Universal Health Coverage in Bangladesh: Activities, Challenges, and Suggestions

A scoping review to evaluate the efficacy of combining traditional healing and modern psychiatry in global mental healthcare

Traditional faith healers (TFHs) are often consulted for serious mental illness (SMIs) in low- and middle-income countries (LMICs). Involvement of TFHs in mental healthcare could provide an opportunity for early identification and intervention to reduce the mental health treatment gap in LMICs. The aim of this study was to identify models of collaboration between TFHs and biomedical professionals, determine the outcomes of these collaborative models and identify any mechanisms (i.e., explanatory processes) or contextual moderators (i.e., barriers and facilitators) of these outcomes. A systematic scoping review of five electronic databases was performed from inception to March 2023 guided by consultation with local experts in Nigeria and Bangladesh. Data were extracted using a predefined data charting form and synthesised narratively. Six independent studies (eight articles) satisfied the inclusion criteria. Study locations included Ghana (n = 1), Nigeria (n = 1), Nigeria and Ghana (n = 1), India (n = 1), Hong Kong (n = 1) and South Africa (n = 1). We identified two main intervention typologies: (1) Western-based educational interventions for TFHs and (2) shared collaborative models between TFHs and biomedical professionals. Converging evidence from both typologies indicated that education for TFHs can help reduce harmful practices. Shared collaborative models led to significant improvements in psychiatric symptoms (in comparison to care as usual) and increases in referrals to biomedical care from TFHs. Proposed mechanisms underpinning outcomes included trust building and empowering TFHs by increasing awareness and knowledge of mental illness and human rights. Barriers to implementation were observed at the individual (e.g., suspicions of TFHs), relationship (e.g., reluctance of biomedical practitioners to equalise their status with TFHs) and service (e.g., lack of formal referral systems) levels. Research on collaborative models for mental healthcare is in its infancy. Preliminary findings are encouraging. To ensure effective collaboration, future programmes should incorporate active participation from community stakeholders (e.g., patients, caregivers, faith healers) and target barriers to implementation on multiple levels.

Assessing health systems' capacities to provide post-abortion care: insights from seven low- and middle-income countries

Background

Abortion-related complications significantly contribute to maternal morbidity and mortality globally. Post-abortion care (PAC) services are essential to safeguarding women's rights by substantially mitigating the health risks associated with abortions - a step which is fundamental to achieving reproductive and maternal health-related Sustainable Development Goals.

Methods

We conducted a secondary analysis of data from the nationally representative Service Provision Assessment (SPA) surveys conducted between 2015 and 2024 across three regions in seven low- and middle-income countries: Afghanistan, Bangladesh, Nepal, the Democratic Republic of Congo (DRC), Ethiopia, Senegal, and Haiti. We included 2951 primary facilities and 473 referral facilities offering normal delivery services. We used PAC signal functions to report capacity to provide basic and comprehensive PAC services in primary and referral facilities, respectively.

Results

Of all primary facilities offering normal delivery services, 50% in Afghanistan, 1% in Bangladesh, 8% in Nepal, 5% in DRC, 34% in Ethiopia, 38% in Senegal, and 19% in Haiti had the capacity to provide basic PAC services. Of the referral facilities, 47% in Afghanistan, 16% in Bangladesh, 50% in Nepal, 52% in DRC, 75% in Ethiopia, 46% in Senegal, and 32% in Haiti had the capacity to provide comprehensive PAC services. Primary facilities in Bangladesh, DRC, and Nepal had critical gaps in referral, ie, effective communication with referral centres and availability of a functional vehicle for emergency transportation. In referral facilities, 74% in Bangladesh and 59% in Nepal had the provision of blood transfusion. In terms of basic PAC services in primary facilities, the capacity of Senegal (from 16% in 2015 to 38% in 2019; P = 0.001) and Haiti (from 12% in 2013 to 19% in 2018; P = 0.007) increased, but the capacity of Bangladesh decreased (from 4% in 2014 to 1% in 2017; P = 0.016) over time.

Conclusions

There are substantial gaps in the capacity to provide basic and comprehensive PAC services in the selected countries. Investing in primary healthcare and improving communication and transportation should be the priority for enhancing basic PAC services, while strengthening referral hospitals to effectively handle emergencies and conduct major surgeries could significantly bolster their capacity to provide comprehensive PAC services.

How and why does mode of birth affect processes for routine data collection and use? A qualitative study in Bangladesh and Tanzania

The World Health Organization recognises Routine Health Information System (RHIS) data as integral to data-driven health systems; needed to improve intrapartum outcomes for maternal and newborn health worldwide. However, research in Bangladesh and Tanzania suggests that mode of birth affects register data accuracy, but little is known about why. To address this gap, we undertook qualitative research in these two public-sector health systems. We conducted 44 in-depth interviews in Bangladesh (Sept-Dec 2020) and 35 in Tanzania (Feb-April 2023). Participants included health and data professionals, managers, and leaders from sub-national and national levels. Thematic analysis was undertaken with inductive and deductive coding. Emerging themes were compared/organised using determinants outlined in the Performance of Routine Information System Management (PRISM) framework. Mode of birth affected RHIS data as one part in a multidimensional system; having a caesarean changed the location of birth, availability of health professionals, and the care pathway, impacting data flow and documentation processes at facility-level. Standardised registers were available in the labour wards, but not in all operating theatres. Health professionals in both countries described feeling overwhelmed by duplicative data tasks and competing clinical care responsibilities, especially in labour wards with low staffing ratios. Health professionals perceived electronic data systems to increase duplication (for all modes of birth), along with other organisational factors. In conclusion, mode of birth influenced processes for routine data collection and use because it affected where, what, when, and by whom data were recorded. We found challenges for capturing register data, leading to potential data gaps, especially for caesarean births. Our findings suggest a broader lens is needed to improve the systems, collection, and use of individual-level data for aggregation, not just registers. Co-design of RHIS processes and tools could rationalise the data burden and increase availability and quality of perinatal data for use.

Assessing the quality of data for selected reproductive health indicators in designated public health facilities in Bangladesh

Background

An effective health management information system plays a pivotal role in evidence-based decision-making and strengthening health service delivery in a country. The Directorate General of Health Services and the Directorate General of Family Planning of Bangladesh have adopted digital health management information system platforms named district health information system and management information system, respectively. Despite its significance, health management information system data has numerous issues, such as missing values, inaccuracies, lack of internal consistency, and the presence of outliers. This study aims to assess the data quality of reproductive health indicators in the health management information system of the Directorate General of Health Services and the Directorate General of Family Planning.

Methods

The study examined two aspects of data quality: a) completeness of data, subdivided into completeness of facility reporting (report submission rate) and completeness of indicator data (presence of missing values); b) internal consistency of reported data, subdivided into presence of outliers, inter-indicator consistency, and consistency between reported data and original records (accuracy rate). The study utilised retrospective monthly data gathered from July 2021 to June 2022, covering 21 reproductive health indicators. Multi-stage cluster sampling was employed to select 112 health facilities for data collection, including 48 facilities from Directorate General of Health Services and 64 from Directorate General of Family Planning, representing various administrative levels across the country.

Result

The report submission rate for Directorate General of Health Services facilities was 98%, while for the Directorate General of Family Planning facilities, it was 86%. However, 35% of data points were missing in the district health information system server of Directorate General of Health Services, whereas no missing values were observed in the management information system server of Directorate General of Family Planning. Less than 3% of outliers were detected in the server data of both directorates. Inter-indicator consistency was maintained at a high rate of 98% in health facilities under both directorates. The accuracy of reported data varied across indicators and facility types: Directorate General of Health Services facilities showed accuracy rates ranging between 75 and 92%, with an aggregated rate of 86%. Different tiers of the Directorate General of Family Planning facilities had accuracy rates ranging from 92 to 96%.

Conclusion

This research emphasises the significance of rectifying missing values, ensuring consistency, and improving reporting systems, with a particular focus on lower-tier health facilities, to enhance the validity and reliability of reproductive health data in Bangladesh.

