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Providing Primary / Reproductive Health Services in Asian Urban Areas with Attention to Vulnerable Populations, Especially Women and Girls

Section Two - Nine AUICK Associate City (AAC) Reports

14. Chittagong, Bangladesh


Historical Background of Reproductive Health (RH) in Chittagong City

Introduction to Study

Objectives of the Study

Methodology

Objective RH Services Data


Mr. Mominur Rashid Amin
 
Private Secretary to the Honorable Mayor, Chittagong City Corporation (Participant of First 2010 Workshop) 
Dr. Mohammad Ali 
Medical Officer, Health Department, Chittagong City Corporation 
Mr. Taufique Sayeed 
Chairman, Department of Computer Science and Engineering, Premier University

Chittagong Map

According 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. 

Historical Background of Reproductive Health (RH) in Chittagong City

Chittagong 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. 

The 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. 

Chittagong 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 overcome. 

Chittagong 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 (AUICK). 

Despite 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. 

Better 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. 

In 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 BDT. 

Non-Government 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 equality. 

Chittagong 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. 

It 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. 

Introduction to Study

This 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 Study

The objectives of the study were: 

(1) 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 issues. 
(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 girls. 

Methodology

The 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. 

A 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 girls. 

Chittagong DataThe respondents were predominantly female (80%) with an average age of about 18-40 years, while the remaining males had an average age of 27-55 years.

Family Composition of Surveyed Households 

The 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. 

Socio-economic Characteristics 

(1) Occupation and Education: 

The respondents were professionals, public representatives, housewives, 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 districts. 

Chittagong Study Respondents

Literacy and education seems to be moderately high among the respondents surveyed: 

Chittagong Study Respondents (Continued)

(2) Income and Expenditure: 

The respondents were divided into poor broad socio-economic categories, 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:

Chittagong Study Respondents (Continued)

Here, the poor category is very distinct and lies entirely below the 5,000 Taka mark. 

Appendix: Data Collection Protocols 

I. Views of Urban Administrators and Non-Governmental Organization (NGO) Service Providers 

Informants 

1) Mayor and Deputy Mayor 
2) Meeting with Urban Council members (organized as possible by field worker) 
3) City Health Director and Deputy 
4) City NGOs (head of city office) 

1. What are considered the most important RH issues and conditions? 

Chittagong Study Response

Discussion/Analysis: 

Most 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. 

Twenty 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. 

‘Family 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 ‘safe motherhood’, but there are more pressing subjects. 

2. Overall, how is the level of the city’s reproductive health condition? 

Chittagong Study Response (Continued)

Discussion/Analysis: 

Thirty 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 health providers. 

So, 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. 

Chittagong 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 funds. 

Maternal 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? 

Chittagong Study Response (Continued)

Discussion/analysis: 

The 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?

Chittagong Study Response (Continued)

Discussion/Analysis: 

A 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 “Red Card” system and “mother-child health” card started 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? 

a) 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% 

Discussion / analysis: 

More 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 services. 

In 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 reproductive health.

Political 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): 
2005: and 
2010: 
Any future projection: 2020 or 2025? 

Discussion/Analysis: 

Size of the city’s slum or below poverty level ($2 per day) population:

Chittagong Study Response (Continued)

Some 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 conditions)

Chittagong Study Response (Continued)

Family 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.

It 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 following: 

a) staff size and categories designated (e.g. MDs, nurses, midwives etc.) 
b) special features 
c) size of budget 

Chittagong 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 slum dwellers. 

Chittagong Study Response (Continued)

Chittagong City Corporation has allocated approximately 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 Corporation. 

9. What is the estimated size of the city’s new immigrant population (the new floating population)? 

In 2000: 
2005: and 
2010 and/or annual growth rate 
Any future projection: 2020 or 2025? 

Will reproductive health services be sufficient for these projected populations? 

Chittagong Study Response (Continued)

The 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 surveyed among 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? 

Two 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? 

Chittagong Study Response (Continued)

Discussion/Analysis: 

A 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 increased. 

Objective RH Services Data

What services are considered part of RH services? 
Please make a separate list of the services, and then complete the following forms as much as possible. 

1. 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).
5. EPI. 
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.

Chittagong Objective RH Services DataChittagong Objective RH Services Data (Continued)

CONTENTS

Top

Foreword

Section One

The New Urban Challenge for Primary and Reproductive Health Care

Executive Summary

1. Background: Urban Growth and Urban Primary / Reproductive Health (RH) Services

2. An AUICK Research Project Report

3. Regional Findings

4. Individual City Findings

5. Summary and Implications

Section Two

Providing Primary / Reproductive Health Services in Asian Urban Areas with Attention to Vulnerable Populations, Especially Women and Girls:

Nine AUICK Associate City (AAC) Reports

6. Kuantan, Malaysia

7. Khon Kaen, Thailand

8. Weihai, China

9. Surabaya, Indonesia

10. Olongapo, Philippines

11. Chennai, India

12. Faisalabad, Pakistan

13. Danang, Vietnam

14. Chittagong, Bangladesh

Annex I.
Research Instrument: AUICK Research Project Outline

Annex II.
AUICK Research Project Participants


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