Challenges Faced by Health Managers in Healthcare Delivery Systems in Bangladesh

Challenges Faced by Health Managers in Healthcare Delivery Systems in Bangladesh | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Challenges Faced by Health Managers in Healthcare Delivery Systems in Bangladesh Md. Mesba Ul Hasan Roman, Sharmim Akter, Dilkhush Jahan, Shirajum Monira Akter, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6792321/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 14 You are reading this latest preprint version Abstract Background Health managers in healthcare delivery systems in Bangladesh face several challenges that make it difficult for them to provide quality service to patients. Despite these challenges, there are also opportunities for improvement. The healthcare delivery system in Bangladesh can be improved by increasing health facilities, providing more skilled workforce, and allocating more financial resources. This research aimed to identify challenges the health managers face. Methods This cross-sectional study was conducted all over Bangladesh by conducting both online and physical data collection simultaneously. All 568 members of the study population were approached in several ways. In total, 140 health managers who had at least 6 months of work experience participated in this study. Face-to-face and web-based data were collected via a semi structured questionnaire. Data analysis was aimed at determining the prevalence and associations between different factors. Results Workload-related challenges were reported by 65% of health managers, whereas target-driven stress affected 85% of them. The monthly target was the most stressful target (86.6%), which was made difficult by the suboptimal availability of resources (84%). Career progression-related challenges were reported by 70.7%, while approximately 70% perceived resource limitation-related challenges. In addition, 86.1% reported facing some sort of challenge in store management. At least 54.8% reported difficulties dealing with the local situation and with local government offices. Health workforce scarcity was perceived by 87.4% of the respondents. Conclusion Healthcare delivery systems in any country trust health managers for their quality and efficiency. This study suggests prioritizing combating those challenges that may result in improved health service delivery and retention by health managers. The study results could provide policy makers and health administrators with a clearer picture of the measures to be taken to alleviate those problems. These findings will be especially helpful in creating and maintaining an environment in which health managers can express themselves in a way that could unlock the full potential of the health care delivery system and managers themselves alike. Challenges health managers Challenges healthcare delivery system Challenges health managers of Bangladesh Figures Figure 1 Figure 2 Background Health managers play a vital role in ensuring the quality and efficiency of healthcare delivery systems in Bangladesh. They oversee all the routine activities of the healthcare delivery system, including preventive, promotive, curative, and domiciliary services. They also work to improve the efficiency, effectiveness, and equity of health care delivery and outcomes. A healthcare delivery system is a complex and dynamic network of interrelated actors that provide health services to the population. Health managers are the key actors who plan, organize, coordinate, monitor and evaluate the performance of the healthcare delivery system. They are responsible for managing health systems in accordance with six core components or “building blocks”, as proposed by the World Health Organization (WHO) ( 1 ) Health managers are also liaison officers who coordinate health division activities with other authorities of the government. Thus, they ensure the proper maintenance of routine activities and carry out activities directed by higher authorities. As the activities of health managers are complex in nature, the challenges they face are also diverse. Challenges have many domains, yet they also come from different levels. ( 2 ) A review article described the context in which healthcare managers operate at three levels. The macro level encompasses the broader social, demographic, technological, economic, political, legal, and cultural factors that shape the healthcare system and its environment. A study in Uganda explained the obstacles that were found to be related to the environment, resources, and social influences. These included a lack of finances and staffing. Additionally, health managers felt that they lacked the authority to make decisions and perceived tension with politicians who had different priorities. ( 3 ) The meso level refers to the organisational aspects of healthcare delivery, such as the infrastructure, resources, governance, clinical and management processes, suppliers, and consumer behaviour involved in providing care. The micro level is related to the individual characteristics of healthcare managers, such as their skills, knowledge, attitudes, values, and motivations. Bangladesh is a country with a large population and high burden of disease. The health system in Bangladesh faces many challenges. A study conducted in 2020 revealed that insufficient health infrastructure, extreme poverty, high population growth, and inappropriate budget allocation are some of the key challenges for health services in Bangladesh. The study also indicated that shortages of drugs, ambulances, and medical equipment worsen the situation ( 4 ). Health managers of Bangladesh face several challenges that hinder their ability to effectively manage healthcare delivery systems and need to be addressed. Some of the domains of challenges that health managers usually face include human resources, financial constraints, infrastructure issues, coordination among stakeholders, governance and accountability, policy-level implications, and sociocultural barriers. A review article in 2018 revealed that doctors felt that their career paths were vague and that high positions were filled by people who came from different fields or ministries without the required qualifications or experience instead of being promoted from within. Women doctors were not guaranteed to stay with their husbands in rural areas ( 5 ) This research aimed to provide insights into the challenges faced by health managers in Bangladesh, a country with a complex healthcare landscape. Understanding these challenges and their impact on service delivery allows policymakers and stakeholders to develop targeted solutions and empower health managers, ultimately improving healthcare outcomes for the people of Bangladesh. Methods This descriptive type of cross-sectional study was carried out in 2023 to identify the challenges faced by health managers in the healthcare delivery system