Cities, slums, and child nutrition in Bangladesh

• Author: Kyoung Yang Kim,Dhushyanth Raju,Ramesh Govindaraj,Quynh Thu Nguyen
• DOI: http://doi.org/10.1111/rode.12564
• Published date: 01 May 2019
• Date: 01 May 2019

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Cities, slums, and child nutrition in Bangladesh

Dhushyanth Raju

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Kyoung Yang Kim

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Quynh Thu Nguyen

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Ramesh Govindaraj

The World Bank, Washington, DC

Correspondence

Dhushyanth Raju, The World Bank, 1818

H Street, NW, Washington, DC 20433.

Email: draju2@worldbank.org

Funding information

Funding from the World Bank's

Bangladesh Health Sector Development

Program Multi Donor Trust Fund (Grant

No. TF011554) is gratefully

acknowledged.

Abstract

This study uses novel household survey data that are repre-

sentative of Bangladesh's large cities, and of slum and non-

slum areas within the cities, to investigate the effects of

demographic and socioeconomic factors on child nutrition

status in 2013. The study also decomposes the difference in

mean child nutrition status between slum and nonslum

areas in 2013, and the increase in mean child nutrition sta-

tus in slum and nonslum areas from 2006 to 2013. Mother's

education attainment and household wealth largely explain

the cross‐sectional difference and intertemporal change in

mean child nutrition status. Although positive in some

cases, the effects of maternal and child health services, and

potential health‐protective household amenities, on child

nutrition status differ by the type of health facility, house-

hold amenity, and urban area (slum or nonslum). Focusing

on nutrition‐sensitive programs for slum residents and the

urban poor is consistent with the results.

KEYWORDS

Bangladesh, urban, slum, undernutrition, height-for-age z scores,

children

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INTRODUCTION

Urbanization is one of the most important demographic currents historically. On the one hand, it offers

a major opportunity for countries to broaden and boost gains in the socioeconomic status of urban resi-

dents. On the other hand, rapid urbanization poses significant development risks, arising from inade-

quate or low‐quality physical and economic infrastructure and a failure to provide basic services for

growing urban populations. The tension between the potential opportunities and perils of urbanization

is arguably strongerfor developing countries, for at leasttwo reasons. First, these countries are expected

© 2018 The World Bank. Review of Development Economics © 2018 John Wiley & Sons Ltd

DOI: 10.1111/rode.12564

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to experience large expansions in their already substantial urban populations in the coming decades.

The total urban population in the least‐developed countries was estimated to be 2.9 billion in 2014, and

the figure is projected to reach 5.2 billion by 2050 (United Nations, 2015a). Second, governments in

developing countries generally have had a poor record in designing, financing, and implementing poli-

cies, rules and regulations, and in providing services in both urban and rural areas, resulting in condi-

tions and outcomes that may be socially inefficient and inequitable (United Nations–Habitat, 2016).

The global imperative to leverage the potential socioeconomic benefits of urbanization, and mit-

igate potential risks, is reflected in, for example, the 2030 Agenda for Sustainable Development

(Goal 11) and the New Urban Agenda adopted by the UN in 2015 and 2016, respectively (United

Nations, 2015b, 2017). Protecting and promoting the health of urban residents—including slum

and poor residents who face a greater risk to their health and nutrition from higher exposure to

adverse environmental factors—is a key element in the UN agenda on urbanization.

Notwithstanding, urban health and nutrition in developing countries is an understudied area. In

the case of Bangladesh, the setting for this study, most of the available evidence comes from quali-

tative studies and empirical research based on small‐scale purposive samples or large‐scale samples

that are representative for urban areas as a whole (e.g., see Choudhury et al., 2012; Srinivasan,

Zanello, & Shankar, 2013). These studies point to substantial inequities in health and nutrition ser-

vice delivery and outcomes within complex, dynamic, and dense urban environments. The amount

and nature of rigorous empirical research on urban health and nutrition has been constrained by

the absence of large‐scale data in developing countries that are representative across and within

urban areas in a country, and are extensive in terms of capturing potential determinants.

In this study, we empirically investigate patterns, trends, and determinants of the nutrition status

of children under age five in the major cities of Bangladesh, with a focus on differences between

slum and nonslum children, using data from a large‐scale household survey that is relatively

unique for a developing country (Ezeh et al., 2017). In 2006, the National Institute of Population

Research and Training (NIPORT) and others conducted the Bangladesh Urban Health Survey

(BUHS), providing, for the first time, extensive data on adult and child healt h and nutrition out-

comes, and a wide range of potentially relevant factors, that are representative for slum and non-

slum areas in city corporations (the country's major cities), and for district municipalities and large

towns. In 2013, the survey was repeated on a new cross‐section which is representative for the

same domains. The two rounds of the BUHS serve as the source of data for this study.

The health and nutrition status of slum residents is of interest for at least three reasons. First,

theory and evidence suggest that the study of slum health and nutrition should be treated as dis-

tinct from the study of urban health, or the study of poverty and health (Ezeh et al., 2017). One

argument for the separate treatment is that the physical and social environments of slum settle-

ments may act to amplify health risks for residents, and produce negative health externalities. The

exposure to concentrated health risks in slum settlements may be particularly harmful to young

children, given that they are more immunologically susceptible than older children and adults. Sec-

ond, the literature on slum health and nutrition is scant (see Ezeh et al., 2017, for a review). Third,

research is needed on the health and nutrition risks and effects of residing in a slum settlement to

guide the design and implementation of policies and interventions related to slum development in

general and slum health in particular (Lilford et al., 2017).

We measure the nutrition status of children under age five by height‐for‐age z‐scores (HAZ).

Height is widely regarded as the most relevant measure of overall child nutrition, and child stunt-

ing (a height‐for‐age z‐score that is more than two standard deviations [SD] below the international

reference median) is viewed as the key indicator for tracking progress in addressing child undernu-

trition. Stunting reflects the cumulative effects of poor diet and recurrent infection. Internati onal

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