National Urban Health Strategy, 2014

1.1. Bangladesh is one of the countries in the world with rapid urban population growth. This is common for a country with declining poverty, increasing industrialization, and a shift towards middle-income economy. This is the reality where people will be migrating to the cities riding on the wheels of a vibrant economy. According to the population census of Bangladesh,the urban share of the national population was 8.8% in 1974 and increased to 27% in 2011. Indication is clear that this trend will continue in the future. It is estimated that the national population will be 230 million by 2040 of which more than half will be living in the urban areas.

1.2. Rural to urban migration, geographical expansion of existing city areas through merging rural areas to cities, inclusion of new areas as city, etc. are the main reasons for the increasing urban population.

1.3. City Corporations, municipalities, and cantonment boards included in the government‟s gazette are considered as urban areas. The city corporations and municipalities are local government bodies and distinct administrative units being administered under Local Government Division of the government through elected representatives as per provision of Article 59 of the Constitution. The cantonment boards are being administered according to the Cantonment Act.

1.4. The Constitution of the Peoples‟ Republic of Bangladesh, Article 59 provides as follows: “ (1) Local government in every administrative unit of the Republic shall be entrusted to bodies, composed of persons elected in accordance with the law. (2) Everybody such as is referred to in clause (1) shall, subject to this Constitution and any other law, perform within the 5 appropriate administrative unit such functions as shall be prescribed by Act of Parliament, which may include functions relating to: (a) administration and the work of public officers; (b) maintenance of public order; and (c) preparation and implementation of plans relating to public services and economic development.”

1.5. Due to rapid population growth in urban areas, like other services, increased demand for health service delivery for the urban people is a common issue. The city corporations and municipalities are public service delivery organizations as prescribed by the law. Among these, delivery of primary health care and public health activities are important services. Though this responsibility has been mandated by the Local Government (City Corporation) Act, 2009 and the Local Government (Municipality) Act, 2009, there are some limitations to perform this responsibility properly in respect of the demands.

1.6. On the other hand, the Ministry of Health and Family Welfare is the leading Ministry to provide health services to the citizens of the country. In rural areas, there is a Community Clinic per 6,000 people, a Health and Family Welfare Center in each Union, a Health Complex in each Upazila, which results in a strong network of primary health and family planning services. However, there is lack of a similar network and program in the urban areas.

1.7. This gap adversely affects the primary health care of one-third of the country‟s population who are living in the urban areas. Particularly, the poor are deprived of essential health care services.

1.8. The necessity of a well-planned strategy for an urban health system has been discussed several times. Various government policies also emphasized the need of an urban health strategy. In this context, this National Urban Health Strategy has been formulated considering overall national goals and policies. In preparing this strategy, due attention has been given to national and international perspectives and commitments. The views of the stakeholders and grass roots level opinions have been considered. 6 2. Goals and Objectives

2.1. This strategy has been prepared based on some indications. First, rapid urbanization, specially unplanned urbanization hinders improvement of health and living standard of the urban people. Second, health care, particularly urban health care should not be limited to curative care only. Third, considering the complexity of the urban system, it is necessary to ensure coordination among activities of different organizations and a permanent arrangement to ensure a proper health system. Fourth, due to the reality of the public sector‟s financial and non-financial limitations, public, private and social partnership is indispensable for urban health care. Fifth, considering the socio-economic condition of the urban poor, it is necessary to work collectively for their health and human development.

2.2. If the National Urban Health Strategy is implemented, it will be possible to prevent the apprehension that urban health will face an acute situation by 2020. Through this strategy, it is expected that the following targets will be achieved: (1) Attain middle income status by 2021, where the urban population, especially the poor, will be healthier, happier, and economically productive; (2) Create environment where urban people, especially the poor, have equitable access to utilize public and private sector health services; (3) Improve overall health indicators of the country through strengthened essential health care system for the urban population.

