... 10
4. Policy, Governance, and Stewardship Issues of Urban Health ...............13
4.1 Urban Health in National Priorities........................................................................... 13
4.2 Public Sector Governance and Organization for Urban Health ......................... 14
4.3 Regulatory Structure and Environment for Urban Health................................... 14
4.4 Governance of Urban Primary Health Services Delivery Project ...................... 15
4.5 Governance of Government Hospitals..................................................................... 15
4.6 Governance of Private Hospitals and Drugstores.................................................. 16
4.7 Coordination and Cooperation among the Urban Health Care Delivery
Institutions....................................................................................................................... 16
5. Urban Health Financing Mechanism in Bangladesh.................................17
6. Review of Research on Urban Health in Bangladesh and
Identification of Research Gaps.........................................................................19
6.1 Demand-side Issues....................................................................................................... 19
6.2 Supply-side Issues........................................................................................................... 20
6.3 Financial Risk Protection.............................................................................................. 21
6.4 Regulation, Governance, and Stewardship............................................................... 22
6.5 Other Issues.................................................................................................................... 22
6.6 Potential Research Topics ........................................................................................... 23
7. Summary and Conclusion ...........................................................................25
8. References.....................................................................................................29
Annex....................................................................................................................33

ii
List of Tables
Table 1: Health Care Financing of Different Provisions of Urban Primary Health
Care in Bangladesh................................................................................................................ 17
Table 2: Potential Research Topics on Urban Health in Bangladesh ................................... 23
Table 3: Summary of the Urban Health Care Delivery Institutions in Terms of
Finance and Governance...................................................................................................... 26
Table A1: Dimensions and Barriers to Accessing Health Services in Urban Areas in
Bangladesh............................................................................................................................... 33
Table A2: Review of Studies/Documents on Urban Health in Bangladesh......................... 34
List of Figures
Figure 1: Provisions of Health Services in Urban Areas in Bangladesh...................................4
Figure 2: Key Issues of Urban Health......................................................................................... 19

iii
ACRONYMS
ADB Asian Development Bank
ANC Antenatal Care
BBS Bangladesh Bureau of Statistics
BDT Bangladeshi Taka
BSMMU Bangabandhu Sheikh Mujib Medical University
CBO Community-Based Organization
CMH Combined Military Hospital
DCT Dhaka Community Trust
DFID Department for International Development
DGFP Directorate General of Family Planning
DGDA Directorate General of Drug Administration
DGHS Directorate General of Health Services
DSCC Dhaka South City Corporation
EPI Expanded Programme on Immunization
GOB Government of Bangladesh
GK Gonoshasthaya Kendra
HSDP Health Service Delivery Point
HSM Hospital Services Management
ICMH Institute of Child and Mother Health
LGD Local Government Division
LGI Local Government Institution
MCH Maternal and Child Health
MLSS Member of Lower Subordinate Staff
MOHFW Ministry of Health and Family Welfare
MOLGRDC Ministry of Local Government, Rural Development and Cooperatives
NHSDP NGO Health Service Delivery Project
OOP Out of Pocket
NGO Non-governmental Organization
PAC Post-Abortion Care
PHC Primary Health Care
PIU Project Implementation Unit
PMU Project Management Unit
PNC Postnatal Care
PPRC Power and Participation Research Centre
SBO Society-Based Organization
SIDA Swedish International Development Agency
UNFPA United Nations Population Fund
UHC Upazila Health Complex
UHSSP Urban Health System Strengthening Project
ULB Urban Local Bodies
ULGI Urban Local Government Institution
UPHCSDP Urban Primary Health Care Services Delivery Project
VSC Vacuum Suction Chamber
WHO World Health Organization

v
EXECUTIVE SUMMARY
1.1 Introduction
There are significant gaps in knowledge on how urban health care services are financed, delivered,
and regulated in Bangladesh. This study, a landscape analysis of urban health care, in particular
primary health care (PHC), was done to better understand the urban health situation. This report
on the analysis provides an overview of existing sector dynamics including policy, financing
mechanisms, stakeholders, studies, and data with an emphasis on gap identification, and
recommendations for further research to close the knowledge gaps. The Health Finance and
Governance Project, financed by USAID, led this study.
Objectives
The objectives of the land scape analysis were as follows:
 Collect information and data on the organization and delivery of health services in urban areas
focusing on maternal and child health (MCH) and PHC services;
 Identify the knowledge gaps and the research focused on addressing those gaps.
Methodology
This study analyses quantitative and qualitative information based on document review, health facility
visits, and key informant interviews of staff at Dhaka, Rajshahi, Chittagong, and Khulna city
corporations. The study also uses information obtained from a policy dialogue on urban health
organized by Power and Participation Research Centre. We have defined city corporations and
municipalities – Urban Local Bodies (ULBs) – as the urban areas. The latter includes all district towns
and a large number of sub-district (upazila) towns.
1.2 Findings
Provision of Urban Health Care
ULBs, by law, are responsible for providing PHC services to their constituents. However, ULBs lack
the basic infrastructure needed to provide these services. The Ministry of Health and Family Welfare
(MOHFW) does not provide much PHC in urban areas as it is not mandated to do so. These
factors, along with the rapid growth of the urban population, means there is a huge supply gap in
government provision of PHC in urban areas. Thus, urban residents turn to alternative providers of
PHC. These providers are broadly grouped as follows:
i. Private hospitals/clinics/doctor’s chambers/pharmacies;
ii. Outpatient facilities in the secondary and tertiary hospitals of the MOHFW and some other
ministries (e.g., Defence, Home, Railway);
iii. The Urban Primary Health Care Services Delivery Project (UPHCSDP) of the Local
Government Division (LGD), funded by the government of Bangladesh (GOB) and donor
agencies;
iv. The NGO Health Service Delivery Project (NHSDP), funded by USAID and the U.K.
Department for International Development (DFID);
v. International non-governmental organizations (NGOs) (Marie Stopes Clinics, Red Crescent
Society, Muslim Aid); and

vi
vi. Local NGOs, community-based organizations (CBOs), society-based organizations (SBOs),
and foundations (BIRDEM Health Care Network, BRAC Manoshi, Gonoshasthaya Kendra,
Dhaka Community Hospital, Ad-din Hospitals, Sajida Foundation, Dushtha Shasthya Kendra,
Bangladesh National Society for the Blind, Lions, Rotary, Isphahani Islamia Eye Hospital, etc.).
1.3 Financing and Governance of the Institutions Providing
Urban Health
The urban PHC providers listed above are financed through different mechanisms, such as private
out-of-pocket (OOP) payments, public budgetary allocation of general tax revenue, a mix of public
and private finance, a mix of private and NGO finance, and a mix of private and external or donor
funding. The main source of private financing is OOP payment on a fee-for-service basis, the most
inefficient and inequitable method of health financing. Annual budgetary allocation based on general
tax revenue is the main source of finance of the health facilities of the MOHFW and other ministries.
The ULB health departments are financed by allocations from the LGD budget, and city corporations
and municipalities are financed by holding tax and fees. External agencies (loans from the Asian
Development Bank (ADB) and grants from United Nations Population Fund (UNFPA) and Swedish
International Development Agency (SIDA)), GOB contributions from general tax revenue, and OOP
payments are the sources of financing of the UPHCSDP. The NHSDP Smiling Sun Network is mainly
financed by donor funding, but it also charges user fees with a safety net for the poor. The urban
PHC services of international NGOs are financed by donor agencies and OOP fee-for-services
payments. The PHC services of local NGOs, CBOs, SBOs, and foundations are financed by fees for
services charged at their outlets, and subsidies from the revenue they generate from other activities.
The governance of the institutions providing PHC in urban areas is associated with the nature of the
organization. The UPHCSDP is managed by the LGD with the assistance of health department of city
corporations and municipalities and partner NGOs. The Smiling Sun Network is governed by the
NGOs under the direction of USAID and DFID. The MOHFW through the Directorates General of
Health Services and of Family Planning govern the outpatient services of government facilities. The
governing body of the respective organization manages NGOs, CBOs, SBOs, and foundations.
Although the provision of PHC is in the jurisdiction of ULBs, none of the players other than the
UPHCSDP coordinates with ULBs. At the facility level, lack of coordination and cooperation among
the NHSDP, the UPHCSDP, Marie Stopes, and other NGOs that offer low-priced health care to the
urban poor is evidence of the disconnectedness of the urban health system. Observation suggests
that there is even competition among the donor-funded providers of urban health care. Such
duplication of resource use is inefficient and the lack of coordination has created gaps in coverage
and quality.

vii
1.4 Conclusions
The huge supply gap in the government provision of PHC in urban areas has led to the growth of
private hospitals/clinics, to which the poor have limited access, especially to the quality ones. To
serve the vast number of low-income residents including slum dwellers, some city corporations and
municipalities, under the stewardship of the Ministry of Local Government, Rural Development and
Cooperatives (MOLGRDC), have since 1998 been offering PHC and limited curative care including
MCH care under a public-private partnership model that has the financial support of donor agencies
including the ADB. As noted earlier, some national and international NGOs, such as the NHSDP,
Marie Stopes, and BRAC Manoshi, also offer PHC services to low-income urban residents.
Dependence on external funding is the major deficiency of government and NGO provision of these
services. The urban health sector suffers from a lack of stewardship by the MOHFW, LGD, and
ULBs. Lack of coordination between the MOHFW and MOLGRDC is a major institutional and
structural constraint. Measures to overcome some of these constraints and challenges can be taken
in the short run: clearly defining the roles and responsibility of the MOHFW, the MOLGRDC, and
ULBs; activating the urban health co-ordination committee formed jointly by the MOHFW and
MOLGRDC; building stewardship capacities of the LGD urban health unit; delegating the
management of the UPHCSDP to ULBs; and establishing mechanisms for effective coordination
between health service providers of different ownership – MOHFW, ULB, private not-for-profit
organizations – and different levels of the health system. However, in the long run, new institutional
arrangements are needed to enable ULBs to play the role of coordinator and steward of PHC for
the growing urban population. The problem is particularly acute in the city corporations and district-
based municipalities due to lack of PHC centers distinct from those of the MOHFW. Upazila Health
Complexes provide PHC in upazila-level municipalities, so the problem is not acute there. The
number of upazila-level municipalities, currently more than 250, is increasing rapidly. This calls for
policy dialogue on integrating urban health care into the national health care system.
Significant gaps remain in knowledge on how urban health care services are financed, delivered, and
regulated in Bangladesh. Following are recommendations for further research to inform how the
gaps can be filled.
 Measure comparative efficiency of the UPHCSDP and other PHC providers (e.g., NHSDP,
Manoshi, and Marie Stopes, secondary and tertiary government facilities and private facilities);
 Do comparative analysis of financial risk protection of urban health schemes (e.g., UPHCSDP,
NHSDP, Manoshi, and Marie Stopes);
 Assess feasibility of Shasthyo Shurokhsha Karmasuchi-type health protection scheme for the
urban poor;
 Do comparative analysis of non-therapeutic quality (e.g., patient satisfaction) of the urban PHC
models (e.g., UPHCSDP, NHSDP, Manoshi, Marie Stopes);
 Assess authorities’ perceptions of ULBs in terms of their willingness and capacity to play a
stewardship role in urban PHC;
 Analyze rural-urban distribution of patients served by the health facilities; and
 Conduct research and policy dialogues on establishing a referral system.

