Patient Satisfaction With the Health Care Services of a Government-Financed Health Protection Scheme in Bangladesh: Cross-Sectional Study.

BACKGROUND: Since 2016, the government of Bangladesh has been piloting a health protection scheme known as Shasthyo Surokhsha Karmasuchi (SSK), which specifically targets households living below the poverty line. This noncontributory scheme provides enrolled households access to inpatient health care services for 78 disease groups. Understanding patients' experiences with health care utilization from the pilot SSK scheme is important for enhancing the quality of health care service delivery during the national-level scale-up of the scheme. OBJECTIVE: We aimed to evaluate patient satisfaction with the health care services provided under the pilot health protection scheme in Bangladesh. METHODS: A cross-sectional survey was conducted with the users of the SSK scheme from August to November 2019. Patients who had spent a minimum of 2 nights at health care facilities were selected for face-to-face exit interviews. During these interviews, we collected information on patients' socioeconomic characteristics, care-seeking experiences, and level of satisfaction with various aspects of health care service delivery. To measure satisfaction, we employed a 5-point Likert scale (very satisfied, 5; satisfied, 4; neither satisfied nor dissatisfied, 3; dissatisfied, 2; very dissatisfied, 1). Descriptive statistics, statistical inferential tests (t-test and 1-way ANOVA), and linear regression analyses were performed. RESULTS: We found that 55.1% (241/438) of users were either very satisfied or satisfied with the health care services of the SSK scheme. The most satisfactory indicators were related to privacy maintained during diagnostic tests (mean 3.91, SD 0.64), physicians' behaviors (mean 3.86, SD 0.77), services provided at the registration booth (mean 3.86, SD 0.62), confidentiality maintained regarding diseases (mean 3.78, SD 0.72), and nurses' behaviors (mean 3.60, SD 0.83). Poor satisfaction was identified in the interaction of patients with providers about illness-related information (mean 2.14, SD 1.40), availability of drinking water (mean 1.46, SD 0.76), cleanliness of toilets (mean 2.85, SD 1.04), and cleanliness of the waiting room (mean 2.92, SD 1.09). Patient satisfaction significantly decreased by 0.20 points for registration times of 16-30 minutes and by 0.32 points for registration times of >30 minutes compared with registration times of ≤15 minutes. Similarly, patient satisfaction significantly decreased with an increase in the waiting time to obtain services. However, the satisfaction of users significantly increased if they received a complete course of medicines and all prescribed diagnostic services. CONCLUSIONS: More than half of the users were satisfied with the services provided under the SSK scheme. However, there is scope for improving user satisfaction. To improve the satisfaction level, the SSK scheme implementation authorities should pay attention to reducing the registration time and waiting time to obtain services and improving the availability of drugs and prescribed diagnostic services. The authorities should also ensure the supply of drinking water and enhance the cleanliness of the facility.

The effectiveness of a government-sponsored health protection scheme in reducing financial risks for the below-poverty-line population in Bangladesh.