2.3. This strategy is divided into two parts. The first part contains a brief analysis of the present situation and looks at future expectations. The second part is an annexure on the implementation process of National Urban Health Strategy. This strategy is a living document, which will be updating time to time, if required. Any recommendation from individuals and organizations for improving the strategy would be highly appreciated. 7 3. Global Perspectives of Urban Health

3.1. The global development trend is toward urbanization. At present, more than half of world‟s population lives in urban areas. Urbanization does not only mean the increase of urban population or the expansion of urban areas. Urbanization will become inclusive when its structure ensures industrialization, employment, environment for livelihood and socio-economic security.

3.2. Health care is a basic issue in urban life. Globalization, demographic change, climate change, and urbanization—these four major trends are influencing the 21st Century‟s urban health landscape. Advancement of technology and strategy, increasing opportunities of livelihood, economic and commercial worthiness, good governance, etc. are considered important and positive factors to these trends. To ensure health care for the jobless and slum population, an equitable health system and reasonable employment opportunities are necessary. Inappropriate wages might help reducing unemployment for time being but poverty will not be eliminated and essential commodities including health care services will not be available. In brief, it is difficult to improve expected living standard after discharging other liabilities of urban setting and to get relief from endemic deprivation.

3.3. Migration from rural to urban is the main cause for increasing urban population. Migration is driven by „pull-push‟ factors such as economic, cultural, political, or environmental. „Pull‟ factors include increased livelihood opportunities and better living conditions. „Push‟ factors include less opportunity, social or economic discrimination, political adversity, and natural disasters. Fertility and mortality rate also affects the increase in population. Extended health care services in urban areas contribute to incrase longevity in affluent families. It has been resulted to increase of older population.

3.4. For development, there is no alternative to industrialization, but it causes increased emissions of carbon dioxide and other greenhouse gases, resulting in the increase global warming. Densely built houses and treeless cities become „heat islands‟. Air, water, food pollution and different communicable diseases are affecting urban residents. Other health threats are natural disasters for cities close to coastal areas or 8 riverbanks. Existence of industries in and around cities such as brick kilns, tanneries, and cement factories are curbing the right to enjoy pure air by urban residents and cause serious health risks. There is significant absence of industrial effluent treatment systems in developing countries like Bangladesh. Untreated effluent is dumping in the nearest natural water bodies. As a result, surface water becomes unusable. This situation underscores the necessity of good governance for good health.

3.5. Except natural geographic barriers, horizontal expansion of cities is a continuous process. Apparently, it helps to mitigate overcrowding. However, it also creates health problems. For instance, it demands long commute and traffic related health risk. Horizontal growth may lead to loss of crop lands, which is a threat to food and nutrition security, and creates problems of safe water supply. Lack of play grounds impedes physical and mental growth of children. In Dhaka, one of the world‟s most populated cities, scope to bicycling safely and play kites in the sky by the romping youth is beyond imagination. Due to the lack of safe walkways, city dwellers are forgetting their walking habit, which causes health risks such as diabetes and cardio-vascular complications. 4. Bangladesh Perspective

4.1. The Government of Bangladesh has been working to achieve the Millennium Development Goals (MDGs). Among eight main goals, three are related to human development (achieve universal primary education, eradicate poverty, and promote gender equality) and three are health related (reduce child mortality rate, reduce maternal mortality ratio, and prevention of HIV/AIDS and malaria). There are intensive interlinkages among these, and without integrated efforts, it will be impossible to achieve the expected results.

4.2. The preface of the National Education Policy 2010 perfectly mentioned, “Education is the main tool for achieving goal of poverty eradication. An educated nation, modern in intelligence and reflection, progressive in sense and wisdom can drive a country to the height of development.” It means building an educated nation is not only the final destination of an education system. Similarly, objective of the Health, Population and Nutrition Sector Development Program (July 2011-June 2016) is to make the population healthier, happier, and economically productive to scaling up the country to a middle-income level by 2021. Harmony 9 among different policies and strategies indicate that the development effort of a country is like an orchestra, where all the sectors, all elements need to perform uniformly and in a common manner.

