Study design

A qualitative descriptive approach was used to understand the experiences of older citizens in terms of their health condition and health care needs, accessibilities, treatment costs, and related factors [22–25]. The present study employed in-depth interviews (IDIs) that provide a comprehensive summary of events reported directly by older adult individuals. This approach delivers more in-depth and circumstantial evidence while providing a comprehensive summary of events in the usual language of the participants [26]. A total of 27 IDIs were conducted up to data saturation with no refusal.

Study settings & population

This study was conducted in the Tangail district of Bangladesh, where the first ever government-initiated health protection scheme was piloted. Tangail is also nearby to the capital city of Bangladesh where various types of healthcare facilities including tertiarly and specialized healthcare are available. Further, due to minimum-distance and better communications, people can avail the healthcare services from the capital city of Bangladesh. Older citizens or the elderly population are defined as people of sixty years or more, according to the National Policy on Elderly People in Bangladesh [27]. The older citizens residing in this district for a minimum of 1 year were eligible as respondents. For each in-depth interview, one after every 3^rd household was targeted and then if any older citizens were found on that very household, were selected for the interview. Additional probing that provided insights relevant to our study was also used. Repetitions within the data were noted, suggesting that the data reached saturation [28]. After interviewing these participants, the research team were satisfied that thematic saturation was reached and recruitment ceased. Therefore, a total of 27 In-Depth Interviews (IDIs) were conducted where gender distribution was equal. Face-to-face interviews were conducted by trained and experienced interviewers using specific interview guidelines.

Data collection

Considering the convenience and availability of the participants, face-to-face individual in-depth interviews were conducted between January and February 2020. The interviews lasted between 40–60 minutes and were all conducted in Bangla- the country’s local language. The study participants were contacted via in-person visits in their households, and the objectives were described clearly. The household list was collected from the local government of Bangladesh. An interview date was fixed for them, who agreed to participate in the in-depth interview. The interviewers were well trained on the guidelines and had significant experience using qualitative data collection tools. This in-depth guideline was adopted from published qualitative literature based on healthcare utilization and barriers and then finalised considering both cultural and socio-demographic aspects of the Bangladeshi context [29]. Participants were first asked to provide written informed consent to participate, and then verbal consent was recorded at the beginning of the interviews. Each discussion between the participant and interviewer was recorded using an audio recorder with the respondents’ permission. Initially, the questions were broad, according to the guidelines, and later probing was applied to achieve more detailed responses.

Data analysis

A content analysis was conducted to analyse the data. To ensure reliability in analyzing the interviews, researchers independently checked all the interviews. Transcriptions were made from each of the recorded interviews by the interviewers in their native language (Bangla), and the transcripts were read with field notes for an overall understanding. All transcripts were translated into English by a bilingual translator directly involved in the study. Later, the transcriptions and translations were checked twice by other investigators. Next, the transcriptions were structured using the framework method proposed by Gale et al. and categorized the answers into five themes [30]. Thematic analysis was conducted to ensure methodological accuracy and transparency of qualitative data analysis. To carry out a thematic analysis, several phases were followed according to the methodology adopted by Braun and Clarke, which included familiarizing the data, generating initial codes, defining and reviewing themes, and drawing up general interpretations [31]. Data were manually coded according to meaningful statements (issues, highlights, concerns, and accomplishments) about older health-related experiences and then categorized by the team investigators. Contents were compared across codes, and key concepts were recognized where core themes were identified. A qualitative analysis expert cross-checked the themes for common agreement and refined the identified themes. The investigators finally listed specific themes based on the guidelines (S1 Text) and code categories that included participants’ perceptions, personal beliefs, and understanding. Finally, an evaluation of the themes with a re-reading of the interviews was performed to ensure that the participants’ insistence, meaning, and perception were precisely captured. All explications provided by the respondents were categorized into five distinct themes that described the experiences and expectations of older citizens about healthcare accessibilities and the future scope of improvement.

