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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. 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. 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. 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.

Introduction Globally, the coronavirus disease 2019 (COVID-19) pandemic tested the resilience of the health system and its shock-absorbing capacity to continue offering healthcare services. The available evidences does not provide comprehensive insight into primary health care (PHC) system functioning across low- and middle- income countries (LMICs) during the pandemic. Therefore, the objective of this scoping review was to generate evidence on the resilience of PHC systems in LMICs during the COVID-19 pandemic. Methods A scoping review was carried out utilizing an iterative search strategy using the National Library of Medicine (NLM) and the WHO COVID-19 electronic databases. Data from the identified studies in LMICs were charted in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist in the first step. The analysis framework was adapted and modified using COVID-19 and health systems resilience framework developed by Sagan et al., Blanchet et al., and the WHO position paper on ‘Building health systems resilience for universal health coverage and health security during the COVID-19 pandemic and beyond’. A total of 26 documents were included on the basis of predefined eligibility criteria for our analysis. Results Our review explored data from 44 LMICs that implemented strategies at the PHC level during the COVID-19 pandemic. Most of the LMICs developed national guidelines on sexual, reproductive, maternal, newborn, child, and adolescent health (SRMNCAH). Most of the countries also transformed and reoriented PHC service delivery by introducing digital healthcare services to continue essential services. Task shifting, task sharing, and redeployment of retired staff were some frequently adopted health workforce strategies adopted by most of the countries. Only a few of the countries demonstrated the availability of necessary monetary resources to respond to the pandemic. Conclusions The functionality of the PHC system during the COVID-19 pandemic was demonstrated by a variety of resilience strategies across the six building blocks of the health system. To strengthen PHC resilience, we recommend strengthening community-based PHC, cross-sectoral collaboration, establishing surveillance systems, capacity building in financial risk planning, and investing in strengthening the digital healthcare system. Key Highlights A majority of the LMICs adopted resilience strategies related to service delivery and health workforce domains. Nigeria was the only country that showed evidence of resilience measures across all six WHO building blocks. Only a few countries reported healthcare financing measures. Most of the LMICs have developed national guidelines on SRMNCAH to ensure the continuation of healthcare services. Interruption in facility-based services shifted the burden to community-based healthcare services and most of the PHC-level services were offered at doorstep or at community sites. For essential service delivery, most of the countries had demonstrated transformative capacity that included use of digital platforms (teleconsultation/telemedicine establishing hotline number, WhatsApp messaging), for appointment system, extended timings, etc. Health workforce strategies varied from task shifting of health workforce, developing contractual agreements, and extending working hours to redeployment of retired staff in a majority of the countries.

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.

Background Oral health is integral to overall well-being and Universal Health Coverage (UHC), yet disparities in dental service utilization (DSU) persist in low- and middle-income countries (LMICs). Socioeconomic status (SES) and educational inequalities exacerbate barriers to accessing essential dental services, limiting UHC progress. Therefore, this study assessed absolute and relative socioeconomic and education-based inequalities in DSU in Bangladesh, Bhutan, and Nepal and identified demographic and socioeconomic determinants. Methods Data from the most recent WHO STEPwise approach to surveillance (STEPS) surveys in Bangladesh (2017–18), Bhutan (2019), and Nepal (2019) were analyzed. Inequalities in DSU were assessed using the slope index of inequality (SII), relative index of inequality (RII), and relative concentration index (RCI). The determinants of DSU were assessed using mixed-effects binary logistic regression models. Results Ever DSU was highest in Bhutan (48.8%), followed by Bangladesh (29.1%) and Nepal (5.6%). Socioeconomic inequalities in DSU were significant in Bhutan, with higher utilization concentrated among the wealthiest groups (SII: 33.9, 95% confidence interval [CI]: 27.8–40.1 for ever DSU; RII: 2.11, 95% CI: 1.86–2.39), while education-based disparities favored individuals with higher education (RII: 1.85, 95% CI: 1.62–2.13). In Bangladesh, education-based inequalities in DSU were evident only in urban areas (SII: 17.3, 95% CI: 8.2–26.5; RII: 1.69, 95% CI: 1.38–2.06). In Nepal, DSU was uniformly low across all groups, with minimal or even reversed socioeconomic and educational disparities. Independent determinants of DSU, identified through adjusted mixed-effects logistic regression, included older age, higher education, and urban residence in Bangladesh; higher education and SES in Bhutan; and female sex in Nepal. Conclusions DSU was limited across Bangladesh, Bhutan, and Nepal, with the lowest rates observed in Nepal. Substantial socioeconomic and educational inequalities in DSU were evident in Bhutan and Bangladesh. These findings underscore the need for UHC-aligned, equity-focused reforms, including national oral health policies, targeted outreach to disadvantaged groups, and expanded access to preventive services.

