Primary / Reproductive Health Services in Asian Urban Areas with
Attention to Vulnerable Populations,
Especially Women and Girls
Two - Nine AUICK Associate City (AAC) Reports
Historical Background of
Health (RH) in Chittagong City
Introduction to Study
Objectives of the Study
Objective RH Services Data
Private Secretary to the Honorable Mayor, Chittagong City Corporation
(Participant of First 2010 Workshop)
Medical Officer, Health Department, Chittagong City
Chairman, Department of Computer Science and Engineering, Premier
to the outline of the AUICK Research Project, the work team has
conducted interviews with the Mayor of Chittagong City Corporation, Mr.
Mohammad Manjur Alam, Panel Mayor-1 Mr. Mohammad Hossain, Panel Mayor-2
Mrs. Jubaira Nargis Khan, Panel Mayor-3 Mr. Chowdhury Hasan Mahmood
Hasnee, Chief Health Officer Mr. Salim Akhter Chowdhury, the Deputy
Director (Family Planning), Director (Health), Civil Surgeon,
(Chittagong), health officers and family planning workers. At the same
time, interviews were conducted with reproductive health workers,
nurses, and health assistants of health care centers.
Background of Reproductive
Health (RH) in Chittagong City
is the second largest city, major port and also referred to as the
commercial capital of Bangladesh. It covers an area of 158 sq. km with
a population of about five million. It is located near the Bay of
Bengal, skirting along the river Karnaphuli and consisting of small
undulating hills and valleys. The city presents an interesting
landscape, quite distinct from all other big towns in the country. It
is divided into 41 wards. Being a port city from its early time, its
natural beauty, geographical location, cultural heritage and
hospitality of the people attracted foreigners and investors for many
years. The city began as a tiny municipality in 1863 and it was renamed
as Chittagong City Corporation in 1990. Now Chittagong City is
experiencing rapid urban growth, along with congestion.
city has an estimated 210 “Slums” where almost one
million people live. In the early 1970s, the majority of the city
population faced serious health problems like diarrhea, acute
respiratory infection, malnutrition, inadequate sanitation facilities,
overcrowding, and poor housing. Reproductive health services,
population control, family planning, use of contraceptives, data on
exact age, births, marriages, and immunization and other health related
vital activities suffered due to illiteracy of the people and lack of
proper knowledge of reproductive health.
City Corporation, along with the central government, is implementing
government policies on health and population control; contraceptive
logistic supply; family planning services to women and girls; antenatal
and postnatal check-up; Expanded Programme on Immunization (EPI) and
other vaccination facilities; pediatrics outdoor; adolescent health
care and advice on reproductive health, neonatal health care, HIV/AIDS
and other Sexual Transmitted Diseases (STD); mother and child nutrition
through model clinics, hospitals, health training institutes, urban
primary health centers, maternity hospitals and midwifery institutes.
But still the problem of reproductive health has not been
City Corporation is involved actively in order to get sustainable
results. In 1973, the growth rate was 3% per annum. Over a span of 37
years, the population growth was reduced by 1.2%. This is because of
the determination and commitment of the Government of Bangladesh, as
well as Chittagong City Corporation, to increment the decisions of the
action of the International Conference on Population and Development
(ICPD) held in Cairo in 1994, and also the implementation of Action
Plans gradually designed by the Asian Urban Information Center of Kobe
these efforts, the population is still growing every year rapidly, due
to the urbanization of Chittagong City. The reality is that rural
populations adjacent to the city/districts are declining. On the other
hand, urban populations of Chittagong City are continuing to increase,
especially poor sections of the population, mostly girls and women, who
seek jobs in garment factories, the Export Processing Zone (EPZ) and
other industries. As a result, “floating” people
and a large number of immigrants from rural areas and adjacent
upazilas/districts are continuing to rise. These migrants and slum
dwellers represent a new highly vulnerable population, creating issues
regarding transport, accommodation, housing, sanitation, HIV/AIDS and
STDs, and other adverse implications. Hence, the economy will have to
create more job opportunities to employ its working age (18-58 years)
population to generate income and alleviate poverty. It also needs
solution of accommodation/housing problems. Otherwise, it will
adversely affect both GDP and GNP growth per capita. Against this
backdrop, the nation has no other option but to pursue a population
policy, creating awareness and training, proper implementation of
reproductive health programs, adoption of a multi sectoral approach
within a broad-based population and development framework, adequate
administrative infrastructure, union health and family planning welfare
centers in the countryside, and establishing the industry and creating
job opportunities in the rural areas.
health family planning services / reproductive health services in the
rural areas will reduce the pressure on rural out-migrants and the flow
of floating people to the city. Needless to say, infant and maternal
mortality rates provide a good indication of a population’s
general welfare. They also contribute greatly to the crude birth rate
and life expectancy.
