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Wearable sensor-based systems and devices have been expanded in different application domains, especially in the healthcare arena. Automatic age and gender estimation has several important applications. Gait has been demonstrated as a profound motion cue for various applications. A gait-based age and gender estimation challenge was launched in the 12th IAPR International Conference on Biometrics (ICB), 2019. In this competition, 18 teams initially registered from 14 countries. The goal of this challenge was to find some smart approaches to deal with age and gender estimation from sensor-based gait data. For this purpose, we employed a large wearable sensor-based gait dataset, which has 745 subjects (357 females and 388 males), from 2 to 78 years old in the training dataset; and 58 subjects (19 females and 39 males) in the test dataset. It has several walking patterns. The gait data sequences were collected from three IMUZ sensors, which were placed on waist-belt or at the top of a backpack. There were 67 solutions from ten teams—for age and gender estimation. This paper extensively analyzes the methods and achieved-results from various approaches. Based on analysis, we found that deep learning-based solutions lead the competitions compared with conventional handcrafted methods. We found that the best result achieved 24.23% prediction error for gender estimation, and 5.39 mean absolute error for age estimation by employing angle embedded gait dynamic image and temporal convolution network.

Background: On January 30, 2020, WHO declared COVID-19 as a Global Public Health Emergency. The first three COVID-19 cases in Bangladesh were confirmed on March 8, 2020. Thus, Bangladesh got substantial time to prepare the people and the health systems to respond to the outbreak However, neither the health ministry nor the government was found to rise to the occasion and provide the necessary stewardship for a coordinated and comprehensive response. Objective: The importance of governance to mount an evidence-based pandemic response cannot be overemphasised. This study presents critical reflections on the Bangladesh government's COVID-19 response through a review of selected papers, with expert deliberations on the review findings to consolidate emerging lessons for future pandemic preparedness. Study design: A scoping review approach was taken for this study. Methods: Documents focusing on COVID-19 governance were selected from a repository of peer-reviewed articles published by researchers using data from Bangladesh (n = 11). Results: Findings reveal Bangladesh's COVID-19 response to be delayed, slow, and ambiguous, reflecting poorly on its governance. Lack of governance capability in screening for COVID-19, instituting quarantine and lockdown measures in the early weeks, safety and security of frontline healthcare providers, timely and equitable COVID-19 testing, and logistics and procurement were phenomenal. The pandemic unmasked the weaknesses of the health system in this regard and “created new opportunities for corruption.” The failure to harmonise coordination among the government's different agencies for the COVID-19 response, along with poor risk communication, which was not culture-sensitive and context-specific. Over time, the government initiated necessary actions to mitigate the pandemic's impact on the lives and livelihoods of the people. Diagnostic and case management services gained strength after some initial faltering; however, the stewardship functions were not seamless. Conclusions: Shortage of healthcare workers, incapability of health facilities to cater to COVID-19 suspects and cases, absence of health system resilience, and corruption in procurement and purchases were limited the government's COVID-19 response. These need urgent attention from policymakers to better prepare for the next epidemic/pandemic.

Summary: Background: Chronic cough is a common respiratory symptom with an impact on daily activities and quality of life. Global prevalence data are scarce and derive mainly from European and Asian countries and studies with outcomes other than chronic cough. In this study, we aimed to estimate the prevalence of chronic cough across a large number of study sites as well as to identify its main risk factors using a standardised protocol and definition. Methods: We analysed cross-sectional data from 33,983 adults (≥40 years), recruited between Jan 2, 2003 and Dec 26, 2016, in 41 sites (34 countries) from the Burden of Obstructive Lung Disease (BOLD) study. We estimated the prevalence of chronic cough for each site accounting for sampling design. To identify risk factors, we conducted multivariable logistic regression analysis within each site and then pooled estimates using random-effects meta-analysis. We also calculated the population attributable risk (PAR) associated with each of the identifed risk factors. Findings: The prevalence of chronic cough varied from 3% in India (rural Pune) to 24% in the United States of America (Lexington,KY). Chronic cough was more common among females, both current and passive smokers, those working in a dusty job, those with a history of tuberculosis, those who were obese, those with a low level of education and those with hypertension or airflow limitation. The most influential risk factors were current smoking and working in a dusty job. Interpretation: Our findings suggested that the prevalence of chronic cough varies widely across sites in different world regions. Cigarette smoking and exposure to dust in the workplace are its major risk factors. Funding: Wellcome Trust.