NGOs' initiatives and grassroots approach for accessing to health care services for the slum people in Dhaka

Objective

This study holds significant importance as it aims to delve into the impactful NGOs' initiatives and grassroots approaches instrumental in providing healthcare services to Dhaka's underserved slum people. It focuses on understanding how these factors influence the use and access to health services, which is a crucial aspect for researchers, policymakers, and healthcare professionals.

Study design

This study was meticulously designed, utilizing a comprehensive cross-sectional mixed-methods design. By incorporating qualitative and quantitative data collection methods, we ensured a thorough understanding of NGOs' initiatives and grassroots approaches to providing healthcare services to slum dwellers in Dhaka, thereby instilling confidence in the validity of our research for the audience.

Methods

A face-to-face interview was used to survey the participants (n = 722) using semi-structured questionnaires, following a systematic sampling technique. Four focus group discussions (FGDs) were also conducted with the slum people. Binary logistic regression was performed to know NGOs' initiatives, roles, and grassroots approach as predictors or independent variables and healthcare services as an outcome or dependent variable. The quantitative data were analyzed using SPSS version 23.0. At the same time, thematic analysis was conducted following Philip Adu's Qualitative data analysis process and Braun and Clarke's six steps of the thematic analysis system, integrating the 11 subthemes with the quantitative findings to highlight the interpretative findings of the qualitative data.

Findings

Major findings revealed that NGOs' initiative roles and grassroots approach had a significant impact on slum dwellers' use and access to healthcare services. The initiatives included affordable health services (OR = 22.86, 95% CI = 3.87, 35.00, P = 0.01), special health services (OR = 5.63, 95% CI = 3.36, 9.42, P = 0.00), engagement of responsible community leaders (OR = 1.72, 95% CI = 1.14, 2.59, P = 0.01), distribution of health and medicine items (OR = 1.92, 95% 2 CI = 1.40, 2.63, P = 0.01), provision of updated information to slum dwellers (OR = 1.37, 95% CI = .99, 1.90, P = 0.05), telehealth and telemedicine (OR = 1.82, 95% CI = 1.55, 2.13, P = 0.01), BCC strategy (OR = 1.26, 95% CI = 1.00, 1.57, P = 0.05), and doorstep services as NGOs' grassroots approach (OR = 1.84, 95% CI = 1.00, 3.38, P = 0.05). Qualitative findings supported the quantitative findings through 2 main themes and 11 sub-themes, which were integrated with quantitative findings to highlight the interpretative findings of qualitative data.

Conclusions

Health services and other facilities for urban slum people through NGOs' initiatives and grassroots approaches are highly affordable and practical, special health services with the involvement of special exceptional health professionals, community supportive services, BCC strategies, and doorstep health services may trigger the use and access to health services for slum dwellers. Results suggest and recommend capitalizing and investing in such initiatives and grassroots approaches from the government, policymakers, and donors with NGOs to find accessible, affordable health services for the unprivileged slum people.

Knowledge attitude and convenience on self-medication practices among university students in Bangladesh exploration using structural equation modeling approach

Self-medication is a prevalent practice among university students globally and is a significant public health concern. However, previous research has been limited in scope, focusing primarily on adolescents or the general public, leaving a gap in understanding the causal relationships associated with self-medication; thus, this study aimed to investigate the factors influencing self-medication practices among university students in Bangladesh by developing a comprehensive causal model. Data from 417 students across five public universities were collected using the simple random walk technique by a team of 10 members. The study utilized constructs of knowledge, attitude, and convenience related to self-medication as independent variables, while self-medication practice as the dependent variable. One-way ANOVA and structural equation modeling (SEM) were employed to develop a causal model of self-medication practice among university students in Bangladesh. The findings revealed that students with better medication knowledge and adverse drug reactions (ADRs) were more likely to practice self-medication. A positive attitude towards self-medication and ADRs was also significantly associated with higher self-medication practice scores. Additionally, those who perceived self-medication as convenient and prescribed medication as inconvenient had higher self-medication practice scores. The attitude towards self-medication had the most substantial negative effect on self-medication practice, followed by the inconvenience of prescribed medication and the convenience of self-medication. The model explained 87% of the variance in self-medication practice, indicating a good fit for the data. University students in Bangladesh possess intermediate knowledge of medication and primary knowledge of ADRs. They exhibit a positive attitude towards self-medication and ADRs. Physical convenience favors self-medication, while the inconvenience of prescribed medication contributes to its lower preference. Policymakers should focus on evidence-based guidelines to reduce the extent of unnecessary self-medication practice and to enhance the quantity and accessibility of prescribed medications to address the issue effectively.

Availability and readiness of healthcare facilities and their effects on antenatal care services uptake in Bangladesh

BACKGROUND

Sustainable Development Goal (SDG) 3.7 aims to ensure universal access to sexual and reproductive healthcare services, where antenatal care (ANC) is a core component. This study aimed to examine the influence of health facility availability and readiness on the uptake of four or more ANC visits in Bangladesh.

METHODS

The 2017/18 Bangladesh Demographic and Health Survey data were linked with the 2017 Health Facility Survey and analyzed in this study. The associations of health facility-level factors with the recommended number of ANC uptakes were determined. A multilevel mixed-effect logistic regression model was used to determine the association, adjusting for potential confounders.

RESULTS

Nearly 44% of mothers reported four or more ANC uptakes, with significant variations across several areas in Bangladesh. The average distance of mothers' homes from the nearest health facilities was 6.36 km, higher in Sylhet division (8.25 km) and lower in Dhaka division (4.45 km). The overall uptake of the recommended number of ANC visits was positively associated with higher scores for the management (adjusted odds ratio (aOR) 1.85; 95% CI, 1.16-2.82) and infrastructure (aOR, 1.59; 95% CI, 1.09-2.19) of health facilities closest to mothers' homes. The odds of using the recommended number of ANC in mothers increased by 3.02 (95% CI, 2.01-4.19) and 2.36 (95% CI, 2.09-3.16) folds for each unit increase in the availability and readiness scores to provide ANC services at the closest health facilities, respectively. Every kilometer increase in the average regional-level distance between mothers' homes and the nearest health facilities reduced the likelihood of receiving the recommended number of ANC visits by nearly 42% (aOR, 0.58, 95% CI, 0.42-0.74).

CONCLUSION

The availability of healthcare facilities close to residence, as well as their improved management, infrastructure, and readiness to provide ANC, plays a crucial role in increasing ANC services uptake. Policies and programs should prioritize increasing the availability, accessibility, and readiness of health facilities to provide ANC services.

Assessing public health sector performance in Bangladesh: Implications for health systems strengthening and universal health coverage - A secondary data analysis

The Ministry of Health and Family Welfare has established a health systems strengthening initiative for measuring the performance of public sector health facilities in Bangladesh. The objective of the performance management initiative is to establish routine systems for measuring and scoring health facility performance and promote best practices in public health service management. The performance initiative includes a set of assessments conducted across the four tiers of the public health sector. The findings of assessments demonstrate improvements in the quality of health services and a sharp increase in the utilisation of services across all tiers during the period 2017-2019. The performance management initiative has also identified areas for improvement in the supply-side health system readiness, including ensuring an adequate supply of human resources, essential medicines, and functioning medical equipment and technologies. This initiative outlines the need to systematically address the issue of high health workforce vacancy rates through effective human resource planning and management strategies. The reporting of these ongoing health systems successes and challenges through the performance management initiative in Bangladesh provides an opportunity to develop evidence-based policy reforms for strengthening supply-side health systems. The initiative results, particularly in the context of growing public demand for services, also justifies a monitoring and evaluation mechanism focusing on the quality and coverage of frontline health facilities and the development of more integrated health systems. The performance management initiative will facilitate the maintenance of essential health services while addressing emergency health needs and tracking progress towards achieving the Universal Health Coverage goal.

