Shehrin Shaila Mahmood

Background: Ensuring affordable and quality primary health care for urban populations remains a persistent challenge in resource-constrained countries such as Bangladesh. The country’s fragmented and pluralistic urban health system exacerbates these challenges, making it particularly difficult to deliver primary health care to urban residents. In Bangladesh, the Aalo Clinic has been piloted to provide essential health services to low-income urban residents, including slum dwellers. Objective: This study aimed to assess how this model affects health care–seeking behavior from medically trained providers (MTPs) for managing chronic diseases. Methods: We conducted implementation research from October 2021 to August 2023 using a cross-sectional study design. To assess the effectiveness of the Aalo Clinic model, the baseline survey was conducted from January to February 2022, and the end-line surveys were carried out from April to June 2023 in the Korail, Mirpur, Shyampur, Dhalpur, and Tongi-Ershadnagar slums, which are adjacent to the clinics. In the baseline survey, we randomly selected 2000 households (with 9196 members), while 2033 households (with 8223 members) were interviewed in the end-line survey. We considered 8919 individuals in the baseline and 7994 individuals in the end-line, all aged 1 year or older. We used descriptive analysis and chi-squared tests to assess changes in health care usage from MTPs and applied logistic regression models to assess the model’s influence on health care usage from MTPs while controlling for other factors. Results: Among slum dwellers, awareness of Aalo Clinic increased by approximately 62 percentage points, from 11.46% (n=227) at baseline to 73.36% (n=1473) at end-line. The usage of health care for the management of chronic diseases from Aalo Clinics’ MTPs was significantly higher at the end-line period (n=63, 11.13%) compared to the baseline period (n=6, 0.59%). Regression analysis indicated that slum dwellers were approximately 23 times more likely (95% CI 8.77-61.80) to use health care from Aalo Clinic for chronic diseases in the end-line period compared to the baseline. However, there was no substantial change in health care usage from non-MTPs, which remained stable at around 38% (baseline: n=388; end-line: n=218) in both periods, and local drug stores continue to be the primary source for managing chronic diseases. Conclusions: Usage of Aalo Clinic MTPs for chronic disease care increased substantially compared to other MTPs among slum dwellers. However, reliance on non-MTPs, particularly local drug stores, remained stable. Ensuring the availability of essential medicines may further reduce dependence on non-MTPs among low-income urban slum residents. Future longitudinal studies are needed to evaluate the long-term impact on chronic disease management in Bangladesh.

Objective: To explore the challenges with healthcare services access, delivery and preparedness in the south-western coastal areas of Bangladesh, focusing on the experiences of communities and service providers. Design, participants and methods: An exploratory qualitative study was conducted, involving four focus group discussions (FGDs) with community people and 29 key informant interviews (KIIs) with different types of stakeholder, including the Upazila Health and Family Planning Officer, Social Welfare Officers, Union Parishad Chairman (local government member), Local Project Implementation Officers, Upazila Nirbahi Officers and non-government organisation (NGO) representatives. FGDs and KIIs were conducted with purposively selected participants between December 2022 and October 2023. Semi-structured guides were employed to facilitate the sessions and interviews. The duration of FGDs ranged from 1 to 1.5 hours, whereas individual interviews lasted between 40 and 60 min. The collected data were analysed manually using a phenomenological approach to explore participants’ lived experiences and perceptions. Setting: The study was conducted in south-western coastal Bangladesh, in Shyamnagar and Ashashuni Upazilas of Satkhira district, and Mongla and Rampal Upazilas of Bagerhat district. Results: We explored two main themes, challenges in healthcare access and delivery during disasters and preparedness strategies adopted by government, NGOs and communities. Healthcare access was constrained by poor transportation, riverine locations, limited ambulances, financial barriers and inadequate local facilities and supplies. Weak emergency response systems and facility readiness further delayed delivery of healthcare, particularly for maternal and injury services. Preparedness included government mobile and union-level medical teams, NGO medical camps and community-led informal care. Despite these efforts, the lack of infrastructure, planning and resources highlights the need for strengthened coordination and targeted interventions to ensure equitable, timely healthcare delivery in coastal Bangladesh. Conclusion: The findings of this study demonstrated that effective collaboration among government authorities, NGOs and local communities with clearly defined roles is essential to ensure healthcare delivery during climate-related natural hazards. Such coordination enables efficient use of resources and addresses community needs. Policymakers should develop strategies to establish and maintain functional preparedness systems, strengthening disaster response and ensuring timely healthcare access.

