Implementation barriers and remedial strategies for community-based health insurance in Bangladesh: insights from national stakeholders.

BACKGROUND: Community-based health insurance (CBHI) is a part of the health system in Bangladesh, and overcoming the obstacles of CBHI is a significant policy concern that has received little attention. The purpose of this study is to analyze the implementation barriers of voluntary CBHI schemes in Bangladesh and the strategies to overcome these barriers from the perspective of national stakeholders. METHODS: This study is exploratory qualitative research, specifically case study design, using key informant interviews to investigate the barriers of CBHI that are faced during the implementation. Using a topic guide, we conducted thirteen semi-structured in-depth interviews with key stakeholders directly involved in the CBHI implementation process. The data were analyzed using the Framework analysis method. RESULTS: The implementation of CBHI schemes in Bangladesh is being constrained by several issues, including inadequate population coverage, adverse selection and moral hazard, lack of knowledge about health insurance principles, a lack of external assistance, and insufficient medical supplies. Door-to-door visits by local community-health workers, as well as regular promotional and educational campaigns involving community influencers, were suggested by stakeholders as ways to educate and encourage people to join the schemes. Stakeholders emphasized the necessity of external assistance and the design of a comprehensive benefits package to attract more people. They also recommended adopting a public-private partnership with a belief that collaboration among the government, microfinance institutions, and cooperative societies will enhance trust and population coverage in Bangladesh. CONCLUSIONS: Our research concludes that systematically addressing implementation barriers by including key stakeholders would be a significant reform to the CBHI model, and could serve as a foundation for the planned national health protection scheme for Bangladesh leading to universal health coverage.

Households' out-of-pocket expenditure for healthcare in Bangladesh: A health financing incidence analysis.

BACKGROUND: Despite improvements in many health indicators, providing access to affordable healthcare remains a considerable challenge in Bangladesh. Financing incidence analysis will enable an evaluation of how well the healthcare system performs to achieve equity in health financing. The objective of this study is to assess the burden of out-of-pocket (OOP) cost on different socio-economic groups by assessing the health financing incidence because OOP cost dominates household expenditure on health in Bangladesh. METHODS: The study was conducted using latest Household Income and Expenditure Survey (HIES) 2016. We focused mainly on four specific indicators: level of monthly household OOP cost on in-patient care, urban-rural differences in OOP cost, socio-economic status differences in different payment mechanisms and the Kakwani index. Descriptive statistics were employed to analyse and summarise the selected variables based on the SES and location of residence (e.g., rural and urban). RESULTS: The study showed the overall OOP healthcare expenditure was 7.7% of the household monthly income while the poorer income group suffered more and spent up to 35% of their household income on healthcare. The Kakwani index indicated that the poorest quintile spends a greater share of their income on healthcare services than the richest quintile. CONCLUSIONS: This study observed that OOP cost in Bangladesh is regressive, that is, poorer members of society contribute a greater share of their income. Therefore, policymakers should initiate health reforms for developing and implementing risk-pooling financing mechanisms such as social health insurance to achieve the Universal Health Coverage in Bangladesh.

Factors associated with unmet fertility desire and perceptions of ideal family size among women in Bangladesh: Insights from a nationwide Demographic and Health Survey.

INTRODUCTION: Along with the developing world, Bangladesh has made a tremendous improvement in declining total fertility rate, however, this declining trend is not uniform to all the socio-demographic stratum. Incongruities exist between the numbers of children that women bearing and what they actually desired which refers to unmet fertility desire. This study aims to elicit women's perception of ideal number of children and predictors of unmet fertility desire in Bangladesh. METHOD: This study analyzed nationally representative cross-sectional Bangladesh Demographic and Health Survey 2014 data. A two-stage stratified random sampling technique was used while a total of 17,863 ever-married women were interviewed between June and November 2014. A total of 10,912 eligible women were included in the analysis. Poisson regression analysis and logistic regression models were used to measure women's perception of the ideal number of children and to determine the influencing factors of unmet fertility desires. RESULT: The mean value of the perceived ideal number of children was 2.22 (SD ± 0.73) and the majority of women (71.2%) expect to have two children in their lifetime. Approximately 46% of mothers reported bearing more children than they desired. The perceived ideal number of children was significantly higher among women who were living in rural areas, from Sylhet division, Muslim, unemployed, and experienced child death and those who justified beating. Findings revealed that several factors such as place of residence, geographic location, religion, wealth index, maternal age and education, partners' education, experiencing child death, and other empowerment-related indicators were significantly associated with unmet fertility desires. CONCLUSION: Perceived ideal number of children differs among women's socioeconomic and demographic strata. Unmet fertility desire was also found which indicates that reproductive knowledge and health care services are still necessary for some socio-demographically disadvantaged/vulnerable people and this group should be regularly monitored to control population growth.