1971, after the liberation war in Bangladesh, 98% of women of
Chittagong were housewives. Now the trend has been changed. At present
30% of women and girls are engaged in education, health, banking and
the garment industry, even in the police and army sectors too. The
government has made a lot of efforts to keep rural people in the
countryside, providing maternal and other health facilities in the
union health care centers, appointing MBBS doctors and upholding the
agriculture facilities, appointing class-1 agriculture officers which
were not previously there. Great restrictions/punishments have also
been imposed by the government on the concerned persons not to marry
below 18 year-old girls under law. It is a great hope to reduce the
population growth rate. The population is growing by an estimated 4.2%
per year, one of the highest rates among Asian cities. The continuing
growth reflects ongoing migration from rural areas to Chittagong City.
With urban population growth, the number of slums and the people who
dwell in them are rapidly increasing. Chittagong is now experiencing a
period of cramped population growth, and slum dwellers are mainly
responsible for this high growth rate. The rapid growth of urban areas
is already apparent in Chittagong City, with poor housing conditions,
high overall population density using the widely suggested threshold of
300 persons per acre, 75% single room occupy and 75% of people below
the income poverty level, or a monthly income of less than 5,000
Organizations (NGOs) are one of the primary service providers for the
urban poor population, and their coverage is incomplete. Considering
the reality of a male dominated society where women have less
opportunity to exercise power in reproductive decisions, more emphasis
has to be put on the focus on women’s health, by including
physical, mental, maternal and reproductive health, and linking these
with the empowerment of women and the attainment of gender
City Corporation is now providing reproductive/primary health/family
planning services to the city dwellers, especially for women and girls,
through 37 urban primary health care centres, seven full fledged
maternity and child hospitals, two urban primary HIV/AIDS centers, one
midwifery institute, one institute of health technology and 20
charitable dispensaries, apart from government medical services. At
least 60% of services provided under Chittagong City Corporation are
targeted to the poor and free of cost, with a focus on women and girls.
The services are through comprehensive RH care centers in 43 areas.
Some NGOs and international organizations are also working together in
the city, like YPSA, SIDA, ADB, DFID, and UNFPA. This is to be done
through improved access to and utilization of effective and sustainable
primary health care services. For primary health care service delivery,
the public sector works in partnership with local and international
NGOs under the control of the Ministry of Health and Family Planning,
the Ministry of Local Government and the private sector.
is an innovative initiative with the goal to improve RH services of the
urban population, especially the poor, particularly focusing on women
and girls who live in slum areas, with the aim of contributing to
achieve the national goals and targets of the Millennium Development
Goals (MDGs). Urban primary health care services initiated in 1998 and
2005 respectively, are now milestones in urban reproductive health
services. Propaganda, legislation and all kinds of motivational work
and service delivery in relation to RH (women and girls) will have to
be put on a WAR-FOOTING. There is no scope for defeat in our war on
population growth and reproductive health, because such a defeat will
spell our doom.
Research Report presents the preliminary findings from a study that has
been supported by the Asian Urban Information Center of Kobe (AUICK),
Japan, and carried out by Mr. Mominur Rashid Amin, Private Secretary to
the Mayor, Chittagong City Corporation, on the basis of a sample survey
of persons in Chittagong City. The study was initiated in July 2010,
and the survey was carried out over three months. This report describes
the preliminary results of primary / reproductive health services in
the Chittagong City area, with attention to vulnerable populations,
especially women and girls. It is expected that all major stakeholders
are involved with the most important port city area of Chittagong, as
informants during the research study.