Ethics statement

This study was performed in line with the principles of the Declaration of Helsinki. The research was approved by the institutional review board at Bangladesh Institute of Development Studies, IRB Protocol#: PSD/01/2019.20/03/REF/HSBAECB. Participants were informed in advance that their participation was voluntary and that all information provided would remain confidential. All study participants provided written consent prior to data collection.

Theme 1: Health condition of older people

Participants recounted their experiences during sickness, describing diverse individual illnesses and varied patterns of disease symptoms presenting throughout the body. Almost all of the respondents mentioned that their health condition was abysmal. The majority of the respondents reported that they had been suffering from several diseases such as a benign tumor, chronic kidney disease, body aches, and gastric ulcer for a long time. Some of them stated that they could not even walk or participate in regular work. Most participants suffered from multiple non-communicable diseases (NCDs), while diabetes and hypertension were the foremost of all diseases. The health condition of older people was so fragile that some of them were not in ambulatory condition. Eye infections, benign tumors, chronic kidney disease, body aches, and gastric ulcers were some major causes of illness. One-third of them had been suffering from those diseases for over 10 years. One male respondent aged (64) stated, “My health condition is declining as my heart is weak, the bulb is damaged and there is a hole in my rectum. Though I had an operation 35 years ago, there is no sign of improvement yet.” Most of the respondents explained their miserable health condition by stating that they had been suffering from such a devastating illness for a long time. Indeed, some came to know about their diseases after a major clinical operation (e.g. tumor, eye diseases, and diabetes) and even after experiencing a stroke. Consequently, they are now living with continuous medication which is often unaffordable and are worried about future medication in this regard. One older respondent (68) expressed, “I have high blood pressure, gastric ulcers, and pains in a different organ. A long time ago, maybe 2 years or more, I had a stroke but I had no sense at that time. Since then, I have been on medication and I have to carry on till death.” The other respondents (69) stated, “Many of my friends and relatives are suffering from hypertension and diabetes and some of them advised me to get examined by a physician for diabetes and hypertension, and then the doctors confirmed me about these diseases.” It was almost eight (8) years ago and I am still suffering.”

With ageing, people are more likely to experience multiple health conditions which leads them to seek healthcare services which also differ in several aspects. Thus, our second theme features the pattern of care-seeking behaviour of this group.

Theme 2: Healthcare-seeking pattern

Healthcare-seeking pattern refers to the sequence of remedial actions that individuals undertake to rectify perceived ill health which is essential to provide need-based healthcare delivery, particularly, for the older population, and to make the healthcare system more pro-poor. Almost every respondent was affirmative about the private clinic or hospital when they had been asked about the source of healthcare. Indeed, pharmacies were their first choice due to the convenient and easily approachable nature. A woman (65) replied, “I take my medicines regularly from pharmacies because my doctor advised me to take my medicines regularly, and most of the pharmacies are near to my door.” The other respondent (70) said that “the drug seller is very well known to me and I can trust easily.” Older people prioritized private clinics/hospitals as they believed quality services are available there than any other institutions. Some of them were used to going to the private facilities because their relatives or close persons worked there by which they could avail quality services at a low-cost (at least without doctor fees). One of the older citizens stated (65), “a doctor from Mymensingh Sadar consults with patients in Life Care Hospital (a private hospital). He was one of my relatives and I used to go to him for care. Three months ago, I have consulted with him and he gave me certain medications including antibiotics. He also suggested about going to another doctor of the same private institution for further treatment.” In most of the cases, the private healthcare facilities were either adjacent to their houses or at the center of their city where they can easily go with existing transportation. One of the respondents (67) replied, “Lack of older-friendly transportation is a big problem for me, as I cannot sit properly with the available transportation and also I have no extra family member who could help me as caregiver.”