Absenteeism by doctors in public healthcare facilities in rural Bangladesh is a form of chronic rule-breaking and is recognised as a critical problem by the government. We explored the factors underlying this phenomenon from doctors' perspectives. We conducted a facility-based cross-sectional survey in four government hospitals in Dhaka, Bangladesh. Junior doctors with experience in rural postings were interviewed to collect data on socio-demographic characteristics, work and living experience at the rural facilities, and associations with professional and social networks. Multiple logistic regression was used to determine the factors associated with rural retention. Of 308 respondents, 74% reported having served each term of their rural postings without interruptions. The main reasons for absenteeism reported by those who interrupted rural postings were formal training opportunities (65%), family commitments (41%), and a miscellaneous group of others (17%). Almost half of the respondents reported unmanageable workloads. Most (96%) faced challenges in their last rural posting, such as physically unsafe environments (70%), verbally abusive behaviour by patients/caregivers (67%) and absenteeism by colleagues that impacted them (48%). Respondents who did not serve their entire rural posting were less likely to report an unmanageable workload than respondents who did (AOR 0.39, 95% CI 0.22-0.70). Respondents with connections to influential people in the local community had a 2.4 times higher chance of serving in rural facilities without interruption than others (AOR 2.40, 95% CI 1.26-4.57). Our findings demonstrate that absenteeism is not universal and depends upon doctors' socio-political networks. Policy interventions rarely target unsupportive or threatening behaviour by caregivers and community members, a pivotal disincentive to doctors' willingness to work in underserved rural areas. Policy responses must promote opportunities for doctors with weak networks who are willing to attend work with appropriate support.

Objective: This paper aimed to identify and explore the major areas of health-sector corruption during COVID-19 pandemic as revealed in the print media. Findings are expected to mitigate health sector corruption in the country and contribute to strengthening the health systems. Method: 2588 news articles on health topics were identified through scanning six leading newspapers in Bangladesh during Mar. 2020 to Mar. 2021. Of these, 97 news articles focusing on corruption in health system were selected for analysis. Findings: Findings reveal an all-embracing corruption at every stage, starting from procurement of medical supplies, to testing for COVID-19 to treatment and management of COVID-19 cases. The news papers reported about the low quality and general-purpose masks given to the frontline health workers, putting their personal protection from the virus at risk. Due to lack of stewardship and an effective monitoring system, quite a few private facilities were providing fake COVID-19 certificates, medicines and medical equipment at very high prices. For example, one particular hospital provided almost two thousand COVID-19 test certificates without testing. Although PPEs were originally sold at BDT 2000 per piece, double the amount was proposed for buying PPEs. Meropenem injection of the same quality was purchased by different government hospitals at unusually high prices. Among the measures taken to contain corruption during COVID-19 included filing cases, issuing arrest warrants and asking for submission of wealth statement and source of income of the accused persons. However, some of the accused eventually got released on bail. Conclusion: The media, as a mirror of the society, successfully made visible the underhand corruption that was happening even during the pandemic, fulfilling its obligations to the society. They faced quite some challenges in revealing related news, especially from the government whose initial reaction was of denial and indifference.Due to lack of transparency and accountability in the sector, the patients as well as the healthcare providers had to suffer a lot.