Objectives of the
objectives of the
To know the present status of the primary reproductive health of women
and girls, especially the vulnerable population.
(2) To find out their knowledge regarding reproductive health
(3) To determine the influence of the socio-economic background of the
slum dwellers in reproductive health decision making.
(4) To measure the level of awareness and satisfaction of women and
girls about the services provided by Chittagong City Corporation and
the Government Health Department.
(5) To identify the problems in acquiring essential services.
(6) To access the way to remove the obstacles of reproductive/primary
health services, especially for vulnerable groups like women and
port city of Chittagong is the second largest city of Bangladesh, with
a population of about 5 million. It is divided into 41 wards, covering
an area of 158 sq. km. One of the most common health hazards of
Chittagong City women are the reproductive health problems. To access
the problems and status, two sets of data have been collected.
Narrative qualitative data and the specific reproductive health
conditions are considered most important under the outline/
questionnaire of AUICK. Since the study is mainly about the perceptions
of the citizens on the reproductive health services provided by
Chittagong City Corporation and similar other bodies, the Mayor, panel
mayors, ward councilors, city health officers, government medical
officers, city NGOs, and city slum dwellers, health officers and
government health assistance information were considered to be the main
sources of information through a field study.
two-stage cluster sampling design was followed to obtain the sampled
households. In stage-1, the Corporation wards were taken as the cluster
sampling units and approximately half the total number of wards were
selected randomly. At stage-2, reproductive health service institutions
and related public representatives, government officials, slum
dwellers, doctors, midwives, health assistants, and nurses were
selected and interviewed. The questionnaire used for the field survey
was designed to focus only on the key issues of reproductive health,
especially regarding vulnerable groups such as women and
respondents were predominantly female
(80%) with an average age of
about 18-40 years, while the remaining males had an average age of
of Surveyed Households
average family size of the surveyed
households was 5, consisting of
3 adults and 2 non-adults. It was lower than the average urban
household size, and that of the country as well. This is remarkable
considering that Chittagong is generally regarded as a conservative
area, resistant to family planning.
(1) Occupation and
respondents were professionals, public
day laborers, women garment factory workers, midwives &
businessman. A lot of workers live in the city for garment jobs without
their families. Their families live in neighboring villages or
and education seems to be moderately
high among the
(2) Income and
respondents were divided into poor broad
based primarily on their own perception of their socio-economic status,
moderated by the interviews and observations on their living standard
and stated income and expenditures. The distributions of 500 households
were surveyed. Their monthly income is shown below:
category is very distinct and lies entirely below the 5,000 Taka
Views of Urban Administrators and
Non-Governmental Organization (NGO) Service Providers
Mayor and Deputy Mayor
2) Meeting with Urban Council members (organized as possible by field
3) City Health Director and Deputy
4) City NGOs (head of city office)
1. What are
considered the most important RH issues and conditions?
of the respondents mentioned that the
most important reproductive health issues are family planning for the
health of mothers against population growth. Most of the women slum
dwellers do not have the power to take reproductive decisions
independently. Either they depend on their husbands or they are forced
to obey their husband without saying anything. A lot of housewives are
becoming valueless in reproductive decision making roles, and turning
into wooden dolls of their male partners. Because of their poverty and
unawareness, the reproductive health situation has worsened. Poverty
ruins the treatment of their pre and post natal period. They do no have
enough money to feed themselves or their children.
percent of the poor women in this
study area are not aware of family planning methods. Above 30% of the
sample size suffered or is suffering from various types of reproductive
health related difficulties, which can be very brutal to their lives.
Five percent of respondents strongly believe that HIV/AIDS and STDs
should be given priority. Here in the city we have such a large
population, and if this condition goes unchecked, it could devastate
the country, and millions could be affected in a short period of time.
They also told that many African countries have been so badly affected
by HIV/AIDS due to ignorance among its population on health, but also
the fabric of society: families destroyed and economic and social
damage also. They should realize that this HIV/AIDS issue has a
correlation with other matters mentioned here. If there was a
comprehensive program to tackle HIV/AIDS, then the matter of sexually
transmitted diseases would be part of that program, as well as family
planning. Much of the economic and problems of Bangladesh derive from
its overwhelming population.
planning against population
growth’ is such an important issue and should have a strong
degree of urgency. There are many cultural and religious issues to
consider when dealing with this matter, therefore some sensitivity and
local knowledge is essential to avoid any tension and to get religious
leaders on our side. ‘Infertility’ can be a social
embarrassment in some communities here in Bangladesh, and obviously
help and advice should be given, similar to the issue of
motherhood’, but there are more pressing subjects.