The effects of spousal migration on perinatal healthcare utilization

Over the last three decades, out-migration has become a stable source of income for more than 12 million Bangladeshis. Of those migrants, 90% are men. Due to patriarchal cultural norms in Bangladeshi society, the migration of a male spouse may have significant consequences for the social well-being and health of left-behind women. In this study, we examine the impact of external (out of country) and internal (rural to urban) spousal migration on the perinatal healthcare utilization of left-behind women. We used data from the 2012 Matlab Health and Socioeconomic Survey (MHSS2) to examine use of antenatal care, presence of a medically qualified attendant at birth, and delivery at a healthcare facility for live births that occurred between 2007 and 2014 for currently married women aged 15-45 (N = 1,458 births among 1,180 women). Adjusted regression models indicated that for births occurring to women with a migrant spouse, odds of receiving antenatal care were significantly higher (OR: 4.1 for births to women with a domestic urban migrant spouse and 4.6 for births to women with an international migrant spouse, p < 0.01). Spousal migration was not linked to having a medically qualified attendant at birth or delivery at a clinic or hospital. Results suggest that spousal migration may be beneficial for receiving health care during a pregnancy, but not for the type of attendant or place of delivery at birth.

Policy analysis of the protection of Iranian households against catastrophic health expenditures: a qualitative analysis

BACKGROUND

Despite the adoption of various policies and strategies in recent decades, the Iranian health system has not succeeded in protecting households against catastrophic health expenditures (CHE) and impoverishment. Accordingly, this qualitative study aimed to critically analyze current policies for reducing CHE.

METHODS

This qualitative study was conducted as a retrospective policy analysis based on a document review and semi-structured interviews with key informants between July to October 2022. Two theoretical frameworks were used, including the Analysis of Determinants of Policy Impact (ADEPT) model and Walt and Gilson's "Policy Triangle framework." The country's related documents were searched through databases. In total, 35 participants were interviewed. Interviews and documents were analyzed using directed content analysis in MAXQDA v12 software. Interobserver reliability, peer check, and member check were done to confirm the trustworthiness of the data.

RESULTS

Twelve main themes and 42 sub-themes emerged from the data. The findings revealed that policy accessibility, policy background, and a clear statement of goals influenced the policy process. However, resources, monitoring and evaluation, opportunities, and obligations negatively affected the implementation process. In addition, a policy analysis based on the policy triangle framework demonstrated that the main factors affecting the policy on reducing CHE in Iran were "conflicts of interest," "contextual factors," "monitoring and evaluation," and "intersectoral relationship" factors.

CONCLUSION

The present study reflected the multifaceted nature of the barriers to reducing CHE in Iran. The implementation of the policy on reducing CHE requires the political will to improve intersectoral collaboration, strengthen the stewardship role of the Ministry of Health, design monitoring and evaluation mechanisms, and prevent personal and organizational conflicts of interest.

Social Determinants and Prevalence of Antenatal Depression among Women in Rural Bangladesh: A Cross-Sectional Study

The prevalence of antenatal depression in Bangladesh ranges from 18 to 33%. Antenatal depression has negative impacts on the mother and child such as suicidal ideations, low birth weight, and impaired fetal development. This cross-sectional study aims to determine the prevalence and social determinants of antenatal depression in rural Sylhet, Bangladesh. Data were collected from 235 pregnant women between March and November 2021. The validated Bangla Edinburgh Postnatal Depression Scale was used to measure antenatal depressive symptoms (ADS). Background information was collected using a structured questionnaire including the Duke Social Support and Stress Scale, pregnancy choices, and WHO Intimate Partner Violence questions. Point-prevalence of antenatal depression was 56%. Intimate partner violence (IPV) before pregnancy (adjusted odds ratio (AOR) 10.4 [95% confidence interval (CI) 2.7-39.7]) and perceived husband's male gender preference (AOR 9.9 [95% CI 1.6-59.6]) were significantly associated with increased odds of ADS among pregnant women. Increased family support was a significant protective factor for ADS (AOR 0.94 [95% CI 0.91-0.97]). Antenatal depression commonly occurs in rural Sylhet, Bangladesh, highlighting the need for improved screening and management within these settings. The findings suggest the need for community-based interventions for women with low family support and experiencing intimate partner violence, and educational programs and gender policies to tackle gender inequalities.

Transforming access to care for serious mental disorders in slums (the TRANSFORM Project): rationale, design and protocol

This paper introduces the TRANSFORM project, which aims to improve access to mental health services for people with serious and enduring mental disorders (SMDs - psychotic disorders and severe mood disorders, often with co-occurring substance misuse) living in urban slums in Dhaka (Bangladesh) and Ibadan (Nigeria). People living in slum communities have high rates of SMDs, limited access to mental health services and conditions of chronic hardship. Help is commonly sought from faith-based and traditional healers, but people with SMDs require medical treatment, support and follow-up. This multicentre, international mental health mixed-methods research project will (a) conduct community-based ethnographic assessment using participatory methods to explore community understandings of SMDs and help-seeking; (b) explore the role of traditional and faith-based healing for SMDs, from the perspectives of people with SMDs, caregivers, community members, healers, community health workers (CHWs) and health professionals; (c) co-design, with CHWs and healers, training packages for screening, early detection and referral to mental health services; and (d) implement and evaluate the training packages for clinical and cost-effectiveness in improving access to treatment for those with SMDs. TRANSFORM will develop and test a sustainable intervention that can be integrated into existing clinical care and inform priorities for healthcare providers and policy makers.

Proportion and associated factors of the utilisation of complementary and alternative medicine exclusively in a hospital in Bangladesh

Background

Complementary and alternative medicine (CAM) has played a critical role in ensuring universal access to basic health care services around the world. In Bangladesh, conventional medicine is a common approach for health care practices, yet, due to Bangladesh’s high out-of-pocket payment, millions of people utilise CAM-based healthcare services for illnesses. In Bangladesh, there is a scarcity of data on how CAM is perceived and utilised. The goal of this study was to determine the proportion and correlates of the utilisation of CAM among patients visiting a tertiary level hospital, in Bangladesh.

Methods

A cross-sectional survey involving 1,183 patients who received health care from a hospital in Bangladesh was interviewed for this study. The associated factors on utilising CAM were identified using multivariable logistic regression analysis.

Results

Thirty-three percent of patients utilised CAM exclusively to treat their illnesses, whereas the rest utilised conventional medicine before CAM. Young adult patients aged 26 to 45 years (AOR = 6.26, 95% CI:3.24–12.07), patients without education (AOR = 2.99, 1.81–4.93), and married patients (AOR = 1.79, 1.08–2.97) were the most likely to be only CAM users. The most common reasons for using CAM were belief in its effectiveness, less adverse effects, affordability and lower costs.

Conclusion

In Bangladesh, CAM plays a significant role in health care delivery, with high-levels of patient satisfaction and health benefits. Patients who are older and have a higher level of education are more hesitant to use CAM for their illness, yet CAM has the potential to play a significant role in reducing hospitalisation by providing high reliability and low costs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12906-022-03709-8.

Universality of universal health coverage: A scoping review

BACKGROUND

The progress of Universal health coverage (UHC) is measured using tracer indicators of key interventions, which have been implemented in healthcare system. UHC is about population, comprehensive health services and financial coverage for equitable quality services and health outcome. There is dearth of evidence about the extent of the universality of UHC in terms of types of health services, its integrated definition (dimensions) and tracer indicators utilized in the measurement of UHC. Therefore, we mapped the existing literature to assess universality of UHC and summarize the challenges towards UHC.

METHODS

The checklist Preferred Reporting Items for Systematic reviews and Meta-analysis extension for Scoping Reviews was used. A systematic search was carried out in the Web of Science and PubMed databases. Hand searches were also conducted to find articles from Google Scholar, the World Bank Library, the World Health Organization Library, the United Nations Digital Library Collections, and Google. Article search date was between 20 October 2021 and 12 November 2021 and the most recent update was done on 03 March 2022. Articles on UHC coverage, financial risk protection, quality of care, and inequity were included. The Population, Concept, and Context framework was used to determine the eligibility of research questions. A stepwise approach was used to identify and select relevant studies, conduct data charting, collation and summarization, as well as report results. Simple descriptive statistics and narrative synthesis were used to present the findings.