The Government of Bangladesh is piloting a non-contributory health protection scheme called Shasthyo Surokhsha Karmasuchi (SSK) to increase access to quality essential healthcare services for the below-poverty-line (BPL) population. This paper assesses the effect of the SSK scheme on out-of-pocket expenditure (OOPE) for healthcare, catastrophic health expenditure (CHE) and economic impoverishment of the enrolled population. A comparative cross-sectional study was conducted in Tangail District, where the SSK was implemented. From August 2019 to March 2020, a total of 2315 BPL households (HHs) (1170 intervention and 1145 comparison) that had at least one individual with inpatient care experience in the last 12 months were surveyed. A household is said to have incurred CHE if their OOPE for healthcare exceeds the total (or non-food) HH's expenditure threshold. Multiple regression analysis was performed using OOPE, incidence of CHE and impoverishment as dependent variables and SSK membership status, actual BPL status and benefits use status as the main explanatory variables. Overall, the OOPE was significantly lower (P < 0.01) in the intervention areas (Bangladeshi Taka (BDT) 23 366) compared with the comparison areas (BDT 24 757). Regression analysis revealed that the OOPE, CHE incidence at threshold of 10% of total expenditure and 40% of non-food expenditure and impoverishment were 33% (P < 0.01), 46% (P < 0.01), 42% (P < 0.01) and 30% (P < 0.01) lower, respectively, in the intervention areas than in the comparison areas. Additionally, HHs that utilized SSK benefits experienced even lower OOPE by 92% (P < 0.01), CHE incidence at 10% and 40% threshold levels by 72% (P < 0.01) and 59% (P < 0.01), respectively, and impoverishment by 27% at 10% level of significance. These findings demonstrated the significant positive effect of the SSK in reducing financial burdens associated with healthcare utilization among the enrolled HHs. This illustrates the importance of the nationwide scaling up of the scheme in Bangladesh to reduce the undue financial risk of healthcare utilization for those in poverty.

Costs of services and funding gap of the Bangladesh National Tuberculosis Control Programme 2016-2022: An ingredient based approach.

BACKGROUND: Bangladesh National Tuberculosis (TB) Control Programme (NTP) has deployed improved diagnostic technologies which may drive up the programme costs. We aimed to estimate the supply-side costs associated with the delivery of the NTP and the funding gap between the cost of implementation and available funding for the Bangladesh NTP. METHODS: An ingredient-based costing approach was applied using WHO's OneHealth Tool software. We considered 2016, as the base year and projected cost estimates up to 2022 using information on NTP planned activities. Data were collected through consultative meetings with experts and officials/managers, review of documents and databases, and visits to five purposively selected TB healthcare facilities. The estimated costs were compared with the funds allocated to the NTP between 2018 and 2022 to estimate the funding gap. FINDINGS: The estimated total cost of NTP was US$ 49.22 million in 2016, which would increase to US$ 146.93 million in 2022. Human resources (41.1%) and medicines and investigations/ supplies (38.0%) were the major two cost components. Unit costs were highest for treating extensively drug-resistant TB at US$ 7,422.4 in 2016. Between 2018-2022, NTP would incur US$ 536.8 million, which is US$ 235.18 million higher than the current allocation for NTP. CONCLUSION: Our results indicated a funding gap associated with the NTP in each of the years between 2018-2022. Policy planners should advocate for additional funding to ensure smooth delivery of TB services in the upcoming years. The cost estimates of TB services can also be used for planning and budgeting for delivering TB services in similar country contexts.

Factors affecting the healthcare utilization from Shasthyo Suroksha Karmasuchi scheme among the below-poverty-line population in one subdistrict in Bangladesh: a cross sectional study.

BACKGROUND: Financing healthcare through out-of-pocket (OOP) payment is a major barrier in accessing healthcare for the poor people. The Health Economics Unit (HEU) of the Ministry of Health and Family Welfare of the government of Bangladesh has developed Shasthyo Suroksha Karmasuchi (SSK), a health protection scheme, with the aim of reducing OOP expenditure and improving access of the below-poverty-line (BPL) population to healthcare. The scheme started piloting in 2016 at Kalihati sub-district of Tangail District. Our objective was to assess healthcare utilization by the enrolled BPL population and to identify the factors those influencing their utilization of the scheme. METHOD: A cross-sectional household survey was conducted from July to September 2018 in the piloting sub-district. A total of 806 households were surveyed using a semi-structured questionnaire. Information on illness and sources of healthcare service were captured for the last 90 days before the survey. Multiple logistic regression models were applied to determine the factors related to utilization of healthcare from the SSK scheme and other medically trained providers (MTPs) by the SSK members for both inpatient and outpatient care. RESULT: A total of 781 (24.6%) people reported of suffering from illness of which 639 (81.8%) sought healthcare from any sources. About 8.0% (51 out of 639) of them sought healthcare from SSK scheme and 28.2% from other MTPs within 90 days preceding the survey. Households with knowledge about SSK scheme were more likely to utilize healthcare from the scheme and less likely to utilize healthcare from other MTPs. Non-BPL status and suffering from an accident/injury were significantly positively associated with utilization of healthcare from SSK scheme. CONCLUSION: Among the BPL population, healthcare utilization from the SSK scheme was very low compared to that of other MTPs. Effective strategies should be in place for improving knowledge of BPL population on SSK scheme and the benefits package of the scheme should be updated as per the need of the target population. Such initiative can be instrumental in increasing utilization of the scheme and ultimately will reduce the barriers of OOP payment among BPL population for accessing healthcare.