4.3. Bangladesh has made substantial progress in the human development indicators. Literacy rate is increasing; particularly notable progress has been achieved in girls‟ education. Enrollment in primary level is around 100% and the drop out rate is also decreasing. The Government‟s highest allocation to the education sector, stipend, establishment of new schools, increasing number of class rooms, free distribution of books at the beginning of the year, teachers‟ training, improved education materials, expansion of technical education, increasing scope of higher education, functioning of non-formal education, etc. have been contributing largely for advancement of the sector. In rural areas, it is rare now to find a child never enrolled in school, but there is no such guarantee for the children of slum and floating families in the urban areas. The disabled and autistic children of rich families are also suffering from similar problem. The National Children Policy 2011 highlights the Government‟s commitment to work in this area.

4.4. In the Sixth Five Year Plan, poverty has been identified as the top most challenge for socio-economic development of Bangladesh. The previous „National Strategy for Accelerated Poverty Reduction‟ also explained this issue in detail. The goal of the Government‟s Perspective Plan (2010-2021) is to reduce poverty; improvement in this field is also encouraging. In Bangladesh, the incidence of poverty in the rural area is still higher than the urban area. This situation is not new, but it is noticeable that poverty in the urban area has been increasing rapidly. According to the population Census of 1974, only 8.8% of the population lived in urban areas, which has increased to 27% in the Census of 2011. Most of the poor in the urban areas live in slums. A large number of them are floating, have no definite place for sleeping at night. Within the thousands of buildings, they are shelterless. Information on these homeless people is absent in household based surveys. Living condition and facilities of the urban ultra-poor is worse than that of rural poor. To ensure improved health of these people is a big challenge.

4.5. Gender equality, empowerment of woman, and prevention of violence against woman are inter related issues. Bangladesh has accorded in the Convention on the Elimination of all forms of Discrimination Against 10 Women (CEDAW). National Women Development Policy, 2011 reflects this commitment. The most outstanding feature of gender equality in Bangladesh is the reduction of disparity in number of boys and girls students in primary and secondary level. In long term, the socio-economic impact will help to elevate Bangladesh to a higher stage. The power of education is numerous; one example of this is creating scope for livelihood and profession. Employment of women implies their empowerment and upholds their rights to take basic decisions. In this era of globalization, there is no alternative to involve women in the mainstream of the economy. By breaking prejudices and traditional norms, women are involved in employment; their contribution is also increasing the country‟s economic development.

4.6. To prevent violence against women, there are many laws and their strict application. Nonetheless, violence against women still is a distressing problem. The report of Violence Against Women (VAW) Survey 2011 published by the Bangladesh Bureau of Statistics show that irrespective of rural or urban, 46.4% of wives were physically assaulted in the previous 12 months by their current husbands. Incidence of acid throwing to women is higher in urban areas than rural. Health problems due to violence against women include losses due to physical injury, problem for treatment of physical injury and treatment cost, risk of life for the mother and the child of pregnant women, and mental disease.

4.7. Overall, the child mortality rate has been reducing in Bangladesh, but the situation is yet not at a satisfactory level. Bangladesh Demographic and Health Survey 2011 stated that 1 out of 23 children dies before the age of one year and 1 out of 19 children dies before the age of five years. To prevent childhood diseases, the Extended Program on Immunization covered 86% of children in 2011. Efforts are continuing to increase the coverage rate. The child mortality rate in slum areas are not declining at the same rate as non-slum and municipality areas.

4.8. As a result of a number of initiatives like vitamin and other micronutrient supplementation, iodized salt, the status of child nutriton is improving significantly. Breast feeding is being popularised. Six month maternity leave for working women has accelarated Exclusive Breast Feeding for six months. Malnourished lactating mothers suffer from inadequate of breast-milk that hampers physical and mental growth of baby. In addition to breast feeding, the progress of supplementary 11 feeding is slow among 6-23 months old children. Stunting among slum children is higher than that of non-slum children. The rate of wasting (low weight compared to height) among them is also higher compared to non-slum children. Both stunting and wasting in children are related to mother‟s malnutrition. This indicates the importance of investing in mother and child nutrition.