1
2. INTRODUCTION
2.1 Background
Bangladesh has experienced rapid urbanization over the years both vertically (via increasing
population density) and horizontally (via geographical coverage).3 Poverty is an integral part of
urbanization in Bangladesh. The Bangladesh Urban Health Survey 2013 estimated that some 8 million
people – approximately 21 percent of the 40 million urban population in the country – live below
the poverty line (NIPORT and ICDDR,B, 2015). Slums, home to 30 percent of the country’s urban
population, are a prominent manifestation of the rapid and unregulated urban growth (Maqbool et
al., 2014). Evidence shows that living conditions in urban slums are extremely poor, often appalling;
residents lack access to safe water, drainage, and sanitation facilities; affordable public transport; and
many other services. In fact, conditions are much worse in urban slums than in most rural areas
(BBS, 2010). Poverty is higher in slum areas than non-slum ones, with 75 percent of slum dwellers in
the lowest two wealth quintiles compared with 20 percent of residents in non-slum areas (HEU,
2012).
Health care in urban areas also is, in general, quite poor. For example, 42.3 percent of urban births
take place at home, and more than 40 percent of urban patients seek health care from informal
providers. The average days patients wait to consult a doctor for the first time after ailment is
significantly higher in urban areas (3.93 days) than in rural areas (2.87 days) and average waiting time
at the provider is significantly higher in urban areas (21.40 minutes) than in rural areas (18.87
minutes) (BBS, 2011). In the city corporation slums, more than one-fourth (about 28 percent) of
women do not receive any antenatal care (ANC) from any source; the use of ANC and postnatal
care (PNC) (first visit) from qualified providers (qualified doctor, nurse/midwife, paramedics, Family
Welfare Visitor, community-based skilled birth attendant, and medical assistant) is respectively only 41
percent and 22.5 percent in the city corporation slums and about 76 percent and 50 percent
respectively in its non-slum areas.
Not surprisingly health outcomes also are poor. Among children under five years of age, 5.7
percent suffer from diarrhea (NIPORT, 2015a); half of under-five children in slums are stunted
(height-for-age below -2SD), whereas only about one-third are in non-slums and other urban areas
(NIPORT, 2015b). Mortality of under-five children in slums is almost double that in rural areas (BBS,
2010). Tuberculosis and hepatitis B are more prevalent in slums than in rural areas (BBS, 2010). To
seek remedies, slum dwellers usually navigate through the patchy primary health care (PHC) system,
and often end up relying on quacks.
Despite these problems, health policy in Bangladesh has not focused on improving health outcomes,
especially in PHC.4 Attention to and dialogue on urban health and nutrition have not kept pace with
the needs on the ground. There are also significant gaps in knowledge on how urban health care
services are financed, delivered, and regulated. Therefore, closing knowledge gaps about the
3 The urban population is growing at about 4 percent annual rate (Rahman, 2014; Maqbool et al., 2014). Around 30
percent of people currently reside in urban areas; this is projected to increase to 60 percent by 2030 (Rahman,
2014). Rural-urban migration, annexation of rural areas to cities, and inclusion of new areas as city are the main
reasons for the increasing urban population.
4
The draft National Urban Health Strategy 2014 emphasizes sustainable city corporation and municipal health
services. It suggests the MOHFW should deliver PHC in urban areas where services not delivered by the Local
Government Institutions (LGIs) and NGOs (LGD 2014).

2
financing and governance of urban institutions that deliver PHC and maternal and child health (MCH)
care has important relevance to policy discussions.
2.2 Scope and Objectives of Study
Thus, the present study, by USAID’s Health Finance and Governance Project, is a landscape analysis
aimed at better understanding of urban health care, especially PHC and MCH care, in Bangladesh.
Specifically, its objectives are to:
 Provide information and data on the organization and delivery of health services in urban areas
focusing on PHC and MCH services; and
 Identify the knowledge gaps and recommend further research to address those gaps.
2.3 Methodology
This study analyses quantitative and qualitative information based on document review, health facility
visits, and key informant interviews done in Dhaka, Rajshahi, Chittagon, and Khulna city
corporations. We visited all the three hospitals run by Dhaka South City Corporation. We also use
the information obtained from a policy dialogue on urban health organized by Power and
Participation Research Centre (PPRC). We considered city corporations and municipalities – Urban
Local Bodies (ULBs) – as the
urban areas.5
2.4 Report Organization
The report gives an overview of sector dynamics including policy, financing mechanisms,
stakeholders, studies, and data with an emphasis on gap identification, and ideas for future research
to address the gaps. It is organized as follows. Section 2 provides an overview of urban primary
health services delivery institutions in Bangladesh. Section 3 explains the policy, governance and
stewardship issues of urban health. Section 4 illustrates urban health financing mechanisms in
Bangladesh. Section 5 provides a review of researches on urban health in Bangladesh and finds the
research gaps. Section 6 provides the summary and concluding remarks.
5 Urban area in Bangladesh, as per 2011 census, encompasses city corporations, paurashavas (municipalities), upazila
(district) headquarters, and cantonment (BBS, 2014). The Upazila Health Complex is the focal point of rural health
including the people living in upazila headquarters, and provides PHC and limited curative care including MCH care.
As this study is mainly concerned with PHC, we focused on the urban areas where the MOHFW does not have the
jurisdictional responsibility to provide PHC, as it does in rural setting. These areas are basically city corporations
and municipalities. Thus, we have defined city corporations and municipalities as urban areas in this study.

3
3. AN OVERVIEW OF URBAN PRIMARY HEALTH
SERVICES DELIVERY INSTITUTIONS IN BANGLADESH
There is a pluralistic provision of health services in urban areas of Bangladesh. Urban Local Bodies
(ULBs), by law, are responsible for providing PHC to the people of their respective constituencies.
However, UBLs lack the basic infrastructure needed to provide PHC services. The Ministry of Health
and Family Welfare (MOHFW) does not provide much PHC in urban areas as this is not within its
jurisdiction; rather, it is responsible for providing policy and technical guidance, contraceptives and
immunization supplies, monitoring and evaluation, and coordination with urban health care delivery
institutions. This situation in the context of the rapid urbanization described earlier has created a
huge supply gap in the government provision of PHC in the urban areas. Thus, many urban residents
seek alternative providers of PHC:
i. Private hospitals/clinics/doctor chambers;
ii. Outpatient facilities in the secondary and tertiary hospitals of the MOHFW and other
ministries (e.g., Defence, Home, Railway);
iii. The Urban Primary Health Care Services Delivery Project (UPHCSDP) of the Local
Government Division (LGD) funded by both the government of Bangladesh (GOB) and donor
agencies;
iv. The NGO Health Service Delivery Project (NHSDP) funded by USAID and the U.K.
Department for International Development (DFID);
v. International non-governmental organizations (NGOs) (Marie Stopes Clinics, Red Crescent
Society, Muslim Aid); and
vi. Local NGOs, community-based organizations (CBOs), society-based organizations (SBOs),
and foundations (BIRDEM Health Care Network, BRAC Manoshi, Gonoshasthaya Kendra,
Dhaka Community Hospital, Ad-din Hospitals, Sajida Foundation, Dushtha Shasthya Kendra,
etc.).6
6 The European Commission with the technical assistance of EPOS Health Management is also in process of starting to
a program aiming at improving the utilization of sustainable, integrated and comprehensive health, nutrition, and
population services by the urban poor.
The Urban Health System Strengthening Project (UHSSP), a four-year program (2015-2019) supported and funded
by DFID, started implementation in January 2016 at three municipalities (Dinajpur, Jessore, and Mymensingh) with
some NGO-based health providers (Smiling Sun, Marie Stopes, and BRAC Manoshi). The UHSSP aims to provide
support to create a more harmonized and supportive environment for urban health by applying a systems approach.
It has four key areas of work: reinforcing convergence among government ministries and (NGOs; improving, through
more efficient and transparent coordination, a pluralistic health management information system; harmonizing social
protection schemes; and improving planning, management and monitoring competencies of local government.