Objective Bangladesh is currently undergoing an epidemic of road traffic crashes (RTCs). In addition to morbidity and mortality, the economic loss from RTC as per cent of gross domestic product is comparatively higher than in countries with similar socioeconomic conditions. However, trauma care remained poorly developed as a specialty and service delivery mechanism. This study aimed to examine the current situation of in-hospital trauma care after RTCs to inform the design of a comprehensive service for Bangladesh.Design, setting and participants This qualitative study attempted to elicit stakeholders’ perceptions and experiences of managing RTCs through in-depth interviews and focus group discussions. Three districts and Dhaka city were selected based on the frequency of occurrence of RTCs. Fifteen in-depth interviews and 5 focus group discussions were conducted with 38 RTC patients, their relatives and community members in the catchment areas of 11 facilities managing trauma patients. Key informant interviews were conducted with 21 service providers and 17 key stakeholders/policy-makers.Results Hospital-based trauma care was generally poor in primary and secondary-level facilities. There was no triage area or triage protocol in the emergency rooms, no trained staff for trauma care, no dedicated RTC patient register and scarce life-saving equipment. Only in Dhaka-based tertiary hospitals was trauma care prioritised. These hospitals follow Advanced Trauma Life Support guidelines and maintain an RTC logbook. Emergency diagnostic services were not always available in the hospitals. Most RTC patients were males; the female participants were additionally vulnerable to physical and mental trauma. Affected people avoided taking legal action considering it a lengthy, complicated and ultimately ineffective process.Conclusion The trauma care services currently available in the studied health facilities are very rudimentary and without the necessary human and financial resources. This needs urgent attention from policymakers, programmers and practitioners to reduce morbidity and mortality from the current epidemic of RTCs in Bangladesh.

Despite considerable investment by the Bangladesh government in measures to strengthen accountability and transparency, absenteeism among doctors remains a barrier to the achievement of Universal Health Coverage. Recent innovations in anti-corruption theory point to the importance of acting on the structural drivers of absenteeism and argue for approaches that are better able to take local and national level context into account. In this qualitative study, we sought to understand the socio-economic and political structures that drive absenteeism among junior doctors in rural health facilities in Bangladesh. We conducted 30 purposively sampled, in-depth interviews with doctors in three divisions of the Bangladesh Health system, (Sylhet, Barishal and Dhaka) the majority of whom worked in medical college hospitals and sub-district facilities. The data was analysed using both theory and data driven thematic analysis. The results explore the ways in which poor local social relations and working conditions, and threats to career progression drove junior doctors to seek ways to leave rural facilities. Their absence was facilitated by weak regulatory mechanisms, bribery, and socio-political networks. These findings reveal how doctors’ absenteeism can be traced to structural issues in the health system and socio-political networks that shape access to resource more widely in Bangladesh. Providers with power and access to networks can be absent for longer periods, overburdening and de-motivating their colleagues who lack connections and thus remain in post. While little can be done about longstanding features of Bangladeshi society, those in authority in the health system can take measures to address existing problems in the weak infrastructure and work environment, including measures for career progression. These are expected to support collective action by the doctors who are unable to make use of powerful social and political networks.

Summary: Universal Health Coverage (UHC) and Global Health Security (GHS) activities encompass mitigation of risks to health and well-being rights posed by infectious disease outbreaks and facilitated by health promotion (HP) activities. This case study investigated Bangladesh's readiness and capacity to ‘prevent, detect and respond’ to such outbreaks of an epidemic/pandemic nature. A rapid review of relevant documents, key informant interviews with policymakers/practitioners, and a deliberative dialogue with a crisscross of stakeholders were used to identify challenges and opportunities for ‘synergy’ among these streams of activities. Findings reveal conceptual ambiguity among respondents about the scope of the three `agendas and their inter-linkages. They perceived the synergy between UHC and GHS superfluous and were obsessed with losing their respective constituencies and resources. Poor coordination among the focal agencies in field activities, lack of supporting infrastructure, and shortage of human and financial resources posed additional challenges for better pandemic/epidemic preparation in future. Funding: This study, “Researching the UHC-GHS-HP Triangle in Bangladesh,” was funded by the Wellcome Trust, UK

