# Implementation challenges for achieving universal health coverage through social health protection scheme: what can we learn from Bangladesh?

## TL;DR

This study explores why a health coverage scheme in Bangladesh failed to reach many poor households, finding issues like poor awareness and service quality.

## Contribution

The study identifies systemic barriers to implementing a social health protection scheme in Bangladesh, offering insights for improving future initiatives.

## Key findings

- Only 16.1% of cardholders utilized health services, indicating low service uptake.
- Beneficiaries had limited awareness of benefits like free diagnostics and referrals.
- Supply-side issues included staff shortages and delays in claim settlements.

## Abstract

In Bangladesh, households experience high out-of-pocket healthcare expenditure, with below-poverty-line population being disproportionately affected. To reduce financial hardship, the government piloted a social health protection scheme targeting poor households in selected sub-districts. This study examined the implementation barriers of the scheme.

A mixed-methods design was applied. Quantitative data were collected through survey of enrolled households (n = 806). The qualitative component comprised KIIs (n = 10) with scheme implementers and healthcare providers, and FGDs (n = 5) with beneficiaries.

Household survey indicated low service utilization (16.1%) among cardholders. Awareness of specific benefits was also limited, with only 19.1 percent aware of free diagnostics and 9.4 percent aware of free referrals. Qualitative findings confirmed these demand-side barriers, highlighting inadequate knowledge of beneficiaries, dissatisfaction with care quality, and negligence in service delivery. Key supply-side challenges included staff shortages, low provider motivation, and delays in claim settlement. The absence of outpatient coverage emerged as a common concern across stakeholders. At the ecosystem level, weak local-level coordination and rigid public financial rules further hindered implementation.

Implementation challenges were largely systemic, reflecting misalignment between program design and operational realities. Addressing these challenges is essential to ensure the success of future initiatives in Bangladesh and comparable settings.