RESULTS

Forty-seven papers were included in the final review. One-fourth of the articles (25.5%) were from the African region and 29.8% were from lower-middle-income countries. More than half of the articles (54.1%) followed a quantitative research approach. Of included articles, coverage was assessed by 53.2% of articles; financial risk protection by 27.7%, inequity by 25.5% and quality by 6.4% of the articles as the main research objectives or mentioned in result section. Most (42.5%) of articles investigated health promotion and 2.1% palliation and rehabilitation services. Policy and healthcare level and cross-cutting barriers of UHC were identified. Financing, leadership/governance, inequity, weak regulation and supervision mechanism, and poverty were most repeated policy level barriers. Poor quality health services and inadequate health workforce were the common barriers from health sector challenges. Lack of common understanding on UHC was frequently mentioned as a cross-cutting barrier.

CONCLUSIONS

The review showed that majority of the articles were from the African region. Methodologically, quantitative research design was more frequently used to investigate UHC. Palliation and rehabilitation health care services need attention in the monitoring and evaluation of UHC progress. It is also noteworthy to focus on quality and inequity of health services. The study implies that urgent action on the identified policy, health system and cross-cutting barriers is required to achieve UHC.

Disease-specific distress healthcare financing and catastrophic out-of-pocket expenditure for hospitalization in Bangladesh

Background

Financial risk protection and equity are two fundamental components of the global commitment to achieve Universal Health Coverage (UHC), which mandates health system reform based on population needs, disease incidence, and economic burden to ensure that everyone has access to health services without any financial hardship. We estimated disease-specific incidences of catastrophic out-of-pocket health expenditure and distress financing to investigate progress toward UHC financial risk indicators and investigated inequalities in financial risk protection indicators by wealth quintiles. In addition, we explored the determinants of financial hardship indicators as a result of hospitalization costs.

Methods

In order to conduct this research, data were extracted from the latest Bangladesh Household Income and Expenditure Survey (HIES), conducted by the Bangladesh Bureau of Statistics in 2016–2017. Financial hardship indicators in UHC were measured by catastrophic health expenditure and distress financing (sale/mortgage, borrowing, and family support). Concentration curves (CC) and indices (CI) were estimated to measure the pattern and severity of inequalities across socio-economic classes. Binary logistic regression models were used to assess the determinants of catastrophic health expenditure and distress financing.

Results

We found that about 26% of households incurred catastrophic health expenditure (CHE) and 58% faced distress financing on hospitalization in Bangladesh. The highest incidence of CHE was for cancer (50%), followed by liver diseases (49.2%), and paralysis (43.6%). The financial hardship indicators in terms of CHE (CI = -0.109) and distress financing (CI = -0.087) were more concentrated among low-income households. Hospital admission to private health facilities, non-communicable diseases, and the presence of chronic patients in households significantly increases the likelihood of higher UHC financial hardship indicators.

Conclusions

The study findings strongly suggest the need for national-level social health security schemes with a particular focus on low-income households, since we identified greater inequalities between low- and high-income households in UHC financial hardship indicators. Regulating the private sector and implementing subsidized healthcare programmes for diseases with high treatment costs, such as cancer, heart disease, liver disease, and kidney disease are also expected to be effective to protect households from financial hardship. Finally, in order to reduce reliance on OOPE, the government should consider increasing its allocations to the health sector.

Determinants and Trends of Health Facility Delivery in Bangladesh: A Hierarchical Modeling Approach

Background

Most maternal deaths occur during childbirth and after childbirth. This study was aimed at determining the trends of health facilities during delivery in Bangladesh, as well as their influencing factors.

Methods

This study used secondary data from three Bangladesh Multiple Indicator Cluster Surveys (MICSs) in 2006, 2012–13, and 2019. The study's target sample was those women who gave birth in the last two years of the survey. A two-level logistic regression was applied to determine the effects on health facility delivery separately in these two survey points (MICSs 2012–13 and 2019).

Results

The results show that the delivery of health facilities has increased by almost 37.4% in Bangladesh, from 16% in 2006 to 53.4% in 2019. The results of two-level logistic regression show that the total variation in health facility delivery across the community has decreased over recent years. After adding community variables, various individual-level factors such as women with secondary education (OR = 0.55 in 2012-13 vs. OR =0.60 in 2019), women from middle wealth status (OR = 0.49 in 2012-13 vs. OR = 0.65 in 2019), religion, and child ever born showed a strong relationship with health facility delivery in both survey years. At the community level, residents showed significant association only in the 2012-13 survey and indicated a 43% (OR = 1.43 for 2012-13) greater availability of health facilities in urban residences than in rural residences. Using media showed a highly significant connection with health facility delivery in both years as well as an increasing trend over the years in Bangladesh (OR = 1.19 in 2012-13 vs. OR = 1.38 in 2019). However, division, prenatal care, and skilled services all contribute greatly to increasing the delivery of health facilities in Bangladesh.

Conclusions

The results of this study suggest that policymakers need to pay attention to individual and community-level factors, especially women's education, poverty reduction, and adequate prenatal care provided by well-trained caregivers.

Challenges to Achieving Universal Health Coverage Tthroughout the World: A Systematic Review

Objectives

No systematic review has explored the challenges related to worldwide universal health coverage (UHC). This study reviewed challenges on the road to UHC.

Methods

A systematic electronic search of all studies that identified the challenges of worldwide UHC was conducted, without any restrictions related to the publication date or language. A hand search and a bibliographic search were also conducted to identify which texts to include in this study. These sources and citations yielded a total of 2500 articles, only 26 of which met the inclusion criteria. Relevant data from these papers were extracted, summarized, grouped, and reported in tables.

Results

Of the 26 included studies, 7 (27%) were reviews, 6 (23%) were reports, and 13 (50%) had another type of study design. The publication dates of the included studies ranged from 2011 to 2020. Nine studies (35%) were published in 2019. Using the World Health Organization conceptual model, data on all of the challenges related to UHC in terms of the 4 functions of health systems (stewardship, creating resource, financing, and delivering services) were extracted from the included studies and reported.

Conclusions

This study provides a straightforward summary of previous studies that explored the challenges related to UHC and conducted an in-depth analysis of viable solutions.

Gender disparity in telehealth usage in Bangladesh during COVID-19

Background and aims

Telehealth allows healthcare workers to see patients virtually in locations that were not accessible previously, which has reduced cost and time and saved lives. The research aims to examine gender disparity among telehealth usage during the pandemic in 2020. This study will leverage a timely national experiment to evaluate the users of telehealth across the Bangladeshi population.

Methods

We obtained de-identified data for 200 patients among outpatient telehealth visits from Global Health Data Exchange as it captured telehealth use throughout Bangladesh.

Results

The analysis showed that male patients had a higher dependency on telehealth than female patients. 14% of the female patients opted for telehealth visits only with 57% cases of missed doses of medication, compared to males with 20% of them choosing telehealth visits and 29% missing their doses of medication. We found that the youngest age group, 16–25, had the highest dependence on telehealth compared to any other age group, and the lowest dependence was among the oldest age group of 45 years and above.

Conclusions

There was a strong association between telehealth use and gender disparity with p value ​= ​0.02 ​< ​0.05. Longitudinal and geographical data are needed to understand more about the gender disparities and impact in telehealth utilizations.

Prevalence and Determinants of Antibiotic Self-Administration Among Adult Antibiotic Users: A Cross-Sectional Study

INTRODUCTION

Each year, antibiotics save hundreds of thousands of lives; nonetheless, antibiotic self-administration is a major concern all over the world. This study aimed to investigate the prevalence of antibiotic self-administration among two-month adult antibiotic users as well as the factors contributing to this prevalence.

