Exploring the context in which different close-to-community sexual and reproductive health service providers operate in Bangladesh: a qualitative study.
BACKGROUND
A range of formal and informal close-to-community (CTC) health service providers operate in an increasingly urbanized Bangladesh. Informal CTC health service providers play a key role in Bangladesh's pluralistic health system, yet the reasons for their popularity and their interactions with formal providers and the community are poorly understood. This paper aims to understand the factors shaping poor urban and rural women's choice of service provider for their sexual and reproductive health (SRH)-related problems and the interrelationships between these providers and communities. Building this evidence base is important, as the number and range of CTC providers continue to expand in both urban slums and rural communities in Bangladesh. This has implications for policy and future programme interventions addressing the poor women's SRH needs.


METHODS
Data was generated through 24 in-depth interviews with menstrual regulation clients, 12 focus group discussions with married men and women in communities and 24 semi-structured interviews with formal and informal CTC SRH service providers. Data was collected between July and September 2013 from three urban slums and one rural site in Dhaka and Sylhet, Bangladesh. Atlas.ti software was used to manage data analysis and coding, and a thematic analysis was undertaken.


RESULTS
Poor women living in urban slums and rural areas visit a diverse range of CTC providers for SRH-related problems. Key factors influencing their choice of provider include the following: availability, accessibility, expenses and perceived quality of care, the latter being shaped by notions of trust, respect and familiarity. Informal providers are usually the first point of contact even for those clients who subsequently access SRH services from formal providers. Despite existing informal interactions between both types of providers and a shared understanding that this can be beneficial for clients, there is no effective link or partnership between these providers for referral, coordination and communication regarding SRH services.


CONCLUSIONS
Training informal CTC providers and developing strategies to enable better links and coordination between this community-embedded cadre and the formal health sector has the potential to reduce service cost and improve availability of quality SRH (and other) care at the community level.
James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh. ilias@bracu.ac.bd.
Ilias
I
Mahmud
James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh. sadia.chowdhury@bracu.ac.bd.
Sadia
S
Chowdhury
James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh. bulbul_ashraf@yahoo.com.
Bulbul Ashraf
BA
Siddiqi
Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK. sally.theobald@lstmed.ac.uk.
Sally
S
Theobald
Royal Tropical Institute, Amsterdam, The Netherlands. h.ormel@kit.nl.
Hermen
H
Ormel
James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh. s.biswas@bracu.ac.bd.
Salauddin
S
Biswas
James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh. yamin@bracu.ac.bd.
Yamin Tauseef
YT
Jahangir
James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh. malabika@bracu.ac.bd.
Malabika
M
Sarker
James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh. sabina@bracu.ac.bd.
Sabina Faiz
SF
Rashid
D000293:Adolescent; D000328:Adult; D001459:Bangladesh; D003153:Community Health Services / Q000191:economics / Q000458:organization & administration*; D005260:Female; D006297:Health Services Accessibility / Q000191:economics / Q000458:organization & administration*; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D057240:Patient Preference; D011204:Poverty Areas; D011369:Professional-Patient Relations; D036301:Qualitative Research; D034121:Reproductive Health Services / Q000191:economics / Q000458:organization & administration*; D012424:Rural Population; D035502:Trust; D014505:Urban Population; D055815:Young Adult