4
Figure 1 is a schematic diagram of all the providers of urban PHC. The following subsections describe
each of the providers.
Figure 1: Provisions of Health Services in Urban Areas in Bangladesh
3.1 Private Health Facilities
Private health facilities are the ultimate source of PHC for the majority of urban residents. Evidence
shows that private health facilities fill the health care needs of about 54 percent of the urban
population (Chowdhury et al. 2016). The private health sector encompasses health services provided
at private hospitals, clinics, nursing homes, maternity centers, doctor chambers, diagnostic and
imaging centers, pharmacies, quacks, etc. There is absolute dominance of private health facilities in all
city corporations as seen from a mapping of the urban health care landscape conducted by Adams,
Ahmed et al. (2015).7 More than 30 percent of the private facilities, irrespective of city corporation,
are doctor chambers (consisting of allopathic, homeopathic, and unani providers), forming an
important source of primary care in the urban areas. The majority of doctor chambers in the Dhaka
South, Dhaka North, and Sylhet city corporations are attached to a pharmacy but in other city
corporations, the majority are independent. Not all doctor chambers are run by formal (medically
qualified) providers. The majority of the doctor chambers in Dhaka North, Dhaka South, and
Narrayanganj city corporations are run by formal providers whereas in Rajshahi and Khulna, most are
run by informal providers (Adams, Ahmed et al., 2015). In all city corporations, most of the allopathic
providers are informal providers.
There is overwhelming urban bias in the distribution of qualified health professionals. As of
November 2015, the Director General of Health Services (DGHS) had registered 13,341 private
facilities in Bangladesh: 32 percent are hospitals and clinics, and 68 percent are diagnostic centers
7 The share of private facilities in Dhaka North, Dhaka South, Narayanganj, Rajshahi, Khulna, and Sylhet city
corporations is respectively about 94, 93, 91, 89, 89, and 89 percent (Adams, Ahmed et al., 2015).
•.Urban Local Bodies
(City Corporations and
municipalities)
•UPHCSDP though
Urban Local Bodies
•NHSDP
•International NGOs (Marie
Stopes, Muslim Aid, Red
Cresent Society)
•Local NGOs/CBOs (BRAC
Manoshi, Ad-din,
Gonoshasthaya Kendra,
BIRDEM Health Network,
Dushtha Shasthya Kendra,
Dhaka Community Hospital,
Sajida Foundatio
•Others
•Government
dispensaries
•Outpatient services of
government medical
colleges hospitals ,
specialzed government
hospitals, and General
Hospitals
•Outpatient services of
CMH, Police Hospital,
Railway Hospital, Sarkari
Karmachari Hospital, etc
•Private medical college
hospitals
•Private hospitals/clinics
•Doctor chambers
•Dianostic centers
•Pharmacies (drug stores)
•Quacks
•Others
I. For-profit
private
providers
II. MOHFW
and other
ministries
III. LGD of
MOLGRDC
IV. NHSDP
V. NGO-, CBO-
and SBO-
based
providers

5
(MOHFW, 2015). As of April 2016, there were 67 private medical college hospitals and 23 private
dental college hospitals; these medical college hospitals have outpatient facilities that offer PHC. As
reported by Ahmed et al. (2015) in the ‘Bangladesh Health System Review,’ hospitals and diagnostic
centers are located mainly
in urban areas, as are the qualified health professionals who staff the secondary and tertiary hospitals.
In addition to being concentrated in urban areas, qualified health professionals are even more
disproportionately concentrated in Dhaka Division, including the capital city (Adams, Ahmed et al.
(2015).
3.2 Ministry of Health and Family Welfare and Other
Ministries
Although urban PHC is not within the MOHFW’s mandate, the ministry plays a significant role in
providing this care. The MOHFW provides PHC to urban residents through two main channels.
The first channel is outpatient service of government medical college hospitals, government
specialized hospitals (e.g., BSMMU Hospital, Dhaka Shishu Hospital, Chittagong Shishu Hospital,
Khulna Shishu Hospital), district hospitals, Maternal and Child Welfare Centers, and Upazila Health
Complexes (UHCs) (in upazila-level municipalities).8 As of January 2015, there were 29 government
medical college hospitals covering all 11 city corporations and some old (especially district-based)
municipalities9 and nine government dental college hospitals in six city corporations. Of the
approximately 114 secondary and tertiary public hospitals, about 37 percent are located in Dhaka
division (MOHFW, 2015). While these hospital outpatient services are an important source of PHC
in urban areas, it also is important to note that these secondary and tertiary health facilities are not
designed to provide PHC and doing so undermines their capacity to provide secondary and tertiary
care and can jeopardize quality of care.
The second channel is urban dispensaries, a traditional venue for MOHFW provision of PHC in urban
areas. Currently there are 35 urban dispensaries, most of which are located in some old cities,
especially in Dhaka and Chittagong city corporations. These dispensaries provide outpatient services
including Expanded Programme on Immunization (EPI) and MCH care. In addition, the MOHFW runs
some EPI centers in urban areas. A recent study by Chowdhury et al. (2016) found that there is no
standard human resource structure for these dispensaries. Some have as many as five medical officer
positions and some have only two. It also found that the dispensaries lack required technical support
staff, essential equipment/instruments/logistics, and a supply of most of the required drugs.
The institutional MOHFW setting for PHC varies by type of urban area. Outpatient facilities of the
government medical college hospitals and specialized hospitals are the major MOHFW institutions for
PHC in the city corporations. The main institutions in district-level municipalities are outpatient
services of district hospitals and Maternal and Child Welfare Centers. The UHC is the sole MOHFW
institution for PHC in the upazila-level municipalities; there is hardly any need for separate provision
of PHC by municipal authorities in these municipalities because the UHC provides all types of PHC.
Chowdhury et al. (2016) found that MOHFW public facilities address about 46 percent of the general
health care needs of the urban population, with district hospitals and Maternal and Child Welfare
Centers playing a crucial role.
8 Municipalities are of two kinds: district town based and upazila (sub-district) town based. District based municipalities
are relatively old compared to the sub-district based ones.
9 www.dghs.gov.bd/index.php/bd/data

6
3.3 Urban Local Bodies
As per City Corporation Act 2009 and Municipalities Act 2009, ULBs are responsible for providing
PHC along with public health and environmental health services, such as water supply, sanitation
facilities, waste disposal, and mosquito control. However, city corporations and municipalities do not
have the necessary infrastructure to provide PHC to the catchment population. They also lack
funding for effective functioning of existing health facilities and retention of staff in the facilities. The
state of existing health facilities in some old city corporations, such as Dhaka South, Chittagong,
Rajshahi, Khulna, and Sylhet, is described below.
Dhaka South City Corporation (DSCC) owns a 50-bed general hospital, a 100-bed children’s hospital,
and a 30-bed maternity center.10 The three hospitals provide both outpatient and inpatient services.
There was a recent attempt to enhance the capacity of the general hospital to 150 beds. Necessary
renovations have been accomplished and the number of beds and cabins has been increased.
However, the hospital does not yet have the MOHFW approval required to use the enhanced
capacity.11 Thus, the number of staff and other facilities remains those of a 50-bed hospital. About
one-third of capacity (38 of the 100 beds) at the children’s hospital is not usable. There are not
enough doctors and other staff to run any of the hospitals effectively. Lack of appropriate skill-mix
and input-mix is also a concern. For example, the surgery ward of the children’s hospital has been
closed for the past four years due to the lack of a surgeon. Despite having a post, it has not been
possible to recruit a surgeon. An appointment in these hospitals is not attractive to physicians due to
lack of a career path. Like all government hospitals, DSCC hospitals cannot retain revenue for regular
maintenance to improve their service delivery.
Chittagong City Corporation has five maternity centers (including one with 100 beds) and 20
charitable dispensaries (each of which has one pharmacist, a MLSS, and a cleaner). However, some of
them are not functioning currently. There are also 25 PHC Centers (each of which has a medical
officer, one pharmacist, a MLSS, and a cleaner). These centers functioned well while the city
corporation was under UPHCSDP in the early phases of the project. Some of them still function, but
not to the same extent – due to their limited resources and manpower, they cannot effectively
provide the needed services.
Rajshahi City Corporation owns a 25-bed hospital with a total staff of 40 including five doctors and
five nurses. In addition, the city corporation has 188 health workers who provide EPI, family planning,
and awareness-building services. Khulna City Corporation operates three PHC Centers, which
altogether have seven medical officers who regularly provide outpatient care; five of them are
seconded from the MOHFW. It also has 70 health workers who provide EPI, family planning, and
awareness-building services. Sylhet City Corporation runs a charitable dispensary, which comprises a
pharmacist, a MLSS, and a cleaner. The city corporation has also 55 health workers providing EPI,
family planning, and awareness-building services.
As per the Bangladesh Population and Housing Census 2011, Dhaka, Chittagong, Rajshahi, Khulna, and
Sylhet city corporations had 8.9, 2.6, 0.45, 0.66 and 0.52 million people, respectively.
As urban population is increasing at about 4 percent annually, the current population of each of the
cities is much higher, presumably making the health facilities owned by the city corporations even
more inadequate to provide PHC.
10 A former DSCC attempted to also get approval for a private medical college hospital, but it failed to meet the
criteria for such a hospital.
11 A regulation states that hospitals under any city corporation need MOHFW approval for expansion and sanctioning
the posts of doctors and other staff even though the city corporation provides the funding.

