Pooled testing of sputum with Xpert MTB/RIF and Xpert Ultra during tuberculosis active case finding campaigns in Lao People's Democratic Republic.

INTRODUCTION: Active case finding (ACF) of individuals with tuberculosis (TB) is a key intervention to find the 30% of people missed every year. However, ACF requires screening large numbers of individuals who have a low probability of positive results, typically <5%, which makes using the recommended molecular tests expensive. METHODS: We conducted two ACF surveys (in 2020 and 2021) in high TB burden areas of Lao PDR. Participants were screened for TB symptoms and received a chest X-ray. Sputum samples of four consecutive individuals were pooled and tested with Xpert Mycobacterium tuberculosis (MTB)/rifampicin (RIF) (Xpert-MTB/RIF) (2020) or Xpert-Ultra (2021). The agreement of the individual and pooled samples was compared and the reasons for discrepant results and potential cartridge savings were assessed. RESULTS: Each survey included 436 participants, which were tested in 109 pools. In the Xpert-MTB/RIF survey, 25 (sensitivity 89%, 95% CI 72.8% to 96.3%) of 28 pools containing MTB-positive samples tested positive and 81 pools containing only MTB-negative samples tested negative (specificity 100%, 95% CI 95.5% to 100%). In the Xpert-Ultra survey, all 32 (sensitivity 100%, 95% CI 89.3% to 100%) pools containing MTB-positive samples tested positive and all 77 (specificity 100%, 95% CI 95.3% to 100%) containing only MTB-negative samples tested negative. Pooling with Xpert-MTB/RIF and Xpert-Ultra saved 52% and 46% (227/436 and 199/436, respectively) of cartridge costs alone. CONCLUSION: Testing single and pooled specimens had a high level of agreement, with complete concordance when using Xpert-Ultra. Pooling samples could generate significant cartridge savings during ACF campaigns.

Cost-effectiveness of a market-based home fortification of food with micronutrient powder programme in Bangladesh.

OBJECTIVE: We estimated the cost-effectiveness of home fortification with micronutrient powder delivered in a sales-based programme in reducing the prevalence of Fe deficiency anaemia among children 6-59 months in Bangladesh. DESIGN: Cross-sectional interviews with local and central-level programme staff and document reviews were conducted. Using an activity-based costing approach, we estimated start-up and implementation costs of the programme. The incremental cost per anaemia case averted and disability-adjusted life years (DALY) averted were estimated by comparing the home fortification programme and no intervention scenarios. SETTING: The home fortification programme was implemented in 164 upazilas (sub-districts) in Bangladesh. PARTICIPANTS: Caregivers of child 6-59 months and BRAC staff members including community health workers were the participants for this study. RESULTS: The home fortification programme had an estimated total start-up cost of 35·46 million BDT (456 thousand USD) and implementation cost of 1111·63 million BDT (14·12 million USD). The incremental cost per Fe deficiency anaemia case averted and per DALY averted was estimated to be 1749 BDT (22·2 USD) and 12 558 BDT (159·3 USD), respectively. Considering per capita gross domestic product (1516·5 USD) as the cost-effectiveness threshold, the home fortification programme was highly cost-effective. The programme coverage and costs for nutritional counselling of the beneficiary were influential parameters for cost per DALY averted in the one-way sensitivity analysis. CONCLUSIONS: The market-based home fortification programme was a highly cost-effective mechanism for delivering micronutrients to a large number of children in Bangladesh. The policymakers should consider funding and sustaining large-scale sales-based micronutrient home fortification efforts assuming the clear population-level need and potential to benefit persists.

The relationship between non-communicable disease occurrence and poverty-evidence from demographic surveillance in Matlab, Bangladesh.

