Exploratory qualitative study to understand the underlying motivations and strategies of the private for-profit healthcare sector in urban Bangladesh

Factors affecting out-of-pocket expenditures for chronic and acute illnesses in Bangladesh

BACKGROUND

In the absence of universal healthcare protection, out-of-pocket (OOP) expenditures are the main source of healthcare financing in Bangladesh. This study assesses the disparities in the overall and the components of OOP expenditures among households with both chronic and acute illnesses compared to those having acute illnesses only. It also identifies factors influencing OOP expenditures over time and examines patterns related to various illness conditions.

MATERIALS AND METHODS

Data from the Household Income and Expenditure Surveys (HIES) of 2016-17 and 2022 were used. A Log-linear Multiple Regression Model was employed to identify factors influencing OOP expenditures in households with different disease profiles.

RESULTS

The average OOP expenditures increased significantly from 2016 to 2022, even after inflation adjustments. Higher expenditures were observed in urban households BDT 939.34 in 2016 and BDT 1605.36 in 2022, and in households having both chronic and acute illness conditions with OOP expenditure of BDT 2290.43 and BDT 3525.32 in 2016 and 2022 respectively. Wealthier households spent more on healthcare, with the cost of medicines being the largest component with over 50% of total OOP expenditures. The regression analysis suggests that area of residence (urban vs rural), household size, level of education of the household head, the presence of elderly members (≥60 years), the number of employed members and sick household members, and hospitalisation of household members were mainly responsible for higher OOP expenditure.

CONCLUSION

Our study provides valuable insights on the determinants of OOP expenditures over time, with a notable increase among households managing both chronic and acute illnesses, and in urban areas. Key contributors to increased expenditures include medicines, medical tests and surgery costs, with cancer causing higher expenses. This study recommends improving treatment protocols help reduce unnecessary prescriptions of medicine and investigations, and alleviate financial burdens of the vulnerable population.

Barriers and facilitators for treatment-seeking among women with genital fistula: a facility-based qualitative study in Bangladesh

BACKGROUND

Women living with genital fistula often endure prolonged suffering and face multiple barriers to accessing treatment. Bangladesh's government has enhanced referral mechanisms, enabling case detection in communities and facilitating surgical interventions at medical college hospitals through nationwide initiatives. However, research on barriers and facilitators for fistula treatment in Bangladesh remains limited. Detailed insights into treatment-seeking paths with time sequences are scarce. This study aimed to explore facilitators and barriers to completing fistula treatment with the description of treatment-seeking paths. This study is important to assist with future policy and program strategies for fistula treatment.

METHODS

A facility-based qualitative study was conducted at Dhaka Medical College Hospital, Dhaka, Bangladesh. Data were collected from February to May 2024 through 18 in-depth interviews (IDIs) with in-patients, five IDIs with families, and 11 key informant interviews with health service providers. Participants' treatment-seeking paths were described chronologically and identified patterns of treatment-seeking paths. Thematic analysis, guided by the Partners for Applied Social Sciences model for health-seeking behavior and access to care, was used to analyze case histories.

RESULTS

The average duration of treatment-seeking by the women was 39 months, with a maximum of 22 years. Women with fistula often sought care at multiple facilities (up to eight), suspended treatment, and encountered systemic obstacles that delayed treatment. Key barriers included scarce information on illness and treatment in the community, less decision-making power, failure of medical communication, and systemic failures in cost, treatment, and referral systems. Facilitators that motivated women to complete treatment included informal peer support through shared treatment experiences and emotional, physical, and financial support.

CONCLUSIONS

Analysis of treatment-seeking paths revealed the absence of standardized treatment routes for women with fistula. To ensure effective care, raising societal awareness about fistula, improving treatment and referral systems, enhancing medical communication, and providing peer and emotional support are strongly recommended.