4.9. Bangladesh has acheived remarkable progress in reducing maternal mortailty. In 2001, maternal mortality rate was 320 per 100,000 live births;within a decade, it reduced to 194 in 2011. However, Bangladesh still remains among one of the high maternal mortality countries. Efficient management of health care delivery plays a main role for reducing maternal mortality. Births attended by skilled health persons increased to 32% in 2011, which is double compared to in 2004. The increase of maternity centers is the main reason for this progress, where the private sector plays a major role. In 2011, 29% of births occured in the clinics, of which 15% were in private clinics, 12% in government hospitals, and 2% in NGO clinics. Although the rate of institutional delivery among urban mothers is higher than that of rural, this rate is very low among the urban poor and slums.

4.10. In order to reduce maternal mortality, it is necessary to increase awareness about the importance of antenatal and postnatal care and to make health care service easily accessible to the urban poor mothers. The major segment of working women in Bangladesh is engaged in the ready made garments sector; a proper health care system is necessary for these women and their children. In this context, day care centers for the children are necessary.

4.11. Child marriage and teenage pregnancy is a multidimensional problem for Bangladesh. This problem is related to maternal mortality, neonatal death, risk of reproductive health, malnutrition, exacerbating family poverty due to excessive number of children, and over population. In Bangladesh, 50% of women give birth to their first child within the age of 18 years as revealed in data of 2011. This is a depressing scenario. This scenario is worse in the urban slums. The reality of insecurity and the financial burden of the poor family are the main causes of early marriage in the slums. 12

4.12. In Bangladesh, 35% of the population is below 15 years of age. An appropriate environment is necessary for proper development of physical and mental health of adolescents. Due to social and family prejudices, adolescents are denied access to information and counseling on reproductive health. Particularly, there is a shortage of counseling and service centers to address problems related to nutrition, reproductive health, mental health, sexual risk, and ethics. These services are few and far for adolescents of urban poor families and adolescent maids. Even many parents are indifferent to these issues. Lack of hygienic and separate toilets for females in the school, workplace, and roadside is also a health problem.

4.13. Health, Population and Nutrition Sector Development Program has targeted to limit two children per woman by 2016; achieving this target in the urban slum is a big challenge. The Bangladesh Urban Health Survey 2006 found that the population growth rate in urban slums was 2.38% and in non-slums 1.79%. To attain the national target of 72% contraceptive prevalence rate by 2016 from 61% in 2011, more attention is needed for one-third of the country‟s population who live in urban areas, particularly the poor. Examples of limitations in this area include medicine stores or pharmacies that are the main sources of pills and condoms, and injectables are mainly supplied by private sources. NGOs are the main source of contraceptives supply in slum areas. There is a shortage of family planning field workers. Moreover, there is no man power arrangement at all for providing door-to-door service in urban areas.

4.14. Although Bangladesh has achieved self-sufficiency in food, for the poor people, food security is still uncertain. The report of the National Micronutrients Status Survey, 2011-12 stated that food insecurity was at an alarming level in 12.3% of households. Food security is visible among 53.3% households in urban areas compared with 36.3% in slum areas. A separate survey reveals that malnutrition in males and females living in slums is higher than that of non-slum areas. However, the situation is the opposite in the case of obesity, overweight, hypertension, and diabetes. Smoking habits among men in the slum is highest followed by district municipalities and non-slum areas. In slums, the habit of smoking develops at an early age and increases with age. The drug addiction rate is higher in slums under city corporation areas compared to district municipalities. 13

4.15. Problems pertaining to daily life are higher among the slum population compared to non-slum and people living in district municpalities. Women suffer more on this count than men. Problem of physical strength and mobility is higher among women than men. Problem of personal care is also higher among women. Loss due to physical injury is an important health issue in urban area. Men suffer more compared to women, although the causes of injuries are different. For men, the main cause of injury is road accidents, while for women domestic violence is the main cause.

4.16. Access to safe water is an important determinant of the health system. Most of the urban people collect their water from a piped source or tube- well. There are variations in access to water depending on location. Most of the residents of district municipalities get water supply from a tube-well. However, the supply of water is inadequate compared to the demand of the urban people, particularly in the city corporation areas. The quality of water is also an issue to consider.

