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Bangladesh’s rapid urbanisation challenges cities’ health services

How German Development Cooperation helps local actors find innovative solutions

City of Sylhet, Bangladesh

Like many other low- and middle-income countries, Bangladesh has a fast growing and rapidly urbanizing population. This poses considerable challenges to urban health systems, including overcrowded and understaffed hospitals, a lack of oversight of healthcare providers, unclear institutional responsibilities and insufficient provision of health information to urban populations. Looking at Sylhet, one of Northern Bangladesh’s biggest cities, this article explores how German Development Cooperation is supporting local actors to address these challenges.

Bangladesh is a fast growing country. Over the last ten years Bangladesh experienced an annual growth of 6.15% of its GDP on average. However, this growth is not limited to economic development. Despite being successful in curtailing the enormous population growth from the 70’s and 80’s, Bangladesh still experiences a high population growth of more than 1% every year.

Its cities are even growing at a much higher rate. On top of population growth, people from rural areas flock to cities for work and a better life. Sylhet, with about 600,000 inhabitants one of Bangladesh’s biggest cities in the North of the country, is no exception.  As Dr. Sudhamay Majumdar, the city’s Chief Medical Officer, puts it: “urbanization is going on very rapidly”.

Sylhet’s health sector struggles to cope with fast urbanization

Unfortunately Sylhet - like the other cities in Bangladesh - is not well equipped to deal with the fast pace of urbanization. As a consequence, access to public services is often hampered.

This is particularly true for the health sector. In most of Bangladesh, the Ministry of Health and Family Welfare is responsible for the provision of health care. However, in the big cities the City Corporations under the Ministry of Local Government, Rural Development and Cooperatives are tasked with providing primary health care services.

As there are limited public funds for health service provision on the city level there is only one public hospital in Sylhet: the tertiary Sylhet Osmani Medical College Hospital, financed by the Ministry of Health and Family Welfare. As the public hospitals have to provide services almost free of charge and are thus cheaper than hospitals from NGOs and certainly from the private sector the Sylhet Osmani Medical College Hospital struggles with overcrowding. The hospital regularly has more than twice as many patients admitted then it has beds, according to its Deputy Director, Dr. Md. Abdus Salam.

Provision of primary health care is predominantly covered by NGOs or private doctors and hospitals with very limited oversight. This results in a lack of quality health care services, especially for the poor. That is part of the reason why the health indicators - such as maternal mortality rate - are worse for Sylhet in comparison to other areas in Bangladesh.


A teacher at the Sylhet Nursing College teaches clinical midwifery skills by using a pelvic model

Addressing Bangladesh’s Demographic Challenges (ABDC) works to improve the supply of health services for the urban poor


In order to improve the access to quality reproductive health services particularly for the urban poor living in the slums of Sylhet, the German Federal Ministry for Economic Cooperation and Development (BMZ) commissioned the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) in 2012 with the Addressing Bangladesh’s Demographic Challenges (ABDC) programmme. In the words of the Principal Advisor of the programme, Mrs. Eva Schoening, its aim is to “enhance the capacity of the City Corporation’s Officials to steer urban reproductive health interventions based on better evidence.”

In order to reach this goal, the ABDC program focuses on three main areas:

  • Quality management and strengthening midwifery education: As the first batch of professional midwives ever in Bangladesh is still in training the ABDC programme supports and advises the training institution in Sylhet.
  • Improving good governance: Since provision of primary care in Sylhet is organized predominantly through NGOs and the private sector the ABDC programme supports the City Corporation in its steering efforts by providing a map of all health service providers, a functioning health information system as well as budget review support.
  • Providing health promotion: Due to the limited availability of information on (reproductive) health topics in schools and beyond the ABDC programme supports different local NGOs that provide predominantly adolescents in Sylhet’s slum areas with crucial health information on reproductive and other health topics.

A peer educator teaches a lesson on healthy reproductive behaviour

Successes and outlook


So far, the ABDC programme has been able to achieve first successes to tackle problems for the urban poor to access quality (reproductive) health services. The midwifery education track is already receiving a lot of attention, the health promotion activities have reached over ten thousand people and the provision of a map with all service providers has given the City Corporation a better understanding of the important actors in the primary service provision in Sylhet.

Finally, the ABDC programme has opened up a vital channel of communication between the local level and the ministerial level as well as between the two different ministries. After receiving substantial additional funding, the project furthermore has enlarged the number of pilot regions to also include Rajshahi and Narayanganj.

Despite those first successes a lot of work still remains to be done. At the same time, rapid urbanization does not only pose a huge challenge to the provision of quality health services in Sylhet or Bangladesh, but also in many other partner countries of the German Development Cooperation. Poor urban dwellers are among those most affected by the lack of clarity on institutional responsibility for urban health and the provision of basic rights and services including health.  An unhealthy city cannot be productive in the long run.

By Heiner Salomon, GIZ Bangladesh, June 2015


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