HOUSEHOLD SURVEYS IN BANGLADESH How well are the urban poor represented? Ru-Yi Lin

STUDY DESIGN AIM To identify the health inequity within urban areas in Bangladesh OBJECTIVE To identify data sources for the Urban HEART indicators To assess the appropriateness of existing data to identify health inequities in urban areas To identify the health needs of the urban poor in Bangladesh, and where possible how this differs from the non-poor

Data analysis Availability and accessibility Applicability Reliability Indicators Data collection Communication Cooperation 7 organizations and government institutions Selected data type Nationwide survey Urban health related study done by organization Specific target groups or for rural areas No information related to selected indicators

Availability Accessibility Both raw data and report are available Sub group analysis can be done Applicability Covers 12 Urban HEART indicators No further information about slum/non-slum groups Reliability Sample size: 18,000 household Urban: 6210 HHs; Rural: HHs Two stages cluster randomize sampling* Covers 7 divisions Used standard sample size formula for key indicators at subnational-level 2011 Bangladesh Demography and Health Survey *Sample frame: select the Enumeration areas (EAs) covered whole country from 2011 census (113 household/EA). 600 EAs been selected(207 in urban/ 393 in rural)->30 Household been selected in each cluster

Availability Accessibility Report is available; raw data not available Sub group analysis can NOT be done Applicability Covers 1 Urban HEART indicator Nationwide data Result can be divided into urban/rural areas No further information about patient’s socioeconomic status Reliability Data collected from patient register system Cover 6 divisions Challenges of routine data collection including duplication and human error The most vulnerable may not have access to health system 2013 National Tuberculosis Control Programme (NTP) annual report

Availability Accessibility Both raw data and report are available Sub group analysis can be done Applicability Covers 2 Urban HEART indicator Results for slum areas in cities Reliability Sample size: 950 Households Cover 3 City Corporation Sample size calculation in report 2014 Promoting Environmental Health for the Urban Poor: Mid-term assessment of Water Aid project

Availability Accessibility Preliminary report is available Raw data and final report NOT available online Sub-group analysis can be done Applicability Covers 8 Urban HEART indicator Data from urban areas Slum/non slum disaggregation by socio- economic/wealth quintiles Reliability Sample size: Households in urban areas* Covers 9 City Corporations Done, but unknown because report is not online yet 2013 Urban Health Survey: Primary Results *Sample frame: Three-stage sampling design of Mohallas from 9 city corporations, District Municipalities and large towns with population over 45,000 from the 2011 census

Availability Accessibility Preliminary report is available Raw data and final report NOT available online Sub group analysis can be done Applicability Covers 5 Urban HEART indicator Only women and children Reliability Sample size: HHs Covers 7 divisions and municipalities Used MICS-5 sample size formula for key MCH indicators at subnational-level Multiple Indicator Cluster Survey: Key District Level Findings

Availability Accessibility Report available online. Request raw data from MoHFW Sub group analysis can be done Applicability Covers 5 Urban HEART indicator Adult women and men Reliability Sample size: 9275 HHs Covers urban and rural area Sample size calculation in report 2010 STEPs: Non-Communicable Disease Risk Factor Survey Bangladesh 2010

Urban HEART Indicators NOT covered Indicator Road traffic injuries (core)Recommend to include in DHS Prevalence of tobacco smoking (core)Missing data in BDHS, GATS Bangladesh 2009 disaggregated by urban/rural Government spending on health (core)National Health Accounts (Heath Economics Unit) Maternal mortality Life expectancy at birth Morbidity and mortality from cancers CVDsDiabetes and hypertension covered in DHS as pre indicator to develop CVDs Respiratory disease HIV/AIDSRespondents may hesitate to answer this question HomicideFrom Police data Mental illnessAlthough stigma – use assessment such as PHQ9 Work related injuriesRecommend to include in DHS Security of tenureRecommend to include in DHS Voter participationFrom election data Insurance coverageFrom National Health Accounts (Heath Economics Unit)

Geographical coverage in analysis Division City CorporationMuni MICS V (7 divisions) V 2011 BDHS V (7 divisions) V 2013 NTP V (6 divisions ) 2013 UH survey V (9 City Corporations) V 2014 PEHUP V (3 City Corporations) 2010 STEPs V (6 divisions) Comila Rarayanganj 2013 Urban Health Survey 2011 BDHS 2014 PEHUP 2012 MICS2013 NTP 2010 STEPs

Definitions of Inequity Used in Each Report BDHSNTPUHSPEHUPMICSSTEPS Urban/rural specific wealth quintile (20%)  Poorest  Poorer  Middle  Richer  Richest Not disaggregated by wealth Slum/non slum  High density & crowed  Poor housing conditions  Poor water & sewerage condition  Poor & very poor SES Slum household income levels  <=Tk.5000  Tk  Tk  Tk  Tk  Tk  Tk  Tk Not disaggregated by wealth Wealth quartile (25%)  1st  2nd  3rd  4th Wealth IndexSlum/non- slum, wealth index IncomeWealth index

Are the urban poor being identified? DHS wealth quintile category Urban n (unweighted) Urban %Rural n (unweighted) Rural % poorest poorer middle richer richest Total Absolute numbers and % sample size per wealth quintile across the national DHS 2011 sample (both urban and rural areas) n = sample size

Response rate of urban poor(est) in DHS Indicator Total respondent Total urban respondent % Urban poorest and poorer respondent % Total rural respondent % Infant mortality % % % Diabetes % % % Access to safe water (HHs) % % % Access to improved sanitation % % % Skilled birth attendance % % % Fully immunized children % % % Unemployment % % % Under-5 mortality % % % Literacy % % Underweight children % % % Breastfeeding % % % Teenage pregnancy % % %

1.DHS, MICS, UHS, STEPs: 1 st -stage sampling from census data, and 2 nd -stage listing of households misses many urban- poorest so urban sample is not representative. 2.BDHS, MICS, STEPs: The sample size is too small to perform sub-urban analysis. 3.DHS, MICS, UHS, STEPs: People who have no house might be excluded in household survey, whom are the extreme poor people (homeless, illegal settlements). 4.DHS, MICS, UHS, STEPs: The wealth index allows us to look at physical assets only; not income, expenditures, savings, or access to credit. 5.All: Requesting access to raw data is often complicated and unclear which prolong the progresses of the study. Challenge

Recommendation 1. Specific or booster surveys of the urban poor  Household data can capture sufficient number of urban poorest people. 2. Improved sampling methods  Households data can be representative of urban poorest people. 3. Mechanisms for sharing information  Easier mechanisms to access raw data.

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