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Saran M, Teli BD, Rezapour A, Motlagh SN, Behzadifar M, Haghighatfard P, Bragazzi NL, Behzadifar M. The impact of the Iranian health transformation plan policy on equitable access to medical imaging services in West Iran. BMC Res Notes 2023; 16:350. [PMID: 38008715 PMCID: PMC10680178 DOI: 10.1186/s13104-023-06634-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 11/20/2023] [Indexed: 11/28/2023] Open
Abstract
OBJECTIVE Equity in the delivery of health services, including diagnostic imaging, is crucial to achieving universal health coverage. The Health Transformation Plan (HTP), launched in 2014, represents a major healthcare policy to improve the quality and accessibility of healthcare services. This study aimed to explore the impact of the HTP on equity in the access to medical imaging in Lorestan province, located in west Iran, from 2014 to 2023. Annual growth rates (AGR) of imaging devices were calculated, whilst equity assessment of medical imaging distribution was carried out by means of the Gini coefficient and the Lorenz curve per 100,000 population. The latter was generated using the cumulative distribution of imaging devices, as well as the cumulative population ratio. RESULTS Between 2014 and 2023, the number of imaging devices has increased threefold. The AGR of installing CT and MRI scanners in Lorestan province increased between 2014 and 2023. The Gini coefficients increased from 0.12 for CT and 0.16 for MRI in 2014 to 0.33 in 2023 for both devices. This indicates a decrease in equity in access to these fundamental health technologies despite the increase in their figures. Policymakers should better allocate medical equipment based on the specific health needs of different regions throughout Iran.
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Affiliation(s)
- Maryam Saran
- Social Determinants of Health Research Center, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Banafsheh Darvishi Teli
- Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Aziz Rezapour
- Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Soraya Nouraei Motlagh
- Social Determinants of Health Research Center, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Meysam Behzadifar
- Social Determinants of Health Research Center, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Payam Haghighatfard
- Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Nicola Luigi Bragazzi
- Human Nutrition Unit Department of Food and Drugs, University of Parma Medical School, Building C, Via Volturno, 39, Parma, 43125, Italy
| | - Masoud Behzadifar
- Social Determinants of Health Research Center, Lorestan University of Medical Sciences, Khorramabad, Iran.
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Sheikh N, Sarker AR, Sultana M, Mahumud RA, Ahmed S, Islam MT, Howick S, Morton A. Disease-specific distress healthcare financing and catastrophic out-of-pocket expenditure for hospitalization in Bangladesh. Int J Equity Health 2022; 21:114. [PMID: 35987656 PMCID: PMC9392951 DOI: 10.1186/s12939-022-01712-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 08/03/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
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.
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Jung H, Lee KS. What Policy Approaches Were Effective in Reducing Catastrophic Health Expenditure? A Systematic Review of Studies from Multiple Countries. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2022; 20:525-541. [PMID: 35285001 DOI: 10.1007/s40258-022-00727-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/27/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND The United Nations set a goal for universal health coverage in all countries by 2030 and selected the catastrophic health expenditure (CHE) indicator as an assessment tool for this goal. Many countries have strived to reduce household CHE. However, no study has compared countries whose policies have had a remarkable effect on decreasing CHE. Therefore, the purpose of this systematic literature review is to find appropriate methods for measuring CHE that can help us to analyze the impact of health policies and identify countries whose health policies are most effective in reducing CHE. METHOD PubMed and Web of Science were searched. Studies that measured the incidence or intensity of CHE in multiple years were included. Two independent reviewers screened the literature, extracted the data, and analyzed the studies selected. Thirty-eight studies met the inclusion criteria for the review. We classified the selected research papers to random sampling and quasi-experimental studies. RESULTS We graphically presented the results of CHE incidence and intensity rates reported in the collected papers as a time series data set. Since most studies did not use sample weights, it was not easy to confirm whether the time series changes of CHE are significant. Therefore, we could find only two countries that had policy effects. Both countries established policies that focus on the poor. CONCLUSION There are so many studies that analyze CHE, but policies that are effective in reducing CHE are unknown. This study uses a systematic literature review methodology to determine effective policies by comparing CHE time series trends among countries. As a policy implication, it was found that because CHE is defined as the ratio of the ability to pay to medical expenses, a policy of differential medical expenses that is based on income level is effective.