Background: The news media play a critical role in disseminating accurate and reliable information during an outbreak like COVID-19, especially in LMICs. Studying how people react and reflect on the information provided and how it affects their trust in health systems is essential for effective risk communication. This study was undertaken to explore and analyse newspaper readers’ reactions to the unfolding news of the COVID-19 outbreak in Bangladesh and how this affected and shaped their compliance with the mitigation measures advised by the Government. Methods: We collected readers’ comments on relevant news and features on the COVID-19 outbreak (n = 1,055) which were posted in the online versions of the four top circulating Bangla newspapers and one online news portal published during Jan.–Apr. 2020. A search protocol was developed and a team of three researchers searched and extracted data for content analysis according to some pre-determined study themes. Results: Data analysis revealed several characteristics with implications for risk-communication: a faith-based and fatalistic attitude to the unfolding pandemic, a “denial” syndrome in the initial stage, a returning expatriate-bashing for specific countries, and a concern about the safety of the frontline health workers. The readers were resentful of the all-pervasive corruption in the health sector even in times of a pandemic and the Government's poorly coordinated, fragmented, and delayed COVID-19 response. The pandemic severely shook their trust in the already weak health system and perceived it to be incompetent, corrupt, and non-responsive. They had deplorable personal and family experiences while seeking treatment for COVID-19 patients. Expert committees were formed to advise the Government, but few recommendations were implemented on the ground. This helpless scenario made people sharply critical of the political leadership, especially for the failure of providing stewardship at the moment of crisis. Conclusions: The COVID-19 related information reaching the people, including misinformation, disinformation, and rumours was equivocal in the early months of the pandemic and failed to build the trust and transparency that is necessary for an inclusive response across constituencies. The Government should pay attention and weightage to people's perceptions about its COVID-19 response and take appropriate measures to re-build trust for implementing pandemic control measures.

Objective Doctor absenteeism is widespread in Bangladesh, and the perspectives of the actors involved are insufficiently understood. This paper sought to elicit preferences of doctors over aspects of jobs in rural areas in Bangladesh that can help to inform the development of packages of policy interventions that may persuade them to stay at their posts.Methods We conducted a discrete choice experiment with 308 doctors across four hospitals in Dhaka, Bangladesh. Four attributes of rural postings were included based on a literature review, qualitative research and a consensus-building workshop with policymakers and key health-system stakeholders: relationship with the community, security measures, attendance-based policies and incentive payments. Respondents’ choices were analysed with mixed multinomial logistic and latent class models and were used to simulate the likely uptake of jobs under different policy packages.Results All attributes significantly impacted doctor choices (p

Abstract Background How the informal providers deliver health services are not well understood in Bangladesh. However, their practices are often considered inappropriate and unsafe. This study attempted to fill-in this knowledge gap by exploring their perceptions about diagnosis and appropriate treatment, as well as identifying existing barriers to provide appropriate treatment. Methods This exploratory study was conducted in two peri-urban areas of metropolitan Dhaka. Study participants were selected purposively, and an interview guideline was used to collect in-depth data from thirteen providers. Content analysis was applied through data immersion and themes identification, including coding and sub-coding, as well as data display matrix creation to draw conclusion. Results The providers relied mainly on the history and presenting symptoms for diagnosis. Information and guidelines provided by the pharmaceutical representatives were important aids in their diagnosis and treatment decision making. Lack of training, diagnostic tools and medicine, along with consumer demands for certain medicine i.e. antibiotics, were cited as barriers to deliver appropriate care. Effective and supportive supervision, training, patient education, and availability of diagnostics and guidelines in Bangla were considered necessary in overcoming these barriers. Conclusion Informal providers lack the knowledge and skills for delivering appropriate treatment and care. As they provide health services for substantial proportion of the population, it’s crucial that policy makers become cognizant of the fact and take measures to remedy them. This is even more urgent if government’s goal to reach universal health coverage by 2030 is to be achieved.

In 2008, Vian reported an increasing interest in understanding how corruption affects healthcare outcomes and asked what could be done to combat corruption in the health sector. Eleven years later, corruption is seen as a heterogeneous mix of activity, extensive and expensive in terms of loss of productivity, increasing inequity and costs, but with few examples of programmes that have successfully tackled corruption in low-income or middle-income countries. The commitment, by multilateral organisations and many governments to the Sustainable Development Goals and Universal Health Coverage has renewed an interest to find ways to tackle corruption within health systems. These efforts must, however, begin with a critical assessment of the existing theoretical models and approaches that have underpinned action in the health sector in the past and an assessment of the potential of innovations from anticorruption work developed in sectors other than health. To that end, this paper maps the key debates and theoretical frameworks that have dominated research on corruption in health. It examines their limitations, the blind spots that they create in terms of the questions asked, and the capacity for research to take account of contextual factors that drive practice. It draws on new work from heterodox economics which seeks to target anticorruption interventions at practices that have high impact and which are politically and economically feasible to address. We consider how such approaches can be adopted into health systems and what new questions need to be addressed by researchers to support the development of sustainable solutions to corruption. We present a short case study from Bangladesh to show how such an approach reveals new perspectives on actors and drivers of corruption practice. We conclude by considering the most important areas for research and policy.

