Introduction

Urbanization poses challenges in developing nations like Bangladesh, with rapid expansion straining the healthcare system [1]. Bangladesh is experiencing rapid urbanization, with 44% of the country’s population living in urban areas in 2021 compared to 24% in 2001 [2]. This surge in urbanization, coupled with a constant influx of internal migrants and the proliferation of slums in major cities, places continuous pressure on the urban health system [3]. Despite socioeconomic advancements, including poverty reduction, increased women’s education, and enhanced life expectancy [4,5], disparities in healthcare accessibility persist between rural and urban areas. In urban settings, these gaps are largely attributed to a due to a weak and fragmented urban health system [6].

In Bangladesh’s pluralistic health system, primary healthcare (PHC) is the first level of contact between individuals and the health system. PHC includes promotive, preventive, and curative services. Core PHC services include maternal, newborn, and child health services, reproductive health and family planning services, health education and counselling, and management of minor ailments [4]. In urban Bangladesh, divided responsibilities between the Ministry of Health and Family Welfare (MoHFW) and the Ministry of Local Government, Rural Development and Cooperatives (MoLGRDC) contribute to a less coherent PHC system compared to rural [7]. Currently, the MoLGRDC offers PHC through the Urban Primary Healthcare Services Delivery Project (UPHCSDP) in partnership with non-government organizations (NGO) and government outdoor dispensaries (GOD), which are inadequate in number and falls short of meeting the needs of growing urban population and remain heavily dependent on development partner’s budget [5].

Service coverage, one of the key Sustainable Development Goals (SDG) indicators for Universal Health Coverage (UHC), is limited by a fragmented urban health system, weak accountability, and limited access to PHC. Another key indicator, catastrophic healthcare expenditure, stems from inadequate public investment in health and the absence of financial protection schemes. With a large informal sector in Bangladesh, achieving financial protection for health relies on expanding public financing. The urban poor are disproportionately affected by a weak health system, leading to experiencing low-quality care, using unregulated private sector while incurring out-of-pocket expenditure (OOPE) due to absence of accessible and quality public PHC services [8,9]. In absence of accessible PHC, patients often seek care from informal providers [10], which may contribute to delays in appropriate treatment.

Strengthening PHC is the most cost-effective strategy in low- and middle-income countries (LMICs) to achieve UHC [11,12]. Despite this emphasis on PHC, its performance remains inadequate in LMICs, necessitating substantial improvement to align with the SDGs and attain UHC [13]. In response to these challenges, several PHC models have been implemented in LMICs. One notable example is Delhi’s Mohalla Clinic, which effectively reaches urban populations through a community-based approach, particularly benefiting the poor [14]. Research indicates that these clinics significantly improved healthcare access for the urban poor, reducing time and costs for availing treatment [15]. This increased access encouraged early treatment-seeking, consequently alleviating the burden on higher-level healthcare facilities [16]. In Bangladesh, private and NGO sectors are also embracing innovative models to enhance preventive and clinical care provision by delivering doorstep and mobile health services to the urban poor, slum dwellers, and factory and office workers.

Despite growing evidence on PHC models from LMICs [17–19], there remains limited evidence on the implementation experiences of innovative urban PHC models specifically tailored to the rapidly expanding urban populations in Bangladesh. Understanding how such models function in real-world settings is crucial for informing urban health reforms and achieving UHC targets. Recently in Bangladesh, recognizing the crucial role of PHC, a UNICEF-supported Government of Bangladesh program introduced a comprehensive urban PHC model named ‘Aalo Clinic’. The Aalo Clinic model aims at providing accessible, affordable care to urbanites, particularly low-income populations. It provides a comprehensive range of PHC services in morning and evening shifts through a digitalized platform, offering a variety of medicines and diagnostic tests free of cost [20]. This study aimed to explore the implementation challenges and opportunities of the Aalo Clinic model from a programmatic perspective in improving urban PHC services in Bangladesh. Strengthening evidence on urban PHC models, such as Aalo Clinic, is critical for informing policy in Bangladesh, where rapid urbanization continues to exacerbate health inequities. Findings from this study can guide policymakers, and development partners to scale up or refine PHC models, improving access, quality, and equity of PHC for urban populations in Bangladesh and similar LMIC settings.

Methods

Results

Table 1 presents the characteristics of the 42 study participants, comprising 24 IDIs and 18 KIIs. In terms of gender distribution, the majority of IDI participants were female (16 of 24), whereas most KII participants were male (14 of 18). Most IDI participants were aged 20–29 years, while the majority of KII participants were aged 40 years and above.