in Bangladesh. A semi-structured questionnaire was developed to collect data relevant to the variables of interest (Uploaded as supplementary material). Based on the pretest findings, the questionnaire was subsequently finalized. Health Service Officers working as facility heads of the administrative units (i.e., upazila, district and division) of Bangladesh were targeted as respondents of this research. The data collection methods were divided into two approaches: face-to-face interviews and web-based data collection. Face-to-face interviews were conducted in the civil surgeon offices of the districts of Kishoreganj and Dinajpur, which were selected purposively. The online data collection was conducted through an online form using the same questionnaire that was distributed to the targeted study population via email and other social communication media. The collected data were processed and then entered into statistical software. The analysis was carried out via both descriptive and inferential statistics. Descriptive data are presented as frequencies, means, standard deviations and percentages, which were used to describe the sociodemographic characteristics and other variables relevant to the specific objectives. Inferential statistics were performed via the chi-square test or Fisher’s exact test. Results Among the study population, 132 Upazila Health and Family Planning Officers (UH&FPO), 8 Civil Surgeons (CS) and 01 divisional directors (Health) responded in the study. Overall, 140 out of 568 responders responded, which is 24.6% of the total study population (Fig. 1). Figure 1: Distribution of response rates across different groups of the study population (N = 568) Almost half of the respondents were 35–39 years old, and the mean age was 40.65 ± 5.69 years. Nearly one-third (30%) of the participants were 40–44 years of age. On average, 4 out of 5 respondents were male (Table 1 ). Table 1 Sociodemographic status of the respondents (n = 140) Categories Frequency Percent (%) Age (in years) 30–34 7 5.0 35–39 64 45.7 40–44 42 30.0 45–49 15 10.7 50–54 5 3.6 55–59 7 5.0 Sex Male 112 80 Female 28 20 Religion Islam 115 82.1 Hinduism 22 15.7 Buddhism 2 1.4 Christianity 1 0.7 Marital status Married 137 97.9 Unmarried 1 0.7 Separated 2 1.4 Location of the facility Rural 112 80 Urban 28 20 The responders were asked about the various challenges they faced in the working environment. The respondents stated that they are fully empowered to perform their duties (77.9%). However, 65% of the respondents stated that they are experiencing a significant workload, and 85% stated that they suffer from target-driven stress in the workplace. Among them, 86.6% cited monthly targets as the most stressful (Table 2 ). Table 2 Information related to perceptions of empowerment, workload and target-driven stress Response Frequency Percent (%) Fully empowered to conduct their duties Yes 109 77.9 Current routine workload Significant workload 91 65.0 Experiencing target driven stress in the workplace Yes 119 85.0 Which frequency of targets are more stressful Monthly 103 86.6 Quarter Yearly 6 5.0 Half-yearly 2 1.7 Yearly 8 6.7 “Suboptimal availability of resources” was stated by 84% of the respondents as one of the reasons for experiencing target-driven stress. (Fig. 2). Figure 2: Reasons behind the target driven stress (Multiple responses) More than half (58.6%) of the respondents stated that they both suffer from target-driven stress and experience a significant workload. A statistical association was found between these two variables via the chi-square test (p < 0.05). (Table 3 ) Table 3 Relationships between target-driven stress and perceived workload Perceived workload Suffering from target driven stress Total ꭓ 2 value p value Yes No Frequency (%) Frequency (%) Frequency (%) Light to moderate workload 37 (26.4) 14 (10.0) 51 (36.4) 9.755 0.002 Significant workload 82 (58.6) 7 (5.0) 89 (63.6) More than 99% of health managers felt that they needed additional security at their residences. Approximately half of the health managers felt that female health managers faced more gender-based stereotyping. (Table 4 ). Table 4 Respondents’ opinions about gender-based stereotyping and additional security at their residence Response Frequency Percent (%) Needing additional security at their residence Yes 137 99.3 Female health managers facing more gender-based stereotyping Agree 67 48.9 Facing gender-based stereotyping Yes 25 18.0 The respondents were asked about career progression-related challenges they faced. The majority of the respondents (89.3%) reported having a specific subdivision for health managers after recruitment. Approximately 95% of the respondents agreed that health administrators need to issue “nonpracticing allowances”. An overwhelming 88.8% feel that changes are needed in the current special foundation training course (SFTC) for health cadres. (Table 5 ). Table 5 Respondents’ opinions about their career path, “nonpracticing allowance”, academic degree and current special foundation training course (SFTC) Response Frequency Percent (%) Having specific subdivision for health managers Agree 125 89.3 Clarity of career path for Health managers Ill defined 119 85.0 Possibility to reach the apex of the career path of BCS Health Cadres No 99 70.7 Health administrators getting “Non-Practicing Allowance” Yes 131 94.9 Have an academic degree (e.g., MPH, MPhil, MSc) in Public Health Yes 43 30.7 Current 8-week Special Foundation training Course (SFTC) Changes needed in Special foundation training course 119 88.8 Resource allocation- and infrastructure maintenance-related challenges were also queried by health managers. The study revealed that 57.3% of facilities had a Bed Occupancy Rate (BOR) above 100%, whereas more than two-thirds (70.9%) perceived that their current quota of resource allocation was suboptimum for their BOR. A statistically significant association was observed between these two variables (p < 0.001). (Table 6 ). Table 6 Relationships between respondents’ facility bed occupancy rate (BOR) and perceived resource allocation against BOR (n = 110) BOR (%) Perceived resources allocation against BOR Fisher’s Exact Test value p value Subopti-mal Optimum Overesti-mate Total Frequency (%) Frequency (%) Frequency (%) Frequency (%) < 75 6 (5.4) 2 (1.8) 0 (0.0) 8 (7.2) 20.132 100 50 (49.1) 7 (6.4) 2 (1.8) 63 (57.3) Total 74 (70.9) 29 (26.4) 3 (2.7) 110 (100) Nearly two-thirds (63.8%) of the respondents stated that they face challenges while executing duties in coordination with other offices, whereas more than half (54.8%) of the respondents stated that the local situation/pressure negatively affects their and their teams’ productivity. (Table 7 ) Table 7 Respondents’ opinions regarding facing any challenge/s while executing duties and how local situations/pressure affect productivity Response Frequency Percent (%) Face challenge/s while executing duties in