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1 Online Open Access publishing platform for Management Research Copyright 2010 All rights reserved Integrated Publishing association Research Article ISSN Factors influencing health and healthcare delivery system for the urban poor in Chittagong city, Bangladesh Shamsun Nahar 1, M Maksudur Rahman 2 1. Lecturer, Department of Geography and Environmental Studies, University of Chittagong, Chittagong-4331, Bangladesh 2. Associate Professor, Department of Geography and Environment, University of Dhaka, Dhaka-1000, Bangladesh dibageocu@yahoo.com ABSTRACT One-third of the urban dwellers in Chittagong city live in congested and unplanned slums and squatter settlements without having the basic urban facilities. The health conditions of the urban poor are extremely unsatisfactory. Also they suffer from many difficulties to receive healthcare facilities. The aim of this paper is to find out the conditions of health and healthcare delivery system in the urban poor areas in Chittagong, the second largest city of Bangladesh. Data required for this study were collected through questioner survey, observation and secondary sources. From the analysis it has been found that urban poor are suffering from various types of diseases and health complexity such as cough, fever, respiratory illness and malnutrition etc, due to water shortage, poor sanitation, and inadequate gas supply. The research findings suggest that they receive a poor medical service; mostly depending on local dispensary for their immediate treatment. It is very risky for their sound health because without the prescription of a qualified physician, it would be turned into hazardous situation in any time. Removing the sufferings of the poor concerned authorities must be ensured an appropriate health care delivery system by creating awareness among the urban poor. Keywords: Urban Poor, Healthcare Delivery System, Slums and Squatter Settlements, Chittagong city 1. Introduction Undoubtedly health is perceived as a burning issue in the city area of Chittagong. It is widely believed by unanimity that a sound economy mainly depends on sound health and healthcare delivery systems. Unfortunately it is a matter of great regret that a lion s share of population in Chittagong area is far away from the minimum amenities of healthcare delivery systems. Moreover, it is not only lack of healthcare facilities but also lack of consciousness as well as the social prejudices towards the healthcare systems. Prominently poor income is also equally responsible for most of the health hazards. This paper examines the present condition of health and healthcare delivery system especially to find out different patterns of diseases, examines the environmental factors which create various types of diseases and coping strategies for the urban poor people in Chittagong city. The health condition is extremely poor and hazardous especially slum and squatter dwellers. Gigantic population and squalid environments with little or lack of essential health consciousness, sanitary and pure drinking water facilities breed a host of communicable and non-communicable diseases in urban slum 288

2 and squatters settlements. At any time, 30 to 40 percent of the population in urban poor communities suffers from diseases (Khan, 1998). Children and women are more vulnerable than other. The major diseases affecting the urban poor particularly are diarrhea, respiratory tract infections, scabies, fever, typhoid, malaria, whooping cough, skin diseases and various types of eye diseases. Most of the diseases are related to environmental conditions, particularly to air and water pollution. However, the healthcare facilities in urban poor locality are poor provided both by the public and private sectors. Most other common scenario of public services, healthcare facilities are not readily available in the slums, especially those situated on public land. Private healthcare facilities have improved but these are almost beyond the capacity of poor people.).most of the poor people of urban areas suffer difficulties due to inadequate healthcare facilities. The poor, in spite of their lack of formal education and economic insecurity, they are failure to demonstrate preference for the modern system of health and so they are usually unable to afford the improved health facilities. In most the people of slum dwellers health problems are the result of malnutrition and dirty living conditions. Moreover, they suffer from frequent disease due to their unhygienic living condition and low level of knowledge on health sector. Besides, maximum urban poor people usually used to take medical prescriptions from local dispensaries due to lack of minimum awareness on health and health related issues which in the long run escalate their health hazards. Chittagong is the