Influence of a pilot urban primary healthcare model on the use of medically trained healthcare providers among the low-income slum populations in Bangladesh: findings from an implementation research study

ObjectiveTo estimate the costs and mortality reductions of a package of essential health interventions for urban populations in Bangladesh and India.MethodsWe used population data from the countries’ censuses and United Nations Population Division. For causes of mortality in India, we used the Indian Million Death Study. We obtained cost estimates of each intervention from the third edition of Disease control priorities. For estimating the mortality reductions expected with the package, we used the Disease control priorities model. We calculated the benefit–cost ratio for investing in the package, using an analysis based on the Copenhagen Consensus method.FindingsPer urban inhabitant, total costs for the package would be 75.1 United States dollars (US$) in Bangladesh and US$ 105.0 in India. Of this, prevention and treatment of noncommunicable diseases account for US$ 36.5 in Bangladesh and U$ 51.7 in India. The incremental cost per urban inhabitant for all interventions would be US$ 50 in Bangladesh and US$ 75 in India. In 2030, the averted deaths among people younger than 70 years would constitute 30.5% (1027/3362) and 21.2% (828/3913) of the estimated baseline deaths in Bangladesh and India, respectively. The health benefits of investing in the package would return US$ 1.2 per dollar spent in Bangladesh and US$ 1.8 per dollar spent in India.ConclusionInvesting in the package of essential health interventions, which address health-care needs of the growing urban population in Bangladesh and India, seems beneficial and could help the countries to achieve their 2030 sustainable development goals.

There are some positive ramifications of urbanization, along these lines, which incorporate the employment opportunities, innovative and infrastructural progressions, enhanced transportation, and correspondence. The betterment of clinical services and educational facilities in urban areas increase the living standard. Urbanization has negative outcomes on wellbeing due essentially to contamination and packed everyday environments. The ARIMA methodology has been used to forecast urban populations (% of total) in Bangladesh up to 2030. ARIMA method considers time-series data from 1972 to 2019 to estimate the forecasting. The current study estimates an increasing trend of urban populations in Bangladesh over time. This study has contributed to creating awareness in the case of the changing urban population.

Sexual and reproductive health and rights (SRHR) and universal health coverage (UHC) are fundamental to health as a human right. One way that countries operationalise UHC is through the development of an essential package of health services (EPHS), which describes a list of clinical and public health services that a government aspires to provide for their population. This study reviews the contents of 46 countries’ EPHS against the standard of the Guttmacher-Lancet Report’s (GLR) nine essential SRHR interventions. The analysis is conducted in two steps; EPHS are first categorised according to the level of specificity of their contents using a case classification scheme, then the most detailed EPHS are mapped onto the GLR’s nine essential SRHR interventions. The results highlight the variations of EPHS and provide information on the inclusion of the GLR nine essential SRHR interventions in low- and lower-middle income countries’ EPHS. This study also proposes a case classification scheme as an analytical tool to conceptualise how EPHS fall along a spectrum of specificity and defines a set of keywords for evaluating the contents of policies against the standard of the GLR. These analytical tools and findings can be relevant for policymakers, researchers, and organisations involved in SRHR advocacy to better understand the variations in detail among countries’ EPHS and compare governments’ commitment to SRHR as a human right.

BackgroundThe COVID-19 pandemic has caused an abrupt reduction in the use of in-person health care, accompanied by a corresponding surge in the use of telehealth services. However, the extent and nature of changes in health care utilization during the pandemic may differ by care setting. Knowledge of the impact of the pandemic on health care utilization is important to health care organizations and policy makers.ObjectiveThe aims of this study are (1) to evaluate changes in in-person health care utilization and telehealth visits during the COVID-19 pandemic and (2) to assess the difference in changes in health care utilization between the pandemic year 2020 and the prepandemic year 2019.MethodsWe retrospectively assembled a cohort consisting of members of a large integrated health care organization, who were enrolled between January 6 and November 2, 2019 (prepandemic year), and between January 5 and October 31, 2020 (pandemic year). The rates of visits were calculated weekly for four settings: inpatient, emergency department (ED), outpatient, and telehealth. Using Poisson models, we assessed the impact of the pandemic on health care utilization during the early days of the pandemic and conducted difference-in-deference (DID) analyses to measure the changes in health care utilization, adjusting for the trend of health care utilization in the prepandemic year.ResultsIn the early days of the pandemic, we observed significant reductions in inpatient, ED, and outpatient utilization (by 30.2%, 37.0%, and 80.9%, respectively). By contrast, there was a 4-fold increase in telehealth visits between weeks 8 (February 23) and 12 (March 22) in 2020. DID analyses revealed that after adjusting for prepandemic secular trends, the reductions in inpatient, ED, and outpatient visit rates in the early days of the pandemic were 1.6, 8.9, and 367.2 visits per 100 person-years (P<.001), respectively, while the increase in telehealth visits was 272.9 visits per 100 person-years (P<.001). Further analyses suggested that the increase in telehealth visits offset the reduction in outpatient visits by week 26 (June 28, 2020).ConclusionsIn-person health care utilization decreased drastically during the early period of the pandemic, but there was a corresponding increase in telehealth visits during the same period. By end-June 2020, the combined outpatient and telehealth visits had recovered to prepandemic levels.