co-ordination with other government offices Yes 88 63.8 How the local situation affect health managers and their employees’ productivity Yes, negatively affect 74 54.8 No, doesn’t affect 44 32.6 Yes, positively affect 17 12.6 Discussion This cross-sectional study was conducted from January to December 2023 to identify the challenges faced by health managers in healthcare delivery systems. Data were collected from Upazila health and family planning officers, civil surgeons, and directors (health) of divisions across Bangladesh. The majority of the participants were between 35 and 39 years old, whereas almost one-third were between 40 and 44 years old. The study population consisted of 568 participants, including 65 CSs, 8 divisional directors (health) and 495 UH&FPOs. The total number of respondents was 140, which was 24.6% of the total study population. Approximately one quarter of the respondents stated that they were not fully empowered to perform their jobs. A possible recommendation is to increase the empowerment and authority of health managers, granting them greater autonomy in their work and involving them in decision-making processes that directly impact their roles. The majority of the participants indicated that they experienced target-driven stress at work. The monthly targets were the most stressful to 85% of the health managers, as observed in the present study. In addition, most of the participants (84%) indicated that "suboptimal availability of resources" was one of the factors. A qualitative study was conducted in 2019 involving 275 heath managers from 11 African countries, including Cuba, Portugal, and the United Kingdom. They reported that 30% of the participants reported insufficient budget allocation for health. This result does not agree with the study data. The discrepancy may be due to the different research methods, geographic variations, and differences in countries’ approaches to addressing resource constraints.( 6 ) Timely and sufficient resource allocation, adopting more flexible target structures that allow for adjustments based on resource availability and unforeseen circumstances, offering training and support programs to help health managers develop effective stress management techniques and building resilient support and feedback mechanisms are the probable steps that health managers can take when considering the responses of health managers. In-depth investigation of the effects of target-driven stress on health managers' well-being and exploration of potential interventions to mitigate its negative effects can also have a long-term impact on their motivation, performance, and retention. A substantial proportion (58.6%) of the respondents perceived having both a significant workload and target-driven stress. The perceived workload of the respondents and their opinions related to target-driven stress were compared and found to be statistically significant (p < 0.05). A nearly unanimous proportion (99.3%) of the health managers expressed a need for enhanced security at their residences. Approximately half of the health managers perceived female colleagues as being subjected to increased gender-based stereotyping. Notably, on average, roughly one in every five respondents indicated having experienced gender-based stereotyping at some point during their professional careers. The average increases to two out of every five for the female respondents. A probable way is to improve the security of the residences of health managers, especially in areas where they are vulnerable or unsafe. It is also recommended that the issue of gender-based stereotyping be addressed further by conducting in-depth research on this topic. An overwhelming majority of participants (89.3%) strongly supported the idea of creating a special subdivision for health managers. However, an outsize proportion of respondents (85%) felt that the career path for health managers lacked clarity, i.e., “Ill defined". Additionally, the study revealed that the majority (70.7%) of the respondents believe that they cannot reach the highest position in their career path as BCS health cadres. This study recommends reviewing and revising the current career path for health managers in collaboration with key stakeholders. Furthermore, providing more clarity of information on promotion criteria can be among the alternatives to explore. This would help to create a clear and transparent career roadmap with well-defined expectations and opportunities for growth. By addressing these critical issues, the BCS health cadre can foster a more equitable and rewarding career progression system, thus attracting and retaining capable individuals and contributing to a more robust and efficient healthcare system. An overwhelming majority of the respondents agreed that health administrators should receive a "nonpracticing allowance". In addition, approximately one-third (30.7%) had an academic degree in public health. Implementing the "nonpracticing allowance" while expanding the availability of a variety of academic opportunities for health administrators might improve their job satisfaction and facilitate their professional development. Most of the respondents (88.8%) believed that the current 8-week Special Foundation Training Course (SFTC) for health cadres requires significant revision. These findings highlight the need for a comprehensive review and potential restructuring of the SFTC to better equip health cadres with the necessary skills and knowledge. The majority of the respondents (57.3%) had BOR values greater than 100%. The mean BOR for the sample was 109.80% ± 26.58%. Furthermore, a majority (69.5%) of respondents considered their current resource allocation to be suboptimal. A statistically significant relationship was found between these two factors. The study data indicate overcrowding and under-resourcing in health care facilities. Apart from increasing resource allocation, in-depth analysis for revising resource allocation strategies can be performed to identify areas where possible alternations can be made. Approximately two-thirds (63.8%) of the participants reported encountering difficulties during duty execution when collaborating with other government offices. However, more than half of the respondents (54.8%) identified the local situation as having a negative influence on their own and their teams' productivity. These findings highlight the need for improved interdepartmental communication and collaboration, as well as efforts to enhance the overall understanding of the healthcare system among officials across different sectors and stakeholders. Local political and administrative leaders are likely to be the most impactful actors in addressing these issues, potentially leading to their eradication or at least significant reduction. Conclusion The challenges health managers must encounter are diverse in nature. From combating the delayed and