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

Universal health coverage (UHC) is now a familiar acronym for the global health agenda that combines a triple policy. It is defined as ensuring universal access to quality healthcare services as per need without the risk of incurring financial hardship [1]. More recently, the adaption of the sustainable development goals (SDGs) by the United Nation assembly explicitly included the UHC goal under SDG 3.8 stating "Achieve Universal Health Coverage, including financial risk protection, access to quality essential healthcare services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all" [2]. Access to healthcare is considered as an important determinant in assessing equity in healthcare delivery [3]. Ideally, the use of healthcare services reflects the need for care; however, that is not always possible for several reasons [4]. In low- and middle-income countries (LMICs), healthcare utilization is influenced by demand and supply-side constraints. In some instances, utilization is determined solely by the ability to pay or out-of-pocket (OOP) payments rather than the need for care [5]. This situation can gradually impose heavy financial burdens on individuals as well as on households and consequently can lead to catastrophic healthcare expenditure (CHE) and economic impoverishment [6, 7]. Like other LMICs, the healthcare financing strategies in Bangladesh employs a combination of general revenue taxation, OOP payments, development partner’s contribution, corporate insurance, and others. OOP spending is the main source of healthcare financing in Bangladesh and the share of OOP payments has increased from 55.9% in 1997 to 67% in 2015 [8]. Reliance on OOP payments for financing healthcare and significantly increasing treatment cost related to non-communicable disease and epidemiological transition (responsible for 60% of the mortality) have led to increase the OOP healthcare spending in Bangladesh. Such a high percentage of OOP expenditure for healthcare is associated with low financial protection of the households. A study using data from 2010, revealed that 14.7% of the households faced CHE from OOP healthcare payments and 3.5% of the total population falls into poverty annually [9]. Another study conducted among 11 Asian countries in 2006 showed that about 5 million people become impoverished annually in Bangladesh from OOP healthcare expenditure [10].

Public spending on health is determined by the capacity of the government to raise revenues and allocate these to the health sector [11]. Bangladesh spends only 3% of its gross domestic product (GDP) in health sector while government expenditure compared to GDP is only 0.69%. Such spending has placed Bangladesh on the list of countries with the lowest health spending in the South-East Asian Region [12].

The latest household income and expenditure survey 2015 of Bangladesh reported that among those who access healthcare, 55.62% utilize services from medically non-trained provider’ (non-MTPs) which includes non-qualified private practitioner, traditional healer, and drug sellers [13]. People prefer to seek health care from non-MTPs in the informal sector, especially the poor and the disadvantaged [14] rather visiting medically trained providers (MTPs) such as medical college hospitals, Upazila Health Complex (UzHC), general practitioners, non-government organization (NGO) hospitals, qualified private practitioners, Union Sub-Centres (USC), and Maternal and Child Welfare Centres (MCWC).

The 2011 National Health Policy of the Government of Bangladesh (GoB) acknowledges that health is a human right, and to achieve UHC, it is necessary to ensure health services for the poor at an affordable cost [15]. Effective measures must be taken to reduce households’ OOP healthcare expenditure and increase utilization of quality healthcare to achieve UHC by 2030. Responding to the global call for UHC, the GoB adopted the first-ever Health Care Financing Strategy in 2012 aiming to achieve UHC by 2032 [16]. Under this strategy, the Shasthyo Surokhsha Karmasuchi (SSK), a GoB health protection scheme, is being piloted by the Health Economics Unit (HEU) of the Ministry of Health and Family Welfare [17]. Although the SSK scheme has a comprehensive plan to bring all the population of the country under health insurance, initially it aimed to pilot only among the below-poverty-line (BPL) population.

Overall, 8% of the SSK members sought healthcare from the scheme of which 1.6% sought inpatient care and 6.4% sought outpatient care. The results of this study revealed that although the SSK health protection scheme provides free inpatient care and outpatient consultation services, it is yet to be popular among the enrolled BPL households, as 26.1% of the members still sought healthcare from MTPs other than the SSK scheme. However, it is still positive that out of 23 individuals requiring inpatient care, 10 of them could access healthcare services under the SSK scheme. Although utilization of the SSK scheme is low, a recent evaluation of it reported that the scheme significantly reduced the OOP expenditure and incidence of CHE among the enrolled households [30]. A similar health protection scheme in India also reported significantly increased utilization of inpatient healthcare among the beneficiaries [27]. In Vietnam, a Health Insurance scheme for the poor also substantially increased service utilization, especially for in-patient care [31]. A systematic review on the impact of health insurance in Africa and Asia found that insurance scheme improved utilization of inpatient and outpatient healthcare services [32].