METHOD AND PARTICIPANTS

This cross-sectional study was conducted among 295 Bangladeshi adults between May 22nd and June 15th, 2021, during the COVID-19 pandemic. Descriptive statistics included frequency distribution, while inferential statistics included the Pearson chi-square test. For data analysis, the statistical software STATA-16 was used.

RESULTS

In this study, the prevalence of antibiotic self-administration was 17.97%. Antibiotic self-administration was found to be significantly more prevalent among those who were unable to take antibiotic on time, incomplete doses, did not know over prescriptions may cause antibiotic resistance, and could not correctly recognize amoxicillin and azithromycin are antibiotics.

CONCLUSION

Due to the increased rate of antibiotic self-administration among adults in Bangladesh, the responsible authority should give more attention towards the factors responsible for antibiotic self-administration and revise their current policy to ensure the safe and effective use of antibiotics.

Patient satisfaction level and its determinants after admission in public and private tertiary care hospitals in Bangladesh

Introduction

Patient satisfaction is an important indicator of the quality of care provided by health care facilities. The objective of this study was to investigate the rate of satisfaction and its associated factors among the patients admitted to tertiary care hospitals in Bangladesh.

Methods

This cross-sectional study was conducted in a public and two private tertiary care hospitals in Bangladesh in December 2019, including 923 consecutive patients admitted to medical and surgical departments. Face-to-face interview using a structured questionnaire was conducted to collect patient-level data. Logistic regression models were used to determine the factors associated with patients' satisfaction.

Results

Patients' overall satisfaction level was 65% (51% in public and 75% in private hospitals) with a satisfaction rate of 63% in hospital staff courtesy, 56.5% in a hospital environment, 67% in physician care, 63% in general patient satisfaction, and 58% in patient's family care. Private hospitals (aOR 3.64, 95% CI 2.2-6.03), conservative management (aOR 3.34, 95% CI 2.10-5.33), shorter hospital stay (aOR 1.58, 95% CI 1.05-2.37) and perceived improvement after treatment (aOR 1.67, 95% CI 1.01-2.76) were associated with patients' satisfaction. In contrast, patients' accommodation on the floor (aOR 0.38, aOR 0.22-0.66) and high health care costs (aOR 0.97, 95% CI 0.95-0.99) were associated with patients' dissatisfaction with the in-patient service they received in both public and private hospitals.

Conclusion

Almost two-thirds of the patients were satisfied with the inpatient service they received, though, the satisfaction rate was higher in private hospitals. Treatment modality, cost, and outcome, as well as hospital environment like accommodation, were associated with their satisfaction level.

Health insurance for university students in Bangladesh: A novel experiment

BACKGROUND AND AIMS

Bangladesh requires some pragmatic initiatives for using its immense potentiality to flourish health insurance. Introducing group health insurance for university students is a groundbreaking idea for stepping toward social health insurance in Bangladesh. This article examined the effect of the health insurance initiative for the university students introduced by the Institute of Health Economics, University of Dhaka, on attitude toward insurance and protecting financial risk against health care expenditure.

METHOD

We used both management information system (MIS) and primary data obtained through mixed methods. We collected the quantitative data from a baseline survey on 310 students and a year-end survey on 151 students. We used bivariate tools to analyze the data.

RESULTS

The results show that the mean score of attitude toward health insurance in the year-end survey (4.04) was significantly higher than the baseline score (3.21). Results also show that a significantly higher percentage of the students reported insurance as "useful" in the year-end survey (83.74%) than the baseline survey (40.40%). The results also reflectes that the scheme has a substantial impact on reducing the out-of-pocket spending for health care, especially for in-patient care, and the anxiety regarding the financing of health care among the students. There is also an indication of sustainability and the feasibility of scaling up such a scheme across the country.

CONCLUSIONS

Introducing such health insurance by all the universities may guide the nation toward large-scale group health insurance and social health insurance.

Mapping the health systems response to violence against women: key learnings from five LMIC settings (2015-2020)

Background

Violence against women (VAW) is a global challenge, and the health sector is a key entry point for survivors to receive care. The World Health Organization adopted an earlier framework for health systems response to survivors. However, documentation on the programmatic rollout of health system response to violence against women is lacking in low and middle-income countries. This paper studies the programmatic roll out of the health systems response across select five low- and middle-income countries (LMIC) and identifies key learnings.

Methods

We selected five LMIC settings with recent or active programming on national-level health system response to VAW from 2015 to 2020. We synthesized publicly available data and program reports according to the components of the WHO Health Systems Framework. The countries selected are Bangladesh, Brazil, Nepal, Rwanda, and Sri Lanka.

Results

One-stop centers were found to be the dominant model of care located in hospitals in four countries. Each setting has implemented in-service training as key to addressing provider knowledge, attitudes and practice; however, significant gaps remain in addressing frequent staff turnover, provision of training at scale, and documentation of the impact of training. The health system protocols for VAW address sexual violence but do not uniformly include clinical and health policy responses for emotional or economic violence. Providing privacy to survivors within health facilities was a universal challenge.

Conclusion

Significant efforts have been made to address provider attitudes towards provision of care and to protocolize delivery of care to survivors, primarily through one-stop centers. Further improvements can be made in data collection on training impact on provider attitudes and practices, in provider identification of VAW survivors, and in prioritization of VAW within health system budgeting, staffing, and political priorities. Primary health facilities need to provide first-line support for survivors to avoid delays in response to all forms of VAW as well as for secondary prevention.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-021-01499-8.

Unmet supportive care needs and predictor of breast cancer patients in Bangladesh: A cross-sectional study

BACKGROUND

Breast cancer survivor goes through a period of needs in their post-treatment daily life. Relatively few studies have been conducted to understand the unmet needs among breast cancer survivors in Bangladesh. Recognize and measure patterns and predictors of unmet needs of breast cancer patients was the aim of the study.

OBJECTIVE

To identify and measure patterns and predictors of unmet needs of breast cancer patients in Bangladesh.

METHOD

A cross-sectional study among 138 breast cancer patients; conveniently selected from two public and two private cancer institutes. Face-to-face interview for data collection and medical record review for checklist was done. Unmet needs have been determined by the supportive care needs survey short form 34 scale. Logistic regression analyses were performed to identify the predictors of unmet needs.

RESULTS

The study indicated the top 10 moderate-to-high needs; among which the top five needs were from the information need domain. Surprisingly, private cancer treatment centers were identified as a significant predictor for unmet needs. Patients from private cancer institutes reported more explanation needs as well as needs with their physical and daily living and sexuality. Furthermore, the type of treatment like patient receiving combine treatment therapy reported more need for help compared to the patient receiving chemotherapy alone. Moreover, housewives reported the low need for patient care and support systems as a result of their reluctant behavior towards their health.

CONCLUSION

Individual's unmet need assessment should be a part of every treatment protocol of breast cancer for a better treatment outcome.

Patients' Satisfaction on the Service Quality of Upazila Health Complex in Bangladesh

This article attempts to measure the state of satisfaction of patients over the quality of health care as well as identify the crucial factors that affect the patients' satisfaction in Upazila Health Complex (UHC). The quantitative approach was used following a structured questionnaire survey method. Four hundred visitors of 2 UHCs in Meherpur district were randomly selected as respondents for the study. The Statistical Package for Social Science IBM version 24 and R software (version 4.0.2) were used to run descriptive statistics, χ² test, confirmatory factor analysis, and principal component analysis for quantitative data analysis. The data reveal that the overall satisfaction score is (2.75 ± 0.943). A 3-dimension model of service quality is found to have a significant relationship with patients' satisfaction at the rural level. Care providers' attitude and responsiveness in service delivery are found to be the most vital factor, while the tangibles and accessibility factors moderately influence the patient's satisfaction on the service quality at UHCs.