Background Community health workers (CHWs) play a critical role in grassroots healthcare and are essential for achieving the health-related Sustainable Development Goals. While there is a critical shortage of essential health workers in low- and middle-income countries, WHO and international partners have reached a consensus on the need to expand and strengthen CHW programmes as a key element in achieving Universal Health Coverage (UHC). The COVID-19 pandemic has further revealed that emerging health challenges require quick local responses such as those utilizing CHWs. This is the second paper of our 11-paper supplement, “Community health workers at the dawn of a new era”. Our objective here is to highlight questions, challenges, and strategies for stakeholders to consider while planning the introduction, expansion, or strengthening of a large-scale CHW programme and the complex array of coordination and partnerships that need to be considered. Methods The authors draw on the outcomes of discussions during key consultations with various government leaders and experts from across policy, implementation, research, and development organizations in which the authors have engaged in the past decade. These include global consultations on CHWs and global forums on human resources for health (HRH) conferences between 2010 and 2014 (Montreux, Bangkok, Recife, Washington DC). They also build on the authors’ direct involvement with the Global Health Workforce Alliance. Results Weak health systems, poor planning, lack of coordination, and failed partnerships have produced lacklustre CHW programmes in countries. This paper highlights the three issues that are generally agreed as being critical to the long-term effectiveness of national CHW programmes—planning, coordination, and partnerships. Mechanisms are available in many countries such as the UHC2030 (formerly International Health Partnership), country coordinating mechanisms (CCMs), and those focusing on the health workforce such as the national Human Resources for Health Observatory and the Country Coordination and Facilitation (CCF) initiatives introduced by the Global Health Workforce Alliance. Conclusion It is imperative to integrate CHW initiatives into formal health systems. Multidimensional interventions and multisectoral partnerships are required to holistically address the challenges at national and local levels, thereby ensuring synergy among the actions of partners and stakeholders. In order to establish robust and institutionalized processes, coordination is required to provide a workable platform and conducive environment, engaging all partners and stakeholders to yield tangible results.

Background Out-of-pocket (OOP) expenditure is one of the most common payment strategies for hospitalization care in Bangladesh, and the share of OOP expenditure has been increasing at an alarming rate. This study aimed to investigate the OOP costs of hospitalization care, the impact of OOP on catastrophic healthcare expenditure (CHE) and financial distress, and the associated factors. Methods We used data from the most recent nationally representative dataset, the Bangladesh Household Income and Expenditure Survey 2022. A total of 14,395 households were surveyed, with 1973 household members hospitalized due to various illnesses. Respondents were asked to provide information regarding hospitalization care for the year preceding the survey. Households were considered to have CHE if they spent at least 25% of their total consumption expenditure or 40% of their non-food consumption expenditure on healthcare. Distress financing was defined as covering OOP healthcare costs by selling assets, borrowing money, or receiving financial assistance from friends or relatives. Multivariate logistic regression models were used to identify the determinants of CHE and distress financing. Results The annual average OOP cost of hospitalization was USD 418, with the OOP cost nearly twice as high in private facilities compared to public ones (USD 538 vs. USD 283). The highest OOP costs were observed for cancer treatment (USD 2365), followed by COVID-19 (USD 1391). Overall, 6.72% and 9.03% of hospitalized patients experienced CHE at 25% of total expenditure and 40% of non-food expenditure, respectively, while about 61% of patients faced distress financing due to hospitalization. Conclusion Financial hardship due to hospitalization remains high in Bangladesh. These findings will help policymakers adopt more effective healthcare financing strategies and improve the efficiency of public health investments.

