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 6/4/2015 1 Factors affecting preference for ed ucation and health services in slum areas in Bangladesh Md. RabiulHaque Dept of Population Sciences (DPS) University of Dhaka (DU) Urban Population in Bangladesh  With a population of over 150 million, Bangladesh is one of the few developing countries that has been experiencing rapid urbanization process primarily due to massive migration from rural areas of middle and lower-income societies to the urban areas.  About 1 in 4 per sons live in urban areas (Census 2001). Urban pop ulation as a per cen tag e of tota l pop ulation increased fro m around 8.21% to nearly 23.3 % during 1974-2011 periods.  The urban population recorded during the 2001 Census was nearly 28.6 million and is currently (2010) estimated at 40 million (GoB, 2012) 2

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  • 6/4/2015

    1

    Factors affecting preference for education and health services in slum areas in Bangladesh

    Md. Rabiul HaqueDept of Population Sciences (DPS)

    University of Dhaka (DU)

    Urban Population in Bangladesh

    With a population of over 150 million, Bangladesh is one of the fewdeveloping countries that has been experiencing rapid urbanizationprocess primarily due to massive migration from rural areas ofmiddle and lower-income societies to the urban areas.

    About 1 in 4 per sons live in urban areas (Census 2001). Urbanpopulation as a percentage of total population increased fromaround 8.21% to nearly 23.3 % during 1974-2011 periods.

    The urban population recorded during the 2001 Census was nearly28.6 million and is currently (2010) estimated at 40 million (GoB,2012)2

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    Rural-Urban population in Bangladesh

    3

    Growth of Urban Population (in Million) in Bangladesh1974 1981 1991 2001 2011

    n % n % n % n % n %Urban 6.27 8.21 13.23 15.18 20.87 19.63 28.61 23.10 33.55 23.30

    Rural 70.12 91.79 73.89 84.82 85.44 80.27 95.25 76.90 116.49 77.70

    Total 76.40 100.0 87.12 100.0 106.32 100.0 123.85 100.0 150.04 100.0

    Bangladesh Bureau of Statistics

    The growth of urban population is expected to increase over the next few decades (UNPD 2014) mainly due to internal migration

    Projected rural-urban population

    Urban population will grow from its current level of 53 millionpeople to 79.5 million in 2028, an increase of 50% in 14 years. Frombeing a largely rural country now (66.5% lives in rural areas in2014), Bangladesh will be an urban country in 2039 when themajority of people will live in urban areas.

    After migration, most of these migrants possessing low human andfinancial condition generally settle in slums, the areas prone tointense poverty and environmental vulnerability.

    One quarter of the population lives in urban areas, where populationdensity is 200 times greater than the national figure.4

    theurban

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    Rural-Urban Populations in Bangladesh: 1950-2050

    5 UNPD 2014 in UHS, 2013

    Urban internal migration, 2005-2011

    6

    Urban internal migration rate, 2005-2011

    2005 2006 2007 2008 2009 2010 2011

    Rural to Urban 20.3 21.9 23.7 17.3 21.9 24.5 23.7

    Urban to Urban 43.5 38.2 41.1 34.4 28.3 8.9 42.5

    By year 2021 nearly 33% of the population of Bangladesh will be livingin urban areas. Of which, one third will be due to natural increase, andtwo thirds due to internal migration from rural areas.

    SVRS

    , 201

    1

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    % of urban population living in slums: 1990-2009

    7 UNPD, 2012

    Population Density : Slum Area and Overall City

    8

    Population Density : Slum Area and Overall CityCity Persons per acre Persons per square-km

    Slum Area City Total Slum Area City Total

    Dhaka 891 121 220246 29857Chittagong 1032 94 255100 23299Khulna 538 82 132988 20346Rajshahi 272 39 67236 9544Sylhet 626 52 154741 12961Barisal 541 29 133730 7152All cities 831 95 205415 23378

    Source: CUS, MEASURE Evaluation, NIPORT, 2006

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    Living space per person

    9

    The median living space per person is much smaller in slums, 48 sq feet, comparedto 120 and 110 sq feet in non-slums and other urban areas, respectively. In slums, 3out of 4 households live in only one room. In comparison, 3 out of 10 householdslive in one room in non-slum and other urban areas. The median living space perperson in slum households increased from 36 sq feet in 2006 to 48 sq feet in 2013.