Background: Rapid urbanization in Bangladesh has strained the healthcare system, leaving urbanites underserved in primary healthcare (PHC). To address this gap, a UNICEF-supported Government of Bangladesh initiative introduced the Aalo Clinic model to expand access to affordable PHC. This study explored implementation challenges and opportunities of the Aalo Clinic model from a programmatic perspective for strengthening urban PHC delivery. Methods: The opportunities and challenges of implementation were explored through qualitative research conducted between June 2022 and May 2023 in six Aalo Clinic intervention areas across four city corporations in Dhaka, Bangladesh. Twenty-four in-depth interviews with service providers and eighteen key informant interviews with clinic-in-charges, community leaders, scheme operators, and policymakers were conducted, along with periodic observations at clinics. A thematic analysis was performed to analyze the data. Results: Three core themes evolved from the analysis – technical, administrative, and financial opportunities and challenges. Aalo Clinic’s integrated digitalized health platform reported to streamline operations through medical documentation and real-time monitoring. Initiatives like prescription audits and client feedback systems reported to promote rational prescribing and delivering quality care. However, key challenges included limited choice of medicine, interrupted internet connection, high patient flow, and longer waiting times. Despite challenges policymakers mentioned Aalo Clinic’s potential to integrate into the national health system, highlighting the need for coordinated efforts to overcome obstacles. Financial sustainability, however, hinges on the model’s integration into the government system and the provision of public funding to support its implementation. Conclusion: The study underscores the importance of addressing implementation challenges while capitalizing on opportunities to scale up the Aalo Clinic model. Recommendations include implementing structured monitoring, ensuring need-based medicine supply, fostering collaboration with the government for referrals, and facilitating cross-learning among urban PHC facilities. By addressing implementation challenges and strengthening multisectoral collaboration, the Aalo Clinic model shows potential to contribute to improved access to quality PHC in urban settings, in line with the broader vision of health for all.

Delivering quality primary healthcare to the urban population has been challenging in many developing countries including Bangladesh. With a fragmented and pluralistic urban health system, the country experiences major hurdles in the provision of primary healthcare to its urban dwellers. Since 2021, an urban primary healthcare model called ‘Aalo Clinic’ is being piloted to serve the low-income urban population in Bangladesh. With an aim to ensure universal health coverage for the urban population, the model delivers an essential package of health services. We aimed to assess the implementation effect of this pilot model on the utilization of healthcare from medically trained providers (MTPs) for the management of acute illness. Following a cross-sectional study design, an implementation research study was conducted between October 2021 and August 2023 in the Korail, Mirpur, Shyampur, Dhalpur, and Tongi-Ershadnagar slums. Cross-sectional household surveys were conducted at baseline and end-line, involving over 2000 households in each round. Descriptive analysis and Chi-squared test were performed to assess the changes in healthcare utilization from MTPs, and logistic regression models were applied to assess the effectiveness of the model on healthcare utilization from MTPs while controlling for other covariates. The utilization of healthcare from MTPs was significantly higher in the end-line (9.81% from Aalo Clinic and 18.6% from non-Aalo Clinic MTPs) compared to the baseline (0.64% from Aalo Clinic and 17.68% from non-Aalo Clinic MTPs). Healthcare utilization from local drug stores declined from 80.56% at baseline to 67.19% at end-line. Multivariate logistic regression showed respondents were 12.43 times more likely (95% CI: 7.49–20.63) to use Aalo Clinic services at end-line, indicating increased uptake of medically trained providers following the model’s implementation. The Aalo Clinic Model was effective in influencing healthcare-seeking pattern of the slum populations and enhancing the utilization of qualified care from MTPs. The study supports replicating the model within existing healthcare structures and scaling it nationwide to advance universal health coverage in urban Bangladesh, contingent on sustained government funding for its operations.

