Benefit incidence analysis of healthcare in Bangladesh – equity matters for universal health coverage

Background: Equity in access to and utilization of healthcare is an important goal for any health system and an essential prerequisite for achieving Universal Health Coverage for any country. Objectives: This study investigated the extent to which health benefits are distributed across socioeconomic groups; and how different types of providers contribute to inequity in health benefits of Bangladesh. Methodology: The distribution of health benefits across socioeconomic groups was estimated using concentration indices. Health benefits from three types of formal providers were analysed (public, private and NGO providers), separated into rural and urban populations. Decomposition of concentration indices into types of providers quantified the relative contribution of providers to the overall distribution of benefits across socioeconomic groups. Eventually, the distribution of benefits was compared to the distribution of healthcare need (proxied by ‘self-reported illness and symptoms’) across socioeconomic groups. Data from the latest Household Income and Expenditure Survey, 2010 and WHO-CHOICE were used. Results: An overall pro-rich distribution of healthcare benefits was observed (CI = 0.229, t-value = 9.50). Healthcare benefits from private providers (CI = 0.237, t-value = 9.44) largely favoured the richer socioeconomic groups. Little evidence of inequity in benefits was found in public (CI = 0.044, t-value = 2.98) and NGO (CI = 0.095, t-value = 0.54) providers. Private providers contributed by 95.9% to overall inequity. The poorest socioeconomic group with 21.8% of the need for healthcare received only 12.7% of the benefits, while the richest group with 18.0% of the need accounted for 32.8% of the health benefits. Conclusion: Overall healthcare benefits in Bangladesh were pro-rich, particularly because of health benefits from private providers. Public providers were observed to contribute relatively slightly to inequity. The poorest (richest) people with largest (least) need for healthcare actually received lower (higher) benefits. When working to achieve Universal Health Coverage in Bangladesh, particular consideration should be given to ensuring that private sector care is more equitable

Changes in inequality of childhood morbidity in Bangladesh 1993-2014: a decomposition analysis

Introduction: Child health remains an important public health concern at the global level, with preventable diseases such as diarrheal disease, acute respiratory infection (ARI) and fever posing a large public health burden in low- and middle-income countries including Bangladesh. Improvements in socio-economic conditions have tended to benefit advantaged groups in societies, which has resulted in widespread inequalities in health outcomes. This study examined how socioeconomic inequality is associated with childhood morbidity in Bangladesh, and identified the factors affecting three illnesses: diarrhea, ARI and fever. Materials and methods: A total of 43,860 sample observations from the Bangladesh Demographic and Health Survey, spanning a 22-year period (1993–2014), were analysed. Concentration curve and concentration index methods were used to evaluate changes in the degree of household wealth-related inequalities and related trends in childhood morbidity. Regression-based decomposition analyses were used to attribute the inequality disparities to individual determinants for the three selected causes of childhood morbidity. Results: The overall magnitude of inequality in relation to childhood morbidity has been declining slowly over the 22-year period. The magnitude of socio-economic inequality as a cause of childhood morbidity varied during the period. Decomposition analyses attributed the inequalities to poor maternal education attainment, inadequate pre-delivery care, adverse chronic undernutrition status and low immunisation coverage. Conclusions: High rates of childhood morbidity were observed, although these have declined over time. Socio-economic inequality is strongly associated with childhood morbidity. Socio-economically disadvantaged communities need to be assisted and interventions should emphasise improvements of, and easier access to, health care services. These will be key to improving the health status of children in Bangladesh and should reduce economic inequality through improved health over time

Fine needle aspiration cytological diagnosis of thyroid nodule with its clinical correlation