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

BACKGROUND: Out-of-pocket (OOP) payments for healthcare have been increasing steadily in Bangladesh, which deteriorates the financial risk protection of many households. METHODS: We aimed to investigate the incidence of catastrophic health expenditure (CHE) and impoverishment from OOP payments and their determinants. We employed nationally representative Household Income and Expenditure Survey 2016 data with a sample of 46 076 households. A household that made OOP payments of >10% of its total or 40% of its non-food expenditure was considered to be facing CHE. We estimated the impoverishment using both national and international poverty lines. Multiple logistic models were employed to identify the determinants of CHE and impoverishment. RESULTS: The incidence of CHE was estimated as 24.6% and 10.9% using 10% of the total and 40% of non-food expenditure as thresholds, respectively, and these were concentrated among the poor. About 4.5% of the population (8.61 million) fell into poverty during 2016. Utilization of private facilities, the presence of older people, chronic illness and geographical location were the main determinants of both CHE and impoverishment. CONCLUSION: The financial hardship due to OOP payments was high and it should be reduced by regulating the private health sector and covering the care of older people and chronic illness by prepayment-financing mechanisms.

Effectiveness of health voucher scheme and micro-health insurance scheme to support the poor and extreme poor in selected urban areas of Bangladesh: An assessment using a mixed-method approach.

BACKGROUND: National healthcare financing strategy recommends tax-based equity funds and insurance schemes for the poor and extreme poor living in urban slums and pavements as the majority of these population utilise informal providers resulting in adverse health effects and financial hardship. We assessed the effect of a health voucher scheme (HVS) and micro-health insurance (MHI) scheme on healthcare utilisation and out-of-pocket (OOP) payments and the cost of implementing such schemes. METHODS: HVS and MHI schemes were implemented by Concern Worldwide through selected NGO health centres, referral hospitals, and private healthcare facilities in three City Corporations of Bangladesh from December 2016 to March 2020. A household survey with 1,294 enrolees, key-informant interviews, focus group discussions, consultative meetings, and document reviews were conducted for extracting data on healthcare utilisation, OOP payments, views of enrolees, and suggestions of implementers, and costs of services at the point of care. RESULTS: Healthcare utilisation including maternal, neonatal and child health (MNCH) services, particularly from medically trained providers, was higher and OOP payments were lower among the scheme enrolees compared to corresponding population groups in general. The beneficiaries were happy with their access to healthcare, especially for MNCH services, and their perceived quality of care was fair enough. They, however, suggested expanding the benefits package, supported by an additional workforce. The cost per beneficiary household for providing services per year was €32 in HVS and €15 in MHI scheme. CONCLUSION: HVS and MHI schemes enabled higher healthcare utilisation at lower OOP payments among the enrolees, who were happy with their access to healthcare, particularly for MNCH services. However, they suggested a larger benefits package in future. The provider's costs of the schemes were reasonable; however, there are potentials of cost containment by purchasing the health services for their beneficiaries in a competitive basis from the market. Scaling up such schemes addressing the drawback would contribute to achieving universal health coverage.