suboptimal availability of resources to local pressure to allow unauthorized activities, from feeling stress to achieving targets to motivating healthcare providers to achieve those goals, they assume the role of fulfilling the healthcare delivery system of Bangladesh. This study may provide a greater understanding of the challenges faced by health managers in Bangladesh. The results could provide policy makers and health administrators with a clearer picture of the measures to be taken to alleviate those problems. These findings will be especially helpful in creating and maintaining an environment in which health managers can express themselves in a way that could unlock the full potential of the health care delivery system and managers themselves alike. In addition, the policy makers will be able to prioritize the issues to address them according to their importance. Abbreviations WHO World Health Organization UH&FPO Upazila Health and Family Planning Officer CS Civil Surgeon SFTC Special Foundation Training Course BOR Bed Occupancy Rate Declarations Ethics approval and consent to participate Ethical approval of the research protocol from the Institutional Review Board (IRB) of National Institute of Preventive and Social Medicine (NIPSOM) was taken prior to the commencement of the study (Memo No.: NIPSOM/IRB/2023/06 Date: 02/07/2023). All the procedures were conducted in accordance with guidelines of the Declaration of Helsinki. Informed consent was taken from all the participants. The respondents were informed about their full freedom to participate or refuse to be involved in the study at any point in time. Consent for publication Not Applicable. Availability of data and materials The datasets used and analysed during the study are available from the corresponding author on request. Competing interests The authors declare that they have no competing interests. Funding The study did not receive any funds or grants from any sources. Authors' contributions SA contributed to data collection, analysis and interpretation. DJ analysis and interpretation of collected data. SMA and MTM contributed to writing the manuscript. UA, MD took part in data collection and report writing. ANMSI contributed to writing the whole report as well as the manuscript. All authors read and approved the final manuscript. Acknowledgements Shah Mehedi Bin Zahur was crucial in data collection in Khulna division. Md Abdullah Saeed Khan helped in writing this manuscript. References World Health Organization. Monitoring the building blocks of health systems : a handbook of indicators and their measurement strategies. World Health Organization; 2010. 92 p. Figueroa CA, Harrison R, Chauhan A, Meyer L. Priorities and challenges for health leadership and workforce management globally: A rapid review. Vol. 19, BMC Health Services Research. BioMed Central Ltd.; 2019. Henriksson DK, Ayebare F, Waiswa P, Peterson SS, Tumushabe EK, Fredriksson M. Enablers and barriers to evidence based planning in the district health system in Uganda; perceptions of district health managers. BMC Health Serv Res. 2017 Feb 2;17(1):1–11. Shahen MA, Islam MR, Ahmed R. Challenges for Health Care Services in Bangladesh: An Overview. Issue 1 Ser I [Internet]. 2020;9(1):13–24. Available from: www.iosrjournals.org Joarder T, Rawal LB, Ahmed SM, Uddin A, Evans TG. Retaining doctors in rural Bangladesh: A policy analysis. Int J Health Policy Manag. 2018 Sep 1;7(9):847–58. Oleribe OO, Momoh J, Uzochukwu BSC, Mbofana F, Adebiyi A, Barbera T, et al. Identifying key challenges facing healthcare systems in Africa and potential solutions. Int J Gen Med. 2019;12:395–403. Additional Declarations No competing interests reported. Supplementary Files Questionnaire.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 21 Jul, 2025 Reviewers agreed at journal 21 Jul, 2025 Reviews received at journal 21 Jul, 2025 Reviewers agreed at journal 15 Jul, 2025 Reviewers agreed at journal 15 Jul, 2025 Reviews received at journal 05 Jul, 2025 Reviewers agreed at journal 26 Jun, 2025 Reviewers agreed at journal 24 Jun, 2025 Reviewers agreed at journal 16 Jun, 2025 Reviewers invited by journal 16 Jun, 2025 Editor assigned by journal 12 Jun, 2025 Editor invited by journal 09 Jun, 2025 Submission checks completed at journal 08 Jun, 2025 First submitted to journal 08 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6792321","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":471843088,"identity":"39b63b6d-3ab0-4495-ba56-5dd3ac1f0a01","order_by":0,"name":"Md. Mesba Ul Hasan Roman","email":"data:image/png;base64,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","orcid":"","institution":"Directorate General of Health Services","correspondingAuthor":true,"prefix":"","firstName":"Md.","middleName":"Mesba Ul Hasan","lastName":"Roman","suffix":""},{"id":471843089,"identity":"97e5089f-0565-4791-b3d4-ce456f69d63e","order_by":1,"name":"Sharmim Akter","email":"","orcid":"","institution":"National Institute of Preventive and Social Medicine","correspondingAuthor":false,"prefix":"","firstName":"Sharmim","middleName":"","lastName":"Akter","suffix":""},{"id":471843090,"identity":"2551372f-6c4a-4f9d-a069-5cc5d8479090","order_by":2,"name":"Dilkhush Jahan","email":"","orcid":"","institution":"National Institute of Preventive and Social Medicine","correspondingAuthor":false,"prefix":"","firstName":"Dilkhush","middleName":"","lastName":"Jahan","suffix":""},{"id":471843091,"identity":"7ef4a0fc-8d3d-4fa0-aea0-4a0df5936cb2","order_by":3,"name":"Shirajum Monira Akter","email":"","orcid":"","institution":"Bangladesh Medical University","correspondingAuthor":false,"prefix":"","firstName":"Shirajum","middleName":"Monira","lastName":"Akter","suffix":""},{"id":471843092,"identity":"fb3983bd-5dbe-4576-97b8-d003190caf1c","order_by":4,"name":"Upal Adhikari","email":"","orcid":"","institution":"Enam Medical College and Hospital","correspondingAuthor":false,"prefix":"","firstName":"Upal","middleName":"","lastName":"Adhikari","suffix":""},{"id":471843098,"identity":"14c84d32-c366-4e60-8053-aa2291acf201","order_by":5,"name":"Mukta Das","email":"","orcid":"","institution":"Bangladesh Medical University","correspondingAuthor":false,"prefix":"","firstName":"Mukta","middleName":"","lastName":"Das","suffix":""},{"id":471843099,"identity":"a9f458cc-bab5-40fa-82e2-0d731cab334d","order_by":6,"name":"Mehnaz Tabassum Mahbub","email":"","orcid":"","institution":"Transform -Bangladesh","correspondingAuthor":false,"prefix":"","firstName":"Mehnaz","middleName":"Tabassum","lastName":"Mahbub","suffix":""},{"id":471843100,"identity":"e2510ad6-2e39-4c44-bf4e-d77c841ab134","order_by":7,"name":"ANM Shamsul Islam","email":"","orcid":"","institution":"National Institute of Preventive and Social Medicine","correspondingAuthor":false,"prefix":"","firstName":"ANM","middleName":"Shamsul","lastName":"Islam","suffix":""}],"badges":[],"createdAt":"2025-05-31 