7
The situation in the municipalities is more vulnerable. As mayors mentioned at a policy dialogue
organized by PPRC, some old municipalities have the position of medical officer in the public health
department, but lack of career prospects and other amenities including higher education and so it is
hard to recruit and keep someone in the position – there is high turnover in the job. As reported by
the mayors, only 17 out of 333 municipalities currently have a medical officer. Where there are
medical officers, they hardly have time to provide curative care as they are heavily engaged with
various public health and environmental health services. Also, as with city corporations, municipalities
need MOHFW approval to sanction the post of medical officer although the municipality pays the
salaries and allowances. The UHC, an MOHFW institution, is the PHC hub in the upazila-based
municipalities. Thus, separate PHC provision in those municipalities may be redundant. However,
coordination between the MOHFW, municipal authority (elected authority for municipal area of the
upazila), and upazila authority (elected authority for the whole upazila) is important for making
services available, and increasing quality of care in the UHC.
3.4 Urban Primary Health Care Services Delivery Project
Providing public health and PHC services to residents, as mentioned earlier, is in the administrative
jurisdiction of the respective city corporation and municipality. Considering limited institutional and
financial capabilities, the LGD of the Ministry of Local Government, Rural Development and
Cooperatives (MOLGRDC) took the initiative to provide urban PHC through a partnership
(UPHCSDP) among ULBs and NGOs; this was done with the financial support of the Asian
Development Bank (ADB) and other donor agencies initially for the period 1998-2005.12 The next
phase of the UPHCSDP project ran until June 2012. The third phase (July 2012-June 2017) is being
implemented with the financial support of the ADB, Swedish International Development Cooperation
Agency (SIDA), and United Nations Population Fund (UNFPA). The major portion of the funds is
given by ADB as a loan. The GOB also provides 13.58 percent of funding (ADB, 2012). (The ADB
share can be also considered as government funding as it is loan money. Thus, the GOB share is
about 80 percent of the total funds.) The project also earns some revenue through user fees from the
non-poor.13
The goal of the UPHCSDP is to improve the health status of the urban population, especially of
mothers and children, and especially the poor, through improved access to and use of efficient,
effective, and sustainable PHC services that are provided for free to the poor; the quality of urban
PHC services in the project area; and the cost-effectiveness, efficiency, and institutional and financial
sustainability for the urban PHC delivery system to meet the needs of the urban poor.
12 The LGD has no responsibility for providing PHC in urban areas as per city corporation and municipality acts.
Providing PHC care is instead the responsibility of LGIs.
13 The project charges BDT 10,000 ($125) for cesarean delivery, BDT 1,000 ($12.5) for normal delivery, and BDT 800
($10) for MR and D&C. The project charges BDT 40 ($0.5) per visit for other care.

8
The project area encompasses 10 of the 11 city corporations (Dhaka South, Dhaka North, Rajshahi,
Khulna, Barisal, Sylhet, Rangpur, Comilla, Narayanganj, and Gazipur)14 and four district municipalities
(Sirajgonj, Kushtia, Gopalgonj, and Kishoregonj). The project provides PHC including ANC, delivery
care, PNC, menstrual regulation, post-abortion care, family planning services, neonatal care, child
health care, reproductive health care, adolescent health care, nutrition services, communicable and
non-communicable disease control, limited curative care, behavior change communication,
diagnostics, violence against women, and emergency transportation. At present, the project covers
more than 10 million urban residents and has a PHC network of 25 Comprehensive Reproductive
Health Care Centers, 112 PHC Centers, and 224 Satellite or Mini Clinics at the community level.
UPHCSDP’s service delivery area is divided into several partnership areas. One NGO service
provider is selected through competitive bidding to deliver services in a partnership area.15 An NGO
may service more than one partnership area if won in the bidding. Each selected NGO has been
delivering services through a PHC network of one Comprehensive Reproductive Health Care
Centre, and a number of PHC Centers and Satellite or Mini Clinics.
While the UPHCSDP is the largest public-private (NGO) partnership project in Bangladesh for
providing PHC to the urban poor, it faces some critical challenges. After about two decades of
operation, the project still depends on external funding for about 70 percent of its expenses. A
significant portion of the external funding is loan money from the ADB. Thus, financial sustainability of
the project is a major challenge. Also, despite being an implementing partner, there is little scope for
ULBs to increase the capacity for providing PHC as the LGD leads the Project Implementation Unit
(PIU). Thus, if the Public-NGO partnership fails due to financial hardship or strict project
requirement, ULBs may not be able to continue providing services. For example, Chittagong City
Corporation had closed down a number health centers previously run under UPHCSDP due to lack
of funding and of capacity to run a large number of health centers. Hence, the institutional
sustainability is also a major concern. Another major concern is the lack of coordination between
ULBs, the LGD, and the MOHFW. The Strategic Thematic Group has put emphasis on the
governance mechanism for ensuring collaboration among the MOHFW, the LGD, and other relevant
ministries (to address social determinants of health) (GOB, 2015).
There has been some criticism of the quality of UPHCSDP services because no one is providing
supervision. While on paper supervision is the responsibility of the ULBs, they lack the capacity to
supervise the partner facilities both medically and administratively.
3.5 NGO Health Service Delivery Project
The NHSDP, a network of 25 NGOs funded by USAID and DFID, provide health services in both
urban and rural areas. The NHSDP aims to attract patients who are able to pay for health services,
while simultaneously extending its reach to the poor. This program offers PHC including MCH care
through static clinics, satellite clinics, and community service providers. Currently, the project has a
network of 388 static clinics, 10,252 satellite clinics, and 7,638 community service providers in all 64
districts of Bangladesh, serving approximately 22 million people, 13.8 percent of the total population
of 159 million in 2014.16
14 Chittagong City Corporation has kept itself outside the current phase of the project.
15 The partner NGOs are: Population Services and Training Center (PSTC), Khulna Mukti Seba Sangstha (KMSS),
Association for Prevention of Septic Abortion, Bangladesh (BAPSA), Nari Maitree, Unity Through Population
Services (UTPS), Dhaka Ahsania Mission (DAM), Simantik, Progoti Samaj Kallyan Prothisthan and Poribar Porikalpana
Sangstha (PSKP & PPS), Srizony Bangladesh, Christian Services Society (CSS), and Resource Integration Center (RIC).
16 Statistics obtained from Pathfinder International.

9
About 60 percent of the static clinics are located in urban areas and the urban catchment population
is 10 million. Dispensing of essential drugs and diagnostic laboratory services are also offered from
Smiling Sun clinics. The "Vital" clinics (which provide the Essential Services Package other than
delivery care) have, on average, 12 staff members and the "Ultra" clinics (which provide the Essential
Services Package including normal and cesarean delivery care and Emergency Obstetric Care
(EmOC)) have, on average, 30 staff members.
The network has a pricing structure that responds to market conditions such as clinic location or
competitive environment. The pricing strategy seeks to balance service expansion, access to the poor,
and program income objectives and financial sustainability. A recent study by Lance et al. (2015) found
overall cost recovery to be about 40 percent. For improving financial sustainability of local NGOs, the
project aims to recover 70 percent of operational costs; to increase and expand quality service
volume; and to ensure that 40 percent of all health services provided are service contacts targeted at
the poor who are unable or only partially able to pay.
Smiling Sun clinics face a number of challenges. Lance et al. (2015) found that the Smiling Sun market
share had declined due to changes in socio-economic conditions of the catchment population; an
increasingly competitive environment, with the strengthening of other NGO programs and entry of
new private sector providers into the market; and an increase in the price of services at Smiling Sun
clinics. Another major challenge is to deal with dual objectives: raising NGO sustainability by
increasing cost recovery while at the same time expanding service volume, particularly among the
poor. These objectives conflict, especially in a context where the same services are available from
other providers (e.g., NGOs, outpatient facilities of government secondary and tertiary hospitals) at
lower or no cost. Our observations from visiting some Smiling Sun clinics suggest that the mandate to
serve the poor and at the same time to improve program sustainability could perhaps be better
achieved through modernizing the diagnostic laboratory, enhancing pharmacy services, and offering
these services to all.
3.6 International NGOs
Some international NGOs like Marie Stopes, Muslim Aid, and the Red Crescent Society serve the
urban population, as mentioned earlier.
Marie Stopes serves urban residents through its referral clinics and mini clinics. Both types of clinics
are staffed by paramedics. The referral clinics are located in all major cities and some district towns.
They provide reproductive and limited general health services including family planning, ANC, and
sexually transmitted infection management. The clinics also support an extensive network of outreach
activities like satellite services for marginalized people. Presently there are 61 referral clinics in 35
districts.17 All referral clinic services are available at mini clinics except VSC, Implants, and PAC. They
offer services at a lower fee in their attempt to serve lower-income people. Safety nets are ensured
for the poorest of the poor through further price subsidization. Marie Stopes operates 65 mini clinics
in 50 districts.
Muslim Aid provides urban PHC through the outpatient facilities of five hospitals located in Dhaka
(Mirpur), Pabna, Pirojpur, Kulaura, and Cox’s Bazar. All the hospitals have inpatient facilities.
Bangladesh Red Crescent Society (BDRCS) also serves both rural and urban people through its
MCH, Non-Communicable Diseases, Road Safety, and Public Health Emergency programs. There are
56 MCH centers; most are located in rural areas but a few are in urban areas. Local women trained
by the Society are the service providers. The Holy Family Red Crescent Medical College Hospital also
provides PHC through its outpatient facilities in Dhaka City.
17 See http://www.mariestopes-bd.org/our-centres