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Affiliation(s)
- HyunWoo Jung
- Department of Health Administration, Graduate School·BK21 Graduate Program of Developing Glocal Experts in Health Policy and Management, Yonsei University, Changjo Hall, Room Number 419, Yonseidaegil 1, Gangwon-do, Wonju, South Korea
| | - Kwang-Soo Lee
- Department of Health Administration, Graduate School·BK21 Graduate Program of Developing Glocal Experts in Health Policy and Management, Yonsei University, Changjo Hall, Room Number 419, Yonseidaegil 1, Gangwon-do, Wonju, South Korea.
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Mulaga AN, Kamndaya MS, Masangwi SJ. Decomposing socio-economic inequality in catastrophic out-of-pocket health expenditures in Malawi. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000182. [PMID: 36962147 PMCID: PMC10021269 DOI: 10.1371/journal.pgph.0000182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 01/09/2022] [Indexed: 06/18/2023]
Abstract
Reducing health inequalities and inequities is one of the key goals that health systems aspire to achieve as it ensures improvement in health outcomes among all population groups. Addressing the factors contributing to inequality in catastrophic health expenditures is important to reducing inequality in the burden of health expenditures. However, there are limited studies to explain the factors contributing to inequalities in catastrophic health expenditures. The study aimed to measure and decompose socio-economic inequality in catastrophic health into its determinants. Data for the analysis come from the fourth integrated household survey. Data for 12447 households in Malawi were collected from April 2016 to April 2017 by the National Statistical Office. The secondary analysis was conducted from June 2021 to October 2021. Catastrophic health expenditure was estimated as a proportion of households whose out-of-pocket health expenditures as a ratio of non-food consumption expenditures exceeds 40% threshold level. We estimated the magnitude of socio-economic inequality using the Erreygers corrected concentration index and used decomposition analysis to assess the contribution of inequality in each determinant of catastrophic health expenditure to the overall socio-economic inequality. The magnitude of the Erreygers corrected concentration index of catastrophic health expenditure (CI = 0.004) is small and positive which indicates that inequality is concentrated among the better-off. Inequality in catastrophic health expenditure is largely due to inequalities in rural residency (127%), socio-economic status (-40%), household size (14%), presence of a child under five years old (10%) and region of the household (10%). The findings indicate that socio-economic inequality in catastrophic health expenditures is concentrated among the better-off in Malawi. The results imply that policies that aim to reduce inequalities in catastrophic health expenditures should simultaneously address urban-rural and income inequalities.
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Affiliation(s)
- Atupele N. Mulaga
- Department of Mathematics and Statistics, Faculty of Applied Sciences, University of Malawi, Blantyre, Malawi
- School of Science and Technology, Malawi University of Business and Applied Sciences, Blantyre, Malawi
| | - Mphatso S. Kamndaya
- School of Science and Technology, Malawi University of Business and Applied Sciences, Blantyre, Malawi
| | - Salule J. Masangwi
- School of Science and Technology, Malawi University of Business and Applied Sciences, Blantyre, Malawi
- Centre for Water, Sanitation, Health and Appropriate Technology Development (WASHTED), Malawi University of Business and Applied Sciences, Blantyre, Malawi
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Rahman MM, Islam MR, Rahman MS, Hossain F, Alam A, Rahman MO, Jung J, Akter S. Forgone healthcare and financial burden due to out-of-pocket payments in Bangladesh: a multilevel analysis. HEALTH ECONOMICS REVIEW 2022; 12:5. [PMID: 35006416 PMCID: PMC8751265 DOI: 10.1186/s13561-021-00348-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 12/08/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Ensuring access to health services for all is the main goal of universal health coverage (UHC) plan. Out-of-pocket (OOP) payment still remains the main source of funding for healthcare in Bangladesh. The association between barriers to accessing healthcare and over-reliance on OOP payments has not been explored in Bangladesh using nationally representative household survey data. This study is a novel attempt to examine the burden of OOP payment and forgone healthcare in Bangladesh, and further explores the inequalities in catastrophic health expenditures (CHE) and forgone healthcare at the national and sub-national levels. METHODS This study used data from the most recent nationally representative cross-sectional survey, Bangladesh Household Income and Expenditure Survey, conducted in 2016-17 (N = 39,124). In order to identify potential determinants of CHE and forgone healthcare, multilevel Poisson regression was used. Inequalities in CHE and forgone healthcare were measured using the slope index of inequality. RESULTS Around 25% of individuals incurred CHE and 14% of the population had forgone healthcare for any reasons. The most common reasons for forgone healthcare were treatment cost (17%), followed by none to accompany or need for permission (5%), and distance to health facility (3%). Multilevel analysis indicated that financial burden and forgone care was higher among households with older populations or chronic illness, and those who utilize either public or private health facilities. Household consumption quintile had a linear negative association with forgone care and positive association with CHE. CONCLUSION This study calls for incorporation of social safety net in health financing system, increase health facility, and gives priority to the disadvantaged population to ensure access to health services for all.
