Background: Improving ability of the health system to reach the poor/disadvantaged populations is important for health and essential to mitigate the income-erosion consequences of ill-health in Bangladesh. This study examined the health-seeking behaviour of some identified disadvantaged population groups, including the effect of poverty focused non-governmental development interventions.
Methods: The thesis is based on five studies from four different research projects, conducted during 1995-2004 in Bangladesh. The first three studies are descriptive cross-sectional studies while the last two used quasi-experimental design to test two interventions implemented by a non-governmental organization (NGO). One is microcredit-based targeted to the poor while the other is grants-based targeted to the 'ultra-poor'. Sample populations came from: a) 2,267 poor (households possessing >= 50 decimals of land, and selling manual labour) and 1,550 non-poor households (I); and 2,005 poor and 950 non-poor households (IV), both from a sub-district having microcredit-based integrated intervention; b) 2,550 households from five different ethnic communities in the Chittagong Hill Tracts (CHT) region (II); c) 966 households with at least one elderly (>=60 years) person from two sub-districts (III); d) and, 4,323 'ultra-poor' households (the 'poorest of the poor') from three famine prone districts having a grants-based development intervention with enhanced health-related inputs (V). Pre-tested structured questionnaires were used in face-to-face interviews to elicit relevant information on health-seeking behaviour with 15 days recall.
Results: The probability to access any type of healthcare, and professional allopathic care (MBBS doctors) was found to be greater for men than for women (OR 1.73 and OR 1.64 respectively). The same was for participation in microcredit-based integrated intervention (OR 1.92) (I). On average, no treatment was sought in 14% of reported illness episodes by different ethnic groups in the CHT region (II). The majority (60-70%) of the ethnic groups sought treatment from unqualified allopathic providers (untrained drug retailers/vendors) while resident Bangalis sought care in greater proportion from the semi-qualified para-professionals (15%) and MBBS doctors (26%). No major difference in health-seeking behaviour and health-expenditure between the elderly and the younger adults (20 -59 years) was observed (III). Poverty emerged as the most significant determinant of health-seeking behaviour and individuals from poor households were nearly two times (OR 1.8, 95%CI: 1.43-2.36) more likely to practice self-care (III). The most commonly consulted provider was a para-professional while in around 20% of illness episodes in plain land, unqualified allopaths were contacted (I, III, IV). Self-care in the context of microcredit-based integrated intervention was associated with female gender (OR 0.69, 95%CI 0.48-0.90), the absence of low cost health services (OR 1.67, 95%CI 1.45-1.88) and illnesses of relatively short duration (IV). Also, grants-based integrated intervention was found to increase the proportion of ultra-poor households seeking 'formal allopathic' (MBBS+para-professional) care by 9% (95% CI 4.2-14.2, p<0.01), and increase the capacity of these households to spend on illnesses in the reference period by 11% (95% CI 5.8-16.6, p <0.001) which in Bangladeshi context reflects increased capacity for health expenditure by the poor/ultra-poor households (V).
Conclusions: An emerging cadre of 'para-professionals' as main provider of formal allopathic care to the disadvantaged populations was observed, in addition to the pre-dominance of self-care. Household poverty was instrumental in shaping health-seeking behaviour. By improving capacity for health-expenditure, a grants-based intervention initiated changes in health-seeking behaviour of the ultra-poor towards greater use of healthcare when ill, and use of formal allopathic providers in preference to unqualified providers. The microcredit-based integrated intervention was found to increase the use of self-care.