Cost-effectiveness of a market-based home fortification of food with micronutrient powder programme in Bangladesh.

OBJECTIVE: We estimated the cost-effectiveness of home fortification with micronutrient powder delivered in a sales-based programme in reducing the prevalence of Fe deficiency anaemia among children 6-59 months in Bangladesh. DESIGN: Cross-sectional interviews with local and central-level programme staff and document reviews were conducted. Using an activity-based costing approach, we estimated start-up and implementation costs of the programme. The incremental cost per anaemia case averted and disability-adjusted life years (DALY) averted were estimated by comparing the home fortification programme and no intervention scenarios. SETTING: The home fortification programme was implemented in 164 upazilas (sub-districts) in Bangladesh. PARTICIPANTS: Caregivers of child 6-59 months and BRAC staff members including community health workers were the participants for this study. RESULTS: The home fortification programme had an estimated total start-up cost of 35·46 million BDT (456 thousand USD) and implementation cost of 1111·63 million BDT (14·12 million USD). The incremental cost per Fe deficiency anaemia case averted and per DALY averted was estimated to be 1749 BDT (22·2 USD) and 12 558 BDT (159·3 USD), respectively. Considering per capita gross domestic product (1516·5 USD) as the cost-effectiveness threshold, the home fortification programme was highly cost-effective. The programme coverage and costs for nutritional counselling of the beneficiary were influential parameters for cost per DALY averted in the one-way sensitivity analysis. CONCLUSIONS: The market-based home fortification programme was a highly cost-effective mechanism for delivering micronutrients to a large number of children in Bangladesh. The policymakers should consider funding and sustaining large-scale sales-based micronutrient home fortification efforts assuming the clear population-level need and potential to benefit persists.

Technical efficiency of public district hospitals in Bangladesh: a data envelopment analysis.

BACKGROUND: District hospitals (DHs) provide secondary level of healthcare to a wide range of population in Bangladesh. Efficient utilization of resources in these secondary hospitals is essential for delivering health services at a lower cost. Therefore, we aimed to estimate the technical efficiency of the DHs in Bangladesh. METHODS: We used input-oriented data envelopment analysis method to estimate the variable returns to scale (VRS) and constant returns to scale (CRS) technical efficiency of the DHs using data from Local Health Bulletin, 2015. In this model, we considered workforce as well as number of inpatient beds as input variables and number of inpatient, outpatient, and maternal services provided by the DHs as output variables. A Tobit regression model was applied for assessing the association of institutional and environmental characteristics with the technical efficiency scores. RESULTS: The average scale, VRS, and CRS technical efficiency of the DHs were estimated to 85%, 92%, and 79% respectively. Population size, poverty headcount, bed occupancy ratio, administrative divisions were significantly associated with the technical efficiency of the DHs. The mean VRS and CRS technical efficiency demonstrated that the DHs, on an average, could reduce their input mix by 8% and 21% respectively while maintaining the same level of output. CONCLUSION: Since the average technical efficiency of the DHs was 79%, there is little scope for overall improvements in these facilities by adjusting inputs. Therefore, we recommend to invest further in the DHs for improvement of services. The Ministry of Health and Family Welfare (MoHFW) should improve the efficiency in resource allocation by setting an input-mix formula for DHs considering health and socio-economic indicators (e.g., population density, poverty, bed occupancy ratio). The formula can be designed by learning from the input mix in the more efficient DHs. The MoHFW should conduct this kind of benchmarking study regularly to assess the efficiency level of health facilities which may contribute to reduce the wastage of resources and consequently to provide more affordable and accessible public hospital care.

Measuring the efficiency of health systems in Asia: a data envelopment analysis.