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Affiliation(s)
- Md Mizanur Rahman
- Hitotsubashi Institute for Advanced Study, Hitotsubashi University, 2-1 Naka Kunitachi, Tokyo, 186-8601, Japan.
| | - Md Rashedul Islam
- Department of Global Health Policy, School of International Health, The University of Tokyo, Tokyo, Japan
| | - Md Shafiur Rahman
- Research Centre for Child Mental Development, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Fahima Hossain
- Global Public Health Research Foundation, Dhaka, Bangladesh
| | - Ashraful Alam
- Department of Global Health Policy, School of International Health, The University of Tokyo, Tokyo, Japan
| | - Md Obaidur Rahman
- Department of Global Health Nursing, Graduate School of Nursing Science, St. Luke's International University, Tokyo, Japan
| | - Jenny Jung
- Global Public Health Research Foundation, Dhaka, Bangladesh
| | - Shamima Akter
- Hitotsubashi Institute for Advanced Study, Hitotsubashi University, 2-1 Naka Kunitachi, Tokyo, 186-8601, Japan
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Rahman M, Tamjid R, Islam MN, Rahman M, Rabbani A, Sarker M. Visual Storytelling for Knowledge Translation: A Study on BRAC’s Novel Health Loans in Protecting the Poor Against Health and Asset Vulnerability In Bangladesh. FRONTIERS IN TROPICAL DISEASES 2021. [DOI: 10.3389/fitd.2021.758904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Knowledge Translation (KT) is a dynamic and iterative process that includes synthesizing, disseminating, exchanging, and ethically sound application of knowledge to improve health and strengthen the health care system. It facilitates sharing the information generated through research outcomes with the public, the policymakers, or others for further scaling up or continuation of the interventions. Literature suggests a substantial gap exists in communicating with the decision-makers. BRAC JPGSPH produced a documentary/video that iterates how BRAC’s revised medical treatment loan program (MTL+) works with its microcredit clients and modalities. After reviewing all possible options for communication, the video was chosen as the best knowledge translation tool. The video creation and dissemination process are comprised of four phases: pre-production, production, post-production, and exhibition. The video production team reviewed documents and articles and conducted multiple interviews before developing the script. Later, a series of interviews were taken with the beneficiaries who receive medical treatment loans, mid-level, senior managers at BRAC, and researchers. After the production, the director, with a professional editor, edited the video. Over three hours of footage was viewed and ultimately compiled into a six-minute-long video documentary. The audience for the video was more expansive than narrow; from potential beneficiaries to policymakers and every group of stakeholders in between, the video was well-understood. The new MTL+ was integrated into the main program and would be scaled up soon.
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Taniguchi H, Rahman MM, Swe KT, Islam MR, Rahman MS, Parsell N, Hussain A, Shibuya K, Hashizume M. Equity and determinants in universal health coverage indicators in Iraq, 2000-2030: a national and subnational study. Int J Equity Health 2021; 20:196. [PMID: 34461904 PMCID: PMC8404248 DOI: 10.1186/s12939-021-01532-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 08/11/2021] [Indexed: 11/26/2022] Open
Abstract
Background Equity is one of three dimensions of universal health coverage (UHC). However, Iraq has had capital-focused health services and successive conflicts and political turmoil have hampered health services around the country. Iraq has embarked on a new reconstruction process since 2018 and it could be time to aim for equitable healthcare access to realise UHC. We aimed to examine inequality and determinants associated with Iraq’s progress towards UHC targets. Methods We assessed the progress toward UHC in the context of equity using six nationally representative population-based household surveys in Iraq in 2000–2018. We included 14 health service indicators and two financial risk protection indicators in our UHC progress assessment. Bayesian hierarchical regression model was used to estimate the trend, projection, and determinant analyses. Slope and relative index of inequality were used to assess wealth-based inequality. Results In the national-level health service indicators, inequality indices decreased substantially from 2000 to 2030. However, the wide inequalities are projected to remain in DTP3, measles, full immunisations, and antenatal care in 2030. The pro-rich inequality gap in catastrophic health expenditure increased significantly in all governorates except Sulaimaniya from 2007 to 2012. The higher increases in pro-rich inequality were found in Missan, Karbala, Erbil, and Diala. Mothers’ higher education and more antenatal care visits were possible factors for increased coverage of health service indicators. The higher number of children and elderly population in the households were potential risk factors for an increased risk of catastrophic and impoverishing health payment in Iraq. Conclusions To reduce inequality in Iraq, urgent health-system reform is needed, with consideration for vulnerable households having female-heads, less educated mothers, and more children and/or elderly people. Considering varying inequity between and within governorates in Iraq, reconstruction of primary healthcare across the country and cross-sectoral targeted interventions for women should be prioritised. Supplementary Information The online version contains supplementary material available at 10.1186/s12939-021-01532-0.