4.17. In urban areas, different types of accidents are a regular phenomena. The most common are fires, which occur both in slums and high-rise buildings. Installations of factories and warehouses in residential areas, use of imflammable materials, and electric short-circuiting are the main causes of fire accidents. Old and dilapidated buildings, construction of sub-standard buildings, lack of sufficient security measures, earthquakes, etc. are the latest addition to causes of urban disasters.

4.18. The existence of factories and commercial establisments in residential areas, uncollected domestic, commercial, industrial and clinical wastes, sound and air pollution, polluted water and inadeqaute swerage system are serious environmental problems for urban public health. A large quantity of undisposed solid waste spreading here and there poses a serious threat for public health. Bronchitis, asthma, and respiratory infections are increasing day by day due to environmental pollution. Gastrointestinal, skin, and respiratory tract infections are increasing alarmingly.

4.19. Health education is an indispensable element of health service. Once it was thought that educated and solvent people only would live in the cities. Because of this, no plan had been taken for city areas to provide health and family planning service through field workers.In fact, a large 14 number of poor and illiterate people are being deprived of receiving health education to increase awareness on family planning, reproductive health care, adolescent health, drug abuse and addiction, infectious diseases, etc.

4.20. There is difference between urban and rural health systems. In the urban areas, preventive or public health issues are more important. Bangladesh National Health Accounts (BNHA-III), 1997-2007 stated that only 12% of the total health expenditure of the country was allocated for preventive health, in which family planning is also included. Public health related activities are part of preventive health. Allocations for this sector are not sufficient. 5. The Way Forward for Urban Health in the Present Situation

5.1. In the Sixth Five Year Plan, the urban development sector targeted five outcomes. These are (i) full access to pure water and sanitation (ii) access to improved municipal services (iii) strengthened urban policy, local governance and management (iv) improved urban public transport system and (v) sustainable City Corporation and municipal health services.

5.2. In large cities, due to the shortage of public sector primary health care and family planning services, private clinics are providing routine health services to the urban people at higher prices. These costly services are not affordable for the urban poor. In public hospitals, even after waiting for a long time in queue, if they are able to manage free prescription, they are unable to purchase medicine at high price. Thus, health services are becoming more expensive day by day and people are becoming poor to meet health expenses. The poor should get health care services free of cost.

5.3. Public health, preventive health, and family planning services do not attract the private sector because these are non-profitable. In this area, there is a deficiency of service delivery for the urban people. It is necessary to increase activities of city corporations and municipalities in these areas. 15

5.4. Food, nutrition, housing, fuel, water supply, and physical environment are inclusive issues related to health status of the urban people. This should be taken in view during preparation and implementation of urban related policies.

5.5. At present, road safety is a public health hazard. To provide emergency service for road accidents, establishing Trauma Centers is a commendable initiative. Traffic control in Dhaka is the top most problem for urban life. The Government is working to resolve the problem through the Dhaka Transport Coordination Authority. For a proper urban life, a good urban transport system is crucial.

5.6. The scope of work, financial capacity and man power of the city corporations in Bangladesh are not negligible. A very small portion of revenue expenditure of the city corporations are used for health care. It is necessary to increase capacity and give attention to ensure an effective role in this area.

5.7. Although there are questions on the quality and cost of private sector health services, in reality, the contribution of the private sector cannot be discounted. It is necessary to rationalize service quality and cost of the private sector.

5.8. Accurate diagnosis of disease and the use of quality and rational drugs are substantially related to health care service delivery. For a number of reasons, there are noticeable weaknesses in these issues. Prudent monitoring and quality control is necessary to overcome the situation.

5.9. Drug addiction is a major health problem in urban areas. It is easy to work to restrict drug abuse but very challenging to control illicit trafficking. Proper avenues and opportunities should be explored to combat the drug abuse problem.