Background: Nodular goiter is common in Bangladesh. Thyroid nodules are important for their malignant potential especially the solitary and cold ones and when functionally euthyroid. Objectives: This study was designed to investigate the frequency of malignancy and cellular aberration detected by fine needle aspiration cytology (FNAC) in euthyroid nodules and its correlation with clinical findings. Methods: Subjects with nodular goiter attending Endocrine out patient department [n=150, nonpregnant, age (mean± SD): 37±12 years; sex (male: female): 21:129] were recruited for this study. All subjects underwent clinical risk stratification, estimation ofFT4 and TSH as well as ultrnsonogram (USG) and isotope scan of thyroid. Thyroid nodules were categorized into malignant, suspicious, benign and indeterminant on the basis of cellular character by FNAC. Statistical analysis was done by Chi-square and multiple regression analysis. Results: Patients were mostly females (86%) and 4.7% had family history of thyroid problems. Some had recent changes of size (14.7%), pain in the nodule (4%) and dysphagia (6%). Nodules were solitary in 45.3% and the rest (54.7%) had multinodular goiter. Enlarged regional lymph node was found in 12.7% patients. About 41 % were partially-cold followed by cold nodules (26.7%), patchy (16.7%), isoform (12%) and hot (4%) by isotope scan. Frequency of malignant (10%) character was highest in cold nodules followed by uniform (5.6%), patchy (4.0%) and partially cold (1.6%) while none in hot nodules; which were 22.5%, 11.1 %, 4.0%, 9.8% and 16.7% respectively for suspicious nodules. About 17% showed cellular aberration and 4.7% were clearly malignant, whereas 124 (82.7%) were benign. Of the malignant, 4 were solitary and 3 were multinodular; which were 10 and 9 among the suspicious ones. A significant number (77%, 20 out of 26) among the malignant/suspicious nodules fell into moderate to high risk category (x2=22.861, p<0.001), while 23.1 % of the FNAC proven malignant/suspicious nodules were of low risk category. Enlarged lymph nodes (p<0.001), increased diameter of nodules of >4 cm (p=0.039) and recent changes in nodular size (p=0.042) were independently and signifi­cantly related to cellular aberration. Conclusions: FNAC is a useful tool for cellular diagnosis of thyroid nodules. Clinical suspicion for malignancy strongly correlates with the FNAC findings. But a good number of clinically Low risk categories would escape malignant cellular character unless FNAC is done

Women’s Preferences for Maternal Healthcare Services in Bangladesh: Evidence from a Discrete Choice Experiment

Despite substantial improvements in several maternal health indicators, childbearing and birthing remain a dangerous experience for many women in Bangladesh. This study assessed the relative importance of maternal healthcare service characteristics to Bangladeshi women when choosing a health facility to deliver their babies. The study used a mixed-methods approach. Qualitative methods (expert interviews, focus group discussions) were initially employed to identify and develop the characteristics which most influence a women’s decision making when selecting a maternal health service facility. A discrete choice experiment (DCE) was then constructed to elicit women’s preferences. Women were shown choice scenarios representing hypothetical health facilities with nine attributes outlined. The women were then asked to rank the attributes they considered most important in the delivery of their future babies. A Hierarchical Bayes method was used to measure mean utility parameters. A total of 601 women completed the DCE survey. The model demonstrated significant predictive strength for actual facility choice for maternal health services. The most important attributes were the following: consistent access to a female doctor, the availability of branded drugs, respectful provider attitudes, a continuum of maternal healthcare including the availability of a c-section delivery and lower waiting times. Attended maternal healthcare utilisation rates are low despite the access to primary healthcare facilities. Further implementation of quality improvements in maternal healthcare facilities should be prioritised

Wealth-related inequalities of women’s knowledge of cervical cancer screening and service utilisation in 18 resource-constrained countries: evidence from a pooled decomposition analysis