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Affiliation(s)
- Hiroko Taniguchi
- Department of Global Health Policy, School of International Health, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.
| | - Md Mizanur Rahman
- Department of Global Health Policy, School of International Health, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.,Hitotsubashi Institute for Advanced Study (HIAS), Hitotsubashi University, 2-1, Naka, Kunitachi, Tokyo, 186-8601, Japan
| | - Khin Thet Swe
- Department of Global Health Policy, School of International Health, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.,Hitotsubashi Institute for Advanced Study (HIAS), Hitotsubashi University, 2-1, Naka, Kunitachi, Tokyo, 186-8601, Japan
| | - Md Rashedul Islam
- Department of Global Health Policy, School of International Health, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Md Shafiur Rahman
- Research Center for Child Mental Development, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu, Shizuoka, 431-3192, Japan.,United Graduate School of Child Development, Osaka University, Kanazawa University, Hamamatsu University School of Medicine, Chiba University and University of Fukui, Osaka, Japan
| | - Nadia Parsell
- Department of Global Health Policy, School of International Health, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Ashraf Hussain
- Department of Family and Community Medicine, College of Medicine, University of Babylon, Babil, Iraq
| | - Kenji Shibuya
- Soma COVID Vaccination Medical Center, Soma City Hall, 63-3, Kitamachi, Nakamura, Soma, Fukushima, 976-8601, Japan
| | - Masahiro Hashizume
- Department of Global Health Policy, School of International Health, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
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Xu J, Zheng J, Xu L, Wu H. Equity of Health Services Utilisation and Expenditure among Urban and Rural Residents under Universal Health Coverage. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:E593. [PMID: 33445637 PMCID: PMC7826610 DOI: 10.3390/ijerph18020593] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 01/07/2021] [Accepted: 01/08/2021] [Indexed: 01/01/2023]
Abstract
Worldwide countries are recognising the need for and significance of universal health coverage (UHC); however, health inequality continues to persist. This study evaluates the status and equity of residents' demand for and utilisation of health services and expenditure by considering the three components of universal health coverage, urban-rural differences, and different income groups. Sample data from China's Fifth Health Service Survey were analysed and the 'five levels of income classification' were used to classify people into income groups. This study used descriptive analysis and concentration index and concentration curve for equity evaluation. Statistically significant differences were found in the demand and utilisation of health services between urban and rural residents. Rural residents' demand and utilisation of health services decreased with an increase in income and their health expenditure was higher than that of urban residents. Compared with middle- and high-income rural residents, middle- and lower-income rural residents faced higher hospitalisation expenses; and, compared with urban residents, equity in rural residents' demand and utilisation of health services, and annual health and hospitalisation expenditures, were poorer. Thus, equity of health service utilisation and expenditure for urban and rural residents with different incomes remain problematic, requiring improved access and health policies.
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Affiliation(s)
- Jianqiang Xu
- School of Management, Xuzhou Medical University, Xuzhou 221004, China;
| | - Juan Zheng
- School of Management, Xuzhou Medical University, Xuzhou 221004, China;
| | - Lingzhong Xu
- School of Public Health, Shandong University, Jinan 250012, China;
| | - Hongtao Wu
- School of Management, Tsinghua University, Beijing 100084, China;
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Hossain SJ, Roy BR, Hossain AT, Mehrin F, Tipu SMMU, Tofail F, Arifeen SE, Tran T, Fisher J, Hamadani J. Prevalence of Maternal Postpartum Depression, Health-Seeking Behavior and Out of Pocket Payment for Physical Illness and Cost Coping Mechanism of the Poor Families in Bangladesh: A Rural Community-Based Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17134727. [PMID: 32630173 PMCID: PMC7370050 DOI: 10.3390/ijerph17134727] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 05/14/2020] [Accepted: 05/18/2020] [Indexed: 12/30/2022]
Abstract
The burden of depression is high globally. Maternal depression affects the mother, the child, and other family members. We aimed to measure the prevalence of maternal postpartum depressive (PPD) symptoms having a child aged 6–16 months, health-seeking behavior for general illness of all family members, out of pocket (OOP) payments for health care and cost coping mechanisms. We conducted a cross sectional study with 591 poor families in rural Bangladesh. The survey was conducted between August and October, 2017. Information was collected on maternal depressive symptoms using the Self Reporting Questionnaire (SRQ-20), health-seeking behavior, and related costs using a structured, pretested questionnaire. The prevalence of depressive symptoms was 51.7%. Multiple logistic regression analysis showed that PPD symptoms were independently associated with maternal age (p = 0.044), family food insecurity (p < 0.001) and violence against women (p < 0.001). Most (60%) ill persons sought health care from informal health providers. Out of pocket (OOP) expenditure was significantly higher (p = 0.03) in the families of depressed mothers, who had to take loan or sell their valuables to cope with expenditures (p < 0.001). Our results suggest that postpartum depressive symptoms are prevalent in the poor rural mothers. Community-based interventions including prevention of violence and income generation activities for these economically disadvantaged mothers should be designed to address risk factors. Health financing options should also be explored for the mothers with depressive symptoms
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Affiliation(s)
- Sheikh Jamal Hossain
- Maternal and Child Health Division (MCHD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka 1212, Bangladesh; (B.R.R.); (A.T.H.); (F.M.); (S.M.U.T.); (F.T.); (S.E.A.); (J.H.)