5.10. The Directorate General of Health Services has introduced a Health Management Information System. Linkage to this system should be established with all service provider agencies. City Corporations and municipalities should work to develop capacity to keep all health service information in their own areas.

5.11. There is a shortage of skilled health workers. Without skilled health workers, it is not possible to improve the health care situation. It is 16 necessary to establish more institutions to train health workers to meet the demand.

5.12. There are many organizations working for urban development, planning, and delivery of services. Some of these are providing services directly, others supporting environment for service delivery and undertake governance responsibilities. To all these organizations, there are reasonable public expectations. Coordination of activities among these organizations is necessary through a comprehensive urban policy, where good health for the urban people will receive priority.

5.13. According to the Rules of Business, the national level health care policy and strategy, technical guidance, etc. are the responsibilities of the Ministry of Health and Family Welfare. As local government bodies are working under Local Government Division, it plays a leading role for financing, supervising, and implementing health services provided by the local government institutions. To ensure the quality and usefulness of these services, there should be effective coordination between both Ministries.

5.14. Several NGOs have been delivering health care services satisfactorily in the urban areas; most of them depend on foreign donations. For their contributions, the health status of the urban poor has significantly improved. It is necessary to increase involvement of the NGOs to provide health care services and to facilitate coordination with Urban Local Bodies.

5.15. Under the Public Private Partnership model, it is necessary to establish and manage more health care centers. 6. Implementation of the National Urban Health Strategy

6.1. The National Urban Health Strategy shall be implemented through integrated efforts at different levels. The urban poor will be the main focus of urban health care and the system will be gender responsive.

6.2. The Urban Development Wing of the Local Government Division will coordinate the strategy centrally.

6.3. A high level coordination committee combined with the Ministry of Health and Family Welfare and the Local Government Division will be 17 supervising the implementation of the National Urban Health Strategy and will be taking necessary policy decisions in this respect.

6.4. Urban health service related issues would be highlighted in all urban development activities through coordination with other organizations/ departments involved in urban development. Different Ministries and Divisions will be encouraged to deliver health services in their own jurisdiction wherever possible.

6.5. Primary and public health services delivery on a permanent basis shall be ensured through increasing efficiency, manpower, and financial capacity of the city corporations and municipalities.

6.6. Cooperation will be extended to coordinate activities of similar services provided by private and non-government organizations.

6.7. Bilateral and multilateral international cooperation shall be encouraged for financial and technical support to foster urban health care services.

6.8. Alternative options for health financing, Public Private Partnership Model, health insurance and other innovative system shall be used. Large-scale industries and commercial enterprises shall be motivated to take initiative to provide health services to their employees under Corporate Social Responsibility.