Older adults with non-communicable chronic conditions and their health care access amid COVID-19 pandemic in Bangladesh: Findings from a cross-sectional study

BACKGROUND

Burgeoning burden of non-communicable disease among older adults is one of the emerging public health problems. In the COVID-19 pandemic, health services in low- and middle-income countries, including Bangladesh, have been disrupted. This may have posed challenges for older adults with non-communicable chronic conditions in accessing essential health care services in the current pandemic. The present study aimed at exploring the challenges experienced by older Bangladeshi adults with non-communicable chronic conditions in receiving regular health care services during the COVID-19 pandemic.

MATERIALS AND METHODS

The study followed a cross-sectional design and was conducted among 1032 Bangladeshi older adults aged 60 years and above during October 2020 through telephone interviews. Self-reported information on nine non-communicable chronic conditions (osteoarthritis, hypertension, heart disease, stroke, hypercholesterolemia, diabetes, chronic respiratory diseases, chronic kidney disease, cancer) was collected. Participants were asked if they faced any difficulties in accessing medicine and receiving routine medical care for their medical conditions during the COVID-19 pandemic. The association between non-communicable chronic conditions and accessing medication and health care was analysed using binary logic regression model.

RESULTS

Most of the participants aged 60-69 years (77.8%), male (65.5%), married (81.4%), had no formal schooling (58.3%) and resided in rural areas (73.9%). Although more than half of the participants (58.9%) reported having a single condition, nearly one-quarter (22.9%) had multimorbidity. About a quarter of the participants reported difficulties accessing medicine (23%) and receiving routine medical care (27%) during the pandemic, and this was significantly higher among those suffering from multimorbidity. In the adjusted analyses, participants with at least one condition (AOR: 1.95, 95% CI: 1.33-2.85) and with multimorbidity (AOR: 4.75, 95% CI: 3.17-7.10) had a higher likelihood of experiencing difficulties accessing medicine. Similarly, participants with at least one condition (AOR: 3.08, 95% CI: 2.11-4.89) and with multimorbidity (AOR: 6.34, 95% CI: 4.03-9.05) were significantly more likely to face difficulties receiving routine medical care during the COVID-19 pandemic.

CONCLUSIONS

Our study found that a sizeable proportion of the older adults had difficulties in accessing medicine and receiving routine medical care during the pandemic. The study findings highlight the need to develop an appropriate health care delivery pathway and strategies to maintain essential health services during any emergencies and beyond. We also argue the need to prioritise the health of older adults with non-communicable chronic conditions in the centre of any emergency response plan and policies of Bangladesh.

Cost of illness for severe and non-severe diarrhea borne by households in a low-income urban community of Bangladesh: A cross-sectional study

The illness cost borne by households, known as out-of-pocket expenditure, was 74% of the total health expenditure in Bangladesh in 2017. Calculating economic burden of diarrhea of low-income urban community is important to identify potential cost savings strategies and prioritize policy decision to improve the quality of life of this population. This study aimed to estimate cost of illness and monthly percent expenditure borne by households due diarrhea in a low-income urban settlement of Dhaka, Bangladesh. We conducted this study in East Arichpur area of Tongi township in Dhaka, Bangladesh from September 17, 2015 to July 26, 2016. We used the World Health Organization (WHO) definition of three or more loose stool in 24 hours to enroll patients and enrolled 106 severe patients and 158 non-severe patients from Tongi General Hospital, local pharmacy and study community. The team enrolled patients between the first to third day of the illness (≤ 72 hours) and continued daily follow-up by phone until recovery. We considered direct and indirect costs to calculate cost-per-episode. We applied the published incidence rate to estimate the annual cost of diarrhea. The estimated average cost of illness for patient with severe diarrhea was US$ 27.39 [95% CI: 24.55, 30.23] (2,147 BDT), 17% of the average monthly income of the households. The average cost of illness for patient with non-severe diarrhea was US$ 6.36 [95% CI: 5.19, 7.55] (499 BDT), 4% of the average monthly income of households. A single diarrheal episode substantially affects financial condition of low-income urban community residents: a severe episode can cost almost equivalent to 4.35 days (17%) and a non-severe episode can cost almost equivalent to 1 day (4%) of household’s income. Preventing diarrhea preserves health and supports financial livelihoods.

The illness cost borne by households, known as out-of-pocket expenditure was 74% of the total health expenditure in Bangladesh in 2017. Most of the studies in Bangladesh that estimated the cost of diarrheal illness collected data from hospital patients and mostly targeted under-five children. Information on economic burden of diarrhea borne by households of low-income urban communities who commonly had ≤ 2 US$ dollar income per capita per day still remained unknown. We conducted this study in East Arichpur area of Tongi township in Dhaka, Bangladesh from September 2015 to July 2016 to estimate cost of illness and monthly percent expenditure borne by households due diarrhea in a low-income urban settlement of Dhaka, Bangladesh. The estimated average cost of illness for patient with severe diarrhea was US$ 27.39 (2,147 BDT) and non-severe diarrhea was US$ 6.36 (499 BDT). A single diarrheal episode substantially affects financial capability of the low-income urban community: a severe episode can cost 4.35 days (17%) and a non-severe episode can cost 1 day (4%) of income of a households. Preventing diarrhea preserves health and supports financial livelihoods.

Household economic burden of childhood severe pneumonia in Bangladesh: a cost-of-illness study

OBJECTIVE

To estimate household cost of illness (COI) for children with severe pneumonia in Bangladesh.

DESIGN

An incidence-based COI study was performed for one episode of childhood severe pneumonia from a household perspective. Face-to-face interviews collected data on socioeconomic, resource use and cost from caregivers. A micro-costing bottom-up approach was applied to calculate medical, non-medical and time costs. Multiple regression analysis was applied to explore the factors associated with COI. Sensitivity analysis explored the robustness of cost parameters.

SETTING

Four urban and rural study sites from two districts in Bangladesh.

PATIENTS

Children aged 2-59 months with severe pneumonia.

RESULTS

1472 children with severe pneumonia were enrolled between November 2015 and March 2019. The mean age of children was 12 months (SD ±10.2) and 64% were male. The mean household cost per episode was US$147 (95% CI 141.1 to 152.7). Indirect costs were the main cost drivers (65%, US$96). Household costs for the poorest income quintile were lower in absolute terms, but formed a higher proportion of monthly income. COI was significantly higher if treatment was received from urban health facilities compared with rural health facilities (difference US$84.9, 95% CI 73.3 to 96.3). Child age, household income, healthcare facility and hospital length of stay (LoS) were significant predictors of household COI. Costs were most sensitive to hospital LoS and productivity loss.

CONCLUSIONS

Severe pneumonia in young children is associated with high household economic burden and cost varies significantly across socioeconomic parameters. Management strategies with improved accessibility are needed particularly for the poor to make treatment affordable in order to reduce household economic burden.

Challenges faced by community health nurses to achieve universal health coverage in Myanmar: A mixed methods study

Objective

This study aimed to identify the challenges of community health nurses (CHNs) in delivering effective community health care to achieve universal health coverage (UHC) in Myanmar.

Methods

A total of 30 CHNs from township health centers in the northeastern, southern, and western parts of Myanmar were purposefully recruited for quantitative and qualitative interviews. Quantitative data were processed using Microsoft Excel software, and qualitative data were analyzed using thematic analysis. This study is registered with researchregistry6201.

Results

Around the country, 30 CHNs uncovered their hardships in implementing primary health care to achieve UHC. Over 90% of the participants agreed to the problem of inadequate health infrastructure, while half of them felt unmotivated when they encountered role conflicts among various cadres of healthcare providers and poor opportunities for career promotion. Major problems arose from the lack of standard professional education at the entry point to community settings because most CHNs did not achieve specialized training in providing public health services. Complications are incapable of evaluating health services for policy-making and the inability to conduct health research to develop evidence-based practices. Insecure work and living conditions, unsupportive community relationships, and undereducation in professional practices were supportive major themes explored by CHNs to achieve a deeper understanding of the barriers to UHC. Not only the health system itself but also the population and other geographical factors have contributed to many challenges to CHNs.