- Correspondence: or ; Tel.: +880-1712191414
| | - Bharati Rani Roy
- Maternal and Child Health Division (MCHD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka 1212, Bangladesh; (B.R.R.); (A.T.H.); (F.M.); (S.M.U.T.); (F.T.); (S.E.A.); (J.H.)
| | - Aniqa Tasnim Hossain
- Maternal and Child Health Division (MCHD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka 1212, Bangladesh; (B.R.R.); (A.T.H.); (F.M.); (S.M.U.T.); (F.T.); (S.E.A.); (J.H.)
| | - Fardina Mehrin
- Maternal and Child Health Division (MCHD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka 1212, Bangladesh; (B.R.R.); (A.T.H.); (F.M.); (S.M.U.T.); (F.T.); (S.E.A.); (J.H.)
| | - SM Mulk Uddin Tipu
- Maternal and Child Health Division (MCHD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka 1212, Bangladesh; (B.R.R.); (A.T.H.); (F.M.); (S.M.U.T.); (F.T.); (S.E.A.); (J.H.)
| | - Fahmida Tofail
- Maternal and Child Health Division (MCHD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka 1212, Bangladesh; (B.R.R.); (A.T.H.); (F.M.); (S.M.U.T.); (F.T.); (S.E.A.); (J.H.)
| | - Shams El Arifeen
- Maternal and Child Health Division (MCHD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka 1212, Bangladesh; (B.R.R.); (A.T.H.); (F.M.); (S.M.U.T.); (F.T.); (S.E.A.); (J.H.)
| | - Thach Tran
- Global and Women’s Health, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia; (T.T.); (J.F.)
| | - Jane Fisher
- Global and Women’s Health, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia; (T.T.); (J.F.)
| | - Jena Hamadani
- Maternal and Child Health Division (MCHD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka 1212, Bangladesh; (B.R.R.); (A.T.H.); (F.M.); (S.M.U.T.); (F.T.); (S.E.A.); (J.H.)
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Adams AM, Ahmed R, Shuvo TA, Yusuf SS, Akhter S, Anwar I. Exploratory qualitative study to understand the underlying motivations and strategies of the private for-profit healthcare sector in urban Bangladesh. BMJ Open 2019; 9:e026586. [PMID: 31272974 PMCID: PMC6615794 DOI: 10.1136/bmjopen-2018-026586] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 04/17/2019] [Accepted: 05/31/2019] [Indexed: 11/03/2022] Open
Abstract
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.