    Household population by age, sex, and domain, 2013

    10 The population in slums is younger than in non-slums; 44% in slums are aged under 20 years compared to 40% in non-slums and other urban areas.

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    Major Districts of Origin of the Slum Dwellers by City

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    Major Districts of Origin of the Slum Dwellers by CityDhaka Chittagong Sylhet Rajshahi Khulna Barisal

    Dist

    ricts

    of O

    rigin

    of t

    he S

    lum

    Dwe

    llers Barisal

    (23%)Chittagong(20%)

    Mymensingh(16%)

    Rajshahi(70%)

    Barisal (36%) Barisal (65%)

    Faridpur(9%)

    Comilla(19%)

    Sunamganj(14%)

    Bagerhat (18%)

    Comilla (9%) Noakhali(15%)

    Comilla(11%)

    Faridpur (17%)

    Mymensingh(7%)

    Rangpur(10%)

    Rangpur(5%)

    Hobiganj(10%)

    Total 53% 54% 59% 70% 70% 65%Source: CUS, MEASURE Evaluation, NIPORT, 2006

    Place of births of slum dwellers by sex and division, 2013

    12

    A third of the female slumpopulation was born in thesame city as their currentresidence.A fifth of women currentlyresiding in City Corporationslums were born in DhakaDivisionOver a third of males inslums were born in thesame city as their currentresidence

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    Prior residence of slum dwellers in Dhaka

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    Prior residence of slum dwellers in Chittagong

    14

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    City corporation slum, and non-slum population by wealth quintiles, UHS 2006 and 2013

    15 HS, 2013

    3 out of 4 slum households are inthe lowest two wealth quintilescompared with 1 in 5 in non-slumareas.Almost 60% of non-slumhouseholds are in the two richestwealth quintiles compared with7% in slums.In slums, a larger proportion ofhouseholds are poorer in 2013than in 2006.

    Education and health situation in urban slums

    16

    Education is a vital requirement for combating poverty,empowering women, protecting children from hazardous andexploitative labor and sexual exploitation, promoting humanrights, protecting the environment, and influencing populationgrowth.

    Mainly, poverty among the slum dwellers stanches inadequateaccess to education and reproductive health services.

    Lack of awareness and insufficient support for schoolingresulted in very low level of literacy among the slum dwellers

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    Overall Educational situation in urban areas

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    Overall Educational situation in urban areasIndicators Municipality City corporation SlumPre-school attendance rate 25.0 27.3 13.0Primary school net intakerate

    73.6 78.1 51.4

    Net attendance rate inprimary school

    84.2 84.3 65.1

    Net attendance rate insecondary school

    54.1 53.4 18.4

    MICS, 2009

    The overall educational situation in urban slums is not considerably satisfactory

    Educational attainment of slum population by survey year: Female

    18

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    Educational attainment of slum population by survey year: Male

    19

    Slum population: Access to safe drinking water

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    Proportion of sources of drinking water in slum areas

    Source of drinking water UHS 2006 UHS 2013

    Piped inside/outside dwelling 60.0 59.3

    Tube-well inside/outside dwelling 39.5 39.7

    Pond/river/stream/rainwater/other 0.5 1.0UHS 2006, 2013

    No visible change observed between two time period

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    Slum population: Access to improved sanitation

    21

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    Slum population: principal method of garbage disposal

    Almost half of slumhouseholds dispose ofgarbage in an open space.

    Collection of garbagefrom home or disposed inbin outside homeincreased in slums from38.7% to 47.9%

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    Total fertility rate

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    Trends in teenage pregnancy

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    Contraceptive use among currently married women age 15-49

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    Trend in utilization of ANC by type of provider

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    Trend in use of health facility for delivery

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    Facility delivery is highestamong women living innon-slums (65%) andlowest in slums (37%).Home delivery is the mostcommon among women inslums and other urbanareas while privatefacility is the mostcommonly used place ofdelivery by women in non-slums.