17:38:03","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6792321/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6792321/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85361923,"identity":"9f530b64-64d9-44ce-af3d-90231f5c2d63","added_by":"auto","created_at":"2025-06-25 06:15:31","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":40370,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of response rates across different groups of the study population (N=568)\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-6792321/v1/7940c1df465cdade9713a32f.png"},{"id":85363023,"identity":"d243697d-86a1-44e4-8d72-b78f646b6c53","added_by":"auto","created_at":"2025-06-25 06:23:31","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":52763,"visible":true,"origin":"","legend":"\u003cp\u003eReasons behind the target driven stress (Multiple responses)\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-6792321/v1/6b786c19596769f66957f2aa.png"},{"id":85364361,"identity":"d9f4bd30-38a3-4e98-a435-159b68494b73","added_by":"auto","created_at":"2025-06-25 06:31:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1142354,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6792321/v1/4977779e-7c84-4605-bf4d-5a5802b4650c.pdf"},{"id":85363025,"identity":"f965fbb8-2d98-430b-813b-12128b0501ec","added_by":"auto","created_at":"2025-06-25 06:23:31","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":98061,"visible":true,"origin":"","legend":"","description":"","filename":"Questionnaire.docx","url":"https://assets-eu.researchsquare.com/files/rs-6792321/v1/a0067dfcbdb57d3be247bb45.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Challenges Faced by Health Managers in Healthcare Delivery Systems in Bangladesh","fulltext":[{"header":"Background","content":"\u003cp\u003eHealth managers play a vital role in ensuring the quality and efficiency of healthcare delivery systems in Bangladesh. They oversee all the routine activities of the healthcare delivery system, including preventive, promotive, curative, and domiciliary services. They also work to improve the efficiency, effectiveness, and equity of health care delivery and outcomes. A healthcare delivery system is a complex and dynamic network of interrelated actors that provide health services to the population. Health managers are the key actors who plan, organize, coordinate, monitor and evaluate the performance of the healthcare delivery system. They are responsible for managing health systems in accordance with six core components or \u0026ldquo;building blocks\u0026rdquo;, as proposed by the World Health Organization (WHO) (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eHealth managers are also liaison officers who coordinate health division activities with other authorities of the government. Thus, they ensure the proper maintenance of routine activities and carry out activities directed by higher authorities. As the activities of health managers are complex in nature, the challenges they face are also diverse. Challenges have many domains, yet they also come from different levels. (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eA review article described the context in which healthcare managers operate at three levels. \u003cem\u003eThe macro level\u003c/em\u003e encompasses the broader social, demographic, technological, economic, political, legal, and cultural factors that shape the healthcare system and its environment. A study in Uganda explained the obstacles that were found to be related to the environment, resources, and social influences. These included a lack of finances and staffing. Additionally, health managers felt that they lacked the authority to make decisions and perceived tension with politicians who had different priorities. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cem\u003eThe meso level\u003c/em\u003e refers to the organisational aspects of healthcare delivery, such as the infrastructure, resources, governance, clinical and management processes, suppliers, and consumer behaviour involved in providing care. \u003cem\u003eThe micro level\u003c/em\u003e is related to the individual characteristics of healthcare managers, such as their skills, knowledge, attitudes, values, and motivations.\u003c/p\u003e \u003cp\u003eBangladesh is a country with a large population and high burden of disease. The health system in Bangladesh faces many challenges. A study conducted in 2020 revealed that insufficient health infrastructure, extreme poverty, high population growth, and inappropriate budget allocation are some of the key challenges for health services in Bangladesh. The study also indicated that shortages of drugs, ambulances, and medical equipment worsen the situation (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHealth managers of Bangladesh face several challenges that hinder their ability to effectively manage healthcare delivery systems and need to be addressed. Some of the domains of challenges that health managers usually face include human resources, financial constraints, infrastructure issues, coordination among stakeholders, governance and accountability, policy-level implications, and sociocultural barriers. A review article in 2018 revealed that doctors felt that their career paths were vague and that high positions were filled by people who came from different fields or ministries without the required qualifications or experience instead of being promoted from within. Women doctors were not guaranteed to stay with their husbands in rural areas (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThis research aimed to provide insights into the challenges faced by health managers in Bangladesh, a country with a complex healthcare landscape. Understanding these challenges and their impact on service delivery allows policymakers and stakeholders to develop targeted solutions and empower health managers, ultimately improving healthcare outcomes for the people of Bangladesh.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis descriptive type of cross-sectional study was carried out in 2023 to identify the challenges faced by health managers in the healthcare delivery system in Bangladesh. A semi-structured questionnaire was developed to collect data relevant to the variables of interest (Uploaded as supplementary material). Based on the pretest findings, the questionnaire was subsequently finalized. Health Service Officers working as facility heads of the administrative units (i.e., upazila, district and division) of Bangladesh were targeted as respondents of this research. The data collection methods were divided into two approaches: face-to-face interviews and web-based data collection. Face-to-face interviews were conducted in the civil surgeon offices of the districts of Kishoreganj and Dinajpur, which were selected purposively. The online data collection was conducted through an online form using the same questionnaire that was distributed to the targeted study population via email and other social communication media. The collected data were processed and then entered into statistical software. The analysis was carried out via both descriptive and inferential statistics. Descriptive data are presented as frequencies, means, standard deviations and percentages, which were used to describe the sociodemographic characteristics and other variables relevant to the specific objectives. Inferential statistics were performed via the chi-square test or Fisher\u0026rsquo;s exact test.