Inequality of childhood undernutrition in Bangladesh: A decomposition approach.

BACKGROUND: Undernutrition is one of the major public health concerns in Bangladesh. This study examined the trends and patterns of childhood undernutrition, inequality, and its socioeconomic contributors in Bangladesh. METHODS: Data were extracted from the last four rounds of the Bangladesh Demographic Health Survey (BDHS). A regression-based decomposition method was applied to assess the socioeconomic contributors of inequality. RESULTS: Although the prevalence of childhood undernutrition has declined during the period 2004 to 2014, the rate of undernutrition is higher among the children of mothers who had lower education, live in rural areas, and are from the poorest wealth quintile. Socioeconomic status accounted for almost half of the total inequality in the prevalence of both stunting and underweight among children, whereas maternal education was ranked second among the contributors. CONCLUSIONS: Findings of the study indicate that undernutrition inequalities in terms of socioeconomic aspects appear to have widened over time. Improving economic activity and maternal education will improve the nutritional status of children and as a consequence reduce inequality. Therefore, investments in education, creation of working opportunities, and empowerment of vulnerable and disadvantaged people along with nutrition-specific interventions will be important measures to eliminate this inequality at the population level.

Economic evaluation of community acquired pneumonia management strategies: A systematic review of literature.

BACKGROUND: Community-acquired pneumonia (CAP) is a major cause of mortality and morbidity worldwide. Efficient use of resources is fundamental for best use of money among the available and novel treatment options for the management of pneumonia. The objective of this study was to systematically review the economic analysis of management strategies of pneumonia. METHODS: A systematic search was performed using Academic Search Complete, MEDLINE, EconLit, Global health, MEDLINE complete and Embase databases using specific subject headings or key words in May 2018 without restricting publication year. All search results were recorded and any type of economic evaluation for management of CAP was included for detailed review. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist was used for quality appraisal. RESULTS: Nineteen studies met the inclusion criteria; ten studies were trial based, five conducted analysis using model based techniques and the rest of the studies were either based on observational, record review or pre-post intervention studies. Most of the studies conducted cost-effectiveness analysis (n = 15) and compared different combinations of antimicrobials. Most were based on developed countries (n = 17), considered adult age groups (n = 16) and used a provider perspective (n = 14). Nine studies reported dominant alternatives (lower cost with higher benefit). Sensitivity analysis was performed by the majority of studies (n = 15). Fourteen studies were assessed as either being excellent, very good or good quality, with no relationship found between publication year and study quality. Methodological variation, type of microbial used, perspective, costs and outcome measures limit the compatibility among the results of the included studies. CONCLUSION: Economic evaluation of interventions for management of CAP to date supports cost-effectiveness of studied interventions. However, evidence relates largely to antimicrobials choice in older populations in developed countries. Parallel economic evaluation of different management strategies of CAP is recommended for both developed and developing countries to support rigorous and robust comparative economic analysis within health care systems. PROSPERO registration no: CRD42018097174.

Sex-specific prevalence, inequality and associated predictors of hypertension, diabetes, and comorbidity among Bangladeshi adults: results from a nationwide cross-sectional demographic and health survey.

