Negotiating and navigating everyday governance for public health services in Dhaka City’s informal settlements: A political ecology analysis

Introduction: In Bangladesh’s complex urban spaces, poor people living in cities’ informal settlements struggle to access affordable public health services. Through a political ecology analysis, this paper explores how residents in informal urban settlements navigate everyday governance to access health services. Methods: This qualitative participatory research was conducted in two informal settlements in Dhaka city, one of the world’s most densely populated megacities. Stories of 16 families were captured through the Governance Diaries method, where repeated in-depth interviews and group discussions were conducted with each family over a period of four months between February and May 2023. Thematic framework analysis was conducted by applying the Urban Political Ecology (UPE) framework. Results: Residents employed various strategies to access essential public health services (healthcare, water, sanitation) by navigating local governance networks and negotiating with service providers. Success in these negotiations was shaped by residents’ socioeconomic status, access to information, political affiliations, and social networks. The ability to manage governance mechanisms for accessing public health services relied on three interconnected resources: 1) Financial resources (internal and external financial support); 2) Social resources (social networks - connections with governance actors and NGOs); and 3) Personal resources (negotiation skills, social and political positions, and personal wealth). Limitations in any of these resources restricted access to services. Conclusion: Personal, social, and financial resources influence the degree to which informal settlement residents can access public health services. Supporting the development of these three resources is crucial for enhancing the ability of diverse residents to engage in local governance networks and improve their access to public health services. Action is required to advance universal health coverage in Bangladesh and ensure that marginalised urban populations have equitable access to essential healthcare services.