BACKGROUND: The COVID-19 pandemic has caused an abrupt reduction in the use of in-person health care, accompanied by a corresponding surge in the use of telehealth services. However, the extent and nature of changes in health care utilization during the pandemic may differ by care setting. Knowledge of the impact of the pandemic on health care utilization is important to health care organizations and policy makers. OBJECTIVE: The aims of this study are (1) to evaluate changes in in-person health care utilization and telehealth visits during the COVID-19 pandemic and (2) to assess the difference in changes in health care utilization between the pandemic year 2020 and the prepandemic year 2019. METHODS: We retrospectively assembled a cohort consisting of members of a large integrated health care organization, who were enrolled between January 6 and November 2, 2019 (prepandemic year), and between January 5 and October 31, 2020 (pandemic year). The rates of visits were calculated weekly for four settings: inpatient, emergency department (ED), outpatient, and telehealth. Using Poisson models, we assessed the impact of the pandemic on health care utilization during the early days of the pandemic and conducted difference-in-deference (DID) analyses to measure the changes in health care utilization, adjusting for the trend of health care utilization in the prepandemic year. RESULTS: In the early days of the pandemic, we observed significant reductions in inpatient, ED, and outpatient utilization (by 30.2%, 37.0%, and 80.9%, respectively). By contrast, there was a 4-fold increase in telehealth visits between weeks 8 (February 23) and 12 (March 22) in 2020. DID analyses revealed that after adjusting for prepandemic secular trends, the reductions in inpatient, ED, and outpatient visit rates in the early days of the pandemic were 1.6, 8.9, and 367.2 visits per 100 person-years (P<.001), respectively, while the increase in telehealth visits was 272.9 visits per 100 person-years (P<.001). Further analyses suggested that the increase in telehealth visits offset the reduction in outpatient visits by week 26 (June 28, 2020). CONCLUSIONS: In-person health care utilization decreased drastically during the early period of the pandemic, but there was a corresponding increase in telehealth visits during the same period. By end-June 2020, the combined outpatient and telehealth visits had recovered to prepandemic levels.

Government and Non-government organizations necessitate the use of population projections for producing the reasonable plans for future development. The purpose of the current study is to build models, and project female population of urban area in Bangladesh by using nationally representative population census data. The exponential model and the exponential growth rate method were used to fulfill the objectives. Model validity was checked through the model validation procedure, and cross-validity prediction power (CVPP). It was found that age pattern for urban female population in Bangladesh followed two parameters negative exponential model. Smallest shrinkage coefficients obtained from CVPP and larger value of F-statistics were showing better fit of these models. The projection of population was done during 2012–2041 employing exponential growth rate method. It was investigated that the projected population in 2012, 2021, 2031 and 2041 would be 17,087, 20,433, 25,395 and 32,204 thousands correspondingly. The female population and female aged population of urban area in Bangladesh would be doubled after 39.12 years and 18.47 years respectively. This should be considered as alarming retaining to good health for the female population of urban area in Bangladesh, therefore need to be addressed policies for better health.

ABSTRACTThis study explores the differences in factors associated with hypertension between younger and older subjects in an urban slum community in Bangladesh. We analyzed the data of 1,008 men and 1,001 women obtained from a cross-sectional survey conducted between October 2015 and April 2016. Multivariable logistic regression models were stratified by age (18 to 44 and 45 to 64 years) in men and women separately. The multivariable model included age (continuous) and the following categorical variables simultaneously: education duration, marital status, tobacco smoking, smokeless tobacco use, total physical activity, body mass index (BMI), waist circumference, and the blood levels of glycated hemoglobin (HbA1c), triglycerides, high- and low-density lipoprotein (HDL and LDL) cholesterol. Hypertension was defined as the presence of either blood pressure ≥140/90 mmHg or the use of antihypertensive medication. The prevalence of hypertension was 13.0% (younger men), 14.6% (younger women), 35.6% (older men), and 38.7% (older women). In younger men, higher waist circumference and increased LDL cholesterol levels were significantly associated with hypertension. In older men, physical activity was the only significant factor that was inversely associated with hypertension. In younger women, higher BMI, increased HbA1c, triglycerides, and LDL cholesterol levels were associated with hypertension. In older women, a higher HbA1c was the only factor significantly associated with hypertension. These findings suggest that public health interventions to prevent hypertension may require different approaches according to sex and age groups within the poor urban population in Bangladesh.