Sustaining women's empowerment for development in resource-limited settings: an exploratory qualitative approach

Background

Women's empowerment is one of the fundamental issues for attaining sustainable development goals crossing multiple dimensions. In Ethiopia, Women's Development Network (WDN), a network of women, was established in 2010 with development aims. Ensuring women's empowerment critically needs collective efforts of platforms such as WDN. However, there was a paucity of information about the patterns of WDN functionalities, its contribution, and factors affecting its functionality in rural areas of Southern Ethiopia. Hence, this study aimed to explore WDN status and factors affecting their functionality in Southern Ethiopia.

Methodology

The study employed an exploratory qualitative design. Data were collected from purposively selected zones using focus group discussions and key informant interviews. Audio-taped materials were transcribed verbatim and analyzed using a thematic approach. Initially, data were coded (open coding) and after several reviews, themes were developed and interpreted in line with the study objectives.

Result

WDN has passed several steps from its establishment up to now. It was seen skeptically at its early inception, very good level of acceptance in the middle, and staggering currently. However, WDN has contributed to improvements in household welfare resulting from increased ability to afford food, clothing, health, and education. Specific to health, WDN has contributed to general awareness creation, maternal and child health utilization, and environmental sanitation. On the other hand, the volunteer nature of the job put pressure on WDN and revealed socioeconomic stresses. Moreover, inconsistent support from stakeholders especially health extension workers, inadequate men's engagement, and sidelining of WDN by some educated women remain challenges for the sustainable functionality.

Conclusion

WDN has contributed to multidimensional development goals, especially health services uptake and environmental sanitation. However, over time, it became flaccid and lost adequate emphasis from most of its stakeholders and supportive structures. Therefore, considering such vital inputs from community participation in resource-limited settings, stakeholders should offer adequate attention to WDN in terms of selection, training, orientation, follow-up, and acquainting with the community they serve. Moreover, efforts are needed to retain women voluntarily serving and build positive images across all stakeholders and fellow women receiving the services.

Bangladesh should engage the private sector for malaria elimination by 2030

Bangladesh reduced malaria incidence by 93% from 2008 to 2020 through the action of governmental and non-governmental organizations. The Bangladesh context is unique to South Asia because its successful public sector malaria control programs have historically not engaged corporate partners (as undertaken in Sri Lanka and proposed in India). However, ∼18 million people continue to live at risk of infection in Bangladesh and for-profit private healthcare providers, catalytic for malaria elimination in many countries, are expected to benefit the national program. We distilled (from a large and complex literature) nine distinct strategies important in other developing settings and weighed them in the context of Bangladesh's flourishing private health care sector, driven by patient demand, self-interest and aspirations for public good, as well as heterogeneity in providers and malaria-prevalence. We propose a new model dependent on five strategies and its immediate deployment considerations in high endemic areas, to empower Bangladesh's phased agenda of eliminating indigenous malaria transmission by 2030.

Private sector engagement for immunisation programmes: a pragmatic scoping review of 25 years of evidence on good practice in low-income and middle-income countries

INTRODUCTION

Many National Immunisation Programmes attempt to leverage the private sector ; however, there is limited consolidated and synthesised documentation on good practices, gaps and lessons learnt. A 2017 WHO guidance document recommended best practices for private sector engagement (PSE) in immunisation. We conducted a pragmatic scoping review to identify gaps, update and consolidate evidence on promising practices in PSE for vaccination.

METHODS

Building on two previous reviews published in 2011 and 2017, we conducted a pragmatic scoping review of peer-reviewed publications from low-income and middle-income countries since September 2016 in PubMed that pertained to PSE and immunisation service delivery. We extracted and analysed findings using a new analytical framework covering motivations, enablers and barriers, risks and challenges, and engagement mechanisms.