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Table 1. Characteristics of study participants (n = 42).

https://doi.org/10.1371/journal.pone.0341924.t001

Three core themes on the implementation-related opportunities and challenges evolved from the analysis– i) technical, ii) administrative, and iii) financial. Each theme is further grouped into sub-themes (Fig 1).

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Fig 1. Thematic summary of implementation opportunities and challenges of the Aalo Clinic model.

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Discussion

This paper offers insights into the implementation of a PHC model, filling a notable gap in research from LMICs, where such evidence is scarce. It provides valuable guidance for decision-making regarding the implementation or refinement of PHC models [22]. While Aalo Clinic presents a promising PHC model for improving access to healthcare services in urban areas of Bangladesh, it faces its own set of challenges. The findings highlight both opportunities presented by the model and implementation-related challenges encountered in its operation, focusing on technical, administrative, and financial aspects.

Aalo Clinic has introduced several innovative approaches within the PHC model including a digitalized system, prescription audit, client feedback system, and empanelment which come with their own unique features and potential benefits. Leveraging technology through the IDHP is a notable strength, facilitating operational efficiency and reducing patients’ hassle of record keeping. Moreover, the paperless digital record system reported to save time, storage, and ensures longer retention of patient records. Studies have shown that electronic health records improve communication between healthcare providers, leading to informed treatment decisions and improved patient outcomes [23]. Furthermore, the use of a unique ID could be scaled up nationwide by incorporating a NID (National Identification) number or a similar identifier ensuring seamless access to patient information and facilitating referrals. These efforts align with broader healthcare IT adoption trends [24], highlighting the Aalo Clinic model as a foundation for expanding technology-driven solutions in Bangladesh. However, challenges with the digitalized systems, such as low-configured devices and interrupted internet, reported to hinder operations, slowed service delivery, and lengthened queues. Similar challenges have been documented on health information systems in LMICs, highlighting the need to upgrade infrastructure and sustainable, locally tailored solutions for successful technology implementation [25]. Notably, Aalo Clinic has transitioned from IDHP to Open Medical Record System (OpenMRS) to align with the national health database (beyond the study period). This transition was reported to enable real-time data transfer, addressing urban health data limitations, while enhancing its scope and ensuring high-quality data for informed decision-making.

Efforts to improve service quality through prescription audits and client feedback systems were described by providers as mechanisms to support adherence to clinical standards and responsiveness to patient concerns. The prescription audit aims to optimize patient care by systematically assessing care against established standards, leading to improved prescription quality and better health outcomes [26]. Additionally, gathering feedback from patients about their healthcare experiences is an essential tool for enhancing the quality of health services provided [27]. A survey reported that 91% of Aalo Clinic users rated their experience positively, indicating a high level of user satisfaction [28]. Aalo Clinic has also adopted anempanelment approach, a fundamental strategy for building or enhancing PHC systems and a key pathway toward achieving UHC [29]. The model empanelled healthcare workers with an aim to ensure continuous access to affordable PHC services through flexible contracts, allowing clinics to adjust staff levels based on the volume of work, thereby enhancing efficiency. Although recruiting adequate physicians for empanelment was challenging, offering attractive packages could incentivize greater participation. Lessons can be learned from models who successfully empanelled physicians such as Delhi’s Mohalla clinic [30]. While effective empanelment is crucial for transitioning towards patient-centred integrated healthcare, there exists limited international guidance on implementing empanelment systems in LMICs [29].