2. Overall, how is
the level of the city’s reproductive health
percent of the above sample size
suffered, or are suffering from various types of reproductive health
related difficulties, which can be very brutal to their lives. The
congestion of living space, unhealthy environment and lack of health
services make the urban poor vulnerable to health risks. The absence of
health facilities within many slums severely restricts access to health
care. Health facilities are not adequate for the slum dwellers. As a
result of this, acute shortages of health facilities mean most slum
dwellers are either entirely left out of health services or receive
very poor quality health care. Because of the weak paying capacity
among slum people, even private health care is also absent in the
slums. The urban poor are forced to take alternative or unqualified
it is necessary to reshape the
decision-making environment in a way that would undermine the coercive
patriarchal system and create conditions favorable to female autonomy,
late marriage and smaller family size. The social context of sexual and
reproductive decision-making should be well explored.
City Corporation is trying with
its best effort to provide RH facilities, but these are not adequate
until now. All the informants believe that it needs more improvement in
terms of establishing more urban health centers and appointing more
doctors, nurses and health workers, and providing sufficient
and health morbidities in slum
communities could have been easily prevented by providing RH services,
and simple and well-understood messages should be given to the
population in a variety of communicative forms.
3. Overall what
priority does the City give RH services?
majority of the respondents (55%) gave a
high rating to the present corporation administration in health care.
In addition, about half of them (55%) felt they have done better also
in respect of other fields. Fifteen percent of respondents mentioned
that the problem is still serious due to other competing demands. They
also stated that there are social and economic problems in the city
such as traffic congestion, unemployment, gas, road maintenance and
construction, and RH does not have a high priority.
4. Overall how do
you feel about the resources available for RH services?
large number of respondents mentioned that
the resources available for RH are somewhat deficient. Some of the
buildings are in good condition, but there could be much improvement in
medical tools, lab facilities, medications, IT equipment to keep
records, availability of contraceptives and skilled medical personnel.
Personnel resources are more deficient, lacking field workers and
doctors due to lower salaries paid. There is an innovative
Card” system and “mother-child health”
by Chittagong City Corporation, which will be more fruitful to keep all
the records on RH at all times.
5. What are the
specific needs of the City to improve its RH services?
None: services are now quite adequate,
including the service by private sector: 0%
b) Less than adequate services, more is needed: 60%
c) Far less than adequate, more is needed: 40%
than half of the respondents mentioned
that funding is the major problem, as well as skilled personnel, modern
equipment, lab training programs, social mobilization and empowerment
of women. The needs should be fulfilled to improve the RH
this study, the decision of having children, choosing family planning
methods, knowledge about family planning methods, numbers of children,
the role of the spouse during the pregnancy period, problems faced for
using contraceptives, health care facilities in postnatal and prenatal
periods, and decisions of marriage are considered as indications of
commitment should be stronger. In
Bangladesh, the political
party backs the Mayor and Ward Councilors although they are not elected
under the banner of a political party. If the Mayor is not elected
under the umbrella of a ruling party, fund allotment and other services
may be hampered or not satisfactory, due to weak political commitment.
It should be changed for the better interest of RH services.
6. What is the
size of the city’s slum or below poverty level ($2
per day) population?
In 2000 (in actual
number or % of total population):
Any future projection: 2020 or 2025?
of the city’s slum or below
poverty level ($2 per day)
steps have been taken to provide slum
people with low
cost. Some low cost houses have been constructed by Chittagong City
Corporation for slum dwellers. Except for this, a proposal has been
sent to the Ministry of Local Government covering adjacent areas to
increase the city from 158 sq. km. to 300 sq. km. so as to cope with
the pressure of migrants.
7. To what extent
are city RH/ Family
Planning (FP) services available to the slum dwellers? Are any factors
impeding this availability? How could it be increased?