One of the key reasons for such low utilization of the SSK scheme was the lack of positive knowledge about the scheme among the enrolled households. We found a significant positive association of knowledge of the SSK scheme with its utilization. Even, having knowledge on the SSK scheme is significantly negatively associated with seeking care from other MTPs. This finding of this study was similar to those of with other studies, which showed that knowledge of insurance scheme significantly affects the utilization of healthcare and dropout rates [33, 34]. Although the SSK management has developed an information, education, and communication (IEC) strategy, we found that most of the households did not have knowledge on the SSK scheme during the survey. This developed IEC strategy should be implemented appropriately among the target population and its effectiveness should be evaluated to understand on what extent the strategy could aware the members about the scheme. A study on the community-based health insurance scheme in Burkina Faso, showed that IEC campaign had positive effect on households’ knowledge about the insurance scheme [33]. Thus, SSK scheme may include strategies like delivering frequent and consistent IEC messages from multiple media channels including mobile information van, visiting member households by the programme personnel, engaging community leaders in promotional campaign of the scheme, frequent loudspeaker announcement [35], and effective outreach via health camps [36]. Furthermore, enhancing community campaigns may increase the demand for healthcare among the target population of this scheme. Another possible factor for low utilization of SSK is that most of the healthcare utilizers (390 out of 639) suffered from symptoms of illness like cough, fever, weakness, pain and discomfort, and dyspepsia. Majority of these care seekers utilized healthcare from non-MTPs (72%). They were not motivated enough to visit SSK facilities for two possible reasons. Firstly, this segment of individuals had symptoms of illness and historically they are used to utilize this kind of non-MTP providers [14]. Therefore, shifting their motivation towards utilizing MTPs will take time and may gradually improve through behaviour change intervention. Secondly, SSK scheme does not offer all types of prescribed medicines for outpatient care which they do for inpatient care. Thus, in addition to increasing awareness of the scheme among SSK members, the SSK programme can attract these non-MTP utilizers through adding benefits for outpatients to the existing benefits package i.e., ensuring all medicines for SSK outpatients. Evidence showed that involvement in insurance scheme resulted in increased utilization of outpatient care at public facilities in Ethiopia [37]. The quality of services of the SSK facilities can be improved further which may motivate the members to visit facilities and will create a positive impression in the communities. Recently, the satisfaction of inpatient services users was measured under a comprehensive evaluation of the SSK scheme [30]. The study showed that about 55% of the SSK inpatients services users were satisfied with the services they received form SSK facilities. Thus, still there is scope for quality improvement which can contribute further to increasing utilization of the scheme. Households' distance from health facility also influenced the utilization of healthcare from the scheme. Households in the Unions of medium and far distance from the health facility were less likely to utilize healthcare from the scheme. It is evident in literature that spatial distribution significantly affects healthcare utilization from health facilities [38‐40]. Even it is valid for such a health protection scheme that provides free healthcare through the existing health facility.

In Bangladesh, below the UzHC level facilities, public facilities like union subcentres and community clinics provides outpatient healthcare services. On average about 36 such facilities are functional in an UzHC area [41]. The SSK scheme programme can think of including these outpatient facilities under the scheme, especially for managing outpatient care, for minimizing existing distance barriers and improving practice of visiting health facilities among the SSK members instead of going to non-MTPs. We observed that individuals from the currently non-BPL households were more likely to utilize healthcare from the SSK scheme. These non-BPL individuals may live nearer to the SSK provider and may be better informed about the SSK services. We found that better-off individuals like those belonging to the second income quintile were more likely to utilize healthcare from the SSK scheme compared to the poorest income group. And although not significant, the odds ratios were greater than one for the individuals from higher income group compared to the poorer. The stylized fact is that healthcare utilization is the lowest among the least well-off group [42].

We found that unemployed individuals were more likely to utilize healthcare services from SSK scheme. In our survey, about 41% of the unemployed individual were aged above 60 years (result not shown) and the proportion of elderly is higher in the unemployed group compared to any other occupation group. The elderly population suffers from different age-related illness and have a higher likelihood of visiting facilities for seeking healthcare. Further although not significant, the odds ratio of utilizing SSK scheme by elderly population were higher compared to the younger. It is also evident in literature that lower-income unemployed are more likely to access public health insurance and other safety net programs [43]. The use of the scheme facility was significantly higher among the people who suffered from an accident / injury compared to the people who suffered from communicable diseases. As accident and injury related problem might require immediate quality care at high costs, people were motivated to visit healthcare facility. A similar finding was observed for a study conducted in a community-based health insurance scheme in Bangladesh [28].

The SSK scheme has a potential to increase healthcare utilization among the enrolled BPL households by addressing the identified factors, namely increasing knowledge through rigorous community campaigns [44] and adding more benefits for the outpatients service to the existing benefit package of the scheme [45]. However, such a mechanism needs to be examined in terms of sustainability and moral hazard before implementation. A similar health protection scheme in India was successful in increasing utilization and improving health outcomes of the enrolled households having features of effective outreach via health camps and inclusion of private facilities for providing healthcare [36] which can also be considered for SSK scheme in Bangladesh. Furthermore, the list of BPL households should be updated regularly for precise targeting and providing services to those who cannot afford it. Such precision may be possible by increasing local-level political commitment. Since healthcare utilization had a significantly negative association with the distance from the SSK facility, the authority can think of linking the lower-level facilities such as union sub-center where the patient will receive outpatient care and be referred to higher-level facilities for inpatient or complicated cases. However, further exploration would be required before implementing such an initiative.

This study investigated healthcare utilization behaviour of the financially disadvantaged BPL population after including them in a health protection scheme. Utilization of healthcare from the scheme facility is low despite the provision of free inpatient care for 78 different types of diseases and outpatient consultation. Knowledge of the scheme was one of the critical barriers to the utilization of the SSK scheme. With appropriate measures in place, such as developing and implementing interpersonal communication strategies and organizing regular awareness-building campaigns, and promotional activities at the community level, the knowledge of the enrolled population may increase over time. Furthermore, as many people utilized care from non-qualified and other MTPs, the policymakers may think of redesigning the benefit package based on the needs of the BPL population which may increase the demand for healthcare from the scheme among them. The evidence generated from this study will help to address the reasons behind the low utilization and the challenges to increase the effectiveness of SSK in improving the healthcare seeking behaviour of the BPL population. Addressing the drawback associated with healthcare utilization is essential before further expansion or scale-up of the scheme. A successful implementation and scale-up of this scheme will be a vehicle to achieve UHC by addressing the healthcare needs of the people who cannot afford quality healthcare in Bangladesh.