10
3.7 Local NGO-, CBO-, and SBO-Based Providers
As mentioned earlier, a number of local NGO, CBO, and SBO providers, including Gonoshasthaya
Kendra, Dhaka Community Trust, Adin Hospitals, BRAC Manoshi, Sajida Foundation, and National
Healthcare Network of Diabetic Association of Bangladesh (Bangladesh Diabetic Somity-BADAS)
serve the urban population.
Gonoshasthaya Kendra (GK) serves urban residents mainly through Gonoshasthaya Nagor
Hospital in Dhanmondi, Dhaka, and Gonoshasthaya Hospital in Savar, Dhaka. In addition to low-
priced outpatient and inpatient services, GK offers a voluntary and social class-based health insurance
where premium and benefits vary across the six social classes (i.e., destitute and ultra poor, poor,
lower middle class, middle class, upper middle class, and rich) of the catchment populations. The
insured are entitled to receive health care from GK-owned health centers and hospitals. The co-
payments for the services are progressive across the social class and the upper three tiers of the
social class face large co-payments, more than 70 percent for most of the services. The major
challenges faced by GK are low enrollment of the rich and an overall low renewal rate. Cost recovery
is also low, at 35 percent of recurrent costs. Thus, the scheme is highly cross-subsidized by the other
entities of GK including a pharmaceutical company, a private medical college, and a private university.
Dhaka Community Trust (DCT) also offers discounted outpatient and inpatient care to the
urban population through its medical college hospital and other health centers. DCT also operates a
scheme to serve garments workers. Under this scheme, DCT provides a doctor and an assistant who
visit a factory once a week and spend a full day or as long as patients are available; the employer
manages the prescribed medicines for the patients and pays to DCT an agreed amount per month for
doctor’s services. Although services on site are free, there are also very high co-payments (90
percent) for inpatient care and referral services provided by Dhaka Community Hospital. Currently,
about 8,000 workers are being served. The current cost recovery for this program is reported to be
100 percent.
Sajida Foundation serves the urban population though provision of low-priced outpatient and
inpatient services from its two hospitals located at Narayanganj and Keraniganj. Sajida has introduced
a Health Card aimed at ensuring proper institution-based health care for people from all social
classes. Specifically, its goal is to provide modern health care facilities to low-income individuals who,
unable to afford proper hospital services, frequently seek informal treatment. Reducing the maternal
and child mortality is a major target of this program. The Health Card offers yearly health care for an
entire family for a fee of Bangladeshi Taka (BDT) 600 (about US$8). Individual cards have also been
introduced at BDT 150 (US$2). Health Card holders can avail general and outdoor treatment free of
charge for their entire family, as well as a 30 percent discount on all pathology tests. They are also
given significant discounts on other services, including operations. Sajida also runs a comprehensive
insurance program including health, which is mandatory for its microfinance borrowers. Sajida’s health
insurance is now the largest in terms of coverage.
Ad-din, a private not-for-profit organization operating in Bangladesh since 1980, aims at improving
the health, educational, social, and financial status of underprivileged people, particularly of women
and children. Ad-din Welfare Centre also runs a hospital-based discounted health scheme for urban
residents. It offers a 10 percent discount for purchasing medicine from Ad-din and a 50 percent
discount for other services. These services are offered free of cost to the ultra poor. Now Ad-din
operates five hospitals, including four medical college hospitals, and a fleet of ambulances. It is well
known for its cleanliness and women-friendly environment as well as providing quality of care at low
cost.
BRAC Manoshi is a urban maternal, neonatal, and child health program designed to significantly
improve maternal, neonatal, and child health in the 11 major cities of Bangladesh through the
following specific objectives: building a cost-effective mobile phone-based solution for data collection
and remote health risk screening for maternal, neonatal, and child health; developing an efficient and
automated scheduling system for health workers; testing an automated risk assessment system on the

11
basis of a pre-defined algorithm; and developing a tool for real-time report generation and
monitoring. Since its inception in 2009, BRAC Manoshi envisages improvements in health status of
poor urban mothers, newborns, and children by offering health care services at their doorstep
through frontline Community Health Workers. The Shasthya Shebikas (Health Volunteers) and
Shasthya Kormis (Health Workers) provide ANC and PNC, essential newborn care, and child health
care. Through behavior change communication interventions, Shasthya Kormis motivate, educate, and
prepare expectant mothers for childbirth, highlighting an array of health issues including maternal and
neonatal danger signs, maternal and neonatal nutrition, and so on. BRAC Delivery Centers are
established within slums to provide intranatal care to mothers and immediate care to newborns.
Urban birth attendants provide services in the centers. In addition, one midwife provides services in
few DCs on rotation basis. Currently, there are 150 centers in all 11 city corporations where
Manoshi is currently being implemented. There are also 57 maternity centers where midwives
provide services and one doctor provides services on rotation basis. Emergency obstetric, neonatal,
and child health complications are referred to the hospital through an established referral system by
strengthening linkages, and ensuring continuum of care.
National Healthcare Network of Diabetic Association of Bangladesh (BADAS) was
established in June 1996 as the National Diagnostic Network with the concept of providing quality
laboratory services all over the country. However, the need for providing quality health care services
at affordable prices at readily accessible places was soon evident. In response, the project was
renamed the National Healthcare Network. Health care components were added along with the
existing quality diagnostics services. Now it has emerged as a center of excellence with 10 outpatient
centers in different parts of Dhaka city. Recently, an executive health care center was established at
Naya Paltan and Ibrahim Probeen Nibash at Banani has been functioning since 29 September 2006.
In addition, numerous charities and foundations provide various types of services in urban areas.
Some of them, such as Bangladesh National Society for the Blind (BNSB), Lions, Rotary, and Isphahani
Islamia Eye Institute and Hospital contribute significantly to eye care in Bangladesh. Each of these
organizations provides primary, secondary, and tertiary level of care.

13
4. POLICY, GOVERNANCE,
AND STEWARDSHIP ISSUES OF URBAN HEALTH
4.1 Urban Health in National Priorities
The National Health Policy 2011 underscored that demand for health services recorded an increase
with the migration of people from rural to urban areas and with an increased number of people living
in urban slums. The National Health Policy wants to ensure easily accessible quality health services for
the people, especially the poor and backward segments of the urban population. Meeting the health
needs of the fast-growing urban poor has become a major challenge for the government. It is noted
that measures should be taken to determine the proper methodology in collaboration with the
MOHFW in order to perform the health-related activities of different ministries.
The Strategic Plan for Health, Population, Nutrition Sector Development Program (HPNSDP) 2011-
2016 documented significant inequities in the use of maternal health services in urban and rural areas
and a rapid increase in urbanization leading to new challenge for effective urban PHC service delivery
as service delivery challenges. It also mentioned that there is need to establish a permanent
coordination structure between the two ministries to take up the mutual mandated responsibility in a
sustained and effective manner. The MOHFW is supposed to tackle this challenge through a
consultative process with the MOLGRDC, city corporations, and concerned stakeholders by way of
jointly assessing, mapping and planning health, population, and nutrition services in urban areas.
The Seventh Five Year Plan, covering 2016-2020, recorded that coverage for slum and street dwellers
are limited not just in terms of health but in family planning and nutrition. Unavailability of facilities in
urban areas means that the disadvantaged suffer the most, which is evident from their health status.
This statement contradicts the findings of the Bangladesh Urban Health Survey 2013, which reported
that 95 percent of the communities in slums and non-slums, and about 90 percent in other urban
areas, had a health facility available within 2 kilometers.
The 10 Year Perspective Plan for 2010-2021 points out that rapid urbanization poses serious
challenges to sustainable urban development. Urban areas are now afflicted by innumerable problems
ranging from lack of services to deteriorating environmental conditions. Urban environmental
problems are of central concern to policymakers because adverse environmental conditions – from
inadequate waste management, poor drainage, air pollution, lack of access to safe water and
sanitation, exposure to excessive noise levels, traffic congestion, and inadequate health services –
exert a heavy toll on the
quality of life.

14
4.2 Public Sector Governance and Organization for Urban
Health
Two ministries, the MOHFW and MOLGRDC (through its LGD), are primarily responsible for urban
health care. The MOHFW is responsible for the administration of as many as 37 health-related laws
and the LGD is responsible for oversight functions of Urban Local Government Institutions (ULGIs)
apart from overall LGIs. The City Corporation Act, 2009 and the Pourashava Act, 2009 clearly assign
responsibility for the provision of preventive health and some curative care to ULGIs. As mentioned
earlier, with support from an ADB-led consortium of donors, LGD has implemented the UPHCSDP
since 1998; the project is now in its third phase. Its main limitation is that its coverage is very limited
in comparison to the huge number of ULGIs, particularly municipalities.
All urban areas are somehow covered by the MOHFW through its network of UHCs district
hospitals, Maternal and Child Welfare Centers, medical college hospitals, specialized hospitals, urban
dispensaries, school health clinics, chest clinics, chest hospitals, leprosy hospitals, and infectious
diseases hospitals, which provide primary, secondary, and tertiary health care. Vaccines and drugs for
TB (DOTS), leprosy, and AIDS are supplied by the DGHS. The Directorate General of Family
Planning (DGFP) operates several service centers in Dhaka and Chittagong cities. In addition, its field
workforces (Family Welfare Assistants and Family Planning Inspectors) continue to function even if
the area is declared as urban. The DGFP also supplies contraceptives to registered NGOs (including
those working for UPHCSDP) and registered non-public sector facilities for providing long-acting and
permanent contraception.
The allocation of functions to the MOHFW and LGD in the existing government documents called
‘Allocation of Functions’ under the ‘Rules of Business’ is not completely clear. The MOHFW is tasked
with setting technical standards, and packaging services, strategies, and policies of the country’s health
sector. Other ministries and departments also provide health services and many of those are in urban
areas. In this group are Combined Military Hospitals (CMH) under the Ministry of Defense; Border
Guard Bangladesh, Police and Jail Hospitals, and Central Drug Addiction Treatment Centre under the
Home Ministry; Railway Hospitals and Health Centers under the Ministry of Railway; Government
Employees Hospital under the Ministry of Public Administration. The LGD is not responsible for
urban PHC under its rules of business – ULBs are.
Through the effort of Urban Public and Environmental Health Sector Development Project
(UPEHSDP), financed by the ADB, an Urban Public and Environmental Health Unit (UPEHU) was
established under the LGD (of the MOLGRDC), headed by a Joint Secretary with three Deputies at
the rank of Deputy Secretary. However, this unit is yet to start functioning because MOLGRDC
officers hold the positions as additional responsibilities. Coordination committees exist at the LGD
and MOHFW under the leadership of the respective Secretary with members from the other ministry
along with others. Regularity of meetings of these committees varies and so does their effectiveness.
4.3 Regulatory Structure and Environment for Urban Health
There are national-level regulatory structures that cover the entire country, both urban and rural
areas. These regulatory bodies for service providers include the Bangladesh Medical and Dental
Council to register graduate physicians, dentists, and medical assistants; Bangladesh Nursing Council
to register nurses and allied professionals; Pharmacy Council of Bangladesh to register pharmacists;
Bangladesh Homeopathic Board to register diploma homeopaths; and Bangladesh Board of Unani and
Ayurvedic systems of Medicine to register diploma unani and ayurvedic practitioners. The is not
regulation and thus no registration for health technologists and graduates of alternative medical care
practitioners (homeopath, unani, and ayurved). As per the Private Practice and Private Clinics and
Laboratories (Regulation) Ordinance, 1982, and Safe Blood Transfusion Law, 2004, the Director of
Hospitals and Clinics under the DGHS issues licenses for establishing hospitals, clinics, diagnostic
centers, and blood banks in the non-government sector.