RESULTS

We collated over 80 well-documented analyses of PSE for vaccination, derived from 54 peer-reviewed publications from 1998 to 2016 included in prior reviews, 21 new publications from 24 countries published since 2016 and 1 new systematic review. The level of PSE was mixed, ranging from 3%-4% to >60% of all childhood vaccinations. Promising practices for PSE included using governance and policy to leverage private providers' motivations and including them in programme efforts. Planning and monitoring efforts were effective when linked with regulatory requirements based on national standards for services, reporting and performance monitoring. Information systems were effective when they included private sector services in vaccine monitoring and surveillance. Challenges identified included ensuring compliance with national schedules and standards and minimising financial exclusion. Few studies documented successful public-private partnership models or other innovative financing models.

CONCLUSION

The published evidence captures numerous strategies to facilitate stronger immunisation programme engagement with the private sector. Stronger PSE can potentially reach zero-dose and underimmunised populations in low-resource settings and build resilient systems. Untapped opportunities exist for more structured testing of approaches to inform global guidance.

Health system challenges and opportunities in organizing non-communicable diseases services delivery at primary healthcare level in Bangladesh: A qualitative study

Introduction

The weak health system is viewed as a major systematic obstacle to address the rising burden of non-communicable diseases (NCDs) in resource-poor settings. There is little information about the health system challenges and opportunities in organizing NCD services. This study examined the health system challenges and opportunities in organizing NCD services for four major NCDs (cervical cancer, diabetes mellitus, cardiovascular diseases, and chronic respiratory illnesses) at the primary healthcare (PHC) level in Bangladesh.

Methods

Using a qualitative method, data were collected from May to October 2021 by conducting 15 in-depth interviews with local healthcare providers, 14 key informant interviews with facility-based providers and managers, and 16 focus group discussions with community members. Based on a health system dynamics framework, data were analyzed thematically. Information gathered through the methods and sources was triangulated to validate the data.

Results

Organization of NCD services at the PHC level was influenced by a wide range of health system factors, including the lack of using standard treatment guidelines and protocols, under-regulated informal and profit-based private healthcare sectors, poor health information system and record-keeping, and poor coordination across healthcare providers and platforms. Furthermore, the lack of functional referral services; inadequate medicine, diagnostic facilities, and logistics supply; and a large number of untrained human resources emerged as key weaknesses that affected the organization of NCD services. The availability of NCD-related policy documents, the vast network of healthcare infrastructure and frontline staff, and increased demand for NCD services were identified as the major opportunities.

Conclusion

Despite the substantial potential, the health system challenge impeded the organization of NCD services delivery at the PHC level. This weakness needs be to addressed to organize quality NCD services to better respond to the rising burden of NCDs at the PHC level.

Public Service Motivation and Determining Factors to Attract and Retain Health Professionals in the Public Sector: A Systematic Review

(1) Background: The motivational determinants of health professionals to choose and remain in the public sector have been increasingly addressed, including the customized approach of Public Service Motivation (PSM). However, to date, no systematic research overview has been performed in this domain, leaving the body of literature unstructured. This article fills this gap by assessing the motivational factors of choice for the public sector in the health field, and the conceptual and methodological trends of this research stream. (2) Methods: This study follows the PRISMA protocol to ascertain patterns in past research and inform researchers, practitioners, and policymakers. Eighty-nine documents published between 1998 and 2021 were retained after selecting them according to their theme and outlined goals. (3) Results: Common motivational determinants are remuneration, available resources, work conditions, and frequency of contact and interaction with patients. The PSM construct and scale are often employed as main frameworks, but there is also a concern in assessing motivation drawing on psychological constructs that reflect the challenging line of work and environment that is health care, such as presenteeism, stress, and perception of hindrances. (4) Conclusions: By focusing on health professionals' motivation, this study contributes to a timely systematization in challenging times for health institutions and their human resources.