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eAmong the study population, 132 Upazila Health and Family Planning Officers (UH\u0026amp;FPO), 8 Civil Surgeons (CS) and 01 divisional directors (Health) responded in the study. Overall, 140 out of 568 responders responded, which is 24.6% of the total study population (Fig.\u0026nbsp;1).\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure 1: Distribution of response rates across different groups of the study population (N\u0026thinsp;=\u0026thinsp;568)\u003c/b\u003e \u003c/p\u003e \u003cp\u003eAlmost half of the respondents were 35\u0026ndash;39 years old, and the mean age was 40.65\u0026thinsp;\u0026plusmn;\u0026thinsp;5.69 years. Nearly one-third (30%) of the participants were 40\u0026ndash;44 years of age. On average, 4 out of 5 respondents were male (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic status of the respondents (n\u0026thinsp;=\u0026thinsp;140)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCategories\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercent (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eAge (in years)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30\u0026ndash;34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e35\u0026ndash;39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e40\u0026ndash;44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e45\u0026ndash;49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e50\u0026ndash;54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e55\u0026ndash;59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e112\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReligion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIslam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e115\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e82.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHinduism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBuddhism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChristianity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e137\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e97.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnmarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeparated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLocation of the facility\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e112\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe responders were asked about the various challenges they faced in the working environment. The respondents stated that they are fully empowered to perform their duties (77.9%). However, 65% of the respondents stated that they are experiencing a significant workload, and 85% stated that they suffer from target-driven stress in the workplace. Among them, 86.6% cited monthly targets as the most stressful (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInformation related to perceptions of empowerment, workload and target-driven stress\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResponse\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercent (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eFully empowered to conduct their duties\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCurrent routine workload\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSignificant workload\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExperiencing target driven stress in the workplace\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e119\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWhich frequency of targets are more stressful\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMonthly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e103\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuarter Yearly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHalf-yearly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYearly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e\u0026ldquo;Suboptimal availability of resources\u0026rdquo; was stated by 84% of the respondents as one of the reasons for experiencing target-driven stress. (Fig.\u0026nbsp;2).\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure 2: Reasons behind the target driven stress (Multiple responses)\u003c/b\u003e \u003c/p\u003e \u003cp\u003eMore than half (58.6%) of the respondents stated that they both suffer from target-driven stress and experience a significant workload. A statistical association was found between these two variables via the chi-square test (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRelationships between target-driven stress and perceived workload\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003ePerceived workload\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eSuffering from target driven stress\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eꭓ\u003csup\u003e2\u003c/sup\u003e value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFrequency (%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLight to moderate workload\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37 (26.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (10.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e51 (36.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e9.755\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSignificant workload\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e82 (58.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (5.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e89 (63.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMore than 99% of health managers felt that they needed additional security at their residences. Approximately half of the health managers felt that female health managers faced more gender-based stereotyping. (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRespondents\u0026rsquo; opinions about gender-based stereotyping and additional security at their residence\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResponse\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercent (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eNeeding additional security at their residence\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e137\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e99.