Introduction: Resource-constrained countries (RCCs) have the highest burden of cervical cancer (CC) in the world. Nonetheless, although CC can be prevented through screening for precancerous lesions, only a small proportion of women utilise screening services in RCCs. The objective of this study was to examine the magnitude of inequalities of women’s knowledge and utilisation of cervical cancer screening (CCS) services in RCCs. Methods: A total of 1,802,413 sample observations from 18 RCC’s latest national-level Demographic and Health Surveys (2008 to 2017–18) were analysed to assess wealth-related inequalities in terms of women’s knowledge and utilisation of CCS services. Regression-based decomposition analyses were applied in order to compute the contribution to the inequality disparities of the explanatory variables for women’s knowledge and utilisation of CCS services. Results: Overall, approximately 37% of women had knowledge regarding CCS services, of which, 25% belonged to the poorest quintile and approximately 49% from the richest. Twenty-nine percent of women utilised CCS services, ranging from 11% in Tajikistan, 15% in Cote d’Ivoire, 17% in Tanzania, 19% in Zimbabwe and 20% in Kenya to 96% in Colombia. Decomposition analyses determined that factors that reduced inequalities in women’s knowledge of CCS services were male-headed households (− 2.24%; 95% CI: − 3.10%, − 1.59%; P < 0.01), currently experiencing amenorrhea (− 1.37%; 95% CI: − 2.37%, − 1.05%; P < 0.05), having no problems accessing medical assistance (− 10.00%; 95% CI: − 12.65%, − 4.89%; P < 0.05), being insured (− 6.94%; 95% CI: − 9.58%, − 4.29%; P < 0.01) and having an urban place of residence (− 9.76%; 95% CI: − 12.59%, − 5.69%; P < 0.01). Similarly, factors that diminished inequality in the utilisation of CCS services were being married (− 8.23%; 95% CI: − 12.46%, − 5.80%; P < 0.01), being unemployed (− 14.16%; 95% CI: − 19.23%, − 8.47%; P < 0.01) and living in urban communities (− 9.76%; 95% CI: − 15.62%, − 5.80%; P < 0.01). Conclusions: Women’s knowledge and utilisation of CCS services in RCCs are unequally distributed. Significant inequalities were identified among socioeconomically deprived women in the majority of countries. There is an urgent need for culturally appropriate community-based awareness and access programs to improve the uptake of CCS services in RCCs

Inequalities in Health Status from EQ-5D Findings: A Cross-Sectional Study in Low-Income Communities of Bangladesh

Background: Measuring health status by using standardized and validated instrument has become a growing concern over the past few decades throughout the developed and developing countries. The aim of the study was to investigate the overall self-reported health status along with potential inequalities by using EuroQol 5 dimensions (EQ-5D) instrument among low-income people of Bangladesh. Methods: A cross-sectional household survey was conducted in Chandpur district of Bangladesh. Bangla version of the EQ-5D questionnaire was employed along with socio-demographic information. EQ-5D questionnaire composed of 2-part measurements: EQ-5D descriptive system and the visual analogue scale (VAS). For measuring health status, UK-based preference weights were applied while higher score indicated better health status. For facilitating the consistency with EQ-5D score, VASs were converted to a scale with scores ranging from 0 to 1. Multiple logistic regression models were also employed to examine differences among EQ-5D dimensions. Results: A total of 1433 respondents participated in the study. The mean EQ-5D and VAS score was 0.76 and 0.77, respectively. The females were more likely to report any problem than the males (P<0.001). Compared to the younger, elderly were more than 2-3 times likely to report any health problem in all EQ-5D dimensions (OR [odds ratio]=3.17 for mobility, OR=3.24 for self-care). However, the respondents of the poorest income group were significantly suffered more from every EQ-5D dimension than the richest income quintile. Conclusion: Socio-economic and demographic inequalities in health status was observed in the study. Study suggests to do further investigation with country representative sample to measure the inequalities of overall health status. It would be helpful for policy-maker to find a new way aiming to reduce such inequalities

The burden of chronic diseases and patients' preference for healthcare services among adult patients suffering from chronic diseases in Bangladesh

Background: Low‐and middle‐income countries (LMICs) have a disproportionately high burden of chronic diseases, with inequalities in health care access and quality services. This study aimed to assess patients' preferences for healthcare services for chronic disease management among adult patients in Bangladesh. Methods: The present analysis was conducted among 10,385 patients suffering from chronic diseases, drawn from the latest Household Income and Expenditure Survey 2016–2017. We used the multinomial logistic regression to investigate the association of chronic comorbid conditions and healthcare service‐related factors with patients' preferences for healthcare services. Results: The top four dimensions of patient preference for healthcare services in order of magnitude were quality of treatment (30.3%), short distance to health facility (27.6%), affordability of health care (21.7%) and availability of doctors (11.0%). Patients with heart disease had a 29% significantly lower preference for healthcare affordability than the quality of healthcare services (relative risk ratio [RRR] = 0.71; 0.56–0.90). Patients who received healthcare services from pharmacies or dispensaries were more likely to prefer a short distance to a health facility (RRR = 6.99; 4.80–9.86) or affordability of healthcare services (RRR = 3.13; 2.25–4.36). Patients with comorbid conditions were more likely to prefer healthcare affordability (RRR = 1.39; 1.15–1.68). In addition, patients who received health care from a public facility had 2.93 times higher preference for the availability of medical doctors (RRR = 2.93; 1.70–5.04) than the quality of treatment in the health facility, when compared with private service providers. Conclusions: Patient preferences for healthcare services in chronic disease management were significantly associated with the type of disease and its magnitude and characteristics of healthcare providers. Therefore, to enhance service provision and equitable distribution and uptake of health services, policymakers and public health practitioners should consider patient preferences in designing national strategic frameworks for chronic disease management. Patient or Public Contribution: Our research team includes four researchers (co‐authors) with chronic diseases who have experience of living or working with people suffering from chronic conditions or diseases