This study explored the current situation of the National Action Plan (NAP) on Antimicrobial Resistance (AMR) implementation in Bangladesh and examined how different sectors (human, animal, and environment) addressed the AMR problem in policy and practice, as well as associated challenges and barriers to identifying policy lessons and practices. Informed by a rapid review of the available literature and following the World Health Organization (WHO) AMR situation analysis framework, a guideline was developed to conduct in-depth interviews with selected stakeholders from January to December 2021. Data were analysed using an adapted version of Anderson’s governance framework. Findings reveal the absence of required inter-sectoral coordination essential to a multisectoral approach. There was substantial coordination between the human health and livestock/fisheries sectors, but the environment sector was conspicuously absent. The government initiated some hospital-based awareness programs and surveillance activities, yet no national Monitoring and Evaluation (M&E) framework was established for NAP activities. Progress of implementation was slow, constrained by the shortage of a trained health workforce and financial resources, as well as the COVID-19 pandemic. To summarise, five years into the development of the NAP in Bangladesh, its implementation is not up to the level that the urgency of the situation requires. The policy and practice need to be cognisant of this fact and do the needful things to avoid a catastrophe.

Objective This study explored the illness experiences and healthcare-seeking behaviour of a cross-section of street dwellers of Dhaka City for designing a customised intervention.Design A qualitative exploratory study of a sample of street dwellers of Dhaka City.Setting Samples were taken from three purposively selected spots of Dhaka City with a high concentration of the target population.Participants Fifteen in-depth interviews and six informal group discussions with 40 street dwellers (≥18 years), and key informant interviews with service providers (n=6) and policymakers (n=3) were conducted during January–June 2019 to elicit necessary data.Primary outcome measures Qualitative narrative of illness experiences of the sampled street dwellers, relevant healthcare-seeking behaviour and experiences of interactions with health systems.Results We focused on three main themes, namely, reported illnesses, relevant healthcare-seeking behaviour and health system experiences of the street dwellers. Findings reveal that most of the street dwellers suffered from fever and respiratory illnesses in the last 6 months; however, a majority did not visit formal facilities. They preferred visiting retail drug shops for advice and treatment or waited for self-recovery. Formal facilities were visited only when treatment from drug shops failed to cure them or they suffered serious illnesses or traumatic injury. The reproductive-age women did not seek pregnancy care and most deliveries took place in the street dwellings. Lack of awareness, financial constraints and fear of visiting formal facilities were some of the reasons mentioned. Those who visited formal facilities faced barriers like the cost of medicines and diagnostic tests, long waiting time and opportunity cost.Conclusions The street dwellers lacked access to formal health systems for needed services as the latter lags far behind to outreach this extremely vulnerable population. What they need is explicit targeting with a customised package of services based on their illness profile, at a time and place convenient to them with minimum or no cost implications.