second largest city, major port and also referred to as the commercial capital of Bangladesh. It covers an area of177 Sq. km. (CUS et al, 2005) with a population of about five million. The city has an estimated 210 Slums where almost one million people live. The slum population of Chittagong City is about that cover 21.7% of total land area of the city (CUS et al, 2005).Chittagong is now experiencing a period of cramped population growth, and slum dwellers are mainly responsible for this high growth rate. More people are adding with this population growth is caused by the rapid influx of rural migrants, and natural increase to slum areas, where appalling living conditions, poor health, malnutrition and poverty are rife. The slum population mostly lives below the poverty line in terms of both calorie intake and the cost of basic needs. In Chittagong City, diseases are galloping day by day. In 1998, 358 families suffer from dysentery, 305 families suffer from diarrhea, 60 families suffer from malaria, 63 families suffer from typhoid, 27 families suffer from jaundice, 98 families suffer from asthma and 13 families suffer from pox (BBS, 2005). 2. Aim and objectives This paper highlights the conditions of health and healthcare delivery system in the urban poor areas of Chittagong City. The specific objectives are 1. To find out the conditions of health and healthcare delivery system and different patterns of diseases in the urban poor areas of Chittagong 2. To examine the environmental factors which create various types of diseases in the urban poor 3. To understand the coping strategies and to propose some recommendations to improve the health and healthcare delivery system for the urban poor in Chittagong City. 289

3 3. Methodology The present research was done mainly based on primary data collection, includes pilot survey, close observation and quantitative data collection. Primary data were collected following data collection tools i.e. questionnaire survey (sample size120) of the head of the household level. A pilot survey was conducted before finalizing the questionnaire.the household head has been taken as respondent. In some cases, the household head was not available during the survey. At that time the home maker of that family was taken as respondent. A close observation was followed during the primary field investigation to know actual scenario of the overall environment and way of life of slum dwellers which may influence health of the urban poor. Secondary data have been gathered from different organization. On the other hand, secondary data such as internet, magazine, books, journals, newspapers and unpublished and published reports were also used. Taking photo graph of the important sights was an important support to write the text. 4. Survey results and discussions 4.1 Demographic and socio-economic profile of the study area Age of the head was considered as a very important demographic variable. With heads grouped in intervals of 5 years, of the total study households about 30% were between years and 24% between years of age. It was due to choice of the adult persons who are the head of the household. In the household survey, it was found that more than half of the respondents are female (55%) and 45% are male. It is mentionable that on data collection time housewives were more available in households than husbands who normally treated as household head in our society. The female respondents highly participated both from Amin Coloy, Motijharn in the household survey. Income level of the residents is a major indicator to determine their ability of receiving services. Monthly income of the head of household is directly related to healthcare utilization, and it may be an important factor in deciding whether to use a service. This survey found that more than half of this household can a poor amount (up to TK. 6000) of monthly income. This poor monthly income indicates a poor budget for health care expenses. According to household survey, it is found that educational status of the respondent varies within the study areas. By analyzing the educational status of the respondents it was found that, 46% respondents are primary educated and second largest level is illiterate. It is another important indication of poor public health status because sometimes the urban poor are the worst sufferer due to lack of knowledge about the health and hygiene. Occupational status of the respondents reflects their socio-decision making process of healthcare delivery system. Occupation also has significant impact on the incidences of malnutrition and health in general (Barooah, 1999; Shulka et al., 1991).. The 11.6% of only the respondents were found to be doing a small business. There are 42.5% of the respondents are day labor and 20% service etc. Some of them are engaged in various types of job. It was found that the slum people are mainly the migrants from different parts of the country. Family structures of the respondents are not actually small. Average family size is consisting of five members. From the survey it was found that, 72% families have 3-6 members, and about 5% have 3 members. The majority of the respondents house tenure systems are renter (65%) and (29%) said that they are the owners of their residence. 290