6.9. A list of activities for implementation of the National Urban Health Strategy is attached in the Annexure. In the list, the strategic plan and implementation process against targeted goals are identified and highlighted. This strategy will be implemented through an Operational Plan to be developed shortly. Signed/- (Monzur Hossain) Senior Secretary Dhaka: November 2014 18 Annexure Implementation Process of the National Urban Health Strategy Actions Strategy Implementation Process Time-frame 1. Universal health coverage  Introduce free health card  Identify acceptable model by reviewing Continuous for urban population with a for the urban poor present situation pro-poor focus  Introduce health insurance  Give responsibilities to Local for employees work in Government Institutes in partnership offices and factories with NGOs for the poor  Introduce voluntary health  All public and private organizations insurance for others will take steps for health insurance for their employees 2. Strengthen preventive and  Coordination across cross -  Introduce management model by Local Continuous primary health care cutting sectors: safe water Government Division for primary management system supply, road and food health care, solid and medical waste safety, housing and management through Local environmental health for Government Institutes urban area  Delivery of primary health care service  Expand and strengthen by Ministry of Health and Family elements of Primary Health Welfare in the urban areas where 19 Actions Strategy Implementation Process Time-frame Care and attention to services not delivered by the Local emerging issues. Government Institutes and NGOs  Better organization and  Take long term human resource management of existing development plan for the Local urban health delivery Government Institutions infrastructure of Local  Similar plan for public and private Government Division, sector. Ministry of Health and Family Welfare, Urban  Mobilize resources locally by Local Local Bodies, private and Government Institutes and other NGO facilities service providers. Utilize corporate and charitable organizations.  Improve human resources for primary health care  Develop effective referral system by services delivery. Steps to Ministry of Health and Family Welfare remove weaknesses in among Local Government Institutes, urban family planning private organizations and NGOs using services, doctor, nurse, experiences of private organizations paramedics and  Strengthen social involvement of Local strengthening community Government Division and related health solution approach. NGOs and more intensive  Adopt a more inclusive monitoringby Local Government approach Institutes and Local Government Division  Give more attention to 20 Actions Strategy Implementation Process Time-frame curative care of non-  Adopt more inclusive approach by communicable diseases in Local Government bodies, Civil urban areas Society Organizations and NGOs to  Ensure working hours at include in the health service activities service centers to suit the for the people such as socially needs of the clients segregated classes, ageing population ,mentally retarded and physically disables/handicap, adolescent and others.  Strengthen health education on proper life style, dietary intake for all ages particularly for the aged people, mental health care, etc.  Determine suitable working hours for the service delivery centers under Local Government Institutes and NGO partnership or under only NGOs to meet needs of the clients urban poor, in particular 3. Reduce urban poverty  Ensure reduction of urban  To accelerate reduction of urban Continuous poverty poverty Local Government Division to establish greater linkages to Urban  Strengthen social safety Governance Infrastructure net program in urban areas 21 Actions Strategy Implementation Process Time-frame Improvement Project (UGIIP) and  Implement the concept to sanitation and sewerage related mitigate health problems to programs and projects reduce poverty  To accelerate reduction of urban  Strengthen integrated poverty similar actions by Local programs as a part of the Government Division to establish urban sector development linkages with ongoing and future policy by capturing the programs/ projects of other ministries synergies of preventive having a bearing on urban poverty. health care with greater focus on mother, child  Provision of urban poverty reduction care, adolescent and old steps in Urban Development Policy age groups.  Take measures in cities with higher  Establish greater linkages incidence of poverty and after to all existing urban reviewing Sixth Five Year Plan development related  Taking stock of all public agencies programs and projects with across different Ministries involved in a special focus on urban development programs and accelerated reduction of ensure coherence and consistency for urban poverty. gains in urban health outcomes 4. Achieve National  Give greater attention to  Directorate General Health Services 2016 Population Policy targets remove the mismatch of and Directorate General Family and supplies of needed Planning to attach more importance in materials in those urban demand and supply side management. Continuous 22 Actions Strategy Implementation Process Time-frame areas where population  Give more importance to urban areas growth rate is higher. where health service activity is weak.  Focus on partnerships with  Intensify supply of Family Planning NGOs for supply system materials at ward level through community workers in partnership with NGOs.  Increasing coverage of Family Planning services with more emphasis in urban slum.  Establish a good referral system  Map urban slums  Establish service centers for Long Acting and Permanent Method  Avoid overlapping of services in each slum 5. Achieve national nutrition  Integrated activities among  Health care for those affected by severe 2016 targets Local Government malnutrition and Institutes, private  Promote good and functional organizations and NGOs. continuous nutritional practices. 23 Actions Strategy Implementation Process Time-frame  Ensure intensive food safety measures  Intensify nutritional education using both traditional and modern methods with emphasis on food-based nutrition.  