Conclusion

Myanmar's CHNs face many challenges in achieving UHC. These challenges are not confined to the health sector. Some situations, such as geographical barriers and transportation problems, remain persistent challenges for healthcare providers. This study highlights the fact that current health systems should be strengthened by qualified healthcare providers and sufficient infrastructure. Meanwhile, public empowerment plays a critical role in promoting health development.

Assessing the incidence of catastrophic health expenditure and impoverishment from out-of-pocket payments and their determinants in Bangladesh: evidence from the nationwide Household Income and Expenditure Survey 2016

Background

Out-of-pocket (OOP) payments for healthcare have been increasing steadily in Bangladesh, which deteriorates the financial risk protection of many households.

Methods

We aimed to investigate the incidence of catastrophic health expenditure (CHE) and impoverishment from OOP payments and their determinants. We employed nationally representative Household Income and Expenditure Survey 2016 data with a sample of 46 076 households. A household that made OOP payments of >10% of its total or 40% of its non-food expenditure was considered to be facing CHE. We estimated the impoverishment using both national and international poverty lines. Multiple logistic models were employed to identify the determinants of CHE and impoverishment.

Results

The incidence of CHE was estimated as 24.6% and 10.9% using 10% of the total and 40% of non-food expenditure as thresholds, respectively, and these were concentrated among the poor. About 4.5% of the population (8.61 million) fell into poverty during 2016. Utilization of private facilities, the presence of older people, chronic illness and geographical location were the main determinants of both CHE and impoverishment.

Conclusion

The financial hardship due to OOP payments was high and it should be reduced by regulating the private health sector and covering the care of older people and chronic illness by prepayment-financing mechanisms.

Impact of childhood cancer on the family: evidence from Bangladesh

Background

The care of children with cancer creates emotional, financial, and social impacts for their families. Information on the impact of childhood cancer (CC) on the family is scarce in Bangladesh. Thus, the study was set out to assess the impact of CC on the families in the local context.

Methods

This cross-sectional study was conducted from January to June 2018 in three purposively selected tertiary hospitals. All the children diagnosed and treated at those hospitals during the study period were eligible for this study. Children undergoing bone marrow transplantation, or those who were seriously ill, or those transferred to another hospital, or those who died were excluded or whose parents were not willing to participate. A total of 242 children were enrolled in the study and their parents were included in the interview. Measures included socio-demographic attributes, financial burden, personal strain, social impact, mastery, and treatment cost. Informed written consent was obtained from the parents and a face-to-face interview was conducted using a semi-structured questionnaire based on (i) About you and your-family and (ii) the Impact-On-Family (IOF) scale. High scores of the scale correlated to high impact. Medical records were reviewed to collect data on the pattern of CC and treatment costs.

Results

Major CCs included leukemia (36.0%), blastoma (18.2%), sarcoma (14.9%), and lymphoma (12.4%). The weighted score was highest for mastery (3.63) followed by financial burden (3.33), personal strain (3.27), and social impact (3.21) domains. The difference of IOFS score was significant by family type (p < 0.05), father's occupation (p < 0.05), type (p < 0.01) and duration of cancer (p < 0.01), and treatment cost (p˂0.01). Families adopted diverse coping strategies including changed lifestyle (98.3%), sought social support (86.0%), rely more on religion (98.8%), and reduced family investment (83.9%) to adjust the impact.

Conclusion

The impact of CC on the family is evident at many levels. In particular, mean scores of financial burden, personal strain, social impact, and mastery domains of the IOF scale were significantly associated with the employment status of parents, residing place, treatment cost, type, and duration of cancer. The study findings could contribute to devising impact-reducing intervention programs in Bangladesh.

A Policy Analysis Regarding Education, Career, and Governance of the Nurses in Bangladesh: A Qualitative Exploration

Nurses, short in production and inequitable in the distribution in Bangladesh, require the government's efforts to increase enrolment in nursing education and a smooth career progression. Given the importance of an assessment of the current nursing scenario to inform the decision makers and practitioners to implement the new policies successfully, we analyzed relevant policies on education, career, and governance of nurses in Bangladesh. We used documents review and qualitative methods such as key informant interviews (n = 13) and stakeholder analysis. We found that nursing education faced several backlashes: resistance from diploma nurses while attempting to establish a graduate (bachelor) course in 1977, and the reluctance of politicians and entrepreneurs to establish nursing institutions. Many challenges with the implementation of nursing policies are attributable to social, cultural, religious, and historical factors. For example, Hindus considered touching the bodily excretions as the task of the lower castes, while Muslims considered women touching the body of the men immoral. Nurses also face governance challenges linked with their performance and reward. For example, nurses have little voice over the decisions related to their profession, and they are not allowed to perform clinical duties unsupervised. To improve the situation, the government has made new policies, including upliftment of nurses' position in public service, the creation of an independent Directorate General, and improvement of nursing education and service. New policies often come with new apprehensions. Therefore, nurses should be included in the policy processes, and their capacity should be developed in nursing leadership and health system governance.

Spatial accessibility to healthcare facilities in coastal region of Bangladesh

Though equal and easy accessibility to healthcare facilities are a fundamental right, people of the coastal region often get poor accessibility to healthcare facilities. This research aimed to assess the spatial accessibility to healthcare facilities in the coastal region of Bangladesh. Patuakhali district was selected as the study area. Accessibility to three levels of healthcare facilities: Community Clinic (CC), Upazila Health Complex (UHC) and District Hospital (DH) was measured individually using Geographic Information System (GIS) adopting the simple distance measures. Finally, overall accessibility to healthcare facilities was measured by overlaying accessibility to all three levels of healthcare facilities according to their relative importance. The findings of this study showed that a significant portion (70%) of Patuakhali district had high accessibility to CC; whereas, almost 60% and 40% of the area had poor accessibility to UHC and DH, respectively. Furthermore, 40% and 28% of the area of Patuakhali district had low and high accessibility to overall healthcare facilities, respectively. Furthermore, accessibility to healthcare facilities was found very poor in rural areas, char areas, and seashore. Thereafter, it is recommended to provide an UHC in every upazila and a DH in the southern part of Galachipa upazila to ensure high spatial accessibility of healthcare facilities.

Antimicrobial Resistance Surveillance in Low- and Middle-Income Countries: Progress and Challenges in Eight South Asian and Southeast Asian Countries

Antimicrobial resistance (AMR) is a serious global health threat and is predicted to cause significant health and economic impacts, particularly in low- and middle-income countries (LMICs). AMR surveillance is critical in LMICs due to high burden of bacterial infections; however, conducting AMR surveillance in resource-limited settings is constrained by poorly functioning health systems, scarce financial resources, and lack of skilled personnel. In 2015, the United Nations World Health Assembly endorsed the World Health Organization's Global Action Plan to tackle AMR; thus, several countries are striving to improve their AMR surveillance capacity, including making significant investments and establishing and expanding surveillance networks. Initial data generated from AMR surveillance networks in LMICs suggest the high prevalence of resistance, but these data exhibit several shortcomings, such as a lack of representativeness, lack of standardized laboratory practices, and underutilization of microbiology services. Despite significant progress, AMR surveillance networks in LMICs face several challenges in expansion and sustainability due to limited financial resources and technical capacity. This review summarizes the existing health infrastructure affecting the establishment of AMR surveillance programs, the burden of bacterial infections demonstrating the need for AMR surveillance, and current progress and challenges in AMR surveillance efforts in eight South and Southeast Asian countries.

Prevalence and Drivers of Self-Medication Practices among Savar Residents in Bangladesh: A Cross-Sectional Study

BACKGROUND

Self-medication practice (SMP) is widely adopted among residents of such countries as Bangladesh. However, the major determinants of SMP have only scarcely been evaluated. Therefore, this cross-sectional study aimed to fill this knowledge gap by assessing the prevalence and determining factors of SMP.

METHODS

A convenience sample of individuals residing in Savar (Dhaka, Bangladesh) >16 years of age and suffering from an illness >2 months underwent face-to-face interviews during January-February, 2019.