4 Figure 1 : Location map of the study area 4.2 Local environmental problems facing the urban poor in Chittagong city Environmental problem has become a major health concern for the urban dwellers. It can be said that, most of the diseases are related to environmental conditions particularly due to air and water pollution, solid waste mismanagement, using garments wastes as fuel for cooking, sanitation problems etc. The health implications of deficient access to water and sanitation are well known. It is estimated that, water shortages account for approximately 12 millions deaths annually throughout the less-developed world. Every year, more than a billion people contract water related diseases and nearly half the urban population in Africa, Asia, and Latin America suffer from one or more diseases associated with inadequate water and sanitation (WHO, 2003). A series of public or publicly organized and mandated private measures against social distress and economic loss caused by the reduction of productivity, stoppage or reduction of earnings or the cost of necessary treatment that can result from ill health. Ill health is a major cause and consequence of poverty. 291

5 Table 1: Household environment problems facing the urban poor in Chittagong City Problems Percentages (n=120) Water shortage Sanitation problems 70.8 Using garment jute, as a fuel for cooking 57.7 Inadequate Gas supply 53.0 Poor ventilation 35.0 Electricity crisis 26.6 Source: Field survey, 2009 Note: Multiple answers are considered Water crisis is the day after day problem of the poor in Chittagong City. They have to pass their life through serious water crisis. The slum dwellers face innumerable problems for water crisis. From the study, it has been found that 84.1% respondents face water problems into the household level. Dwellers have no any good management of clean-drinking water. They have to collect necessary drinking water from the deep tube-wells. It is to be noted that the WASA is not providing water supply to the poor. But the condition is different at Matijharna. Here the people collect water mainly from the stand point, supply of WASA. But dwellers have been suffering from water problems due to limited standpoints with acute water shortage in this area. Water-borne diseases like diarrhea and dysentery are regular phenomena in cities. In Amin colony the poor collect water from the Amin Jute Mill; however the supplied water is not available for all the dwellers. The employee can collect water from this Mill, thus many dwellers have to depend on other sources of water which may not be reliable. The sanitation condition found very poor in the surveyed areas, as 70% of respondents had sanitation problems. Sanitation problem is a threat to the health of the urban dwellers particularly to the poor and to the overall urban environment. Living with poor sanitation ultimately causes various diseases such as, epidemics like diarrhea, cholera, skin diseases etc. The World Health organization estimates that worldwide 2.4 billion people lack access to improved sanitation (WHO and UNICEF 2000). According to household survey 57.7% of respondents claimed that they have no gas facilities for cooking. Alternatively, they have to use garments jute as cooking fuel at indoor causing serious air pollution. As poor ventilation is severe problem of slum housing, the dust from biomass fuel may hang for a long time inside house can causes many diseases like asthma, cough, bronchitis etc. The household survey 83% respondents mentioned the problem of solid waste mismanagement, a serious health hazard for the locality, confronting urban government in developing countries like Bangladesh (Rao, 1998). Inadequate collection and disposal of solid waste can create environmental degradation which can cause the spread of vector-borne diseases like typhoid, diarrhea, dengue, skin diseases, fever, asthma etc. 4.3 Diseases pattern of urban poor in Chittagong City According to the household survey, it is found that maximum urban poor suffer from fever, cough and cold, respiratory illness, headache, skin disease, high blood pressure, etc. Within these disease cough and cold, respiratory illness, headache, skin diseases are highly related and caused by the local environment 292

