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Background From March 2020, the COVID-19 pandemic has shocked health systems worldwide. This analysis investigated the effects of the pandemic on basic health services utilization in the Democratic Republic of the Congo (DRC) and examined the variability of COVID effects in the capital city Kinshasa, in other urban areas, and in rural areas. Methods We estimated time trends models using national health information system data to replicate pre-COVID-19 (i.e., January 2017–February 2020) trajectories of health service utilization, and then used those models to estimate what the levels would have been in the absence of COVID-19 during the pandemic period, starting in March 2020 through March 2021. We classified the difference between the observed and predicted levels as the effect of COVID-19 on health services. We estimated 95% confidence intervals and p-values to examine if the effect of the pandemic, nationally and within specific geographies, was statistically significant. Results Our results indicate that COVID-19 negatively impacted health services and subsequent recovery varied by service type and by geographical area. COVID-19 had a lasting impact on overall service utilization as well as on malaria and pneumonia-related visits among young children in the DRC. We also found that the effects of COVID-19 were even more immediate and stronger in the capital city of Kinshasa compared with the national effect. Both nationally and in Kinsahsa, most affected services had slow and incomplete recovery to expected levels. Therefore, our analysis indicates that COVID-19 continued to affect health services in the DRC throughout the first year of the pandemic. Conclusions The methodology used in this article allows for examining the variability in magnitude, timing, and duration of the COVID effects within geographical areas of the DRC and nationally. This analytical procedure based on national health information system data could be applied to surveil health service disruptions and better inform rapid responses from health service managers and policymakers.

BackgroundMalnutrition imposes enormous costs resulting from lost investments in human capital and increased healthcare expenditures. There is a dearth of research focusing on the prediction of women’s body mass index (BMI), and the malnutrition outcomes (underweight, overweight and obesity) in developing countries. This paper attempts to fill out this knowledge gap by predicting the BMI and the risks of malnutrition outcomes for Bangladeshi women of childbearing age from their economic, health, and demographic features.MethodsData from the 2017-18 Bangladesh Demographic and Health Survey and a series of supervised machine learning (SML) techniques are used. Additionally, this study circumvents the imbalanced distribution problem in obesity classification by utilizing an oversampling approach.ResultsStudy findings demonstrate that support vector machine and k-nearest neighbor are the two best-performing methods in BMI prediction based on coefficient of determination (R2), root mean square error (RMSE), and mean absolute error (MAE). The combined predictor algorithms consistently yield top specificity, Cohen’s kappa, F1-score, and AUC in classifying the malnutrition status, and their performance is robust to alternative standards. The feature importance ranking based on several nonparametric and combined predictors indicates that socioeconomic status, women’s age, and breastfeeding status are the most important features in predicting women’s nutritional outcomes. Furthermore, the conditional inference trees corroborate that those three features along with the partner’s educational attainment and employment significantly predict malnutrition risks.ConclusionTo the best of our knowledge, this is the first study that predicts BMI and one of the pioneer studies to classify all three malnutrition outcomes for women of childbearing age in Bangladesh, let alone in any lower-middle income country, using SML techniques. Moreover, in the context of Bangladesh, this paper is the first to identify and rank features that are critical in predicting nutritional outcomes using several feature selection algorithms. The estimators from this study predict the outcomes of interest most accurately and efficiently compared to other existing studies in the relevant literature. Therefore, study findings can aid policymakers in designing policy and programmatic approaches to address the double burden of malnutrition among Bangladeshi women, thereby reducing the country’s economic burden.

Background Since March 2020, the COVID-19 pandemic has been a major shock to health systems across the world. We examined national usage patterns for selected basic, essential health services, before and during the COVID-19 pandemic, to determine whether COVID-19 affected reporting of service utilization and the use of health services. Methods We used routine health information system data since January 2017 to analyze reporting and service utilization patterns for a variety of health services. Using time series models to replicate pre-COVID-19 trajectories over time we estimated what levels would have been observed if COVID-19 had not occurred during the pandemic months, starting in March 2020. The difference between the observed and predicted levels is the COVID effect on health services. Findings: The time trends models for Uganda and Bangladesh closely replicated the levels and trajectories of service utilization during the 38 months prior to the COVID-19 pandemic. Our results indicate that COVID-19 had severe effects across all services, particularly during the first months of the pandemic, but COVID-19 impacts on health services and subsequent recovery varied by service type. In general, recovery to expected levels was slow and incomplete across the most affected services. Conclusion Our analytical approach based on national information system data could be very useful as a form of surveillance for health services disruptions from any cause leading to rapid responses from health service managers and policymakers.