Along with Aalo Clinic’s gained popularity, participants reported increased patient flow, which they described as contributing to longer waiting times and space constraints, consistent with prior research findings [31,32]. Longer waiting times can significantly diminish patients’ satisfaction and willingness to revisit the clinic [32]. Notably despite increased patient flow, the average consultation was reported about 13 minute per patient as reported in a survey [28], which is longer than consultation time reported in many low-and even high-income countries [33]. Additionally, participants reported that space constraints could compromise patient privacy, which could be mitigated through use of screens or temporary partitions. In rural areas, there are currently 13,948 community clinics, each providing PHC to approximately 6,000 people [34]. In contrast, urban areas have only 35 GOD under the MoHFW providing outpatient services, with 19 of them located in Dhaka [34]. Estimates from a quantitative analysis suggested that with one Aalo Clinic per ward in Dhaka city (129 wards total), each clinic would serve 79,680 people. If more clinics are added, three clinics for every ward, the population load per clinic would decrease to 26,560 people [28]. On the other hand, in pluralistic health systems like Bangladesh, an efficient referral system is crucial, providing a systematic approach to ensure appropriate, timely, and affordable healthcare access for the population [35]. However, establishing a referral linkage with government facilities and the Aalo Clinic has proven challenging due to the lack of policies in place. While Aalo Clinic has partnered with a few private facilities for discounted diagnostic tests, these services remain unaffordable for most low-income patients, despite the reduced charges. Financial constraints stand out as a major reason for slum dwellers’ reluctance to seek healthcare [36,37], with the majority belonging to impoverished households, their healthcare choices are significantly influenced by resource availability [9]. Offering free consultations, medicines, and diagnostics at facilities like Aalo Clinic could serve as a pivotal incentive for enhancing healthcare utilization, particularly among the impoverished. However, providers at Aalo Clinic have cited stock-outs of medicines and a demand for a wider range of medications, highlighting the necessity for a need-based supply system.

Aalo Clinic offers several unique features not found in other existing PHC models of Bangladesh, such as GOD [38] or primary healthcare centers (PHCC) under UPHCSDP [39]. These include evening hours services, electronic medical records, and discounted services outside the clinic. While PHCCs offer free registration, medicines, and limited diagnostic tests, these benefits are only available to their ‘red card holders’ (ultra-poor population groups) [39]. Notably, the UPHCSDP is also facing challenges similar to Aalo Clinic [39]. To ensure efficiency in resource use and effective coverage for UHC, existing models should learn from each other. Implementers need to identify ways to integrate popular features of Aalo Clinic into the current PHC models, given their similar structures. Additionally, PHC services could be delivered in collaboration with other private stakeholders, such as NGOs, utilizing the existing facilities of Aalo Clinic. Additionally, domiciliary care by community health workers can be integrated to enhance awareness and promote preventive care in urban areas.

Policymakers have also recognized Aalo Clinic’s potential in providing PHC services for urban residents and emphasized the importance of coordination for integrated healthcare delivery. Moreover, they have underlined the prospect of incorporating Aalo Clinic’s services or features into urban PHC provision under the 5^th HNPSP (Health, Nutrition, and Population Sector Program). Such integration would be crucial for the program’s sustainability, leading to more efficient healthcare delivery and benefiting a larger portion of the population in need. The National Urban Health Strategy 2020 acknowledges the existing gaps in urban PHC services and emphasizes the need to enhance capacity, governance, and stewardship of both public and private sectors to ensure equitable and high-quality healthcare for urban populations [40]. This study aligns with the strategy’s objective of generating robust evidence for informed decision-making. However, one of the critical challenges identified in this model is its dependence on external funding, reflecting concerns echoed throughout healthcare financing literature [41,42]. This reliance weakens long-term sustainability, particularly when coupled with the uncertain nature of continued donor support [42]. The requirement for unwavering political commitment adds another layer of complexity [43]. Nonetheless, Aalo Clinic has attracted significant political interest, paving the way for integrating its features into the broader health sector program, which is noteworthy. Further research is required to investigate adaptation strategies for long-term financial sustainability of such models, including alternative funding mechanisms like public-private partnerships or innovative financing models. While considerable progress has been made in PHC reforms across LMICs, this study provides additional implementation insights by examining the Aalo Clinic model in Bangladesh. In line with global PHC reform recommendations, the opportunities and challenges identified in the Aalo Clinic model highlight the importance of integrated service delivery, public-private partnerships, and pro-poor targeting to enhance access and equity [44].

Conclusion

Implementing an urban PHC model in a resource-poor setting presents both opportunities and challenges that must be carefully explored to ensure accessible, affordable healthcare services for urban population. The study highlights the importance of addressing implementation challenges while capitalizing on opportunities to scale up the Aalo Clinic model, which has the potential to facilitate the achievement of UHC sin Bangladesh by enhancing service coverage and reducing OOPE. Aalo Clinic offers several innovative features that can be integrated into the existing urban PHC models. Recommendations include implementing structured monitoring, ensuring need-based medicine supply, fostering collaboration with the government for referrals, and facilitating cross-learning among urban PHC facilities. By addressing implementation challenges, leveraging opportunities, and strengthening multi-sector collaboration, the Aalo Clinic model shows potential to contribute to improved access to quality PHC in urban settings, in line with the broader vision of health for all.

Supporting information