In low-income countries, a growing proportion of the disease burden is attributable to non-communicable diseases (NCDs). There is little knowledge, however, of their impact on wealth, human capital, economic growth or household poverty. This article estimates the risk of being poor after an NCD death in the rural, low-income area of Matlab, Bangladesh. In a matched cohort study, we estimated the 2-year relative risk (RR) of being poor in Matlab households with an NCD death in 2010. Three separate measures of household economic status were used as outcomes: an asset-based index, self-rated household economic condition and total household landholding. Several estimation methods were used including contingency tables, log-binomial regression and regression standardization and machine learning. Households with an NCD death had a large and significant risk of being poor. The unadjusted RR of being poor after death was 1.19, 1.14 and 1.10 for the asset quintile, self-rated condition and landholding outcomes. Adjusting for household and individual level independent variables with log-binomial regression gave RRs of 1.19 [standard error (SE) 0.09], 1.16 (SE 0.07) and 1.14 (SE 0.06), which were found to be exactly the same using regression standardization (SE: 0.09, 0.05, 0.03). Machine learning-based standardization produced slightly smaller RRs though still in the same order of magnitude. The findings show that efforts to address the burden of NCD may also combat household poverty and provide a return beyond improved health. Future work should attempt to disentangle the mechanisms through which economic impacts from an NCD death occur.

Distribution of chronic disease mortality and deterioration in household socioeconomic status in rural Bangladesh: an analysis over a 24-year period.

BACKGROUND: Little is known about long-term changes linking chronic diseases and poverty in low-income countries such as Bangladesh. This study examines how chronic disease mortality rates change across socioeconomic groups over time in Bangladesh, and whether such mortality is associated with households falling into poverty. METHODS: Age-sex standardized chronic diseases mortality rates were estimated across socioeconomic groups in 1982, 1996 and 2005, using data from the health and demographic surveillance system in Matlab, Bangladesh. Changes in households falling below a poverty threshold after a chronic disease death were estimated between 1982-96 and 1996-2005. RESULTS: Age-sex standardized chronic disease mortality rates rose from 646 per 100 000 population in 1982 to 670 in 2005. Mortality rates were higher in wealthier compared with poorer households in 1982 [Concentration Index = 0.037; 95% confidence interval (CI): 0.002, 0.072], but switched direction in 1996 (Concentration Index = -0.007; 95% CI: -0.023, 0.009), with an even higher concentration in the poor by 2005 (Concentration Index = -0.047; 95% CI: -0.061, -0.033). Between 1982-96 and 1996-2005, the highest chronic disease mortality rates were found among those households that fell below the poverty line. Households that had a chronic disease death in 1982 were 1.33 (95% CI: 1.03, 1.70) times more likely to fall below the poverty line in 1996 compared with households that did not. CONCLUSIONS: Chronic disease mortality is a growing proportion of the disease burden in Bangladesh, with poorer households being more affected over time periods, leading to future household poverty.

Is healthcare a 'Necessity' or 'Luxury'? an empirical evidence from public and private sector analyses of South-East Asian countries?

South-East Asian Regional (SEAR) countries range from low- to middle-income countries and have considerable differences in mix of public and private sector expenditure on health. This study intends to estimate the income-elasticities of healthcare expenditure in public and private sectors separately for investigating whether healthcare is a 'necessity' or 'luxury' for citizens of these countries. Panel data from 9 SEAR countries over 16 years (1995-2010) were employed. Fixed- and random-effect models were fitted to estimate income-elasticity of public, private and total healthcare expenditure. Results showed that one percent point increase in GDP per capita increased private expenditure on healthcare by 1.128%, while public expenditure increased by only 0.412%. Inclusion of three-year lagged variables of GDP per capita in the models did not have remarkable influence on the findings. The citizens of SEAR countries consider healthcare as a necessity while provided through public sector and a luxury when delivered by private sector. By increasing the public provisions of healthcare, more redistribution of healthcare resources can be ensured, which can accelerate the journey of SEAR countries towards universal health coverage.

Prevalence and associated factors of contraceptive discontinuation and switching among Bangladeshi married women of reproductive age.

