Barriers to health care access for sanitation workers in five municipalities of Bangladesh: an evaluation of Shasthya Nirapotta Scheme using multinomial logistic regression approach

Sanitation workers in Bangladesh face significant social, economic and institutional barriers to access healthcare facilities, despite their significant contributions to public health and urban sanitation. This study evaluates the effectiveness of a health care initiative targeting sanitation workers, the Shasthya Nirapotta Scheme (SNS), by identifying factors that influence its frequency of utilization. A cross-sectional quantitative study was conducted among 155 sanitation workers in five municipalities using structured questionnaire. Bivariate analyses identified candidate variables associated with SNS utilization frequency, which were subsequently included in a multinomial logistic regression model. Model assumptions were verified, including the absence of multicollinearity (VIF < 2) and satisfactory goodness-of-fit. Multiple factors were significantly associated with frequent SNS utilization. Compared with females, male workers were less likely to use services “sometimes” (AOR = 0.28, 95% CI: 0.09–0.82, p = 0.021). The absence of social discrimination increased the odds of frequent use more than eightfold (AOR = 8.36, 95% CI: 1.98–35.15, p = 0.004). Perceiving the premium as affordable was strongly predictive of frequent utilization (AOR = 13.75, 95% CI: 3.73–50.68, p < 0.001). A lack of administrative bottlenecks (AOR = 24.21, 95% CI: 5.96–98.27, p < 0.001), proximity of health facilities (AOR = 15.57, 95% CI: 3.87–62.69, p < 0.001), and negligible travel time (AOR = 9.61, 95% CI: 2.57–35.88, p < 0.001) were also strong predictors of frequent use. The findings reveals that beyond financial constraints, sociocultural stigma, bureaucratic inefficiencies and spatial exclusion critically shape healthcare-seeking behavior. This study highlights the urgent need for integrated policy interventions that go beyond infrastructure and affordability—emphasizing dignity, accessibility, and institutional inclusion—to ensure equitable healthcare access for sanitation workers.