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

Background: 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. 

Method: 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. 

Results: 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. 

Conclusion: 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.