Background Tobacco taxes are an effective method of reducing consumption, but Bangladesh’s tax policy is weak and needs improvement in many areas. Objective This study aimed to analyse the political economy of tobacco tax design and implementation in Bangladesh. Methods We reviewed 45 tobacco tax documents, conducted stakeholder mapping, 12 key informant interviews and stakeholder analysis. We used thematic and content analysis approaches. Results In Bangladesh, the tobacco tax structure is complex and difficult to implement and not designed to curb tobacco consumption. The dual role of the Bangladesh government as regulator of and shareholder in the largest tobacco company weakens the formulation and implementation of tobacco taxes as health policy instruments. Tobacco is one of Bangladesh’s highest revenue sectors. As such, tobacco companies yield significant indirect influence on the government and media to shape the conversation around tobacco taxes and to weaken those taxes’ design and implementation. Despite significant challenges, a strong antitobacco network (including academia, civil society organisations, non-government organisations, the WHO and media actors) continues to advocate for the use of tobacco taxes to reduce tobacco consumption. Conclusion Our findings illustrate a complex interplay of political economy factors that challenge the design and implementation of tobacco taxes in Bangladesh. Creating opportunities for consultation and collaboration between the Ministries of Finance and Health regarding the formulation of tobacco taxes will be very important. National action plans with multi-stakeholder involvement are essential to achieving tobacco control goals through actionable steps.

BACKGROUND Ensuring affordable and quality primary health care for urban populations remains a persistent challenge in resource-constrained countries such as Bangladesh. The country’s fragmented and pluralistic urban health system exacerbates these challenges, making it particularly difficult to deliver primary health care to urban residents. In Bangladesh, the Aalo Clinic has been piloted to provide essential health services to low-income urban residents, including slum dwellers. OBJECTIVE This study aimed to assess how this model affects health care–seeking behavior from medically trained providers (MTPs) for managing chronic diseases. METHODS We conducted implementation research from October 2021 to August 2023 using a cross-sectional study design. To assess the effectiveness of the Aalo Clinic model, the baseline survey was conducted from January to February 2022, and the end-line surveys were carried out from April to June 2023 in the Korail, Mirpur, Shyampur, Dhalpur, and Tongi-Ershadnagar slums, which are adjacent to the clinics. In the baseline survey, we randomly selected 2000 households (with 9196 members), while 2033 households (with 8223 members) were interviewed in the end-line survey. We considered 8919 individuals in the baseline and 7994 individuals in the end-line, all aged 1 year or older. We used descriptive analysis and chi-squared tests to assess changes in health care usage from MTPs and applied logistic regression models to assess the model’s influence on health care usage from MTPs while controlling for other factors. RESULTS Among slum dwellers, awareness of Aalo Clinic increased by approximately 62 percentage points, from 11.46% (n=227) at baseline to 73.36% (n=1473) at end-line. The usage of health care for the management of chronic diseases from Aalo Clinics’ MTPs was significantly higher at the end-line period (n=63, 11.13%) compared to the baseline period (n=6, 0.59%). Regression analysis indicated that slum dwellers were approximately 23 times more likely (95% CI 8.77-61.80) to use health care from Aalo Clinic for chronic diseases in the end-line period compared to the baseline. However, there was no substantial change in health care usage from non-MTPs, which remained stable at around 38% (baseline: n=388; end-line: n=218) in both periods, and local drug stores continue to be the primary source for managing chronic diseases. CONCLUSIONS Usage of Aalo Clinic MTPs for chronic disease care increased substantially compared to other MTPs among slum dwellers. However, reliance on non-MTPs, particularly local drug stores, remained stable. Ensuring the availability of essential medicines may further reduce dependence on non-MTPs among low-income urban slum residents. Future longitudinal studies are needed to evaluate the long-term impact on chronic disease management in Bangladesh. CLINICALTRIAL