Evaluating the implementation related challenges of Shasthyo Suroksha Karmasuchi (health protection scheme) of the government of Bangladesh: a study protocol

Background Rapidly increasing healthcare costs and the growing burden of noncommunicable diseases have increased the out-of-pocket (OOP) spending (63.3% of total health expenditure) in Bangladesh. This increasing OOP spending for healthcare has catastrophic economic impact on households. To reduce this burden, the Health Economics Unit (HEU) of the Ministry of Health and Family Welfare has developed the Shasthyo Surokhsha Karmasuchi (SSK) health protection scheme for the below-poverty line (BPL) population. The key actors in the scheme are HEU, contracted scheme operator and hospital. Under this scheme, each enrolled household is provided 50,000 BDT (620 USD) coverage per year for healthcare services against a government financed premium of 1000 BDT (12 USD). This initiative faces some challenges e.g., delays in scheme activities, registering the targeted population, low utilization of services, lack of motivation of the providers, and management related difficulties. It is also important to estimate the financial requirement for nationwide scale-up of this project. We aim to identify these implementation-related challenges and provide feedback to the project personnel. Methods This is a concurrent process documentation using mixed-method approaches. It will be conducted in the rural Kalihati Upazila where the SSK is being implemented. To validate the BPL population selection process, we will estimate the positive predictive value. A community survey will be conducted to assess the knowledge of the card holders about SSK services. From the SSK information management system, numbers of different services utilized by the card holders will be retrieved. Key-informant interviews with personnel from three key actors will be conducted to understand the barriers in the implementation of the project as per plan and gather their suggestions. To estimate the project costs, all inputs to be used will be identified, quantified and valued. The nationwide scale-up cost of the project will be estimated by applying economic modeling. Discussion SSK is the first ever government initiated health protection scheme in Bangladesh. The study findings will enable decision makers to gain a better understanding of the key challenges in implementation of such scheme and provide feedback towards the successful implementation of the program

Nitrogen, phosphorus and sulphur mineralization in soil treated with amended municipal solid waste compost under aerobic and anaerobic conditions

Purpose Our study had considered some organic amendments to enhance nutrient level of marketed municipal solid waste (MSW) compost for its potential use as fertilizer for growing crops in alluvial soils. Method We prepared three types of amended compost by mixing 20% mustard oil cake (MOC), and 30% poultry manure (PM) or cowdung (CD) or sugarcane press mud (SPM) with 50% MSW compost. The nitrogen (N), phosphorus (P) and sulphur (S) mineralization study was done in soil treated with three amended and one unamended composts with three replications through an incubation experiment at a temperature of 25 ± 1°C for 82 days under aerobic (field capacity) and anaerobic (submerged) conditions. The mineralization data were fitted to the first-order kinetic model. Results The soil NO3--N content was 2-3 times higher in aerobic condition than in anaerobic condition, while the NH4+-N was higher in anaerobic soils. The kinetic model reveals that poultry manure and sugarcane press mud had higher capability to supply N for use by the crops. The P release was the highest at day 15 with three-time higher availability in anaerobic condition. The S mineralization in soil was higher in field capacity than in submerged condition. ConclusionThe compost mixture comprising MSW, MOC and SPM in a ratio of 5:2:3 demonstrated the highest cumulative N, P and S mineralization in both aerobic and anaerobic conditions. The N and S availability decreased while the P availability increased in submerged soils which result has fertilizer management implications for wet  land rice crop