Ensure social safety for the urban poor.  Strengthen monitoring and evaluation including surveillance 6. Adopt innovative service  Local Government  Use computers and introduce referral 2016 delivery using modern Division’s steps as a part system in Primary Health Care Centers and technology, management of Vision 2021 with Local  Local Government Division to review policy and practices. Government Institutes and continuous the recruitment rules of Local NGOs to implement Government Institutes to empower Health, Population and them to meet personnel shortages in Nutrition Sector health and related units. development Program  Simplify operative procedure  More supportive role supported by decentralization. among Local Government Institutes  Adopt flexible management practices and operative system by the 24 Actions Strategy Implementation Process Time-frame NGOs 7. Improve institutional  Local Government  Local Government Division to review 2016 governance and capacity Division to establish and its interface with different bodies such and development strengthen its cooperation as central government agencies (e.g. with all relevant Ministries Urban Development Directorate, continuous and agencies such as National Housing Authority, Public Ministry of Environment Work Directorate under Ministry of and Forest, Works etc.) Specialized Authorities, Communications, National those responsible for water supply and Housing Authorities, sewerage, Dhaka Transport Ministry of Home Affairs, Coordination Board under Ministry of etc. to achieve desirable Communications and Development outcomes of urban health. Authority such as Rajdhani Unayyan Kortipokkho, Chittagong Development Authority, Khulna Development Authority and Rajshahi Development Authority since these bodies are responsible for urban development in order to ensure growth of healthy cities.  The existing level of coordination by Local Government Institutes with above agencies/ bodies be reviewed for more strengthening to obtain gains 25 Actions Strategy Implementation Process Time-frame of urban health 8. Strengthen health service  Appoint physicians, nurses  Local Government Division through 2016 program of the City and health workers by intensive collaboration with Ministry Corporations and Local Government of Health and Family Welfare will municipalities Division in all zone or Establish citizen’s health care centers wards of all city supplement to existing district and corporations and wards or Upazila based health system structure zone in case of  Besides existing structure of Ministry municipalities of Health and Family Welfare, will  Establish health care establish suitable health care center centers through ensuring through determining public demand Institutional capability 9. Financing and resource  Ensure separate budget  Local Government Division to take Continuous mobilization allocation for urban health priority action for separate budget to care increase partnership carry out Health, Population and among Local Government Nutrition activities from revenue part Institutes and continuity of the budget by making it a well- and NGOs argued case for consideration and approval by the Ministry of Finance  Mobilize local resources and/ or Planning Commission and side by side allocation from government to Local  Local Government Division to ensure Government Institutes for more allocation in all relevant areas health service delivery supportive of urban health. 26 Actions Strategy Implementation Process Time-frame  Local Government Division to develop procedures and guidelines to ensure  Explore the availability of transparency and financial probity in resources from private the use of funds without limiting the corporate bodies as part of flexibility of operations of Local their social responsibility Government Institutes and partner  Ensure more support from NGOs. development partners in  Similar action to strengthen short and medium term monitoring, evaluation and supervision  Ensure transparency and by Local Government Institutes accountability, monitoring,  Establish and strengthen urban health evaluation and supervision related management information  Strengthen Public Private system with linkage to HMIS of Partnership Directorate General of Health Services  Avail opportunities for  Review the existing Public Private more investment in urban Partnership framework; identify its health by NGOs and Urban strength, weakness, opportunities and Local Institutes threats to fully exploit the achievable  Examine feasibility to use gains for urban health. funds from Municipal  LGD to establish linkages with the Development Board NGO-Private Sector Unit proposed to be established by Ministry of Health and Family Welfare through its own 27 Actions Strategy Implementation Process Time-frame separate wing for HMIS.  Review and update proposals from interested NGOs/ Local Government Division for approval by Ministry of Finance for Public Private Partnership funding support.  Hold discussions with Municipal Development Board for obtaining funds based on their existing framework and procedures. 10. Sustainability  Ensure sustainability of  Apart from stable fund flow for 2016 urban health program sustainability, establish a permanent and based on Public Private structure for bi-annual consultations Partnership and other with partner NGOs, private sector and continuous programs health governance policy makers and think tanks for delivery of quality services in all areas connected with urban health. To reinforce through involving non-health sources who do not provide health services but related to the services.  Constitute an effective coordination committee with Ministry of Health and 28 Actions Strategy Implementation Process Time-frame Family Welfare, Local Government Division and other related ministries  Consolidate coordinating mechanism across ministries dealing with cross- cutting issues.  Decentralize greater authority  Build more effective alliances with the NGOs, private sector, businessmen and other relevant non-state actors  Build capacity at Local Government Division, NGOs, private sector and Local Government Institutes 29