6 Table 2: Diseases pattern of the urban poor in Chittagong Disease pattern Percentage (n=120) Fever 55.0 Cough and cold 53.3 Gastric 26.6 Respiratory illness 22.5 Headache 20.8 Skin disease 16.7 High blood pressure 16.6 Jaundice 8.33 Source: Field survey 2009 Note: Multiple answers are considered In Bangladesh most of the peoples are attacked by fever - a very common health problem- in different times of the year. It has seen that in the last three months prior to the survey conducted the adults are the worst sufferer of the fever. But the survey revealed that the majority of the adult and young suffers from cough and cold. The most important factor burning biomass fuel, which pollute the indoor environment can cause cough. It is noticeable that, female are the worst sufferer of cough, because they are mainly involved in cooking, as seen in Amin Colony where 82.8% of respondents claimed they were suffering from severe indoor pollution. On the other hand, in Motijharna area, most of the respondents indicate that outdoor air pollution is the major cause of cough. Air is polluted through the emission of smoke by various vehicles as identified by the respondents to be a major cause of outdoor air pollution. From the study it has been found that, young and economically active people were suffering from severe respiratory problems, (33%) of female and 26% of male adult suffering from respiratory illness. Also many respondents said the other main cause of respiratory illness of this area is indoor air pollution due to alternative using of garments jute as a fuel for cooking. Table 3: Respondents suffering from malnutrition in Chittagong (% of sample) Family Members Male Female Family Members Male Female (during the Yes (%) Yes (%) (last three months Yes (%) Yes (%) survey) prior to the survey ) Child 0 11 Child 5 19 Young Young Adult Adult Old 8 3 Old 7 7 Source: Field survey, 2009 Malnutrition, a very common disease among the poor in the country like Bangladesh, is likely to be influenced by poverty. Some environmental determinates, as for example, unhygienic latrine, parasite infection, poor personal hygiene due to impoverish housing facilities, unsafe water etc, are responsible for poor utilization of nutrients in the body which in turn cause malnutrition problem among population (Karim et al. 2002). A study showed that 94% of children below the age of five in Bangladesh suffer from some degree of malnutrition. From the field survey it was found that 46% of adult people suffering malnutrition. Young are also affected by this problem; among them 20% of male and 11% of female are suffering from the malnutrition. Nineteen percent of the country s population lives in hard core poverty, defined 293

7 as subsistence on less than 1805 Kcal a day. Female are worst sufferer of this problem. In this study 26% of female and 20% of male have been suffering from malnutrition for the last three months prior to the survey conducted. The overall scenario is very painful in Bangladesh since ICDDR,B found as many as 70% of mothers and children suffer from malnutrition (ICDDRB, 2008).The major cause of this malnutrition in Bangladesh is multiple including unemployment, poverty and inflation of food price. The fact remains that roughly half of its 126 million citizens live in deprivation, while roughly half of all children under 6 years show some evidence of chronic malnutrition (World Bank, 2003).The overwhelming majority of the populations are unable to afford adequate quantity and quality of food. Children suffer the most from malnutrition 44.2 percent of all urban children suffer from stunting or chronic malnutrition about 6.9 percent suffer from acute malnutrition (Khan, 1990). Pregnant women, mothers and their children are at particular risk of poor health and nutrition, and evidence suggests that maternal ill-health and malnutrition is a crucial factor in the transmission of poverty across generations (Begum and Sen., 2005). Table 4: Respondents suffering from cough and cold in the surveyed areas of Chittagong (% of sample) Male Female Family Members Male Female Family Members Yes (%) Yes (%) (last three months Yes (%) Yes (%) (during the survey) prior to the survey ) Child Child 6 16 Young Young Adult Adult Old Old 8 5 Source: Field survey, 2009 Note: Multiple answers are considered 4.3 Satisfaction level with local dispensaries and public hospital Maximum respondents (66.7%) of the urban poor areas where the household survey done take treatment from the local medicine shop (Table 5). The fact is that they tend to expend money for food and housing and do not get proper education for which they are not conscious of their health. Some of the poor receive healthcare from the City Corporation Hospitals and Chittagong Medical College Hospital with no charge, despite the fact that this opportunity is very limited. The respondents also claimed that from the public hospital most of them do not get proper medicine and healthcare facilities. Table 5: Reasons for taking such treatment Type of medical treatment taken Reasons Percentage Local dispensaries Low monthly income and ignorance about health 66.7 Private Better treatment 18.5 Public Better treatment and less expensive 14.8 Total Source: Field survey,