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Affiliation(s)
- Alayne Mary Adams
- Department of International Health, Georgetown University, Washington, District of Columbia, USA
- BRAC James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
- Health Systems and Population Studies Division, icddr,b, Dhaka, Bangladesh
| | - Rushdia Ahmed
- BRAC James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
- Health Systems and Population Studies Division, icddr,b, Dhaka, Bangladesh
| | - Tanzir Ahmed Shuvo
- Department of Health Services Policy and Management, University of South Carolina, Columbia, South Carolina, USA
| | | | - Sadika Akhter
- Health Systems and Population Studies Division, icddr,b, Dhaka, Bangladesh
| | - Iqbal Anwar
- Health Systems and Population Studies Division, icddr,b, Dhaka, Bangladesh
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Rezaei S, Hajizadeh M. Measuring and decomposing socioeconomic inequality in catastrophic healthcare expenditures in Iran. J Prev Med Public Health 2019; 52:214-223. [PMID: 31390684 PMCID: PMC6686108 DOI: 10.3961/jpmph.19.046] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 05/09/2019] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES Equity in financial protection against healthcare expenditures is one the primary functions of health systems worldwide. This study aimed to quantify socioeconomic inequality in facing catastrophic healthcare expenditures (CHE) and to identify the main factors contributing to socioeconomic inequality in CHE in Iran. METHODS A total of 37 860 households were drawn from the Households Income and Expenditure Survey, conducted by the Statistical Center of Iran in 2017. The prevalence of CHE was measured using a cut-off of spending at least 40% of the capacity to pay on healthcare services. The concentration curve and concentration index (C) were used to illustrate and measure the extent of socioeconomic inequality in CHE among Iranian households. The C was decomposed to identify the main factors explaining the observed socioeconomic inequality in CHE in Iran. RESULTS The prevalence of CHE among Iranian households in 2017 was 5.26% (95% confidence interval [CI], 5.04 to 5.49). The value of C was -0.17 (95% CI, -0.19 to -0.13), suggesting that CHE was mainly concentrated among socioeconomically disadvantaged households in Iran. The decomposition analysis highlighted the household wealth index as explaining 71.7% of the concentration of CHE among the poor in Iran. CONCLUSIONS This study revealed that CHE is disproportionately concentrated among poor households in Iran. Health policies to reduce socioeconomic inequality in facing CHE in Iran should focus on socioeconomically disadvantaged households.
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Affiliation(s)
- Satar Rezaei
- Research Center for Environmental Determinants of Health, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Mohammad Hajizadeh
- School of Health Administration, Faculty of Health, Dalhousie University, Halifax, NS, Canada
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Nundoochan A, Thorabally Y, Monohur S, Hsu J. Impact of out of pocket payments on financial risk protection indicators in a setting with no user fees: the case of Mauritius. Int J Equity Health 2019; 18:63. [PMID: 31053077 PMCID: PMC6500054 DOI: 10.1186/s12939-019-0959-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 04/16/2019] [Indexed: 12/20/2022] Open
Abstract
Background Mauritius embraces principles of a welfare state with free health care at point of use in any public facilities. However, the health financing landscape changed in 2007 when Private Health Expenditure (PvtHE) surpassed General Government Health Expenditure. PvtHE is predominately out of pocket (OOP) with only 3.4% related to premiums for private insurance. In 2014, Household OOP Expenditure on health accounted for 52.8% of total health expenditure. OOP is known to be regressive and to impact negatively on households’ living standards. Objectives This paper aims to examine trends in OOP in Mauritius, to assess its impacts through an analysis of key indicators of financial protection, namely catastrophic health expenditure (CHE) and impoverishment due to OOP health expenditure. It also aims to predict core determinants of CHEs. Methods Household Budget Surveys (HBS) of 2001/2002, 2006/2007 and 2012 were the primary source data. CHE and impoverishment were used to assess financial hardships resulting from OOP health payments. The incidence of CHE was estimated at three threshold levels (10,25 and 40%), using the budget share and the capacity to pay approaches. Impoverishment due to OOP was measured by changes in the incidence of poverty and intensity of poverty using the US$ 3.1 international poverty line. Logistic regression analysis was used to identify determinants of CHE. Findings Household CHE increased from 5.78% in 2001/02 to 8.85% in 2012 and 0.61% in 2001/02 to 1.25% in 2012, for 10 and 40% thresholds, respectively. The incidence of CHE was significantly higher in urban areas compared to rural areas. The highest levels of CHEs were among households’ heads, who are retired rising from 1.62% in 2001/02 to 3.71% in 2012, followed by households’ head who are widowed from 2.29% in 2001/02 to 2.63% in 2012 and homemakers from 2.12% in 2001/02 to 2.57% in 2012 at the 40% threshold. The share of households pushed below the poverty line due to OOP dropped from 0.4% in 2001/02 to 0.2% in 2006/07 before rising to 0.34% in 2012. In 2012, poverty gap occurred only among households under poorest quintile 1 (0.24%) and quintile 2 (0.03%). Overall poverty gap dropped from 0.08% in 2001/02 to 0.05% in 2012. Logistic regression analysis revealed that the odds ratio of facing CHE were significant only among households with heads being retired and with a presence of an elderly member in the household. Conclusion Despite the rise in incidence of CHE between 2001 and 2012 the impact of OOP on the level of impoverishment and poverty gap has not been significant.