15
The Directorate General of Drug Administration (DGDA) is the drug regulatory authority for
both allopathic and alternate medical care. However due to limitations of the regulatory bodies,
many unregistered service providers and health facilities, including drug shops, exist, including in
urban areas
4.4 Governance of Urban Primary Health Services Delivery
Project
The LGD is the executing agency of the UPHCSDP. The Project Director is a government official and
appointed by the government (LGD). A Project Management Unit (PMU) headed by a Project
Director provides technical, administrative, and logistical leadership for project implementation. The
PMU is assisted by Bangladeshi and international individual consultants and consulting firms. The firms
are project performance monitoring & evaluation, behavior change and communication marketing,
ICT solution and HMIS, and operations research firms. Individual consultants are Urban Health
Strategy Expert, Resource Management Specialist, PPP Transaction Specialist, Urban PHC Specialist,
Procurement Specialist, Quality Assurance Specialist, Gender Specialist, Environment Specialist,
Financial Management Specialist, Human Resource Development Specialist, and Training Management
Specialist. A National Project Steering Committee chaired by the LGD Secretary provides guidance to
the PMU. The Director General of the LGD Monitoring, Inspection and Evaluation Wing is the
UPHCSDP Chief Coordinator. The health departments of city corporations and selected
municipalities are the implementing agencies in their respective project areas through a Project
Implementation Unit (PIU). The PIUs are assisted by contracted NGOs to deliver PHC services to
the people of the project areas. Each city corporation and municipality has a Partnership Committee
chaired by the Mayor. There is a Ward Primary Health Care Coordination Committee chaired by the
respective local Ward Councilor and co-chaired by the female Ward Councilor and Zonal Health
Officer. The MOHFW has no role in the implementation of this project.
4.5 Governance of Government Hospitals
Government hospitals in urban areas may belong to the MOHFW, or Ministries of Defense, Home,
Railway, and Public Administration (see above). Some city corporations have facilities ranging from
dispensary to only outpatients to hospital. These are governed by the health department of the
respective city corporation. MOHFW urban facilities may belong to the DGHS or the DGFP.
Prominent DGFP facilities include district-level Maternity and Child Welfare Centers, which are
controlled by the district’s Deputy Director, Family Planning. In addition, at Dhaka, two 100-bed
hospitals (Azimpur Maternity and Child Health Training Institute and Mohammodpur Fertility Services
and Training Center) are run by the DGFP. UHCs are supervised by the DGHS Director for PHC. All
hospitals at district level and above (medical college hospitals, specialized hospitals) are supervised by
the DGHS Director of Hospitals. All DGHS hospitals have a Health Care Development Committee,
chaired by the local Member of Parliament; members are drawn from among government officials,
local elites, civil society representatives, and other professionals. However, in general these
committees seldom meet and are ineffective.
Two government (MOHFW) hospitals have been granted autonomy through two separate laws. The
first is the Institute of Child and Mother Health (ICMH). Its Board of Governors is chaired by the
Minister of Health and Family Welfare, and members include two local Members of Parliament,
Secretaries of the MOHFW, Ministry of Finance, DGHS, and DGFP, the Director of Nursing Services,
the President of the Bangladesh Medical Association, a renowned pediatrician, a renowned
gynecologist, two renowned nutritionists, and a senior ICMH Medical Officer. The ICMH Executive
Director is Member Secretary. The ICMH gets an annual grant from MOHFW. Second, Bangabandhu
Sheikh Mujib Medical University (BSMMU) and the hospital attached to it are autonomous.

16
BSMMU gets an annual grant and other development assistance from the MOHFW. Both autonomous
hospitals can retain their income (from user fees etc.), which is not allowed for other government
hospitals. Both hospitals can recruit their staff (doctor, nurse, para-professionals, etc.) and they
are not transferable. BSMMU practices this. However, ICMH also receives staff by transfer from
the MOHFW.
Contracting is increasingly in practice in government hospitals. Raw materials for food service,
stationery, and medicines have been supplied by contractors since before independence. The newly
added contracted services are security and cleaning.
4.6 Governance of Private Hospitals and Drugstores
Hospital Service Management (HSM) personnel under the DGHS are responsible for the licensing and
registration of private clinics/hospitals. The current registration and licensing system has no specific
definition of health care facilities or list of services they can provide, and private clinics/hospitals do
not renew their licenses on a regular basis due to there being no penalty for late renewal
(Chowdhury et al. 2016). The HSM lacks the capacity needed to regularly monitor the huge number
of private clinics/hospitals for compliance with the regulations. Similarly, the DGDA lacks the
manpower and infrastructure needed to implement the regulations for the licensing and registration
of drugstores (Chowdhury et al. 2016). Although the DGDA has developed the over-the-counter
drug list, they are yet to implement it due to lack of institutional capacity.
4.7 Coordination and Cooperation among the Urban Health
Care Delivery Institutions
There are coordination gaps between the MOHFW and MOLGRDC in terms of service delivery,
monitoring and supervision, and other system issues. There is overall lack of coordination between
the two ministries, between the DGFP and city corporations for delivering family planning services
and related monitoring and supervision, and between the DGFP and DGHS for providing family
planning services at district hospitals and Maternal and Child Welfare Centers.
There is complete lack of coordination and collaboration between different providers providing
health services in urban areas (Hussain and Ahmed, 2015).18 There is also no coordination between
the UPHCSDP and NHSDP other than some understanding on demarcation of their geographic
service areas. The NHSDP uses some of the premises built under the UPHCSDP. However, such
understanding is absent with other providers. Observation suggests that low-priced providers
compete with each other. There is lack of coordination between hospital services provided by the
MOHFW and other ministries. The MOHFW lacks capacity to meet all its stewardship and
monitoring responsibilities. There is no effective referral linkages among these providers. Defining
the roles and responsibilities of each service provider is essential to deliver a cohesive health care
service to urban areas. Thus, Strategic Thematic Group 2015 report has made recommendations
for effective collaboration with the LGD on urban health (MOHFW 2015). The report also
recommended establishing a permanent institutional mechanism and an effective referral system
among urban providers.
18 However, collaboration should by the respective city corporation/municipality and its Mayor as an elected representative
can always do so. The LGD has no mandate for this.

17
5. URBAN HEALTH FINANCING MECHANISM
IN BANGLADESH
The World Health Organization (WHO) defines health financing as the mobilization, accumulation
(pooling), and allocation of money to cover the health needs of the people. In other words, it sees
revenue collection, pooling of resources, and purchasing of services as the three key functions of
health financing. There are different models of financing and provision of health care to meet the
health needs: (i) public finance and public provision, (ii) public finance and private provision, (iii)
private finance and private provision, (iv) private finance and public provision, (v) mixed finance and
public-private (NGO) partnership, and (vi) mixed finance and private (NGO) provision. We have
used these notions, listed in Table 1, to understand the health financing of the different providers
of urban health care discussed in Section 2.
Table 1: Health Care Financing of Different Provisions of Urban Primary Health Care in
Bangladesh
Type of Urban
Health Provider
Sources of Pooling of Resources Type of Health Financing and
Provision of Health Care
Private
hospitals/clinics/docto
r chambers
Out-of-pocket (OOP) payments through fee for
service
Private finance and private provision
Outpatient facilities in
MOHFW and other
ministry secondary
and tertiary hospitals
Budgetary allocation to the MOHFW based on the
revenue generated mainly by general tax and fees
Public finance and public provision
ULBs Allocation from LGD share of budget, and city
corporation and municipalities holding tax and fees
Public-finance and public provision
UPHCSDP External agencies (loan from ADB and grants from
UNFPA and SIDA), general tax and fees, and OOP
payments
Mixed finance and public-private
(NGO) partnership
NHSDP, funded by
USAID and DFID
Donor agencies (USAID and DFID) and OOP
payments through fee-for-service payment
Mixed finance and NGO provision
International NGOs Donor agencies and OOP payments through fee for
services
Local
NGOs/CBOs/SBOs
Cross-subsidization of other activities, insurance
premium, donor funding, and OOP payments through
fee for services
The major sources of private financing are (i) OOP payments by urban individuals/households; (ii)
NGO/CBO funding (both national and international); and (iii) insurance premiums paid by urban
individuals, households, and firms.

18
The main source of public finance is the annual budgetary allocation received by the MOHFW and
other ministries from the Ministry of Finance based on the resources accumulated from tax and fees
paid by individuals, households, and firms throughout the economy; the resources are pooled by
Ministry of Finance, city corporations, and municipalities. A part of the MOHFW allocation is spent
by government hospitals/health centers/dispensaries located in urban areas (i.e., cities and
municipalities). Another part of the MOHFW allocation is spent by hospitals run by different
government units including army, air, and naval forces. A fraction of the allocation received by
MOLGRDC from Ministry of Finance is distributed among the city corporations and municipalities.
Some of this allocation is spent on the activities of health units of the city corporations and
municipalities. City corporations also spend a small share of their revenue generated through
holding tax.
The intermediaries/revenue managers of urban health financing are the MOHFW, MOLGRDC, other
government agencies, city corporations and municipalities, insurance companies, and NGOs/CBOs
serving urban areas. The purchasers of urban health services are: all public sector providers serving
in the cities and municipalities, hospitals run by different government agencies including the CMH,
private providers in the cities and municipalities, pharmacies/drugstores in the cities and
municipalities, the UPHCSDP, and national/international NGOs/CBOs.