This chapter concludes that although the growth of urbanization in Bangladesh prior to the twentieth century was very slow, the process of urbanization got momentum after 1947. The process continued to a great speed up until now. From 1974 until 2011, urban population in Bangladesh has increased 6.8 times as compared to 1.7 times in the rural population. According to last Census data that took place in 2011, there is 42.70 million of the urban population in the country which has been projected as 98.6 million in 2030. Although Bangladesh is considered as a rural economy, the rapid growth of urbanization has superseded the contribution of rural economy in the GDP, meaning that the share of the rural sector to GDP has reduced from 74.64 percent in 1972–1973 to 57 percent in 2000–2001. On the other hand, urban contribution to GDP has increased from 25.36 percent in 1972–1973 to 43 percent in 2001. Finally, it has been argued in this chapter that the age-old “rural–urban divide” has become problematic in the context of growing urbanization and rapid advancement of the rural sector in Bangladesh, which has necessitated the interfacing between rural and urban areas.

Bangladesh is undergoing a rapid urbanization process. About one-third of the population of major cities in the country live in slums, which are areas that exhibit pronounced concentrations of factors that negatively affect health and nutrition. People living in slums face greater challenge to improve their health than other parts of the country, which fuels the growing intra-urban health inequities. Two rounds of the Bangladesh Urban Health Survey (UHS), conducted in 2013 and 2006, were designed to examine the reproductive health status and service utilization between slum and non-slum residents. We applied an adaptation of the difference-in-differences (DID) model to pooled data from the 2006 and 2013 UHS rounds to examine changes over time in intra-urban differences between slums and non-slums in key health outcomes and service utilization and to identify the factors associated with the reduction in intra-urban gaps. In terms of change in intra-urban differentials during 2006–2013, DID regression analysis estimated that the gap between slums and non-slums for skilled birth attendant (SBA) during delivery significantly decreased. DID regression analysis also estimated that the gap between slums and non-slums for use of modern contraceptives among currently married women also narrowed significantly, and the gap reversed in favor of slums. However, the DID estimates indicate a small but not statistically significant reduction in the gap between slums and non-slums for child nutritional status. Results from extended DID regression model indicate that availability of community health workers in urban areas appears to have played a significant role in reducing the gap in SBA. The urban population in Bangladesh is expected to grow rapidly in the coming decades. Wide disparities between urban slums and non-slums can potentially push country performance off track during the post-2015 era, unless the specific health needs of the expanding slum communities are addressed. To our knowledge, this is the first systematic explanation and quantification of the role of various factors for improving intra-urban health equity in Bangladesh using nationally representative data. The findings provide a strong rationale for continuing and expanding community-based reproductive health services in urban areas by the NGOs with a focus on slum populations.

Insurance Coverage and Health Care Utilization Among Asian Youth Before and After the Affordable Care Act.

Background: Pakistan developed its first national Essential Package of Health Services (EPHS) as a key step towards accelerating progress in achieving Universal Health Coverage (UHC). We describe the rationale, aims, the systematic approach followed to EPHS development, methods adopted, outcomes of the process, challenges encountered, and lessons learned.Methods: EPHS design was led by the Ministry of National Health Services, Regulations & Coordination. The methods adopted were technically guided by the Disease Control Priorities 3 Country Translation project and existing country experience. It followed a participatory and evidence-informed prioritisation and decision-making processes.Results: The full EPHS covers 117 interventions delivered at the community, health centre and first-level hospital platforms at a per capita cost of US$29.7. The EPHS also includes an additional set of 12 population-based interventions at US$0.78 per capita. An immediate implementation package (IIP) of 88 district-level interventions costing US$12.98 per capita will be implemented initially together with the population-based interventions until government health allocations increase to the level required to implement the full EPHS. Interventions delivered at the tertiary care platform were also prioritised and costed at US$6.5 per capita, but they were not included in the district-level package. The national EPHS guided the development of provincial packages using the same evidence-informed process. The government and development partners are in the process of initiating a phased approach to implement the IIP.Conclusion: Key ingredients for a successful EPHS design requires a focus on package feasibility and affordability, national ownership and leadership, and solid engagement of national stakeholders and development partners. Major challenges to the transition to implementation are to continue strengthening the national technical capacity, institutionalise priority setting and package design and its revision in ministries of health, address health system gaps and bridge the current gap in financing with the progressive increase in coverage towards 2030.