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Affiliation(s)
- Ajoy Nundoochan
- World Health Organization Country Office, Port Louis, Mauritius.
| | | | | | - Justine Hsu
- Department of Health Systems Governance and Financing, World Health Organization, Geneva, Switzerland
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Liu K, Subramanian SV, Lu C. Assessing national and subnational inequalities in medical care utilization and financial risk protection in Rwanda. Int J Equity Health 2019; 18:51. [PMID: 30917822 PMCID: PMC6437855 DOI: 10.1186/s12939-019-0953-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Accepted: 03/19/2019] [Indexed: 11/17/2022] Open
Abstract
Background Ensuring equitable access to medical care with financial risk protection has been at the center of achieving universal health coverage. In this paper, we assess the levels and trends of inequalities in medical care utilization and household catastrophic health spending (HCHS) at the national and sub-national levels in Rwanda. Methods Using the Rwanda Integrated Living Conditions Surveys of 2005, 2010, 2014, and 2016, we applied multivariable logit models to generate the levels and trends of adjusted inequalities in medical care utilization and HCHS across the four survey years by four socio-demographic dimensions: poverty, gender, education, and residence. We measured the national- and district-level inequalities in both absolute and relative terms. Results At the national level, after controlling for other factors, we found significant inequalities in medical care utilization by poverty and education and -in HCHS by poverty in all four years. From 2005 to 2016, inequalities in medical care utilization by the four dimensions did not change significantly, while the inequality in HCHS by poverty was reduced significantly. At the district level, inequalities in both medical care utilization and HCHS were larger than zero in all four years and decreased over time. Conclusions Poverty and poor education were significant contributors to inequalities in medical care utilization and HCHS in Rwanda. Policies or interventions targeting poor households or households headed by persons receiving no education are needed in order to effectively reduce inequalities in medical care utilization and HCHS. Electronic supplementary material The online version of this article (10.1186/s12939-019-0953-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kai Liu
- Department of Social Security, School of Labor and Human Resources, Renmin University of China, Beijing, China
| | - S V Subramanian
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Chunling Lu
- Division of Global Health Equity, Brigham & Women's Hospital, Boston, MA, USA. .,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA. .,Department of Science and Technology-National Research Foundation (DST-NRF) Center of Excellence in Human Development, University of Witwatersrand, Johannesburg, South Africa.
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Joarder T, Chaudhury TZ, Mannan I. Universal Health Coverage in Bangladesh: Activities, Challenges, and Suggestions. PSYCHE; A JOURNAL OF ENTOMOLOGY 2019; 2019:4954095. [PMID: 33281233 PMCID: PMC7691757 DOI: 10.1155/2019/4954095] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 02/20/2019] [Indexed: 12/17/2022]
Abstract
Catastrophic health expenditure forces 5.7 million Bangladeshis into poverty. Inequity is present in most of health indicators across social, economic, and demographic parameters. This study explores the existing health policy environment and current activities to further the progress towards Universal Health Coverage (UHC) and the challenges faced in these endeavors. This qualitative study involved document reviews (n=22) and key informant interviews (KII, n=15). Thematic analysis of texts (themes: activities around UHC, implementation barriers, suggestions) was done using the manual coding technique. We found that Bangladesh has a comprehensive set of policies for UHC, e.g., a health-financing strategy and staged recommendations for pooling of funds to create a national health insurance scheme and expand financial protection for health. Progress has been made in a number of areas including the roll out of the essential package of health services for all, expansion of access to primary health care services (support by donors), and the piloting of health insurance which has been piloted in three sub districts. Political commitment for these areas is strong. However, there are barriers pertaining to the larger policy level which includes a rigid public financing structure dating from the colonial era. While others pertain to the health sector's implementation shortfalls including issues of human resources, political interference, monitoring, and supervision, most key informants discussed demand-side barriers too, such as sociocultural disinclination, historical mistrust, and lack of empowerment. To overcome these, several policies have been recommended, e.g., redesigning the public finance structure, improving governance and regulatory mechanism, specifying code of conduct for service providers, introducing health-financing reform, and collaborating with different sectors. To address the implementation barriers, recommendations include improving service quality, strengthening overall health systems, improving health service management, and improving monitoring and supervision. Addressing demand-side barriers, such as patient education and community empowerment, is also needed. Research and advocacy are required to address crosscutting barriers such as the lack of common understanding of UHC.