INTRODUCTION: Contraceptive discontinuation is a worldwide incident that may be connected with low incentive to avoid pregnancy. Contraceptive discontinuation highly contributes to unplanned pregnancy and unwanted births. OBJECTIVES: The objective of this study was to observe the prevalence of discontinuation and switching of contraceptive methods among Bangladeshi married women. In addition, the sociodemographic factors associated with contraceptive discontinuation and switching were assessed. METHODS: Secondary cross-sectional data was used in this study. A total of 16,273 married Bangladeshi women of reproductive age (15-49 years) were considered in the present study, from the Bangladesh Demographic and Health Survey, 2011. Logistic regression models were used to determine the relationships between key sociodemographic factors and user status. RESULTS: The prevalence of discontinuation and switching of contraceptive method among women were 38.4% and 15.4%, respectively. The logistic regression model demonstrated that women in early reproductive years (25-29 years and 30-34 years) significantly more often (odds ratio [OR] =0.84 and 0.71, respectively) discontinued use of contraceptives. Significantly higher rates of discontinuation were pronounced among women who used the pill (OR =0.72) and injectable contraception users (OR =0.60), had small family size (OR =0.49), lived in a rural community (OR =1.65), and who were less educated (OR =1.55). CONCLUSION: Contraceptive discontinuation may reflect an association among less education, currently married, and smaller family size. Awareness of contraceptive methods can decrease the burden of unplanned pregnancies and thus progresses the family planning program.

The impact of age and sex on healthcare expenditure of households in Bangladesh.

The impact of age and sex on health care expenditure has recently become one of the major concerns in many developing countries like Bangladesh. Age and sex differences in the use of health care services can be substantial at several stages of life which are reflected in overall healthcare expenditure. We examined the impact of age and sex of the population on overall healthcare expenditure of households in Bangladesh. A total of 10,705 populations who spent for receiving any type of healthcare services were analyzed from Bangladesh Household Income and Expenditure Survey data, 2010. Sex and age group were considered as childhood (0-19), young adult (20-39), middle-aged adult (40-64), senior aged (65-84) and old senior aged (84+) for the entire analysis. Total healthcare expenditure was derived by considering direct cost such as physician's fee, cost of medicine, diagnostic, transportation, tips and informal payment etc. Indirect and intangible cost was not considered in the analysis. The study found that overall health care expenditure of male (US$ 11.5) is higher than female (US$ 11.2) while this is higher for female (US$ 14.2) than male (US$ 11.3) in the reproductive age. The highest health expenditure was observed in male (US$ 69.7) of age 65-69 years and in female (US$ 23.4) of age 75-79 years. The cost for hospitalization was significantly higher (US $23.7) for female than male (US$ 21.1). Overall health expenditure was observed to be significantly higher in elderly than younger people. These findings provide an experimental framework for the continuing inquiry of equity in the allocation of health care expenditure between male and female at different age, which suggest current health care system in Bangladesh place a significant financial strain on the elderly population.

Cost of behavior change communication channels of Manoshi -a maternal, neonatal and child health (MNCH) program in urban slums of Dhaka, Bangladesh.

BACKGROUND: The cost of behavior change communication (BCC) interventions has not been rigorously studied in Bangladesh. This study was conducted to assess the implementation costs of a BCC intervention in a maternal, neonatal and child health program (Manoshi) run by BRAC, which has been operating in the urban slums of Dhaka since 2007. The study estimates the costs of BCC tools per exposure among the different types of BCC channels: face-to-face, group counseling, and mass media. METHODS: The study was conducted from November 2010 to April 2011 in the Dhaka urban slum area. A micro-costing approach was applied using primary and secondary data sources to estimate the cost of BCC tools. Primary data were collected through interviews with service-providers and managers from the Manoshi program, observations of group counseling, and mass media events. RESULTS: Per exposure, the cost of face-to-face counseling was found to be 3.08 BDT during pregnancy detection, 3.11 BDT during pregnancy confirmation, 12.42 BDT during antenatal care, 18.96 BDT during delivery care and 22.65 BDT during post-natal care. The cost per exposure of group counseling was 22.71 BDT (95% CI 21.30-24.87) for Expected Date of Delivery (EDD) meetings, 14.25 BDT (95% CI 12.37-16.12) for Women Support Group meetings, 17.83 BDT (95% CI 14.90-20.77) for MNCH committee meetings and 6.62 BDT (95% CI 5.99-7.26) for spouse forum meetings. We found the cost per exposure for mass media interventions was 9.54 BDT (95% CI 7.30-12.53) for folk songs, 26.39 BDT (95% CI 23.26-32.56) for street dramas, 0.39 BDT for TV-broadcasting and 7.87 BDT for billboards. Considering all components reaching the target audience under each broader type of channel, the total cost per exposure was found to be 60.22 BDT (0.82 USD) for face-to-face counseling, 61.40 BDT (0.82 USD) for group counseling and 44.19 BDT (0.61 USD) for mass media. CONCLUSIONS: The total cost for group counseling was the highest per exposure, followed by face-to-face counseling and mass media. The cost per exposure varied substantially across BCC channels due to differences in cost drivers such as personnel, materials and refreshments. The cost per exposure can be valuable for planning and resource allocation related to the implementation of BCC interventions in low resource settings.