Background Many low- and middle-income countries cannot measure maternal mortality to monitor progress against global and country-specific targets. While the ultimate goal for these countries is to have complete civil registrations systems, other interim strategies are needed to provide timely estimates of maternal mortality. Objective The objective is to inform on potential options for measuring maternal mortality. Methods This paper uses a case study approach to compare methodologies and estimates of pregnancy-related mortality ratio (PRMR)/maternal mortality ratio (MMR) obtained from four different data sources from similar time periods in Bangladesh, Mozambique, and Bolivia—national population census; post-census mortality survey; household sample survey; and sample vital registration system (SVRS). Results For Bangladesh, PRMR from the 2011 census falls closely in line with the 2010 household survey and SVRS estimates, while SVRS’ MMR estimates are closer to the PRMR estimates obtained from the household survey. Mozambique's PRMR from household survey method is comparable and shows an upward trend between 1994 and 2011, whereas the post-census mortality survey estimated a higher MMR for 2007. Bolivia's DHS and post-census mortality survey also estimated comparable MMR during 1998–2003. Conclusions Overall all these data sources presented in this paper have provided valuable information on maternal mortality in Bangladesh, Mozambique, and Bolivia. It also outlines recommendations to estimate maternal mortality based on the advantages and disadvantages of several approaches. Contribution Recommendations in this paper can help health administrators and policy planners in prioritizing investment for collecting reliable and contemporaneous estimates of maternal mortality while progressing toward a complete civil registration system.

Background Significant levels of funding have been provided to low- and middle-income countries for development assistance for health, with most funds coming through direct bilateral investment led by the USA and the UK. Direct attribution of impact to large-scale programs funded by donors remains elusive due the difficulty of knowing what would have happened without those programs, and the lack of detailed contextual information to support causal interpretation of changes. Methods This study uses the synthetic control analysis method to estimate the impact of one donor’s funding (United States Agency for International Development, USAID) on under-five mortality across several low- and middle-income countries that received above average levels of USAID funding for maternal and child health programs between 2000 and 2016. Results In the study period (2000–16), countries with above average USAID funding had an under-five mortality rate lower than the synthetic control by an average of 29 deaths per 1000 live births (year-to-year range of − 2 to − 38). This finding was consistent with several sensitivity analyses. Conclusions The synthetic control method is a valuable addition to the range of approaches for quantifying the impact of large-scale health programs in low- and middle-income countries. The findings suggest that adequately funded donor programs (in this case USAID) help countries to reduce child mortality to significantly lower rates than would have occurred without those investments.

Background Diabetes, one of the major metabolic disorders, is rising in Bangladesh. Studies indicate there is inequality in prevalence and care-seeking behavior, which requires further exploration to understand the socioeconomic disparities in the pathophysiology of diabetes. This study examined the latest nationally representative estimates of diabetes prevalence, awareness, and management among adults aged 18 years and above in Bangladesh and its association with socioeconomic status in 2017–18. Methods We used the 2017–18 Bangladesh Demographic and Health Survey data. Diabetic status of 12,092 adults aged 18 years and above was measured in the survey using fasting plasma glucose levels. We applied multivariate logistic regressions to examine the role of socioeconomic status on diabetes prevalence, awareness, and management, after controlling for relevant covariates. Results Overall, 10% of adults had diabetes in Bangladesh in 2017–18, with the highest prevalence of 16% in the age group 55−64 years. Our analyses found statistically significant disparities by socioeconomic status in the prevalence of diabetes as well as the person’s awareness of his/her diabetic condition. However, the effect of socioeconomic status on receiving anti-diabetic medication only approached significance (p = 0.07), and we found no significant association between socioeconomic status and control of diabetes. Conclusions We expect to see an ‘accumulation’ of the number of people with diabetes to continue in the coming years. The rising prevalence of diabetes is only the tip of an iceberg; a large number of people with uncontrolled diabetes and a lack of awareness of their condition will lead to increased morbidity and mortality, and that could be the real threat. Immediate measures to increase screening coverage and exploration of poor control of diabetes are required to mitigate the situation.

UNSTRUCTURED Given the low Covid-19 testing coverage in the country, this study tested whether the daily change in the number of new Covid-19 cases is due to increase (or decrease) in the number of tests done daily. We performed Granger causality test based on vector autoregressive models on Bangladesh case and test numbers between 8 March and 5 June 2020, using publicly available data. The test results show that the daily number of tests Granger-cause the number of new cases (p

Given the low Covid-19 testing coverage in the country, this study tested whether the daily change in the number of new Covid-19 cases is due to increase (or decrease) in the number of tests done daily. We performed Granger causality test based on vector autoregressive models on Bangladesh’s case and test numbers between 8 March and 5 June 2020, using publicly available data. The test results show that the daily number of tests Granger-cause the number of new cases (p

Educational attainment among women is a well-recognized predictor for maternal mortality. Data from nationally representative surveys and the United Nations are used in the analysis for estimating maternal mortality due to improved education status up to 2030. Analysis of data from 2001 and 2010 Bangladesh Maternal Mortality Survey shows that MMR varies considerably by education level. The study shows that during 2011–2030, 15% maternal deaths will be averted due to fertility change (i.e. fewer births) and 24% of the maternal deaths can be averted only by improving the female education levels. However, in order to achieve the Ending Preventable Maternal Mortality (EPMM) target of 59 maternal deaths per 100,000 live births by 2030 for Bangladesh, a further 64% reduction will be required. Factors outside the health sector, like female education, will continue to have an impact maternal mortality in Bangladesh. However, reaching the EPMM target for Bangladesh by 2030 will also require significant investments in maternal health programs, in particular those to increase access to and quality of services.