RESULTS

Among 520 interviewees fulfilling entry criteria, the prevalence of SMP was reported as 60.2%. Drug shops, previous knowledge or prescription, and consulting with peers (friends or relatives) were the most sought sources of SMP, whereas simple illness, higher consulting fees, unsatisfactory health-care services, and delayed access were reported as the motives. From the regression analysis, the sociodemographic risk factors of SMP were reported as being older (compared to <18 years), married, illiterate (compared to having higher education), having engaged in any occupation (ie, service, business, homemaker, and others compared to student), and suffering from chronic illness.

CONCLUSION

SMP is highly prevalent and exhibits significant socioeconomic determinants. Development of proper health care-access systems and public education should be implemented to reduce the rate of SMP.

Provider performance and facility readiness for managing infections in young infants in primary care facilities in rural Bangladesh

BACKGROUND

Neonatal infections remain a leading cause of newborn deaths globally. In 2015, WHO issued guidelines for managing possible serious bacterial infection (PSBI) in young infants (0-59 days) using simplified antibiotic regimens when compliance with hospital referral is not feasible. Bangladesh was one of the first countries to adopt WHO's guidelines for implementation. We report results of an implementation research study that assessed facility readiness and provider performance in three rural sub-districts of Bangladesh during August 2015-August 2016.

METHODS

This study took place in 19 primary health centers. Facility readiness was assessed using checklists completed by study staff at three time points. To assess provider performance, we extracted data for all infection cases from facility registers and compared providers' diagnosis and treatment against the guidelines. We plotted classification and dosage errors across the study period and superimposed a locally weighted smoothed (LOWESS) curve to analyze changes in performance over time. Focus group discussions (N = 2) and in-depth interviews (N = 28) with providers were conducted to identify barriers and facilitators for facility readiness and provider performance.

RESULTS

At baseline, none of the facilities had adequate supply of antibiotics. During the 10-month period, 606 sick infants with signs of infection presented at the study facilities. Classification errors were identified in 14.9% (N = 90/606) of records. For infants receiving the first dose(s) of antibiotic treatment (N = 551), dosage errors were identified in 22.9% (N = 126/551) of the records. Distribution of errors varied by facility (35.7% [IQR: 24.7-57.4%]) and infection severity. Errors were highest at the beginning of the study period and decreased over time. Qualitative data suggest errors in early implementation were due to changes in providers' assessment and treatment practices, including confusion about classifying an infant with multiple signs of infection, and some providers' concerns about the efficacy of simplified antibiotic regimens.

CONCLUSIONS

Strategies to monitor early performance and targeted supports are important for enhancing implementation fidelity when introducing complex guidelines in new settings. Future research should examine providers' assessment of effectiveness of simplified treatment and address misconceptions about superiority of broader spectrum antibiotics for treating community-acquired neonatal infections in this context.

Caregiver acceptability of the guidelines for managing young infants with possible serious bacterial infections (PSBI) in primary care facilities in rural Bangladesh

INTRODUCTION

Many infants with possible serious bacterial infections (PSBI) do not receive inpatient treatment because hospital care may not be affordable, accessible, or acceptable for families. In 2015, WHO issued guidelines for managing PSBI in young infants (0-59 days) with simpler antibiotic regimens when hospital care is not feasible. Bangladesh adopted WHO's guidelines for implementation in outpatient primary health centers. We report results of an implementation research study that assessed caregiver acceptability of the guidelines in three rural sub-districts of Bangladesh during early implementation (October 2015-August 2016).

METHODS

We included 19 outpatient primary health centers involved in the initial rollout of the infection management guidelines. We extracted data for all PSBI cases (N = 192) from facility registers to identify gaps in referral feasibility, simplified antibiotic treatment, and follow-up. Focus group discussions (FGD) and in-depth interviews (IDI) were conducted with both caregivers (6 FGDs; 23 IDIs) and providers (2 FGDs; 28 IDIs) to assess caregiver acceptability of the guidelines.

RESULTS

Referral to the hospital was not feasible for many families (83.3%; N = 160/192) and acceptance varied by infection severity. Barriers to referral feasibility included economic and household factors, and previous experiences with poor quality of care at the sub-district hospital. Conversely, providers and caregivers indicated high acceptability of simplified antibiotic treatment. 80% (N = 96/120) of infants with clinical severe infection for whom referral was not feasible returned to the facility for the second antibiotic injection. Some providers reported developing local solutions-including engaging informal providers in treatment of the infant-to address organizational barriers and promote treatment compliance. Follow-up of young infants receiving simplified treatment is critical, but only 67.4% (N = 87/129) of infants received fourth day follow-up. Some providers' reported deviations from the guidelines that shifted responsibility of follow-up to the caregiver, which may have contributed to lapses.

CONCLUSION

Caregivers' perception of trust and communication with providers were influential in caregiver acceptability of care. Few caregivers accepted referral to the sub-district hospital, suggesting low acceptability of this option. When referral was not feasible, many caregivers reported satisfaction with simplified antibiotic treatment. Local solutions described by providers require further examination in this context to assess the safety and potential value of these strategies in outpatient treatment. Our findings suggest strengthening providers' interpersonal skills could improve caregiver acceptability of the guidelines.

Hits and misses of Bangladesh National Health Policy 2011

National Health Policy (NHP) is a guiding principle for a country to identify the priority of health-care needs, resource allocations according to prioritization, and to achieve specific health-care goals. In addition, NHP is usually wide-ranging, all-inclusive plan that pursues each and every population to move on the road to better health. NHP targets to achieve universal health coverage and delivering quality health-care services to all at inexpensive cost, through a preemptive, protective, and prophylactic health-care program in all national and international developmental policy and planning. There are quite a few constituents that are valuable in executing health policy. These elements include novelty, technical compendium, communiqué, conglomerates, administration, supervision, and political awareness and promise. Health policies can be implemented at all levels of the government system. It helps in strengthening the overall health-care system of the country by effective public-private coordination and collaboration. In the year 1990, the Government of Bangladesh (GoB) tried to promulgate an NHP. Unfortunately, the attempt failed. The health-care system of the country operated without a policy until 2011. In the year 2011, the country's first health policy was published by the GoB. Though the country has have achieved excellent progress in providing health care, but yet Bangladesh has a few critical challenges that need immediate attention. In this article, we will try to address the pros and cons of the Bangladesh NHP 1990 and the positive aspects and challenges of NHP 2011.

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

OBJECTIVES

This paper explores the underlying motivations and strategies of formal small and medium-sized formal private for-profit sector hospitals and clinics in urban Bangladesh and their implications for quality and access.

METHODS

This exploratory qualitative study was conducted in Dhaka, Sylhet and Khulna City Corporations. Data collection methods included key informant interviews (20) with government and private sector leaders, in-depth interviews (30) with clinic owners, managers and providers and exit interviews (30) with healthcare clients.

RESULTS

Profit generation is a driving force behind entry into the private healthcare business and the provision of services. However, non-financial motivations are also emphasised such as aspirations to serve the disadvantaged, personal ambition, desire for greater social status, obligations to continue family business and adverse family events.The discussion of private sector motivations and strategies is framed using the Business Policy Model. This model is comprised of three components: products and services, and efforts to make these attractive including patient-friendly discounts and service-packages, and building 'good' doctor-patient relationships; the market environment, cultivated using medical brokers and referral fees to bring in fresh clientele, and receipt of pharmaceutical incentives; and finally, organisational capabilities, in this case overcoming human resource shortages by relying on medical staff from the public sector, consultant specialists, on-call and less experienced doctors in training, unqualified nursing staff and referring complicated cases to public facilities.

CONCLUSIONS

In the context of low public sector capacity and growing healthcare demands in urban Bangladesh, private for-profit engagement is critical to achieving universal health coverage (UHC). Given the informality of the sector, the nascent state of healthcare financing, and a weak regulatory framework, the process of engagement must be gradual. Further research is needed to explore how engagement in UHC can be enabled while maintaining profitability. Incentives that support private sector efforts to improve quality, affordability and accountability are a first step in building this relationship.