19
6. REVIEW OF RESEARCH ON URBAN HEALTH
IN BANGLADESH AND IDENTIFICATION OF
RESEARCH GAPS
Evidenced-based information on key issues of urban heath, depicted in Figure 2, is crucial for policy
discussion. To identify research gaps, we have reviewed the available studies on each of the key
issues. We have also suggested some studies for addressing the knowledge gaps.
Figure 2: Key Issues of Urban Health
6.1 Demand-side Issues
Access to health care: Low level of access to quality health care in urban areas is a major
concern. Access is defined as ‘the timely use of service according to need’ (Peters et al., 2008).
Utilization of health care is used as an operational proxy for access to health care. There are four
dimensions of access: geographic accessibility, availability, affordability, and acceptability of health
care (O’Donnell, 2007; Jacobs et al. 2011). There are a number of demand-side barriers associated
with each of these dimensions in the urban context of Bangladesh. (See Annex Table A1.)
Studies that have been done on the urban context have concentrated on health seeking behavior
rather than all the dimensions of access. Various national-level surveys, including the Household
Income and Expenditure Survey, Bangladesh Demographic and Health Survey, and Bangladesh Urban
Health Survey, provide information on health seeking behavior of urban households. A number of
studies/documents have looked at health seeking behavior using small samples or secondary data.
•Spatial distribution of the
urban health providers
• Efficiency of institutions
providing urban health
• Responsiveness of urban
health providers
•Not receiving care due to
lack of affordability
•Burden of OOP payments
•Inequity in OOP payments
• Access to quality health
care
• Equity in use of health
care
• Intra-urban equity in
health care use and
health outcomes
•Low priority to health by ULBs
•Capacity of the ULBs for providing
urban health care
•Capacity of ULBs to contract with
NGOs and monitor quality of health
care provided by NGOs
•Coordination among the institutions
providing urban health
• Stewardship role of MOHFW
• Scalability and sustainability of of
UPHCSDP
IV. Regulation ,
governance
and
stewardship
V. Others
I. Demand side
II. Supply side
III. Financial risk
protection

20
(See Annex Table A2.) For example, Jahan et al. (2015) studied the self-reported morbidity status
and health seeking behavior of urban slum dwellers in Dhaka city based on a sample of 900
households from 30 slums. The study found that an overwhelming majority (99 percent) of the
households and 88 percent of the individuals had an illness episode during the three months
preceding the survey. General cough, cold, and fever was the most dominant category of illness
(about 48 percent of cases). About 82.4 percent slum dwellers received health care from informal
providers. Khan et al. (2012) estimated the determinants of seeking health care from the most
frequently used source in urban slums. The study found that two frequently used health care sources
were pharmacies (42.6 percent) and government hospitals/clinics (13.5 percent). The likelihood of
using pharmacies were higher for those who used non-hygienic toilets, reported food deficiency at a
family level, expressed dissatisfaction about family income, and stated poor health status.
Equity in use of health care: Ensuring equity in health care access and utilization is another
critical issue in the urban context of Bangladesh. There are a couple of principles of equity: “equal
access to health care for those in equal need of health care; and equal utilization of health care for
those in equal need of health care” (Oliver and Mossialos, 2004). Equal access for equal need
requires conditions whereby those with equal needs have equal opportunities to access health care
(i.e., horizontal equity), and, as a corollary, those with unequal needs have appropriately unequal
opportunities to access health care (i.e., vertical equity).
Some studies focused on socio-economic inequalities of using health care (See Table A2). For
instance, Kamal et al. (2016) used 2001 and 2010 Bangladesh Maternal Mortality and Health Care
Survey data to examine trends in use of ANC from medically trained providers and in deliveries
taking place at health facilities. The study found the gap in use of ANC provided by medically trained
personnel narrowed in urban and rural areas between 2001 and 2010 while that in facility deliveries
widened. The difference in use of ANC by the rich and the poor was not as pronounced as that in
utilization of facilities for deliveries. The study also found that over the last decade, equity in
utilization of health facilities for deliveries has improved at a faster rate in urban areas. Private sector
has surpassed the public sector and appears to be the dominant provider of maternal health care in
both domains with the share of NGOs increasing in urban areas.
However, there are no studies on horizontal and vertical inequity in use of health care. Nor are
there studies on gender equity and equity in different age groups using robust methodology. There is
also no study on intra-urban equity in health care use and health outcomes.
6.2 Supply-side Issues
Spatial distribution of the providers: Mapping of urban health facilities was conducted to find
the availability and competitiveness of urban health providers; for example, Adams, Islam, and
Ahmed (2015) conducted a health facility mapping of six urban slum settlements in Dhaka to explore
the configuration of health care services proximate to where the poor reside. (See Table A.) Three
methods were employed: (i) social mapping and listing of all Health Service Delivery Points (HSPDs);
(ii) creation of a geospatial map including Global Positioning System (GPS) to co-ordinate all HSPDs
in the six study areas, and (3) implementation of a facility survey of all HSDPs within six study areas.
Adams, Ahmed et al. (2015) also prepared a detailed map of health care providers of Dhaka North,
Dhaka South, Khulna, Sylhet, Rajshahi, and Narayanganj cities, and made a compendium of maps and
information on the composition and distribution of health facilities in urban Bangladesh to produce
the Urban Health Atlas. The purpose of the compendium is to provide a quick reference and
introduction to this rich set of data useful to policymakers, health planners, and researchers.
Efficiency: One of the objectives of private-public partnership (i.e., NGO contracting model) in the
UPHCSDP is improving efficiency along with ensuring equity. More elaborately, a fundamental
objective of the UPHCSDP is to improve the efficiency of urban health services by improving the
spatial distribution of health centers (Comprehensive Reproductive Health Care Centers, PHC
Centers, and Mini Clinics) in accordance with population density and geographical factors; supporting

21
cost-effective interventions to reduce mortality and morbidity; enabling low-cost private sector
participation in the provision of preventive and promotive health care services by partner NGOs;
allowing appropriate user fees; improving the monitoring and supervision system; and concentrating
on the provision of health services that will create the greatest public good in order to use scarce
government resources more efficiently. However, there is little research on assessing efficiency of
the UPHCSDP, although Heard et al. (2013) included an efficiency component with utilization,
equity, and quality issues in an impact study of the UPHCSDP of Chittagong City Corporation.
Responsiveness: Responsiveness is an indicator used to measure how well a health system
performs relative to non-health or non-therapeutic aspects. As per the WHO, there are eight
dimensions of responsiveness: dignity (talked respectfully), autonomy (involvement in decision
making about personal health care), confidentiality (of information), prompt attention (waiting time),
communication (clear explanations), social support, basic amenities (cleanliness), and choices of
providers (Hsu et al., 2006). Improving these non-health functions of a health system is important
because they are integral to increasing people's well-being, that being a universal and ultimate
mission of a health system. The WHO defined two elements to measure the concept of
responsiveness: respect for persons and client orientation (Darby et al., 2000 Hsu et al., 2006).
Respect for persons includes three sub-elements: dignity, autonomy, and confidentiality. Client
orientation (which mainly gauges the components of consumer satisfaction) has four sub-elements:
prompt attention, quality of basic amenities, access to social supports for hospitalized individuals, and
choice of health providers. These dimensions measure non-therapeutic quality of health care, which
has much impact on health outcome.
As a universal and ultimate mission of a health system improving these non-health or non-
therapeutic functions of a health system is important because it is an indisputable component to
increasing people's well-being. Evidence on comparative responsiveness of different providers of
PHC delivery in urban areas in Bangladesh has great importance for informing policy discussion in
this context. The literature on Bangladesh has focused on perceived quality of care (which includes
some dimensions of responsiveness) rather than responsiveness as a whole.19 For example,
Andaleeb et al. (2007) examined the determinants of patient satisfaction of hospitalized care in public
and private hospitals in Dhaka City and foreign hospitals using exit interview method. Using both
exit interview and qualitative tools (focus group discussion and in-depth interview), Gazi et al. (2015)
explored the perceived quality of reproductive health care in both users’ and non-users’
perspectives at 14 facilities of the UPHCSDP and NHSDP Smiling Sun Network in Sylhet City
Corporation. Although these studies included some dimensions of responsiveness (e.g., reliability,
assurance, empathy) for assessing the perceived quality of care, the study does not look at all
dimensions of responsiveness, or at the comparative responsiveness of different providers, in the
urban PHC context in Bangladesh. In other words, currently, there is no research in which a model
of urban health (e.g., UPHCSDP, NHSDP, Marie Stopes, BRAC Manoshi, and Ad-din) is performing
better in terms of responsiveness.
6.3 Financial Risk Protection
A fairly financed health system, as per WHO definition, is one that does not deter households from
receiving needed care due to payments required at the time of service and one in which each
household pays approximately the same percentage of income for needed services. A health
financing system that deters people from seeking needed services or impoverishes individuals and
families will worsen health outcomes.
19 This is to note that research on responsiveness of health system has been conducted in many developing countries
(e.g., Hsu et al., 2006; Peltzer, 2009; and Peltzer and Phaswana-Mafuya 2012).