    Delivery by medically trained provider by place of delivery

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    Medically trained birth attendants

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    Use of medically trained providers hasincreased.Delivery by medically trained providersin slums doubled between 2006 and2013.Yet differences exist between slumsand non-slums, births among non-slumwomen is 1.8 times more likely to beassisted by a medically trainedprovider compared to births amongslum women.

    PNC for women and newborn from amedically trained provider by 2days of delivery

    30

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    Trend in childhood mortality rate in City Corporation slums

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    Care seeking for childhood ARI from trained facilities/persons

    32

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    Trend in nutritional status of under-five children

    33

    Contraceptive prevalence rate (CPR)

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    HPNSDP aims to reach a CPR of 72% by2016. Couples in slums are closest tothis level with a CPR of 69.6% in 2013.Over the last 7 years, CPR increased by12% points in slums compared with 2%points in non-slums.

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    Total Fertility Rate

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    HPNSDP aims to reach TFR of 2.0 by 2016 has already been reached. The difference in TFR between slum and non-slum has narrowed from 0.6 birth in 2006 to 0.3 birth in 2013

    Number of ANC 4+ visits

    36

    HPNSDP targets to achievecoverage of ANC 4+ visits of 50%by 2016. This target has beensurpassed in non-slums only (58%)but 29% only in slum areas.ANC 4+ is 2 times higher in non-slumscompared to women in slums.The absolute difference in seekingANC 4+ between slums and non-slums is 29% points.

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    Use of medically trained provider at delivery

    37

    HPNSDP aims to achieve skilledbirth attendance rate of 50% by2016.This target has been surpassed innon-slum and other urban areasbut in slum areas.Non-slum women are 1.8 timesmore likely to be assisted by amedically trained providercompared to births among slumwomen. Absolute difference is 31percentage points

    Trend in stunting of under five children

    38

    HPNSDP targets to reduceprevalence of stunting amongyoung children to 38% by 2016.

    This target has been achieved innon-slum (33%) and other urbanareas (37%).

    In slums, stunting is still as highas 50% in 2013.

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    PNC for newborns, UHS 2006 and 2013

    39

    HPNSDP aims to achieve50% PNC for newborns by2016 from a medicallytrained provider. In 2013,both non-slums (49%) andother urban areas (45%)are close to reaching thistarget.Slums are lagging behind inapproaching this PNC levelwith a rate of 27% in 2013.

    Availability of health services within 1 km

    40

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    Employment, Women, 2013

    41Women in slums are more likely to work full time than women in non-slum and

    other urban domains. 1 in 3 women in slums was in employment compared with 1 in 6 in non-slum areas

    Reasons to migration of slum dwellers

    42

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    Key Challenges

    Rapid growing urban population: The rapid growth of urbanizationhas adverse socio-economic and environmental consequences,especially in slum areas. We need to turn these human resourcesfrom burden to asset. Urban slum populations are the integral butunderprivileged parts of urban population, without which thedevelopment will not sustain. Thus, preference of education andhealth services for these urban slum populations are inevitable.

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    Key Challenges---

    Hidden contribution to GDP by urban slum population: The growth ofmodernized industries and export oriented services attracted therural people to migrate into urban cities. Rapid improvement inRMG sector triggered the establishment of such factories in urbanareas. A majority of the workers of these industries live in theurban slums contributing to national development. But, poorlivelihood, infrastructural shortcomings, poor governance of urbanslums could not manage to make this contribution sustainable.

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    Key Challenges---

    Poverty induced labor force participation: The push and pull factorsof rural to urban migration results in establishment of slumsettlements. The slum dwellers participation in labor force makesthem a crucial partner of urban development. Around 75% of maleslum dwellers from DMA are participating in income generatingactivities while around 34% of women from that area do the same(UHS 2006). This higher proportion of male participation wasconsistent across the different city corporations.