Though the majority of the study participants preferred private clinics, they often visited district public hospitals for regular checkups for chronic diseases like diabetes, asthma, heart diseases, eye operation, and kidney operation as public hospitals are highly subsidized in Bangladesh. Indeed, we observed that the participants choose district public hospitals when it comes to an emergency situation. Very few numbers of them went to Dhaka, the capital of Bangladesh for consulting specialized doctors and for better care. On the other hand, the participants were often unwilling to visit sub-district level public hospitals due to the lack of medical personnel and medical technologies. Nevertheless, very few of them visited these places and had to buy medicines from the pharmacy or other sources due to the scarcity of medicines in those facilities. A statement from a respondent (70), “at first I went to Modhupur Hospital (sub-district level hospital) for treating asthma-related problems, but that wasn’t solved. That’s why, I visited Mymensingh Sadar Hospital (a district-level public hospital), about 8–9 years ago. They prescribed me several medicines after several lab tests and diagnoses. Now my disease is under control to some extent. But, when I stop taking medicine, it further comes out.”

Indeed, the distance and the availability of healthcare facilities plays a significant role behind the care-seeking pattern. However, people visits the healthcare centres with expectations to get quality services at an affordable cost. So, we tried to seek for the answers regarding this issue which has been depicted in the next theme.

Theme 3: Expectations from the health facilities

People usually choose a healthcare facility for their convenience or better quality service which is also cost-effective from a household perspective. The easy and accessible transportation system, amenities, quality service, availability, and accessibility of healthcare are the prerequisites of healthcare services. The majority of our respondents sought healthcare from the private clinics/hospitals because they believed that they could get at least quality healthcare services although there was a very higher treatment cost in the private clinics/hospitals. The quality of services and associated amenities were not satisfactory in sub-district level hospitals according to their observation, therefore, they often sought care at district level hospitals and even shift to private hospitals. A respondent (65) replied, “I normally sought care from a private clinic because in nearby Modhupur Hospital (a sub-district level hospital) there were no services and scope of my treatment (e.g. diabetes). Therefore, the authority suggested me visit a private clinic. However, that particular private clinic suggested me to admit to the Tangail Diabetic Hospital (a specialized diabetes hospital).” The older citizens often sought healthcare from the nearest facilities which they could reach easily with the least cost and time. Moreover, sometimes it cost more than expected if the distance of the healthcare facilities were relatively longer. One-third of the respondents preached that financial issues were the main obstacles to their treatment care. A respondent (67) stated, “I prefer health facilities (private clinic) that are adjacent to my house. However, when I visited a nearby sub-district level hospital, I found nobody was there; not any nurse or even no doctor was there. My time and money both were wasted. As I have to spend my money whether I sought care from either private or public hospital, therefore, nearby private facilities are a better call for me.” Another respondent (64) told us, “I have a relative doctor in a private clinic who doesn’t accept any consultation fees from me. Moreover, if I have to diagnose anything, he manages discounts for me. Most of all, waiting time is very little in there.”

Overall, the environment and the facilities of the health centers were not satisfactory even for the private clinics. However, some private clinics had the practice of maintaining cleanliness and better quality. Public hospitals like Upazila Health Complex (sub-district level) lagged behind in these contexts. Most of the respondents replied that the medicine ward was not clean at all and the toilets and floors were not washed daily. Moreover, there were no sufficient seats for the patients, and doctors hardly visit patients. Sometimes the caregivers and the attendants had to take shelter on the floor, and special care for older patients is unavailable.

Theme 4: Out-of-pocket (OOP) cost—a barrier to healthcare

In Bangladesh, the high cost of medical expenses creates a significant barrier while seeking care. As a result, we wanted to highlight this burning issue and incorporated it as one of our core themes. OOP expenditure includes any payment related to medical fees, purchase of medicines (prescribed or not), user fees for care, and payments for equipment and diagnostic tests [32]. Out-of-pocket cost is generally higher for older people because morbidity complications are higher for older people compared to others. Sometimes the price of drugs becomes excessively high for them. One of them (68) replied, “From the pharmacy, I came to know the price of my drugs is too high, therefore I have purchased only half of the listed medicine and I need to wait for further arrangement of money.” In a public hospital, the treatment cost is often shared with households as public hospitals are highly subsidized in Bangladesh. However, all treatment costs are incurred by households if someone seeks care from private facilities. Some of the respondents replied that they could not seek care from a specialized doctor because of the high consultation fee which was unaffordable for them. Every time they visited the private facilities, they had to spend at least Bangladeshi Taka (BDT) 500–700 as consultation fees. Indeed, they also had to spend on other categories like medicines, diagnostic tests, hospital charges, bed fees, etc., which appeared to be a high financial burden for them. Most of the time, the older people did not go to the hospital or take any services if the cost were high. Whether it is a public or private hospital, the in-patient cost is pretty similar for both. Indeed, various surgery-related cost was higher in private facilities, which often becomes a catastrophic health burden for them. One of the respondents stated (68), “The treatment cost is relatively higher where I usually visit for my health-related problems. I had to spend forty thousand BDT for only five days when I had a medical operation.” Another respondent (66) stated, “Sometimes I face financial catastrophes. Sometimes I just restrain myself from going to the doctor as my family is very needy. Once I was suffering from a cataract but couldn’t receive the treatment due to financial constraints.”