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Affiliation(s)
| | | | - Ishtiaq Mannan
- Bangladesh Country Office, Save the Children, Dhaka 1212, Bangladesh
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Mahmood I, Bergbower H, Mahmood A, Goodman A. Maternal Health Care in Cox’s Bazar, Bangladesh: A Survey of Midwifery Experience at Hope Foundation and a Review of the Literature. ACTA ACUST UNITED AC 2019. [DOI: 10.4236/ojog.2019.912158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Fottrell E, Ahmed N, Shaha SK, Jennings H, Kuddus A, Morrison J, Akter K, Nahar B, Nahar T, Haghparast-Bidgoli H, Khan AKA, Costello A, Azad K. Diabetes knowledge and care practices among adults in rural Bangladesh: a cross-sectional survey. BMJ Glob Health 2018; 3:e000891. [PMID: 30057800 PMCID: PMC6058170 DOI: 10.1136/bmjgh-2018-000891] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 05/25/2018] [Accepted: 06/16/2018] [Indexed: 11/13/2022] Open
Abstract
Background Population knowledge of how to prevent, detect and control diabetes is critical to public health initiatives to tackle the disease. We undertook a cross-sectional survey of adults in rural Bangladesh to estimate knowledge and practices related to diabetes. Methods In 96 villages in Faridpur district, trained fieldworkers surveyed 12 140 randomly selected men and women aged ≥30. They collected data on sociodemographic status, knowledge of diabetes and history of blood and urine glucose testing. Fasting and 2-hour post-glucose load capillary blood tests ascertained the diabetic status of respondents. Levels of knowledge and practices were analysed by sociodemographic characteristics and diabetic status. Results The population showed low levels of diabetes knowledge overall, with only one in three adults able to report any valid causes of the disease. Knowledge of diabetes causes, symptoms, complications, prevention and control was significantly associated with age, education, wealth and employment. Only 14% of respondents reported ever having had a blood glucose test and strong associations with wealth were observed (least poor relative to most poor 2.91 (2.32–3.66)). 78.4% of known diabetics (ie, with a prior diagnosis) reported that they did not monitor their blood glucose levels on at least a monthly basis. However, they had better knowledge of the causes (odds relative to normoglycaemic individuals 1.62 (1.23–2.09)), symptoms (5.17 (3.41–7.82)), complications (5.18 (3.75–7.14)), prevention (4.18 (3.04–5.74)) and control (8.43 (4.83–14.71)). Conclusion Knowledge of diabetes among rural adults in Faridpur is extremely poor. Levels of diabetes testing are low and monitoring of blood glucose among known diabetics infrequent. Diabetes prevention and control efforts in this population must include large-scale awareness initiatives which focus not only on high-risk individuals but the whole population. Trial registration number ISRCTN41083256; Pre-results.
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Affiliation(s)
- Edward Fottrell
- Institute for Global Health, University College London, London, UK
| | - Naveed Ahmed
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | | | - Hannah Jennings
- Institute for Global Health, University College London, London, UK
| | - Abdul Kuddus
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Joanna Morrison
- Institute for Global Health, University College London, London, UK
| | | | - Badrun Nahar
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Tasmin Nahar
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | | | - A K Azad Khan
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Anthony Costello
- Institute for Global Health, University College London, London, UK
| | - Kishwar Azad
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
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Mamin FA, Hayes R. Physiotherapy in Bangladesh: Inequality Begets Inequality. Front Public Health 2018; 6:80. [PMID: 29629365 PMCID: PMC5876230 DOI: 10.3389/fpubh.2018.00080] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 03/05/2018] [Indexed: 11/13/2022] Open
Abstract
Background The demand for health services in developing countries often outweighs provision. This article describes the present condition of physiotherapy in Bangladesh. Physiotherapy is not recognized as a profession by the government. There is no single registration and regulation body. The health-related and economic benefits of physiotherapy are not felt by the majority of Bangladeshi citizens. Areas covered The burden of disease is changing, and Bangladesh needs a profession that specializes in physical rehabilitation to face these challenges. This article outlines the benefits to patients and the wider economy from a broad physiotherapy regime for all Bangladeshi citizens. It describes the many barriers the profession faces. Conclusion Physiotherapy is efficacious in many post-trauma situations and long-term conditions. Economic evidence supports the provision physiotherapy as a cost-effective treatment which should be considered as part of the provision of a universal health-care service. Official recognition of the protected “physiotherapist” title and a single registration and regulation agency are recommended.
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Affiliation(s)
- Firoz Ahmed Mamin
- Department of Physiotherapy, Bangladesh Health Professions Institute, Centre for Rehabilitation of the Paralysed, Savar, Dhaka, Bangladesh
| | - Rieke Hayes
- Department of Physiotherapy, Bangladesh Health Professions Institute, Centre for Rehabilitation of the Paralysed, Savar, Dhaka, Bangladesh
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