Motivation to test, treat, and report malaria cases: a quantitative assessment among private sector providers in the Greater Mekong Subregion

Background

Accurately testing, treating, and tracking all malaria cases is critical to achieving elimination. Ensuring health providers are able and motivated to test, treat, and report cases is a necessary component of elimination programmes, and particularly challenging in low endemic settings where providers may not encounter a large volume of cases. This study aimed to understand provider motivations to test, treat, and report malaria cases to better optimize programme design, adjust incentive schemes, and ultimately improve reporting rates while growing the evidence base around private providers in the Greater Mekong Subregion (GMS).

Methods

With funding from the Bill & Melinda Gates Foundation, this study aimed to identify and validate distinctive subtypes of motivation among private sector providers enrolled in the Greater Mekong Subregion Elimination of Malaria through Surveillance (GEMS) programme, implemented by Population Services International. Quantitative questionnaires were administered electronically in person by trained enumerators to various provider groups in Myanmar, Lao PDR, and Vietnam. A three-stage confirmatory factor analysis was then conducted in STATA.

Results

Following this analysis, a two-factor solution that describes motivation in this population of providers was identified, and providers were scored on the two dimensions of motivation. The correlation between the two rotated factors was 0.3889, and the Kaiser–Meyer–Olkin (KMO) measure of sampling adequacy was 0.93, indicating an excellent level of suitability. These providers, who are often assumed to only be financially motivated, engaged in malaria elimination activities because of both internal and external motivational factors that are independent of remuneration or financial gain. For all three countries’ data, significant covariances between the two latent variables for internal and external motivation were found. The models were found to be of adequate to good fit for the data across all three countries. It was determined that private sector providers, who were previously believed to be primarily financially motivated, were also motivated by personal factors. Motivation was also associated with key outcomes of importance to malaria elimination, such as reporting and stocking of tests and treatments.

Conclusion

Maintaining or increasing provider motivation to test and treat is essential in the fight to eliminate malaria from the GMS, as it helps to ensure that providers continue to pursue this goal, even in a low incidence environment where cases may be rare and in which providers face financial pressure to focus on areas of health service provision. Establishing mechanisms to better motivate providers through intrinsic factors is likely to have a substantive impact on the sustainability of malaria case management activities.

Modelling improved efficiency in healthcare referral systems for the urban poor using a geo-referenced health facility data: the case of Sylhet City Corporation, Bangladesh

Background

An effective referral system is critical to ensuring access to appropriate and timely healthcare services. In pluralistic healthcare systems such as Bangladesh, referral inefficiencies due to distance, diversion to inappropriate facilities and unsuitable hours of service are common, particularly for the urban poor. This study explores the reported referral networks of urban facilities and models alternative scenarios that increase referral efficiency in terms of distance and service hours.

Methods

Road network and geo-referenced facility census data from Sylhet City Corporation were used to examine referral linkages between public, private and NGO facilities for maternal and emergency/critical care services, respectively. Geographic distances were calculated using ArcGIS Network Analyst extension through a “distance matrix” which was imported into a relational database. For each reported referral linkage, an alternative referral destination was identified that provided the same service at a closer distance as indicated by facility geo-location and distance analysis. Independent sample t-tests with unequal variances were performed to analyze differences in distance for each alternate scenario modelled.

Results

The large majority of reported referrals were received by public facilities. Taking into account distance, cost and hours of service, alternative scenarios for emergency services can augment referral efficiencies by 1.5–1.9 km (p < 0.05) compared to 2.5–2.7 km in the current scenario. For maternal health services, modeled alternate referrals enabled greater referral efficiency if directed to private and NGO-managed facilities, while still ensuring availability after working-hours. These referral alternatives also decreased the burden on Sylhet City’s major public tertiary hospital, where most referrals were directed. Nevertheless, associated costs may be disadvantageous for the urban poor.

Conclusions

For both maternal and emergency/critical care services, significant distance reductions can be achieved for public, NGO and private facilities that avert burden on Sylhet City’s largest public tertiary hospital. GIS-informed analyses can help strengthen coordination between service providers and contribute to more effective and equitable referral systems in Bangladesh and similar countries.