DIGITAL HEALTH ADOPTION IS ASSOCIATED WITH BETTER HEALTHCARE PERFORMANCE BUT PERSISTENT INEQUITY IN BANGLADESH: A NATIONWIDE CONVERGENT MIXED-METHODS STRUCTURAL EQUATION MODELLING STUDY

Background: Bangladesh is scaling digital health under its Digital Health Strategy 2023–2027, yet empirical evidence on how adoption relates to health-system performance and equity is fragmented. We examined how governance, change management and implementation barriers shape digitalization adoption, and how adoption relates to performance, patient-reported outcomes and perceived health inequality. Methods: A convergent parallel mixed-methods study was conducted in all eight administrative divisions. A multistage stratified sample of 420 health workers, managers, patients, policymakers and community members completed a validated 74-item instrument covering seven constructs (response rate 94.4%). Confirmatory factor analysis and covariance-based structural equation modelling with 5,000 bootstrap resamples tested the hypothesized model. Thirty key informant interviews and eight focus group discussions were analysed with the framework method and integrated through a joint display. Results: The model fitted the data well (χ²/df = 2.14; CFI = 0.943; TLI = 0.931; RMSEA = 0.052; SRMR = 0.061). Digitalization adoption was associated with higher healthcare performance (β = 0.541, p < 0.001), better patient-reported outcomes (β = 0.463, p < 0.001) and lower perceived inequality (β = −0.318, p < 0.001). Policy and governance quality influenced adoption directly (β = 0.338) and through change management effectiveness (indirect β = 0.159, 95% bias-corrected CI excluding zero). The national digital infrastructure score was 52.7/100 (Dhaka 78.4; Mymensingh 38.9). Female gender (OR 0.48, 95% CI 0.37–0.63), monthly household income below BDT 10,000 (OR 0.38, 0.28–0.51) and rural residence (OR 0.43, 0.33–0.57) independently predicted lower use. Governance was the lowest-rated construct (mean 2.94/5). Conclusions: Digitalization is linked to stronger health-system performance in Bangladesh, but gains depend on governance, deliberate change management and closing gender, income and geographic gaps. Without these, digital health risks benefiting the already advantaged.