Objective The COVID-19 pandemic imposed unprecedented challenges to health systems globally. This study explored slum dwellers’ experience of receiving essential health services during the pandemic and the challenges faced by healthcare providers in urban areas of Bangladesh. Design The study followed a cross-sectional study design using qualitative methods. Setting The study was conducted in Dhaka and Gazipur City Corporations during November 2020–February 2021. Participants 17 key informant interviews were carried out with healthcare providers and policy-makers and 22 in-depth interviews were carried out with slum dwellers. Thematic analysis was performed. Results The study identified challenges to the provision of essential healthcare in selected areas of Dhaka and Gazipur City Corporations during the COVID-19 pandemic. The lack of information on the availability of functional healthcare facilities, fear of contracting COVID-19 and restrictions on movement and transportation, resulted in delays in seeking essential healthcare during a pandemic. Access to healthcare facilities was further hindered by various hospitals’ decision to refuse care to general patients without valid, negative COVID-19 test results. Healthcare providers identified patients’ tendency to hide COVID-19 symptoms as a barrier to providing healthcare services to general patients. Conversely, patients concealed their symptoms to avoid COVID-19 tests and gain access to required treatment. In addition, the reallocation of human resources for COVID-19 treatment disrupted the delivery of essential health services. Conclusion The pandemic affected the accessibility of the slum population to essential healthcare and disrupted health service delivery. The findings of the study have highlighted gaps in the health system during an emergency response period like COVID-19. The study will assist the government and other stakeholders in designing tailored interventions and allocating resources in a more efficient manner to ensure universal health coverage in the face of health emergencies.

Background: Bangladesh has made substantial progress in maternal health. However, persistent inequities in service use undermine the achievements at the national level. In 2007, the government introduced a Maternal Health Voucher Scheme (MHVS) to reduce barriers to service utilization. The current study explores the impact of MHVS on reducing distance inequality in utilization across the maternal and newborn continuum of care (MNCoC). Methods: A cross-sectional survey was conducted from October’2017 to April’2018 in four selected MHVS sub-districts of Chattogram and Sylhet Divisions of Bangladesh. 2,400 women with at-least one child aged below two years were randomly selected. Both bivariate and multivariate analyses were carried out to explore the absolute and relative influence of the voucher scheme and chi-square test was used for hypothesis testing. Results: Nineteen percent of the women were MHVS beneficiaries and 23% of them lived within 5 km of the health facility. Among the beneficiaries no significant differences were observed in the utilization of at-least 4 antenatal visits, skilled-assistance at delivery, postnatal care, and MNCoC between those living closer to the health facility and those living far away. However, a higher facility delivery rate was observed among beneficiary women living closer. By contrast, for non-beneficiaries, a significant difference was found in service use between women living closer to health facilities compared to those living further away. Conclusion: The study found the use of MNCoC to be similar for all MHVS beneficiaries irrespective of their distance to health facilities whereas non-beneficiary women living further away had lower utilization rates. MHVS could have potentially reduced distance-related inequality for its beneficiaries. However, despite the provision of transport incentives under MHVS the reduction in inequality in facility delivery was limited. We propose a revision of the transportation incentive adjusting for distance, geographical remoteness, road condition, and transport cost to enhance the impact of MHVS.

Objective Our study explored the impact of the COVID-19 pandemic on the food environment from the perspective of the urban poor and food vendors. Design This was a qualitative study conducted during September 2020 and February 2021. Setting The study was carried out in two purposively selected informal settlements of Dhaka City, Bangladesh. Participants We conducted 21 in-depth interviews with residents of informal settlements and 10 key informant interviews with food vendors and food aid workers. Result The availability of staple foods was not disrupted during the pandemic but some perishables foods became more expensive due to supply chain disruptions and increased transportation costs. Limited market hours affected market access and mobility restrictions adversely affected local vendors. Cart vendors selling perishables incurred business losses they could ill afford. Demand for food reduced as employment disruption lead to reduced purchasing power and, therefore, reduction of quantity, quality and desirability of foods purchased. Respondents reported skipping meals and going hungry. The aid received was considered inadequate to meet needs. Conclusion The food environment of the urban poor was disrupted from both supply and demand sides and the organisational response (both government and non-government) was severely inadequate. The social safety net needs to be extended and redesigned to ensure food security and health for the urban working poor in the future.

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. 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. 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. 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.