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    Key challenges---

    Higher drop-out rate in slum areas:The education situation in slumarea are not convincing due tohigher drop-out rate. Itindicates the necessity ofadequate and properintervention of education inslum areas which will eventuallycontribute to the overall humandevelopment of the nation.

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    Vulnerable health situation in slum areas: The health situation in slum areas isnot convincing in terms of service utilization and hazardous for the dwellers.The over populated, dense and squalid environment of the slum areas breedboth communicable and non-communicable diseases. Moreover, the RH: FP-MCHservices to women are not available. Maternity hospitals and female wardsespecially for urban poor women are inadequate in the urban areas. The poorparticularly find access to the service difficult. Private medical facilities haveimproved in large cities, but these are only for the well to do. Even thoughseveral GO, NGO and INGO initiatives are implemented to improve the heathsituation in slum areas; the sustainable development is still far reached.

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    Key Challenges---

    Barriers for poor education and health

    Poverty induced labor force participation at early age

    Poor living and environmental condition in slum settlements

    Wealth status Migration status Mothers education Frail access to basic services Threats of extortion and exploitation 48

    Lack of permanent job and security High rate of mobility Unrecognized slums Uncertain daily wages Traditional practices Low social capital Lack of recognition of their

    contribution in development

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    HPNSDP (2011-2016) identified priority intervention for urban health services include:

    Developing an urban health strategy with time bound action plan in collaborationwith MOLGRDC. The focal person for urban health in MOHFW will take theinitiative for formulating the strategy in consultation with relevant stakeholders.

    Commissioning a study to determine how the two Ministries can jointly assess, map,coordinate, plan and work together to provide quality HPN services for theurban population.

    Establishing a permanent institutional arrangement and governance mechanismincorporating relevant ministries, agencies and institutions with responsibilityto urban health.

    Expanding/upgrading urban dispensaries for effective and quality PHC services(including reproductive health, nutrition and health education services).49

    Defining an adequate referral system between the various urban dispensariesand the second and third level hospitals, and exploring feasibility ofintroducing General Physician (GP) system

    Developing and utilizing urban HIS for effective management of urban health careBuilding capacity of the various service providers under MOHFW and MOLGRDCDetermining the role and accountability of different NGOs and the private sector

    in the delivery of urban health. Formalizing relationships through PPPs andthrough diversification of health service delivery strategies

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    HPNSDP (2011-2016) identified priority intervention for urban health services include ---

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    National Urban Sector policy 2011 recommendations

    Urban poverty and slum improvement The need for improvement of slums Resettlement of slum dwellers Ensuring tenure security Special zones for the urban poor Access to infrastructure services Supporting informal sector activities

    Urban Heath and Education Ensure implementation of universal free and compulsory education at primary

    level and free secondary education for girls Promote hierarchical structure of educational institutions51

    National Urban Sector policy 2011 recommendations---

    Make provision for specific educational zones/ areas for secondary andtertiary education in urban plans

    Dedicated arrangement for primary, non-formal and vocational education with special programs for women

    Provision of free primary healthcare for the underserved population with emphasis to the special health needs of women and children

    Designate zones/areas for clinics, hospitals and health sector related infrastructure at appropriate locations by hierarchy of services and ban establishment of large units of such services within residential areas

    Organize advocacy for urban social services approach for healthy urban development

    Organize awareness and advocacy programs for education expansion52

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    Conclusion and recommendations

    53

    Recognize the importance of addressing the right of the people from urban slums. Creating awareness regarding the necessity of education and appropriate behaviors

    of reproductive health, family planning and child health in slum areas throughintervention

    Strengthening and expanding existing interventions regarding education and healthservices in slum areas

    Establishing effective linkage between slum community and health facilities forreferral in case of reproductive health related complications

    Establishing housing for poor and slum improvement in order to eradicate the risk ofeviction of slum dwellers without proper rehabilitation or relocation.

    Provision of free selected health care services for women and children. Patronizing urban research in order to focus on planned urbanization.

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    ThankYou

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    Authors Mohammad Bellal Hossain Md Rabiul Haque Md Kamrul IslamAssistMohammad Sazzad Hossain

    55