Impact of educational intervention on willingness-to-pay for health insurance: A study of informal sector workers in urban Bangladesh.

BACKGROUND: The reliance on out-of-pocket payments for health services leads to a catastrophic burden for many households in Bangladesh. The World Health Organization suggests that risk-pooling mechanisms should be used for financing healthcare. Like many low-income countries (LIC), a large share of employment in Bangladesh is in the informal sector (88%). Inclusion of these workers in health insurance is a big challenge. Among other barriers, the "literacy gap" for health insurance" is a reason for the low insurance uptake in Bangladesh. The aim of this study is, therefore, to assess the impact of an educational intervention on willingness-to-pay (WTP) for health insurance among informal sector workers in urban Bangladesh. METHOD: An educational intervention on occupational solidarity and health insurance is offered to groups of informal workers. Educational sessions take place once a week (3-4 hours) during three subsequent weeks for each occupational group. For assessing the impact of the educational intervention, WTP for joining health insurance using occupational solidarity between workers in "pre- and post-treatment" periods as well as between "control and treatment" groups were compared. Multiple-regression analysis is applied for predicting WTP by educational intervention, while controlling for demographic and socioeconomic characteristics. RESULTS: The coefficient of variation (CoV) of the WTP is estimated in control and treatment groups and expected to be lower in the latter. The WTP for health insurance is higher (33.8%) among workers who joined the educational intervention in comparison with those who did not (control group). CoV of WTP is found to be generally lower in post-treatment period and in treatment group compared to pre-treatment period and control group respectively. CONCLUSION: Educational interventions can be used for increasing demand for health insurance scheme using occupational solidarity among informal sector workers.

A systematic review of economic evaluations of health and health-related interventions in Bangladesh.

BACKGROUND: Economic evaluation is used for effective resource allocation in health sector. Accumulated knowledge about economic evaluation of health programs in Bangladesh is not currently available. While a number of economic evaluation studies have been performed in Bangladesh, no systematic investigation of the studies has been done to our knowledge. The aim of this current study is to systematically review the published articles in peer-reviewed journals on economic evaluation of health and health-related interventions in Bangladesh. METHODS: Literature searches was carried out during November-December 2008 with a combination of key words, MeSH terms and other free text terms as suitable for the purpose. A comprehensive search strategy was developed to search Medline by the PubMed interface. The first specific interest was mapping the articles considering the areas of exploration by economic evaluation and the second interest was to scrutiny the methodological quality of studies. The methodological quality of economic evaluation of all articles has been scrutinized against the checklist developed by Evers Silvia and associates. RESULT: Of 1784 potential articles 12 were accepted for inclusion. Ten studies described the competing alternatives clearly and only two articles stated the perspective of their articles clearly. All studies included direct cost, incurred by the providers. Only one study included the cost of community donated resources and volunteer costs. Two studies calculated the incremental cost effectiveness ratio (ICER). Six of the studies applied some sort of sensitivity analysis. Two of the studies discussed financial affordability of expected implementers and four studies discussed the issue of generalizability for application in different context. CONCLUSION: Very few economic evaluation studies in Bangladesh are found in different areas of health and health-related interventions, which does not provide a strong basis of knowledge in the area. The most frequently applied economic evaluation is cost-effectiveness analysis. The majority of the studies did not follow the scientific method of economic evaluation process, which consequently resulted into lack of robustness of the analyses. Capacity building on economic evaluation of health and health-related programs should be enhanced.