OBJECTIVES: To determine the sex-specific prevalence, inequality and factors associated with healthcare utilisation for diabetes mellitus (DM), hypertension and comorbidity among the adult population of Bangladesh. STUDY DESIGN: This study analysed cross-sectional nationwide Bangladesh Demographic and Health Survey data from 2011. Comorbidity was defined as the coexistence of both DM and hypertension. Several socioeconomic and demographic factors such as age, sex, education, geographic location, administrative division, employment status, education and wealth index were considered as major explanatory variables. Inequality in prevalence and healthcare utilisation was measured using the 'Lorenz curve'. Adjusted multiple logistic regression models were performed to observe the effects of different factors and reported as adjusted ORs (AORs) with 95% CIs. A p value of <0.05 was adopted as the level of statistical significance. SETTING: The study was conducted in Bangladesh. PARTICIPANTS: A total of 7521 adult participants with availability of biomarkers information were included. RESULTS: The mean age of the study participants was 51.4 years (SD ±13.0). The prevalence of hypertension, diabetes and comorbidity were 29.7%, 11.0% and 4.5% respectively. Socioeconomic inequality was observed in the utilisation of healthcare services. A higher prevalence of hypertension and comorbidity was significantly associated with individuals aged >70 years (AOR 7.0, 95% CI 5.0 to 9.9; AOR 6.7, 95% CI 3.0 to 14.9). The risk of having hypertension, diabetes and comorbidity were significantly higher among more educated, unemployed as well as among individuals from Khulna division. CONCLUSIONS: The study revealed a rising prevalence of hypertension, diabetes and comorbidity with inequality in service utilisation. A joint effort involving public, private and non-governmental organisations is necessary to ensure improved accessibility in service utilisation and to reduce the disease burden.

Coverage and Determinants of Full Immunization: Vaccination Coverage among Senegalese Children.

Background and Objectives: In line with the global success of immunization, Senegal achieved impressive progress in childhood immunization program. However, immunization coverage is often below the national and international targets and even not equally distributed across the country. The objective of this study is to estimate the full immunization coverage across the geographic regions and identify the potential factors of full immunization coverage among the Senegalese children. Materials and Methods: Nationally representative dataset extracted from the latest Continuous Senegal Demographic and Health Survey 2017 was used for this analysis. Descriptive statistics such as the frequency with percentage and multivariable logistic regression models were constructed and results were presented in terms of adjusted odds ratio (AOR) with a 95% confidence interval (CI). Results: Overall, 70.96% of Senegalese children aged between 12 to 36 months were fully immunized and the coverage was higher in urban areas (76.51%), west ecological zone (80.0%), and among serer ethnic groups (77.24%). Full immunization coverage rate was almost the same between male and female children, and slightly higher among the children who were born at any health care facility (74.01%). Children who lived in the western zone of Senegal were 1.66 times (CI: 1.25-2.21; p = 0.001) and the children of Serer ethnic groups were 1.43 times (CI: 1.09-1.88; p = 0.011) more likely to be fully immunized than the children living in the southern zone and from the Poular ethnic group. In addition, children who were born at health facilities were more likely to be fully immunized than those who were born at home (AOR = 1.47; CI: 1.20-1.80; p < 0.001), and mothers with recommended antenatal care (ANC) (4 and more) visits during pregnancy were more likely to have their children fully immunized than those mother with no ANC visits (AOR: 2.06 CI: 1.19-3.57; p = 0.010). Conclusions: Immunization coverage was found suboptimal by type of vaccines and across ethnic groups and regions of Senegal. Immunization program should be designed targeting low performing areas and emphasize on promoting equal access to education, decision-making, encouraging institutional deliveries, and scaling up the use of antenatal and postnatal care which may significantly improve the rate full immunization coverage in Senegal.

Coverage and factors associated with full immunisation among children aged 12-59 months in Bangladesh: insights from the nationwide cross-sectional demographic and health survey.