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFemale health managers facing more gender-based stereotyping\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFacing gender-based stereotyping\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe respondents were asked about career progression-related challenges they faced. The majority of the respondents (89.3%) reported having a specific subdivision for health managers after recruitment. Approximately 95% of the respondents agreed that health administrators need to issue \u0026ldquo;nonpracticing allowances\u0026rdquo;. An overwhelming 88.8% feel that changes are needed in the current special foundation training course (SFTC) for health cadres. (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRespondents\u0026rsquo; opinions about their career path, \u0026ldquo;nonpracticing allowance\u0026rdquo;, academic degree and current special foundation training course (SFTC)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResponse\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercent (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eHaving specific subdivision for health managers\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e125\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e89.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eClarity of career path for Health managers\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIll defined\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e119\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePossibility to reach the apex of the career path of BCS Health Cadres\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHealth administrators getting \u0026ldquo;Non-Practicing Allowance\u0026rdquo;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e131\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHave an academic degree (e.g., MPH, MPhil, MSc) in Public Health\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCurrent 8-week Special Foundation training Course (SFTC)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChanges needed in Special foundation training course\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e119\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eResource allocation- and infrastructure maintenance-related challenges were also queried by health managers. The study revealed that 57.3% of facilities had a Bed Occupancy Rate (BOR) above 100%, whereas more than two-thirds (70.9%) perceived that their current quota of resource allocation was suboptimum for their BOR. A statistically significant association was observed between these two variables (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRelationships between respondents\u0026rsquo; facility bed occupancy rate (BOR) and perceived resource allocation against BOR (n\u0026thinsp;=\u0026thinsp;110)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eBOR (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003ePerceived resources allocation against BOR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eFisher\u0026rsquo;s Exact Test value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSubopti-mal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOptimum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOveresti-mate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFrequency (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFrequency (%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;75\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (5.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8 (7.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e20.132\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e75\u0026ndash;100\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (16.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (18.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e39 (35.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e\u0026gt;\u0026thinsp;100\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50 (49.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (6.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e63 (57.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74 (70.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (26.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (2.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e110 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eNearly two-thirds (63.8%) of the respondents stated that they face challenges while executing duties in coordination with other offices, whereas more than half (54.8%) of the respondents stated that the local situation/pressure negatively affects their and their teams\u0026rsquo; productivity. (Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRespondents\u0026rsquo; opinions regarding facing any challenge/s while executing duties and how local situations/pressure affect productivity\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResponse\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercent (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eFace challenge/s while executing duties in co-ordination with other government offices\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHow the local situation affect health managers and their employees\u0026rsquo; productivity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes, negatively affect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo, doesn\u0026rsquo;t affect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes, positively affect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis cross-sectional study was conducted from January to December 2023 to identify the challenges faced by health managers in healthcare delivery systems. Data were collected from Upazila health and family planning officers, civil surgeons, and directors (health) of divisions across Bangladesh. The majority of the participants were between 35 and 39 years old, whereas almost one-third were between 40 and 44 years old.\u003c/p\u003e \u003cp\u003eThe study population consisted of 568 participants, including 65 CSs, 8 divisional directors (health) and 495 UH\u0026amp;FPOs. The total number of respondents was 140, which was 24.6% of the total study population.\u003c/p\u003e \u003cp\u003eApproximately one quarter of the respondents stated that they were not fully empowered to perform their jobs. A possible recommendation is to increase the empowerment and authority of health managers, granting them greater autonomy in their work and involving them in decision-making processes that directly impact their roles.\u003c/p\u003e \u003cp\u003eThe majority of the participants indicated that they experienced target-driven stress at work. The monthly targets were the most stressful to 85% of the health managers, as observed in the present study. In addition, most of the participants (84%) indicated that \"suboptimal availability of resources\" was one of the factors.