Equity in maternal health services use in Bangladesh: an analysis of social gradients, demographic and structural determinants, and major policy changes

Equity in health services use is related to utilizing equal treatment for equal health needs, irrespective of socio-economic status. Inequity in maternal health services in low- and middle-income countries has become a central public health policy and research issue in recent years to achieve universal health coverage by 2030. The dissertation’s main objective was to examine how equity in maternal health services evolved in Bangladesh and to assess the roles of the facility readiness and the national health program on equity. In the first paper of the dissertation, we assessed if the socioeconomic equity improved more in high facility readiness districts than in the rest of the country by using data from three rounds of household sample surveys linked to health facility surveys during 2001‒2016. Our analyses documented impressive improvement in the overall use of maternal health services, but the increase was not uniform for all the population groups. Though there has been a modest but significant reduction in the inequity in antenatal care and treatment for complications, both the services are still used disproportionately more by women from higher wealth quintiles. On the other hand, the inequity in facility delivery significantly increased by 135% during the study period. The nonpoor-poor gap in the high facility readiness districts increased faster than the low readiness districts, resulting in a more inequitable distribution of facility delivery. The second paper of the dissertation estimated the impact of sector-wide approach (SWAp) for the health sector in Bangladesh on equitable coverage of skilled birth attendance (SBA) using a novel, data-driven impact evaluation technique known as synthetic control analysis (SCA). We used data from a series of nationally representative surveys such as the Demographic and Health Survey (DHS) and the Multiple Indicator Cluster Survey (MICS), and widely accepted and used global sources such as the World Bank and the World Health Organization for Bangladesh and 16 potential control countries covering 1990–2017. The SCA optimization process selected three countries (Zimbabwe, Dominican Republic, and Haiti) to construct the synthetic control for Bangladesh (i.e., ‘Synthetic Bangladesh’) and resulted in a reasonable fitting for pre-SWAp trends for inequity in SBA use between Bangladesh and Synthetic Bangladesh. The inference procedures involving placebo test and bootstrap confidence intervals indicated a robust, statistically significant causal effect of the health SWAp on increasing SBA inequity in Bangladesh. To our knowledge, this is the first systematic investigation of the role of facility readiness on maternal health equity and statistical impact evaluation of health SWAp in Bangladesh. The empirical evidence and policy measures presented here provide a way forward to provide equitable care for safe delivery services. The policymakers and the program managers need to ensure the readiness of essential maternal health services at all levels in the health sector to provide equitable maternity care in Bangladesh.Doctor of Philosoph

Effects of individual, household and community characteristics on child nutritional status in the slums of urban Bangladesh

Background Bangladesh urban population is expected to overtake rural population by 2040, and a significant part of the increase will be in slums. Wide disparities between urban slums and the rest of the country can potentially push country indicators off track unless the specific health and nutrition needs of the expanding slum communities are addressed. The study aims at describing the individual, household and community determinants of undernutrition status among children living in major urban strata, viz. City Corporation slums and non-slums, in order to understand the major drivers of childhood undernutrition in urban slum settings. Methods Data are derived from Bangladesh Urban Health Survey conducted in 2013. This survey is a large-scale, nationally representative of urban areas, household survey designed specifically to provide health and nutrition status of women and children in urban Bangladesh. Results Data showed that 50% of under-5 children in slums are stunted and 43% are underweight, whereas for non-slums these rates are 33 and 26% respectively. In terms of severity, proportion of under-5 children living in slums severely underweight or stunted are nearly double than the children living in non-slums. Logistic analyses indicate that mother’s education, child’s age, and household’s socio-economic status significantly affects stunting and underweight levels among children living in the urban slums. Logistic models also indicate that all individual-level characteristics, except exposure to mass media and mother’s working outside home, significantly affect undernutrition levels among children living on non-slums. Among the household- and community-level characteristics, only household’s socioeconomic status remains significant for the non-slums. Conclusions Poor nutritional status is a major concern in slum areas, particularly as this group is expected to grow rapidly in the next few years. The situation calls for specially designed and well targeted interventions that take into account that many of the mothers are poorer and less educated, which affects their ability to provide care to their children

Diagnosis of chronic conditions with modifiable lifestyle risk factors in selected urban and rural areas of Bangladesh and sociodemographic variability therein

<p>Abstract</p> <p>Background</p> <p>Bangladesh suffers from a lack of healthcare providers. The growing chronic disease epidemic's demand for healthcare resources will further strain Bangladesh's limited healthcare workforce. Little is known about how Bangladeshis with chronic disease seek care. This study describes chronic disease patients' care seeking behavior by analyzing which providers diagnose these diseases.</p> <p>Methods</p> <p>During 2 month periods in 2009, a cross-sectional survey collected descriptive data on chronic disease diagnoses among 3 surveillance populations within the International Center for Diarrheal Disease Research, Bangladesh (ICDDR, B) network. The maximum number of respondents (over age 25) who reported having ever been diagnosed with a chronic disease determined the sample size. Using SAS software (version 8.0) multivariate regression analyses were preformed on related sociodemographic factors.</p> <p>Results</p> <p>Of the 32,665 survey respondents, 8,591 self reported having a chronic disease. Chronically ill respondents were 63.4% rural residents. Hypertension was the most prevalent disease in rural (12.4%) and urban (16.1%) areas. In rural areas chronic disease diagnoses were made by MBBS doctors (59.7%) and Informal Allopathic Providers (IAPs) (34.9%). In urban areas chronic disease diagnoses were made by MBBS doctors (88.0%) and IAP (7.9%). Our analysis identified several groups that depended heavily on IAP for coverage, particularly rural, poor and women.</p> <p>Conclusion</p> <p>IAPs play important roles in chronic disease care, particularly in rural areas. Input and cooperation from IAPs are needed to minimize rural health disparities. More research on IAP knowledge and practices regarding chronic disease is needed to properly utilize this potential healthcare resource.</p

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research