OBJECTIVE: To estimate the coverage and factors associated with full immunisation coverage among children aged 12-59 months in Bangladesh. STUDY DESIGN: The study is cross sectional in design. Secondary dataset from Bangladesh Demographic and Health Survey was used for this analysis. Immunisation status was categorised as 'fully immunised' if the children had received all the eight recommended vaccine doses otherwise 'partially/unimmunised'. SETTINGS: Bangladesh. PARTICIPANT: Children aged 12-59 months were the study participants. Participants were randomly selected through a two-stage stratified sampling design. A total of 6230 children were eligible for the analysis. RESULTS: About 86% of the children (5356 out of 6230) were fully immunised. BCG has the highest coverage rate (97.1%) followed by oral polio vaccine 1 (97%) and pentavalent 1 (96.6%), where the coverage rate was the lowest for measles vaccine (88%). Coverage was higher in urban areas (88.5%) when compared with rural ones (85.1%). Full immunisation coverage was significantly higher among children who lived in the Rangpur division (adjusted OR (AOR)=3.46; 95% CI 2.45 to 4.88, p<0.001), were 48-59 months old (AOR=1.32; 95% CI 1.06 to 1.64, p=0.013), lived in a medium size family (AOR=1.56; 95% CI 1.32 to 1.86, p<0.001), had parents with a higher level of education (AOR=1.96; 95% CI 1.21 to 3.17, p=0.006 and AOR=1.55; 95% CI 1.05 to 2.29, p=0.026) and belonged to the richest families (AOR=2.2; 95% CI 1.5 to 3.21, p<0.001). The likelihood of being partially or unimmunised was higher among children who had the father as their sole healthcare decision-maker (AOR=0.69; 95% CI 0.51 to 0.92, p<0.012). CONCLUSIONS: There were significant variations of child immunisation coverage across socioeconomic and demographic factors. These findings will inform innovative approaches for immunisation programmes, and the introduction of relevant policies, including regular monitoring and evaluation of immunisation coverage-particularly for low-performing regions, so that the broader benefit of immunisation programmes can be achieved in all strata of the society.

Cost of Caregivers for Treating Hospitalized Diarrheal Patients in Bangladesh.

INTRODUCTION: Diarrheal diseases are a global public health problem and one of the leading causes of mortality, morbidity and economic loss. The objective of the study is to estimate the economic cost of caregivers and cost distribution per diarrheal episodes in Bangladesh. METHODS: This was a cross-sectional hospital-based study conducted in public hospitals in Bangladesh. A total of 801 diarrheal patients were randomly selected and interviewed during January to December 2015. Simple descriptive statistics including frequencies, percentage, mean with 95% CI and median are presented. RESULTS: The overall average cost of caregivers was BDT 2243 (US$ 28.58) while only BDT 259 (US$ 3.29) was spent as out of pocket payments. Caregivers mostly spent money (US$ 1.63) for food, lodging, utility bills, and other lump sum costs followed by the transportation costs (US$ 1.57). The caregivers spent more (US$ 44.45) when they accompanied the patients who were admitted in inpatients care and almost 3.6 times higher than for out-patients care (US$ 12.42). CONCLUSIONS: The study delivers an empirical evidence to the health-care programmers and policy makers about the economic cost of caregivers during diarrheal treatment care, which should be accounted for in designing future diarrheal prevention programme.

Cost comparison and determinants of out-of-pocket payments on child delivery care in Bangladesh.

OBJECTIVES: The objective of this study is to capture the relevant out-of-pocket (OOP) costs, coping mechanisms, and associated factors that are related to child delivery in Bangladesh through the use of nationwide household level data. DATA AND METHODS: The study was conducted using a secondary data source of the latest Bangladesh Demographic and Health Survey 2014. A cross-sectional survey was performed for 6 months, from June to November 2014, where closed-ended questions regarding child delivery-related expenditure were included. Log linear regression and descriptive analysis methods were used to analyze these data. RESULTS: Analysis indicated that the average self-reported OOP payment per child delivery was US$ 79.23 (SD ±128.05). The highest OOP was observed for C-section (US$ 249.89, SD ±153.54), followed by institutional normal delivery (US$ 61.62, SD ±75.28). The average cost per normal home delivery was US$ 15.89 (SD ±25.84). The richest quintile spent significantly more than the poorest quintile regarding C-section (US$ 281 vs US$ 204), normal delivery at an institution (US$ 80 vs US$ 65), and even normal delivery at home (US$ 22 vs US$ 13). CONCLUSIONS: The study showed that there was a huge variation of OOP, which was dependent on the facility and socioeconomic demographic status of the households. As such, policy efforts need to focus on lowest wealth quintiles to avoid economic burdens during child delivery-related activities, and therefore, financial risk protection should be provided. Social health insurance might be an option for financing during child delivery, which is in line with the core objective of the Healthcare Financing Strategy of Bangladesh, which is to achieve universal health coverage.