Patient and provider perspectives of pluralistic primary care services in urban Bangladesh: a qualitative study

Rapid urbanisation and the growing prevalence of non-communicable diseases (NCDs) present significant challenges for low- and middle-income countries (LMICs). Among these, Dhaka, the densely populated capital of Bangladesh, experiences these pressures more intensely than most. As a result, the city's public primary health care (PHC) services are struggling to meet the increasing health demands of its urban poor. This study, therefore, examines healthcare access and utilisation in Dhaka's urban slums, giving special attention to the contrasting perceptions of service delivery held by healthcare providers and patients regarding NCD care. We used a qualitative case study approach, purposively sampling four NGO clinics and two Government Outdoor Dispensaries (GoDs) as our cases, all of which are accessible to individuals of diverse age groups, genders, and socio-economic backgrounds. For each case, we conducted in-depth interviews with male, female, and hijra patients within the catchment areas. The data collection process took place between December 2022 to August 2023, following the Consolidated Criteria for Reporting Qualitative Research (COREQ) guideline. Results from this study identified key factors influencing healthcare-seeking behaviour at PHC centres for NCDs. These included: (1) Costs and perceptions of cost, (2) Availability and quality of NCD medicines and opening times of facilities, (3) Behaviour of providers and patients, particularly with socially stigmatised groups, (4) Perception of PHC focus on Maternity and Neonatal Child Health (MNCH), and (5) Patient perceptions of NCDs. Despite the increasing prevalence of NCDs, patients face multiple barriers to accessing PHC services. These barriers stem not only from limitations in the services provided but also from patients' perceptions of both NCDs and primary care itself, which significantly influence their health-seeking behaviour. This study advances understanding of barriers to PHC utilisation in Dhaka by revealing how men and hijras are excluded, how restricted facility hours limit working-class men's access, and how social networks can help reduce exclusion. While global frameworks offer valuable guidance, context-specific strategies such as public-private collaboration, inclusive service design and community engagement are necessary to address persistent inequities in PHC access in Dhaka City.