8 The poor always suffer from many disease but they are unable to take modern and expensive medical treatment. The major reasons for which the poor taking health care facilities from dispensaries are: Economic condition of the poor is not good, health service is not available, lack of awareness of health issues and the local dispensaries are located in reasonable distance. The treatments of private hospitals are highly expensive which the poor cannot bear. This situation impels the poor to take medical treatment from private hospitals and clinics. 5. Conclusion Chittagong is the second largest and rapidly growing city in Bangladesh. Urban poor are suffering various types of health related difficulties, which can be very brutal to their lives. The congestion of living spaces, unhealthy environment and lack of health services are the prerequisite of health problems. Health is one of the basic needs of human being. But the health care facilities in urban poor locally are poor provided both by the public and private sectors. Private facilities have improved but these are costly. So, poor people of urban areas suffer difficulties to receive health care facilities. According to household survey, it was found that urban poor like to take treatment facilities from the local dispensaries than from other sources. The main reason is that the local dispensaries are available and the treatment is of low cost. On the other hand, public hospitals are not available. They suffer from many diseases such as fever, cough and cold, asthma and malnutrition which are caused by various reasons. Environmental problems such as indoor and outdoor air pollutions causes of fever, cough and respiratory illness..the research findings suggest that as they receive their medical aid from by near by dispensary, it is very risky for their sound health because without the description of a qualified doctor may cause hazardous situation to the poor any time. The results of this study indicate that a joint effort both by the governmental, non governmental and private organizations can solve the health care delivery problems for the urban poor in Chittagong city. Both poverty reduction and sound awareness programs needed to be extended in the urban poor areas by enhancing urban amenities and infrastructure facilities for the development of locals. 6. References 1. Ali, M. M. (2001), Malnutrition: Problems and Solution, Observer Magazine, Friday, May, 4, p Azad, T. M. A and Batan, M. A. (2012), Healthcare in Urban Slums: do we care, The Daily Star, Dhaka, November 24, Begum, S. and Sen, B. (2005), Pulling rickshaws in the city of Dhaka: a way out of poverty? Environment and urbanization, 17(2), pp Banglapedia, (2001), National Encyclopedia of Bangladesh, Asiatic society of Bangladesh, Dhaka. 5. Borooah,V. K. (1999), Occupation Class and the Probability of Long-term Limiting Illness,Social science and Medicine, 49, pp BBS (2005), Preliminary Report on Bangladesh Population Center, Dhaka: Government of Bangladesh. 295

9 7. Centre for Urban Studies (CUS) measures, evaluation and national institute of Population and Training (NIPORT) (2006), Slums of Urban Population, mapping and census, Islam N. (1996), Dhaka: From City to Mega city, Dhaka: Urban Studies Programme, Department of Geography, University of Dhaka. 9. ILO Social Health protection: An ILO towards universal access to health care Ministry of Health and Family Welfare, Government of Bangladesh, 2008 Bangladesh Health Workforce Strategy, Khan, A.U. 1990, Health Sector Report, in Urban Poor in Bangladesh, Center for Urban Studies, Dhaka. 12. NRDC: The United Nations World Summit on Sustainable Development Safe Water and Sanitation for the Developing World. 13. Nath, D.k. (2010), Health matters, The Daily Star, Dhaka, May19, NIPORT, MEASURE Evaluation ICDDR, B& ACPR, 2006 Bangladesh Urban Health Survey, Shukla, A., Kumar, S. and Ory, F.G.(1991), Occupational Health and the Environment in and Urban Slum in India, Social Science and Medicine, 33(3), pp UN-Habital (2003), water and sanitation in the world s Cities: Local Actions for Global Goals, Earthscan, London. 17. UN-HABITAL (2007), Press Release on its Report, The Challenges of Slums: Global Report on Human Settlements World Health Organization Programme for Control of Diarrheal Diseases. Sixth Programme Report , Geneva: World Health Organization, 1988 (WHO/ CDD/ 88.28). 19. WHO (2000), Water and Sanitation Country Profile: Senegal, Water and sanitation sector assessment. Part 11, Regional office for Africa, WHO, Brazzaville available at country profiles / Senegal. Pdf, accessed 12 March,