OOP healthcare expense often absorbs a large proportion of the total household budget which can lead to catastrophic health expenditure (CHE). In many cases, people are forced to cut their total household consumption or, to take out loans, or to take financial help from others just to meet these health expenses which are considered as the major coping mechanisms.

Theme 5. Coping strategies for the healthcare expenditure

Various coping strategies were observed for mitigating healthcare expenditure. During the in-person interviews, we found that the older citizens mainly met their healthcare expenditure through family funds, financial support from other family members or friends, borrowing, support from others, and even selling assets. One of them (67) replied, “Most of the time, my younger son transferred money using the mobile app and then I got to purchase the medicines from pharmacies.” The other respondent (69) stated, “I received money from my elder daughter whenever I became sick.” Two-thirds of the older people reported having financial difficulties during healthcare payments. Indeed, some people had to take loans and bear the debt burden for longer. Some of them worked in other people’s homes to pay the debt. Meanwhile, a few of them could not seek medical care due to financial constraints. Even if they had managed medical care, they could not buy medicines and administer them properly. Further, some older citizens solely rely on their children’s wealth. For this reason, they sometimes had to wait longer for their children’s compliance. A respondent, aged 71, stated that “I have huge financial problems. I have to go to Upazila Health Complexes by rickshaw. After buying a ticket by Bangladeshi taka 5, I have to take medicine from outside the hospital. For mitigating treatment costs, I had to borrow three lac Bangladeshi taka from the bank. Now I am repaying the money by working in other’s houses which is difficult for me.”

This study tried to capture important suggestions from older citizens regarding healthcare management and treatment care in public hospitals. However, two-thirds of the respondents mentioned various issues related to the hospital management and other support systems; such as the need for separate and furnished waiting rooms where they could easily sit down, ensuring availability of health personnel including physicians, nurses for older care, 24/7 hospital services, robust referral systems, quality healthcare services, older-friendly accessibilities. They also strongly advised on improving the cleanliness of the facilities and ensuring the availability of medical equipment for investigations in public hospitals as they can’t afford many diagnostic tests in private sectors. One of the respondents, aged 68, stated, “In hospitals, it would be better if we get healthcare services in the separate chamber/ segments where only older patient would be treated; such as establishing an older friendly health unit where an older citizen would go and get treatment faster than other age groups. Currently, many hospitals have insufficient doctors, and nurses than needed, so the number of doctors and nurses has to be increased and those who are already recruited have to do their duty properly. Doctor visit fees should be further reduced, and the government should be strict about it. The price of the drug should be written on the packet. Poor people should be given a card with which they can get a 50% discount on drugs and free medicines from the government hospital. People are not getting exactly what the government is providing; they need to be monitored.”

Conclusion

With the increase in older people, the health burden is also on the rise, but still there is inadequate data on health care seeking experiences of older population in Bangladesh. There must be strategic implementation of policies focusing on the barriers and shortfalls, which prevent them from seeking health care. This study has documented the experiences of older people regarding healthcare-seeking and accessibility, affordability, and healthcare coping strategy. The study findings suggest that the improvement to older-friendly health infrastructure is necessary and universal pension schemes and social health protection schemes should be introduced to improve the health of older citizens in Bangladesh.