(Please provide a rough percentage estimate and then discuss
planning services are now mostly
available to the
slum dwellers. The roles of health workers are also prominent in the
supply of contraceptives. Two thirds of the total respondents (65%)
received family planning materials from health workers, 15% from NGO
clinics, and lastly 20% reported that they received materials from
other sources, such as husbands, relatives or pharmacies.
is a good
indicator that the previous birth rate was 26.1/1,000 live births, but
in the most recent year it has decreased to 26/1,000 live births. The
City Corporation has established 38 urban health care centers to
deliver RH services and family planning materials free of cost, but
this does not completely cover the slum areas. One of the main
constraints regarding the use of contraceptives is also religious
beliefs. Training, seminars, motivation and awareness among the
religious leaders and contraceptives free of cost to all slum dwellers
are necessary. As a result, the situation could be improved.
8. Are there
special programs to increase RH services to slum dwellers?
Is so, please describe them, especially in terms of the
a) staff size and
categories designated (e.g. MDs, nurses, midwives
b) special features
c) size of budget
City Corporation and the
government Family Planning
Department have conducted some special programs to increase RH services
to slum dwellers. The City Corporation itself has a modern midwifery
institute, 72 female family planning assistants, 35 midwives, and about
200 nurses and pharmacists to provide RH services, especially to the
City Corporation has allocated
3% of its total budget for RH services. The cleaners, shopkeepers and
special low class communities who live in slums are given training,
awareness programs and free contraceptives by the City
What is the estimated size of the city’s new immigrant
(the new floating population)?
2010 and/or annual growth rate
Any future projection: 2020 or 2025?
health services be sufficient for these projected
percentage of the new immigrants to
Chittagong City is
increasing gradually. This is due to their seeking jobs in the city.
Agricultural land/work in rural areas is declining. On the other hand,
the population is increasing. Sometimes with separation from the
husband, poverty, and low income in rural areas, the trend of migrants
is rising up. The migrant rate will be more and more by 2020/2025 in
Chittagong. The findings indicate that all the variables included in
the analysis have had a significant effect on rural out-migration,
except the variable ‘family size’. The study
the respondents found that poorer and landless have a greater
propensity of migration than richer and large land area owners. RH
services for the projected population in 2020/2025 will not be
sufficient. They should be considered and planned in advance, to tackle
the future adverse situations.
10. To what extent
are city RH services regularly available to the
migrants? Does this represent a problem for the city? Are there any
special health and social programs to deal with this new floating
population? What kinds of program are necessary?
thirds of migrants get RH services
regularly from the urban health
care centers free of cost from Chittagong City Corporation. Floating
migrants are a serious problem creating health hazards for the city.
Despite the RH problems, they also spread Sexually Transmitted Diseases
(STDs) and HIV/AIDS. Chittagong City Corporation has initiated various
projects for awareness programs, low housing construction, mother child
health cards, birth and death registration, and mother and child red
cards, within a limited budget. A Management Information System (MIS)
has been introduced by Chittagong City Corporation to show all records
on factors such as birth, age, pregnant women statistics, mothers, sex
and occupations through a computerized method. The Management
Information System (MIS) should be up-dated and cover all of the city
area immediately. Family planning materials should be delivered free of
cost to all - especially for the floating population. HIV/AIDS/STDs
should be checked. Mobile clinics can also be introduced.
11. What is
the breakdown of the total budget for RH services in terms
of the following?
Major portion of the reproductive health
expenditure is borne by
Chittagong City Corporation. On the other hand, the central government,
especially the Ministry of Health and Family Planning, allocates 35% of
the budget. Some NGOs and donor agencies like YPSA, UNFPA and SIDA
sometimes contribute in special cases. There should be coordination
among the departments to uphold the existing reproductive health
situation. Allocation by the central government should be
What services are
considered part of RH
Please make a separate list of the services, and then complete the
following forms as much as possible.
Maternal and child health care.
2. Neonatal child health care and pediatric surgery.
3. Gynae and Obstetrics departments.
4. HIV/AIDS, Sexually Transmitted Diseases (STDs).
6. Family planning services.
7. Health education services.
8. Free contraceptives.
9. Mother child health cards and red cards.
10. Free reproductive health services to slum dwellers.