Pakistan has a mixed-health system where up to 60% of health expenditures are out of pocket. Almost 80% of primary healthcare (PHC) facilities are in the private sector, which is deeply embedded within the country's health system and may account for the unaffordability of healthcare. Since 2016, the existing national health insurance program or Sehat Sahulat Program (SSP), has provided invaluable coverage and financial protection to the millions of low-income families living in Pakistan by providing inpatient services at secondary and tertiary levels. However, a key gap is the non-inclusion of outpatient services at the PHC in the insurance scheme. This study aims to engage a private provider network of general practitioners in select union councils of Islamabad Capital Authority (ICT) of Pakistan to improve access, uptake, and satisfaction and reduce out-of-pocket expenditure on quality outpatient services at the PHC level, including family planning and reproductive health services. A 24-month research study is proposed with a 12-month intervention period using a mixed method, two-arm, prospective, quasi-experimental controlled before and after design with a sample of 863 beneficiary families from each study arm, i.e., intervention and control groups (N = 1726) will be selected through randomization at the selected beneficiary family/household level from four peri-urban Union Councils of ICT where no public sector PHC-level facility exists. All ethical considerations will be assured, along with quality assurance strategies. Quantitative pre/post surveys and third-party monitoring are proposed to measure the intervention outcomes. Qualitative inquiry with beneficiaries, general practitioners and policymakers will assess their knowledge and practices. PHC should be the first point of contact for accessing health services and appears to serve as a programmatic engine for universal health coverage (UHC). The research aims to study a service delivery model which harnesses the private sector to deliver an essential package of health services as outpatient services under SSP, ultimately facilitating UHC. Findings will provide a blueprint referral system to reduce unnecessary hospital admissions and improve timely access to healthcare. A robust PHC system can improve population health, lower healthcare expenditure, strengthen the healthcare system, and ultimately make UHC a reality.

BackgroundDespite one-third of the urban population in Bangladesh living in urban slums and at increased risk of non-communicable diseases (NCDs), little is known about the NCD risk profile of this at-risk population. The aim of the study was to identify the prevalence of the NCD risk factors and the association of NCD risk factors with socio-demographic factors among the adults of urban slums in Dhaka, Bangladesh.MethodA cross-sectional study was conducted among adult slum dwellers (aged 25 and above) residing in three purposively selected urban slums of Dhaka for at least six months preceding the survey. The risk factors assessed were- currently smoking, fruit and vegetable intake, physical activity, hypertension and body mass index (BMI). Information on self-reported diabetes was also taken. A total of 507 participants (252 females; 49.7%) were interviewed and their physical measures were taken using the WHO NCD STEPS instrument.ResultThe overall prevalence of NCD risk factors was: 36.0% (95% CI: 31.82–40.41) for smoking; 95.60% (95% CI: 93.60–97.40) for insufficient fruit and vegetable intake; 15.30% (95% CI:12.12–18.71) for low physical activity;13.70% (95% CI: 10.71–16.92) for hypertension; 22.70% (95% CI: 19.31–26.02) for overweight or obesity; and 5.00% (95%: 3.20–7.00) for self-reported diabetes. In the logistic regression model, the clustering of three or more NCD risk factors was positively associated with younger age groups (p = 0.02), no formal education (p <0.001) and primary education level (p = 0.01), but did not differ by sex of the participants, monthly income and occupation.ConclusionAll NCD risk factors are markedly high among the urban slum adults. These findings are important to support the formulation and implementation of NCD-related polices and plan of actions that recognize urban slum populations in Bangladesh as a priority sub-population.

Background The COVID-19 pandemic led to a decrease in the provision and use of healthcare. Few studies reported reasons for these changes. We aimed to (i) describe the frequency of changes in healthcare utilization in those requiring ongoing treatment, and possible reasons thereof, and (ii) assess characteristics associated with change, during the second wave of the pandemic. Methods Participants from the Corona Immunitas e-cohort study (age ≥20 years) completed monthly questionnaires between September 2020 and February 2021. We used descriptive and bivariate statistics, to compare participants reporting a change in healthcare utilization with those who reported no change. We used negative binomial regression to explore characteristics associated with the number of changes. Results In total, 3190 adults from nine research sites participated in this study. One-fifth (N = 658, 21%) reported the need for regular treatment. About 14% of them reported a change in healthcare utilization, defined as events in which participants reported that they changed their ongoing treatment, irrespective of the reason. Reported reasons for change were medication changes and side-effects, specifically for hypertension, or pulmonary embolism treatment. Females were more likely to report changes in healthcare utilization (Incidence Rate Ratio (IRR)=1.69, p = 0.030), and those with hypertension were least likely to report changes (IRR=0.45, p = 0.092). Conclusions Among those who needed regular treatment, few reported changes in healthcare utilization. The importance of continuity of care for females and chronic diseases other than hypertension must be emphasized. This calls for tailored measures considering gender disparities. Key messages • Changes in healthcare utilization were more pronounced in women than men during the Covid-19 pandemic. • Tailored disease surveillance is necessary considering gender disparities and chronic diseases other than hypertension.

SARS-CoV-2 pandemic effect on pediatric asthma health care utilization in an urban hospital