Tracey Koehlmoos: Providing healthcare for the homeless in Dhaka, Bangladesh

Tracey KoehlmoosStreet dwellers, as homeless people are called locally, are ubiquitous in Dhaka. As a health systems researcher, much of my work is far removed from the people around me. Things like systematic reviews, knowledge translation platforms, and capacity building seem to have little immediate impact on the ultrapoor, but recently we completed a small project to help them. 

Four years ago, Dr. Jasim Uddin and I surveyed the homeless in different areas of Dhaka about their health seeking behaviour and living conditions. Although so many of our photos were of smiling families who appeared to be camping under the stars, the abysmal reality uncovered by that study is well documented, and was well received by policy makers, development partners, urban planners, academics, and non-government organisations (Koehlmoos et al. 2009, Uddin et al. 2009).    

Although most of the homeless people we talked to had been ill recently, they did not seek health services. They were too busy scraping a living to attend to their own healthcare needs, let alone those of their children. Most had been on the streets for more than three years, and all of the women had delivered their babies on the streets without assistance. We now know that there were long-term homeless men, women, and children suffering from illness, violence, and poor sanitation. We were haunted by our inability to take action without partners.  

In late 2008 we found that partner in GTZ (German Technical Cooperation). GTZ helped bring together diverse stakeholders along with the funds  to test  models of care. Soon we were able to partner with the Directorate General of Health Services, the Dhaka City Corporation, the 2nd Urban Primary Health Care Project, the Bangladesh Railway, the National Sports Council, and several NGOs with an interest in urban health services or poverty reduction. You might wonder, “Why the sports council?” but the car park of the stadium is one of the big gathering spots for homeless people.

Being scientists, we wanted to know if what we were going to do would work well enough to justify how much it would cost. After an initial survey of the  population, we launched three small clinics in May 2009. We had two trained paramedics, a supervisor, a rickshaw driver, and space donated by our partners. The utilisation and quality of the clinics were closely monitored by all of the partners.  In April 2010 we did a follow up survey. This might seem like an obvious conclusion, but we learned that the homeless did use the clinics. More than 60 babies were born with skilled attendance, and the respondents who were dissatisfied simply said they wanted the clinic to be open more evenings and for longer hours. We felt that we could not close the clinics just because the science was finished.

Together with GTZ, we found enough funds to keep the clinics open for an additional eight months. Finally on 30 December 2010 we passed our small network of evening clinics to a capable NGO, Marie Stopes International, who are committed to continuing this work.

When we disseminated our findings in mid-January 2011 to our partners and other groups working with the homeless who we have met along the way, we were overwhelmed by their interest in adopting this model into existing programmes or expanding it to serve more locations.  We will continue to champion and promote this type of service until it becomes a norm. However, I do realise that conveniently located, evening health clinics are of course a band aid to the real problems of the urban homeless who really need jobs, security, and homes.

Koehlmoos T, Uddin J, Ashraf A, Rashid M (2009) Homeless in Dhaka: Violence, Sexual Harassment and Drug Abuse. J Health Population Nutrition, 27(4): 452-461.

Uddin MJ, Koehlmoos T, Ashraf A (2009)  Health needs and health-seeking behaviours of streetdwellers in Dhaka city. Health Policy and Planning.  24(5):385-394.

Tracey Koehlmoos is programme head for health and family planning systems at ICDDR,B and adjunct professor at the James P. Grant School of Public Health, BRAC University, Dhaka, Bangladesh.