Background Bangladesh ranks among the world’s top ten countries in the number of diabetic patients. The prevention of this disease requires treating patients with essential medicines, and the first crucial step in the uptake of these medicines is availability. We aimed to assess the availability of essential medicines for diabetes (EM-Diabetes) and to explore health facility characteristics associated with the availability of those medicines. Methods We performed the analysis using nationally representative data from the two waves of the cross-sectional Bangladesh Health Facility Survey (BHFS) in 2014 and 2017. Data are available for 1548 and 1524 health facilities in the 2014 and 2017 BHFS. Study samples of this study were 217 facilities (73 from 2014 and 144 from 2017) that offer diabetes diagnosis and treatment services. The outcome variable ‘EM-Diabetes availability’ was calculated as a counting score of the tracer medicines: metformin, glibenclamide, injectable insulin, and injectable glucose solution. A multivariable Poisson regression model was used to identify the health facility characteristics (such as, managing authority, location, external supervision, regular quality assurance activities, national guidelines for diagnosis and management of diabetes, etc.) associated with EM-Diabetes availability. Results Since 2014, there have been minimal increases in Bangladeshi health facilities that provide diabetes screening and treatment services (from 4.7% to 9.4%). Among facilities offering diabetes services, 64.5% (BHFS 2014) and 55.7% (BHFS 2017) facilities had no EM-Diabetes on-site at all. Between 2014 and 2017, the availability of metformin increased (from 27.5% to 40.1%), but there was a decrease in the availability of glibenclamide (from 16.5% to 9.1%), injectable insulin (from 20.4% to 11.4%), and injectable glucose solution (from 20.4% to 19.2%). Furthermore, publicly owned facilities [relative risk (RR) = 0.44, 95% confidence interval (CI): 0.25–0.78 for 2014 and RR= 0.54, 95% CI: 0.41–0.71 for 2017] and facilities in rural settings [RR= 0.26, 95% CI: 0.12–0.55 for 2014 and RR= 0.60, 95% CI: 0.44–0.81 for 2017] were significantly associated with decreased availability of EM-Diabetes in both survey years. Moreover, routine user fees [RR=3.70, 95% CI: 1.86–7.38] and regular quality assurance activities [RR= 1.62, 95% CI: 1.12–2.34] were also significantly associated with increased EM-Diabetes availability in 2017 only. Conclusions Overall, the health facilities in Bangladesh had insufficient essential medicines for treating diabetes. In general, the availability of EM-Diabetes declined from 2014 to 2017, except for metformin. Policymakers should consider a wide range of policy implications, focusing on the management of public facilities, rural facilities, routine user fees, and quality assurance activities to improve the availability of EM-Diabetes at health facilities in Bangladesh.

This report is organized in such a way that the key policy options and strategic priorities are based on the country context, including the burden of non-communicable diseases (NCDs) and associated risk factors and the existing capacity of the health system. Chapter one describes the country and regional contexts and the evidence of the demographic and epidemiological transitions in Bangladesh; chapter two outlines the disease burden of major NCDs, including the equity and economic impact and the common risk factors; chapter three provides an assessment of the health system and its capacity to prevent and control major NCDs; chapter four summarizes ongoing NCD interventions and activities in Bangladesh and highlights the remaining gaps and challenges; and chapter five presents key policy options and strategic priorities to prevent and control NCDs.

Background Bangladesh, a densely populated South Asian country, faces numerous challenges in its healthcare system. Given the population of almost 160 million, there is an urgent need for a comprehensive health policy. Despite the government's recent advancements in improving healthcare services, there is still a significant amount of work that need to be accomplished. Discussion In Bangladesh, individuals are required to cover 68.50% of the total expenses for therapy directly from their own funds. Healthcare seekers in Bangladesh encounter numerous obstacles as a result of the exorbitant cost of medical services, including expenses for prescription medications, treatment charges, and diagnostic examinations. Health insurance is essential for mitigating financial risk and plays a pivotal role in societal safety nets, bolstering public health and health care. Insufficient health care in low and middle‐income nations results in a significant number of deaths. The World Health Organization (WHO) underscores the significance of health financing in attaining universal coverage, emphasizing the necessity of generating revenue, accumulating funds, and allocating resources to guarantee access and quality in healthcare services. Conclusion To summarize, the healthcare system in Bangladesh is confronted with significant issues that are worsened by the financial demands placed on its populace. Adopting universal health coverage might play a crucial role in promoting fair and equal access to health care, improving health results, and strengthening economic stability for the approximately 160 million individuals in the country.