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.

Using Matlab demographic surveillance data (HDSS), we assess if misreporting of age at marriage could be contributing to the apparent persistence of early marriage in Bangladesh. A random sample of 1766 women aged 15–29 born in HDSS area was selected. Almost two-thirds misreported their age at marriage, but not randomly—56 percent under-reported while seven percent over-reported their age at first marriage.Among the currently married group aged 20–24, the reported mean age at first marriage was 16.8 years, comparable to 16.6 years given by Bangladesh Demographic and Health Survey 2011 for the same age group. However a cross-check with their actual dates of birth recorded in the Matlab HDSS database reveals that the true mean age at first marriage was 18.6 years—giving an average difference of almost two years between reported and actual ages at marriage. The paper identifies rising dowry as a likely determinant of age misreporting.

This paper illustrates the importance of collecting facility-based data through regular surveys to supplement the administrative data, especially for developing countries of the world. In Bangladesh, measures based on facility survey indicate that only 70% of very basic medical instruments and 35% of essential drugs were available in health facilities. Less than 2% of officially designated obstetric care facilities actually had required drugs, injections and personnel on-site. Majority of (80%) referral hospitals at the district level were not ready to provide comprehensive emergency obstetric care. Even though the Management Information System reports availability of diagnostic machines in all district-level and sub-district-level facilities, it fails to indicate that 50% of these machines are not functional. In terms of human resources, both physicians and nurses are in short supply at all levels of the healthcare system. The physician-nurse ratio also remains lower than the desirable level of 3.0. Overall job satisfaction index was less than 50 for physicians and 66 for nurses. Patient satisfaction score, however, was high (86) despite the fact that process indicators of service quality were poor. Facility surveys can help strengthen not only the management decision-making process but also the quality of administrative data.

The study examined noncommunicable diseases risk factors among adults 25 to 64 years old of the Matlab Health and Demographic Surveillance System using World Health Organization STEP-wise methodology. The prevalence of smoking was found to be very high for males (53.9%) and it increased initially with age, whereas smoking was almost nil for females (0.8%). About 30% each of males and females used smokeless tobacco and its consumption increased with age. Consumption of vegetable/fruit is very low in this population (90% below recommended level), whereas one third of males and two thirds of female have low levels of physical activities. The raised blood pressure was more prevalent among females than in males (21.0% vs 12.5%, respectively) and the same was true for being overweight (13.9% vs 10.3%, respectively). Raised blood pressure increased with age but overweight did not vary by age for males, whereas it increased initially for females. Smoking (males) and use of smokeless tobacco decreased with increase in education, but both blood pressure and overweight increased.

Summary Background Bangladesh is one of the only nine Countdown countries that are on track to achieve the primary target of Millennium Development Goal (MDG) 5 by 2015. It is also the only low-income or middle-income country with two large, nationally-representative, high-quality household surveys focused on the measurement of maternal mortality and service use. Methods We use data from the 2001 and 2010 Bangladesh Maternal Mortality Surveys to measure change in the maternal mortality ratio (MMR) and from these and six Bangladesh Demographic and Health Surveys to measure changes in factors potentially related to such change. We estimate the changes in risk of maternal death between the two surveys using Poisson regression. Findings The MMR fell from 322 deaths per 100 000 livebirths (95% CI 253–391) in 1998–2001 to 194 deaths per 100 000 livebirths (149–238) in 2007–10, an annual rate of decrease of 5·6%. This decrease rate is slightly higher than that required (5·5%) to achieve the MDG target between 1990 and 2015. The key contribution to this decrease was a drop in mortality risk mainly due to improved access to and use of health facilities. Additionally, a number of favourable changes occurred during this period: fertility decreased and the proportion of births associated with high risk to the mother fell; income per head increased sharply and the poverty rate fell; and the education levels of women of reproductive age improved substantially. We estimate that 52% of maternal deaths that would have occurred in 2010 in view of 2001 rates were averted because of decreases in fertility and risk of maternal death. Interpretation The decrease in MMR in Bangladesh seems to have been the result of factors both within and outside the health sector. This finding holds important lessons for other countries as the world discusses and decides on the post-MDG goals and strategies. For Bangladesh, this case study provides a strong rationale for the pursuit of a broader developmental agenda alongside increased and accelerated investments in improving access to and quality of public and private health-care facilities providing maternal health in Bangladesh. Funding United States Agency for International Development, UK Department for International Development, Bill & Melinda Gates Foundation.

Bangladesh is committed to achieving universal health coverage (UHC) by 2032; to this end, the government of Bangladesh is exploring policy options to increase fiscal space for health and expand coverage while improving service quality and availability. Despite Bangladesh’s impressive strides in improving its economic and social development outcomes, the government still confronts health financing and service delivery challenges. In its review of the health system, this study highlights the limited fiscal space for implementing UHC in Bangladesh, particularly given low public spending for health and high out-of-pocket expenditure. The crisis in the country’s human resources for health (HRH) compounds public health service delivery inefficiencies. As the government explores options to finance its UHC plan, it must recognize that reform of its service delivery system with particular focus on HRH has to be the centerpiece of any policy initiative.