BACKGROUND:Antimicrobial resistance (AMR) has become an emerging issue in the developing countries as well as in Bangladesh. AMR is aggravated by irrational use of antimicrobials in a largely unregulated pluralistic health system. This review presents a 'snap shot' of the current situation including existing policies and practices to address AMR, and the challenges and barriers associated with their implementation. METHODS:A systematic approach was adopted for identifying, screening, and selecting relevant literature on AMR situation in Bangladesh. We used Google Scholar, Pubmed, and Biomed Central databases for searching peer-reviewed literature in human, animal and environment sectors during January 2010-August 2019, and Google for grey materials from the institutional and journal websites. Two members of the study team independently reviewed these documents for inclusion in the analysis. We used a 'mixed studies review' method for synthesizing evidences from different studies. RESULT:Of the final 47 articles, 35 were primary research, nine laboratory-based research, two review papers and one situation analysis report. Nineteen articles on human health dealt with prescribing and/or use of antimicrobials, five on self-medication, two on non-compliance of dosage, and 10 on the sensitivity and resistance patterns of antibiotics. Four papers focused on the use of antimicrobials in food animals and seven on environmental contamination. Findings reveal widespread availability of antimicrobials without prescription in the country including rise in its irrational use across sectors and consequent contamination of environment and spread of resistance. The development and transmission of AMR is deep-rooted in various supply and demand side factors. Implementation of existing policies and strategies remains a challenge due to poor awareness, inadequate resources and absence of national surveillance. CONCLUSION:AMR is a multi-dimensional problem involving different sectors, disciplines and stakeholders requiring a One Health comprehensive approach for containment.

Background Retaining doctors in rural areas is a challenge in Bangladesh. In this study, we analyzed three rural retention policies: career development programs, compulsory services, and schools outside major cities – in terms of context, contents, actors, and processes. Methods Series of group discussions between policy-makers and researchers prompted the selection of policy areas, which were analyzed using the policy triangle framework. We conducted document and literature reviews (1971-2013), key informant interviews (KIIs) with relevant policy elites (n = 11), and stakeholder analysis/position-mapping. Results In policy-1, we found, applicants with relevant expertise were not leveraged in recruitment, promotions were often late and contingent on post-graduation. Career tracks were porous and unplanned: people without necessary expertise or experience were deployed to high positions by lateral migration from unrelated career tracks or ministries, as opposed to vertical promotion. Promotions were often politically motivated. In policy-2, females were not ensured to stay with their spouse in rural areas, health bureaucrats working at district and sub-district levels relaxed their monitoring for personal gain or political pressure. Impractical rural posts were allegedly created to graft money from applicants in exchange for recruitment assurance. Compulsory service was often waived for political affiliates. In policy-3, we found an absence of clear policy documents obligating establishment of medical colleges in rural areas. These were established based on political consideration (public sector) or profit motives (private sector). Conclusion Four cross-cutting themes were identified: lack of proper systems or policies, vested interest or corruption, undue political influence, and imbalanced power and position of some stakeholders. Based on findings, we recommend, in policy-1, applicants with relevant expertise to be recruited; recruitment should be quick, customized, and transparent; career tracks (General Health Service, Medical Teaching, Health Administration) must be clearly defined, distinct, and respected. In policy-2, facilities must be ensured prior to postings, female doctors should be prioritized to stay with the spouse, field bureaucrats should receive non-practising allowance in exchange of strict monitoring, and no political interference in compulsory service is assured. In policy-3, specific policy guidelines should be developed to establish rural medical colleges. Political commitment is a key to rural retention of doctors.

Background: Improvement of health workers' performance is vital for the improvement of health-care service delivery, and workload management is an important factor in improving performance. This study aimed to assess the current workload and staffing need for delivering optimum health-care services in the public-sector district health system in Bangladesh. Methods: Between July 2, 2017, and Nov 30, 2017, we followed the steps of WHO's Workload Indicator of Staffing Need (WISN) methodology. We combined qualitative (document reviews, key informant interviews, in-depth interviews, observations) and quantitative methods (time-motion survey), to collect data in 24 health facilities from district hospitals up to community clinics in Jhenaidah and Moulvibazar districts, Bangladesh. The study included physicians, nurses, medical assistants, family welfare visitors, community care providers, and family welfare assistants. Workload components were defined on the basis of inputs from experts (n=5), refined further by actual service providers (n=87). We used WHO WISN software to calculate standard workload, category allowance factor, individual allowance factor, total required number of staff, WISN difference, and WISN ratio. Findings: Seven of the 20 staff categories had a very high workload (WISN ratio 0·30–0·49), and five staff categories had extremely high workload (0·10–0·29) indicating an overall high workload in the service providers studied. Medical consultants had the highest workload (WISN ratio 0·16), followed by other specialists. The staff category with the most number of positions needing to be filled was nurses at district hospitals (a mean of 136 vacant positions per facility), followed by general physicians (35). We noted that nurses were predominantly occupied with support activities (60% in the case of district nurses and 50% in sub-district facilities), instead of actual nursing care. If the vacant posts were filled, the workload for existing workers is reduced. However, simply filling the vacant posts would not be sufficient to reduce staff workload in some staff categories, such as nursing. Interpretation: WISN method of estimating workload and staff requirements can aid policymakers in making the best uses of existing human resources. Thus, WISN should be incorporated as a planning tool for managers at the district level. Implementation research should be carried out on how the workload-based staffing decisions can be effectively integrated into health systems. Funding: WHO Bangladesh.