OBJECTIVE: This study aims to estimate the technical efficiency of health systems in Asia. SETTINGS: The study was conducted in Asian countries. METHODS: We applied an output-oriented data envelopment analysis (DEA) approach to estimate the technical efficiency of the health systems in Asian countries. The DEA model used per-capita health expenditure (all healthcare resources as a proxy) as input variable and cross-country comparable health outcome indicators (eg, healthy life expectancy at birth and infant mortality per 1000 live births) as output variables. Censored Tobit regression and smoothed bootstrap models were used to observe the associated factors with the efficiency scores. A sensitivity analysis was performed to assess the consistency of these efficiency scores. RESULTS: The main findings of this paper demonstrate that about 91.3% (42 of 46 countries) of the studied Asian countries were inefficient with respect to using healthcare system resources. Most of the efficient countries belonged to the high-income group (Cyprus, Japan, and Singapore) and only one country belonged to the lower middle-income group (Bangladesh). Through improving health system efficiency, the studied high-income, upper middle-income, low-income and lower middle-income countries can improve health system outcomes by 6.6%, 8.6% and 8.7%, respectively, using the existing level of resources. Population density, bed density, and primary education completion rate significantly influenced the efficiency score. CONCLUSION: The results of this analysis showed inefficiency of the health systems in most of the Asian countries and imply that many countries may improve their health system efficiency using the current level of resources. The identified inefficient countries could pay attention to benchmarking their health systems within their income group or other within similar types of health systems.

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 non-communicable 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.

The impact of community-based health insurance on the utilization of medically trained healthcare providers among informal workers in Bangladesh.

We aimed to estimate the impact of a Community-Based Health Insurance (CBHI) scheme on utilization of healthcare from medically trained providers (MTP) by informal workers. A quasi-experimental study was conducted where insured households were included in the intervention group and uninsured households in comparison group. In total 1,292 (646 insured and 646 uninsured) households were surveyed from Chandpur district comprising urban and rural areas after 1 year period of CBHI introduction. Matching of the characteristics of insured and uninsured groups was performed using a propensity score matching approach to minimize the observed baseline differences among the groups. Multilevel logistic regression model, with adjustment for individual and household characteristics was used for estimating association between healthcare utilization from the MTP and insurance enrolment. The utilization of healthcare from MTP was significantly higher in the insured group (50.7%) compared to the uninsured group (39.4%). The regression analysis demonstrated that the CBHI beneficiaries were 2.111 (95% CI: 1.458-3.079) times more likely to utilize healthcare from MTP.CBHI scheme increases the utilization of MTP among informal workers. Ensuring such healthcare for these workers and their dependents is a challenge in many low and middle income countries. The implementation and scale-up of CBHI schemes have the potential to address this challenge of universal health coverage.

Effects of occupational illness on labor productivity: A socioeconomic aspect of informal sector workers in urban Bangladesh.

OBJECTIVES: The informal sector is the dominant area of employment and the economy for any developing country including Bangladesh. The cost of productivity loss due to absence from work or presenteeism with illness has rarely been examined in the Bangladesh context. This current study, therefore, attempted to examine the impact of ill health of informal sector workers on labor productivity, future earning, and healthcare-related expenditure. METHODOLOGY: A cross-sectional survey was conducted among three occupational groups of informal workers (rickshaw pullers, shopkeepers and restaurant workers) that were generally found in all urban areas in Bangladesh. A total of 557 informal workers were surveyed for this study. RESULTS: Most of the respondents (57%) reported that they had been affected by some type of illness for the last six months. The overall average healthcare expenditure of informal workers was US$48.34, while restaurant workers expended more (US$53.61). Self reported sickness absenteeism was highest (50.37days) in the case of shop keepers, followed by rickshaw pullers (49.31 days), in the last six months. Considering the income loss due to illness in the past six months, the rickshaw pullers were exposed to the highest income loss (US$197.15), followed by the shop keepers (US$151.39). CONCLUSIONS: Although the informal sector contributes the most to the economy of Bangladesh, the workers in this sector have hardly any financial protection. This study provides critical clues to providing financial and social protection to informal sector workers in Bangladesh.