22
Thus, assessing the level of not receiving care due to lack of affordability, burden of OOP payments,
and inequity in OOP payments is critical for evaluating financial risk protection provided by any
health scheme. However, no evaluation has been done on financial risk protection of any of the
urban health schemes (e.g., UPHCSDP, NHSDP, Manoshi, and Marie Stopes).
6.4 Regulation, Governance, and Stewardship
Rapid and unplanned urbanization accompanied by low priority of health by ULBs raises some
research issues, such as the perception of ULB authorities regarding their capacity for providing
urban health care; capacity of the ULBs for contracting with NGOs and monitoring the quality of
health care provided by NGOs; coordination among the institutions providing urban health;
stewardship role of MOHFW; and scalability and sustainability of the UPHCSDP. Although this
report touches on some issues, rigorous study on these issues is crucial for informing policy
decisions. It has been predicted that the majority of people will live in urban areas by 2039,
making Bangladesh an urban city. This raises a fundamental research question whether re-thinking
is necessary for integrating urban health with national health care system.
6.5 Other Issues
Some evaluations have been done of Smiling Sun clinics in regard to the use of family planning and
maternal health care. (See Table A2.) Evaluations of the first and second phase of the UPHCSDP
were also conducted.20 Other, independent evaluations also have been carried out in some project
areas. For example, Heard et al. (2013), based on baseline and follow-on household surveys, an end-
line health facility survey, and routinely collected data, evaluated the impact of the UPHCSDP of
Chittagong City Corporation on use, efficiency, equity, and quality of care. The study also compared
the results between NGO-contracting health centers and city corporation-managed health centers.
(See Table A2.) There were significant improvements in both government and NGO-run areas.
However, larger improvements were observed on selected coverage indicators in the NGO area
compared to the government area. Improvements in coverage among the poorest 50 percent of the
population were greater in the NGO-run area. The cost per service delivered was 47 percent lower
in the NGO area. However, there is no evaluation on other city corporations and municipalities to
rank them in terms of performance in the health outcomes. There is no such evaluation for other
schemes, such as Manoshi and Marie Stopes.
There is also no research to compare the effectiveness of different models of providing urban health
care on increasing access to health care, equity in health care utilization, quality of health care, health
status, and financial risk protection. There is a recent research on estimating the health expenditures
of the urban population (Hossain 2016).
As secondary- and tertiary-level hospitals do not record the residential location (i.e., rural or urban)
of patients there is lack of information for analyzing rural-urban distribution of patients served by the
health facilities. There is also a gap in the referral network; no research has been done on how the
patients are referred and what the follow-up process is.
20 http://www.adb.org/sites/default/files/evaluation-document/35676/files/in212-08.pdf
http://www.adb.org/sites/default/files/linked-documents/42177-013-ban-oth-04.pdf

23
6.6 Potential Research Topics
Table 2 suggests topics for further research, based on the analysis of the earlier section.
Table 2: Potential Research Topics on Urban Health in Bangladesh
Issues Research Gap Potential Research topics
Access to health
care
 Lack of a comprehensive study incorporating all
the dimensions (geographical accessibility,
availability, affordability, and acceptability) of
access to health care.
 Determining access barriers to health
care of urban poor in terms of
geographical accessibility, availability,
affordability, and acceptability.
 Finding the most effective urban health
model in terms of geographical
accessibility, availability, affordability,
and acceptability.
Equity and
efficiency
 Lack of study on the horizontal and vertical
inequity in use of health care.
 Lack of study on gender equity and equity in
different age groups using robust methodology.
 Lack of research on assessing efficiency of
UPHCSDP.
 Measuring vertical inequity in use of
health care in urban areas.
 Measuring comparative efficiency of
UPHCSDP and other schemes (e.g.,
NHSDP, Manoshi and Marie Stopes).
 Measuring intra-urban equity in health
care use and health outcomes.
Financial risk
protection
 No evaluation study on any of the urban health
schemes (e.g., UPHCSDP, NHSDP, Manoshi,
and Marie Stopes) in terms of financial risk
protection (i.e., reducing inequity in health
outlays as well as magnitude of health outlays).
 No research to compare the effectiveness of
different models on increasing access to health
care, health status, and financial risk protection;
thus it is not known which model of providing
urban health is the most effective.
 No action research or even any feasibility study
on urban poor for introducing any prepaid
mechanism.
 Assessing the burden of OOP outlays
of the urban poor.
 Comparative analysis of financial risk
protection of urban health schemes
(e.g., UPHCSDP, NHSDP, Manoshi, and
Marie Stopes);
 Assessing the feasibility of Shasthyo
Shurokhsha Karmasuchi-type health
protection scheme for the urban poor.
Responsive-ness
(non-therapeutic
quality)
 No research using all the dimensions of
responsiveness or non-therapeutic quality
(dignity, autonomy, confidentiality, prompt
attention, communication social support, basic
amenities, and choices of providers) as defined
by WHO.
 No research on which model of urban health
(e.g., UPHCSDP, NHSDP, Marie Stopes, BRAC
Manoshi, Ad-din) is performing better in terms
of responsiveness.
 Comparative analysis of responsiveness
(non-therapeutic quality or patient) of
the urban health models (e.g.,
UPHCSDP, NHSDP, Manoshi, Marie
Stopes, government providers, private
providers).
Governance and
stewardship
 No research on assessing the perception and
capacity of the authorities of the ULBs for
playing the stewardship role of urban health
care.
 Assessing the perception and capacity
of the authorities of the ULBs for
playing the stewardship role of urban
health primary care.
 Conducting policy dialogues on
whether re-thinking is necessary for
integrating urban health with national
health care system.
 Conducting policy dialogues to
determine better operational
coordination mechanisms.

24
Issues Research Gap Potential Research topics
Other issues
including referral
 There is lack of information for analyzing rural-
urban distribution of patients served by the
health facilities.
 There is also a gap in the referral network, no
research on how the patients are referred and
what the follow-up process is.
 Analyzing rural-urban distribution of
patients served by the health facilities.
 Conducting research and policy
dialogues for establishing referral
system.

25
7. SUMMARY AND CONCLUSION
This report describes the landscape of urban health care in Bangladesh, with an emphasis on
financing and governance issues and research gap. Although the GOB has a comprehensive health
infrastructure for the rural population, its urban health services are limited to a few tertiary care
hospitals, some dispensaries, and EPI centers. ULBs, by law, are responsible for providing PHC and
public health services to the people of their respective constituencies. However, historically, PHC
has not been a ULB priority. The MOHFW has not developed any infrastructure (other than some
outpatient facilities in some secondary and tertiary hospitals) for providing PHC in urban areas, in
contrast to what it has done in rural areas, because this is not in its mandate. Thus, there is a huge
supply gap in government provision of PHC in the urban areas. Rapid growth of the urban
population has widened this gap, and has led to the growth of private and NGO hospitals/clinics.
However, the poor have limited access to private facilities, especially to high-quality ones. In this
context, some city corporations and municipalities, under the stewardship of the MOLGRDC, have
since 1998 been offering PHC and limited curative care including MCH care under a public-private
partnership model financially supported by several donor agencies including the ADB. In addition,
several national and international NGOs, such as the NHSDP, Marie Stopes, and BRAC Manoshi,
offer PHC to low-income people in the urban areas.
Table 3 summarizes urban health care delivery institutions in terms of finance and governance.
Regarding financing, the NGO Smiling Sun Network and the UPHCSDP are mainly financed by donor
funding, but they charge user fees with a safety net for poor clients. Not-for-profit providers are
financed by fee for services charged at their outlets; they subsidize their care with revenue
generated from their other activities. They also sometimes receive some donor funding. The main
source of finance of outpatient facilities of government medical college hospitals, government
maternity centers and specialized hospitals is the annual budgetary allocation of the MOHFW. The
source of financing is similar for the hospitals/medical centers run by different government agencies
(e.g., Police Hospital, CMH, and Railway Hospital).
Regarding governance, the Smiling Sun Network is managed by the NGOs with the advice from
USAID, and the UPHCSDP is managed by the LGD assisted by the health department of city
corporations and municipalities and partner NGOs. Government facilities are managed by the
MOHFW.
Although the provision of PHC is the jurisdiction of ULBs, none of the players other than the
UPHCSDP coordinates with ULBs. Lack of coordination and cooperation among the NHSDP,
UPHCSDP, Marie Stopes, and others (including MOHFW and other government facilities) that offer
low-priced health care to the urban poor is the evidence of the disconnectedness of urban health
system. Observation suggests that the donor-funded providers of urban health care actually compete
against each other. This duplication of resource use is inefficient and exacerbates gaps in coverage
and quality.

26
Table 3: Summary of the Urban Health Care Delivery Institutions
in Terms of Finance and Governance
Name/Type of
Organization/Network
Service Providers Finance Management Comments
Private facilities Private
clinics/hospitals/doctor
chambers/pharmacies,
outpatient facilities of
private medical college
hospitals
Fee for services Private/NGO/Trust/
Foundation
No ownership
and/or
coordination
with ULBs
MOHFW Outpatient facilities of
government medical
college hospitals,
government maternity
centers, and
specialized hospitals
Tax finance and
allocation from
health budget
MOHFW No ownership
and/or
coordination
with ULBs
Other ministries Hospitals/medical
centers run by
different (e.g., Polish
Hospital, CMH)
Tax finance and
allocation from
health budget
The respective
agency
No ownership
and/or
coordination
with ULBs
ULBs ULBs managed
hospitals/health
centers
Budgetary
allocation of ULBs
to the health
department
ULBs themselves No coordination
with MOHFW
and other
institutions
providing urban
health
UPHCSDP Selected NGOs ADB and other
donor agencies
with GOB co-
funding, and user
fees with proper
safety net to the
extreme poor
LGD and health
departments of city
corporations and
municipalities with
the assistance of
partner NGOs
Some ownership
and coordination
with ULBs
NHSDP Selected NGOs USAID with DFID
co-funding, and
use fees with
proper safety net
for the extreme
poor
Implemented by
NGOs, but
supervision,
monitoring, and
guidelines are
provided by USAID
No ownership
and/or
coordination
with ULBs
International NGOs Marie Stopes, Muslim
Aid, Red Crescent
Society
Donor fundings
and fee-for-servce
The respective
organization
No ownership
and/or
coordination
with ULBs
Local NGOs/CBOs/
SBOs
Dhaka Community
Trust, Gonoshasthaya
Kendra, Ad-din
Hospital, Marie Stopes
Clinics, BRAC
Manoshi, etc.
Fee for service and
cross-subsidy
The respective
organization
No ownership
and/or
coordination
with ULBs
Dependence on external funding is the major deficiency of government and NGO provision of urban
health for low-income people. The urban health sector suffers from lack of stewardship by the
MOHFW, the LDG, and ULBs themselves. Lack of coordination between the MOHFW and
MOLGRDC is the major institutional and structural barrier to providing PHC in urban areas.

Landscape of Urban Health Financing and Governance in Bangladesh

Landscape of Urban Health Financing and Governance in Bangladesh

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