BackgroundBangladesh is currently faced with an emerging scenario of increased number of female physicians in the health workforce which has health system implications. For a health system to attract and retain female physicians, information is needed regarding their motivation to choose medical profession, real-life challenges encountered in home and workplaces, propensity to choose a few particular specialties, and factors leading to drop-out from the system. This exploratory mixed-methods study attempted to fill-in this knowledge gap and help the policy makers in designing a gender-sensitive health system.MethodsThree-hundred and fifteen final year female medical students from four purposively selected medical colleges of Dhaka city (two each from public and private colleges) were included in a quantitative survey using self-administered questionnaire. Besides, 31 in-depth interviews with female students, their parents, and in-service trainee physicians, and two focus group discussions with female students were conducted. Gender disaggregated data of physicians and admitted students were also collected. Data were analysed using Stata version 13 and thematic analysis method, as appropriate.ResultsDuring 2006-2015, the female physicians outnumbered their male peers (52% vs. 48%), which is also supported by student admission data during 2011-2016 from the sampled medical colleges, (67% in private compared to 52% in public). Majority of the female medical graduates specialized in Obstetrics and Gynaecology (96%). Social status (66%), respect for medical profession (91%), image of a 'noble profession' (91%), and prospects of helping common people (94%) were common motivating factors for them. Gender disparity in work, career and work environment especially in rural areas, and problems of work-home balance, were a few of the challenges mentioned which forced some of them to drop-out. Also, this scenario conditioned them to crowd into a few selected specialties, thereby constraining health system from delivering needed services.ConclusionsIncreasing number of female physicians in health workforce, outnumbering their male peers, is a fact of life for health system of Bangladesh. It's high time that policy makers pay attention to this and take appropriate remedial measures so that women can pursue their career in an enabling environment and serve the needs and priorities of the health system.

Responsiveness entails the social actions by health providers to meet the legitimate expectations of patients. It plays a critical role in ensuring continuity and effectiveness of care within people centered health systems. Given the lack of contextualized research on responsiveness, we qualitatively explored the perceptions of outpatient users and providers regarding what constitute responsiveness in rural Bangladesh. An exploratory study was undertaken in Chuadanga, a southwestern Bangladeshi District, involving in-depth interviews of physicians (n = 17) and users (n = 7), focus group discussions with users (n = 4), and observations of patient provider interactions (three weeks). Analysis was guided by a conceptual framework of responsiveness, which includes friendliness, respecting, informing and guiding, gaining trust and optimizing benefits. In terms of friendliness, patients expected physicians to greet them before starting consultations; even though physicians considered this unusual. Patients also expected physicians to hold social talks during consultations, which was uncommon. With regards to respect patients expected physicians to refrain from disrespecting them in various ways; but also by showing respect explicitly. Patients also had expectations related to informing and guiding: they desired explanation on at least the diagnosis, seriousness of illness, treatment and preventive steps. In gaining trust, patients expected that physicians would refrain from illegal or unethical activities related to patients, e.g., demanding money against free services, bringing patients in own private clinics by brokers (dalals), colluding with diagnostic centers, accepting gifts from pharmaceutical representatives. In terms of optimizing benefits: patients expected that physicians should be financially sensitive and consider individual need of patients. There were multiple dimensions of responsiveness- for some, stakeholders had a consensus; context was an important factor to understand them. This being an exploratory study, further research is recommended to validate the nuances of the findings. It can be a guideline for responsiveness practices, and a tipping point for future research.