Health systems and urban areas

With rapid urbanization in recent decades and over 40 million people living in urban areas in Bangladesh in 2011, the country faces challenges in providing adequate health services for the burgeoning urban population. Given the need to improve basic health conditions and provision of health services in urban areas, especially for the poor, the Government of Bangladesh launched the first Urban Primary Health Care Project (UPHCP I) in 1998 and continued with a second phase (UPHCP II) from 2005 to 2012. Provision of services is through contracted non-government organizations (NGOs) in partnership areas (PAs). Assessment of the evidence show that there have been interim achievements with UPHCP II, namely, improvements across several service quality indicators, increasing equity of maternal and child health service coverage for the poor, and decreased cost over time in some PAs. Most rankings of PA performance across health service quality, cost, and maternal and child health coverage are weakly correlated, with only a few PAs scoring in the top-ranked half across all indicators. However, service quality indicators, such as training of staff, functioning of equipment, availability of drugs, infection prevention, waste disposal, use of registers, and overall and waiting time satisfaction of non-poor patients, have improved over time.

With the urban population increasing in both number and percentage, urban health inequalities has been rising up the research agenda. A crucial aspect of health, both for the MDGs and the post-2015 agenda, is maternal health. This paper looks at inequalities in the percentage receiving sufficient antenatal care and children born within a facility and assesses how these have changed over time. Countries which have been most successful in reducing inequalities while increasing the proportion of mothers with these services will be studied, and countries which have not succeeded in this way will also be assessed.
Using 125 Demographic and Health Surveys from 33 countries, new measures of wealth were constructed using Principal Components Analysis, applying only to urban residents, based on the assets that the household owns. Wealth was used both as a continuous measure (factor score) and in quintiles. The difference and ratio between richest and poorest quintiles was calculated, while concentration indices calculated.
Results indicated that countries were diverse in the evolution of inequality with some successfully reducing it and others showing an increase over time. Policies to improve maternal health should tackle inequalities, while still increasing the overall level of service use in the whole population.

West Africa stands out as the region with some of the worst health and mortality indices. There are nonetheless sharp differentials in health and well-being by urban/rural residence, and individual characteristics such as education and age. Whereas some inequalities are structural in origin, there are, however, inequalities which have a more local origin, depending on household and family level factors that affect, for example, access to health services as well as life styles and behaviour.

After a discussion of some concepts underlying the description of individual and population health states, we use two case studies based on several years of West African field work – women’s health in Accra and the welfare of young people in Bamako – to illustrate how adoption of the capability framework can refine the analysis of unequal access to health. We apply the capability approach developed by Sen and colleagues to distinguish, inter alia, the role of the resources of the context (offer side) from inequalities of individual capacity to use them to improve their well being, due to social, family and individual characteristics. This framework seems especially promising to examine the complex determinants of urban health.

Close to 50% of the estimated 24 million Ghanaians live in rural areas but only 32.1% of the health sector workforce works in rural areas. Doctor patient ratio in a predominantly rural region is 1:18,257 compared to 1:4,099 in an urban region. These rural-urban inequities have contributed significantly to Ghana’s slow progress in achieving the millennium development goals 4,5 and 6. This study was conducted in 64 clinics among 324 staff in 16 rural and urban districts. Objective was to ascertain rural-urban differences in health staff motivation and the implications on quality care in health facilities. Results showed significant differences in quality care performance of rural and urban facilities in terms of “staff training in resuscitative techniques”, “orientation to job”, and “safe use of medications”. Staff in rural facilities were more de-motivate by poor water and electricity supply than those in urban facilities (p<0.05). Motivating staff along these identified gaps will help improve quality care and clients participation in the national health insurance scheme, which is experiencing enrolment and re-enrolment challenges because of poor service quality in accredited health facilities.