\u003c/p\u003e \u003cp\u003eA qualitative study was conducted in 2019 involving 275 heath managers from 11 African countries, including Cuba, Portugal, and the United Kingdom. They reported that 30% of the participants reported insufficient budget allocation for health. This result does not agree with the study data. The discrepancy may be due to the different research methods, geographic variations, and differences in countries\u0026rsquo; approaches to addressing resource constraints.(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eTimely and sufficient resource allocation, adopting more flexible target structures that allow for adjustments based on resource availability and unforeseen circumstances, offering training and support programs to help health managers develop effective stress management techniques and building resilient support and feedback mechanisms are the probable steps that health managers can take when considering the responses of health managers. In-depth investigation of the effects of target-driven stress on health managers' well-being and exploration of potential interventions to mitigate its negative effects can also have a long-term impact on their motivation, performance, and retention.\u003c/p\u003e \u003cp\u003eA substantial proportion (58.6%) of the respondents perceived having both a significant workload and target-driven stress. The perceived workload of the respondents and their opinions related to target-driven stress were compared and found to be statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eA nearly unanimous proportion (99.3%) of the health managers expressed a need for enhanced security at their residences. Approximately half of the health managers perceived female colleagues as being subjected to increased gender-based stereotyping. Notably, on average, roughly one in every five respondents indicated having experienced gender-based stereotyping at some point during their professional careers. The average increases to two out of every five for the female respondents. A probable way is to improve the security of the residences of health managers, especially in areas where they are vulnerable or unsafe. It is also recommended that the issue of gender-based stereotyping be addressed further by conducting in-depth research on this topic.\u003c/p\u003e \u003cp\u003eAn overwhelming majority of participants (89.3%) strongly supported the idea of creating a special subdivision for health managers. However, an outsize proportion of respondents (85%) felt that the career path for health managers lacked clarity, i.e., \u0026ldquo;Ill defined\". Additionally, the study revealed that the majority (70.7%) of the respondents believe that they cannot reach the highest position in their career path as BCS health cadres.\u003c/p\u003e \u003cp\u003eThis study recommends reviewing and revising the current career path for health managers in collaboration with key stakeholders. Furthermore, providing more clarity of information on promotion criteria can be among the alternatives to explore. This would help to create a clear and transparent career roadmap with well-defined expectations and opportunities for growth. By addressing these critical issues, the BCS health cadre can foster a more equitable and rewarding career progression system, thus attracting and retaining capable individuals and contributing to a more robust and efficient healthcare system.\u003c/p\u003e \u003cp\u003eAn overwhelming majority of the respondents agreed that health administrators should receive a \"nonpracticing allowance\". In addition, approximately one-third (30.7%) had an academic degree in public health. Implementing the \"nonpracticing allowance\" while expanding the availability of a variety of academic opportunities for health administrators might improve their job satisfaction and facilitate their professional development.\u003c/p\u003e \u003cp\u003eMost of the respondents (88.8%) believed that the current 8-week Special Foundation Training Course (SFTC) for health cadres requires significant revision. These findings highlight the need for a comprehensive review and potential restructuring of the SFTC to better equip health cadres with the necessary skills and knowledge.\u003c/p\u003e \u003cp\u003eThe majority of the respondents (57.3%) had BOR values greater than 100%. The mean BOR for the sample was 109.80% \u0026plusmn; 26.58%. Furthermore, a majority (69.5%) of respondents considered their current resource allocation to be suboptimal. A statistically significant relationship was found between these two factors. The study data indicate overcrowding and under-resourcing in health care facilities. Apart from increasing resource allocation, in-depth analysis for revising resource allocation strategies can be performed to identify areas where possible alternations can be made.\u003c/p\u003e \u003cp\u003eApproximately two-thirds (63.8%) of the participants reported encountering difficulties during duty execution when collaborating with other government offices. However, more than half of the respondents (54.8%) identified the local situation as having a negative influence on their own and their teams' productivity. These findings highlight the need for improved interdepartmental communication and collaboration, as well as efforts to enhance the overall understanding of the healthcare system among officials across different sectors and stakeholders. Local political and administrative leaders are likely to be the most impactful actors in addressing these issues, potentially leading to their eradication or at least significant reduction.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe challenges health managers must encounter are diverse in nature. From combating the delayed and suboptimal availability of resources to local pressure to allow unauthorized activities, from feeling stress to achieving targets to motivating healthcare providers to achieve those goals, they assume the role of fulfilling the healthcare delivery system of Bangladesh.\u003c/p\u003e \u003cp\u003eThis study may provide a greater understanding of the challenges faced by health managers in Bangladesh. The results could provide policy makers and health administrators with a clearer picture of the measures to be taken to alleviate those problems. These findings will be especially helpful in creating and maintaining an environment in which health managers can express themselves in a way that could unlock the full potential of the health care delivery system and managers themselves alike. In addition, the policy makers will be able to prioritize the issues to address them according to their importance.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.9982%;\"\u003e\n \u003cp\u003eWHO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83.0018%;\"\u003e\n \u003cp\u003eWorld Health Organization\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.9982%;\"\u003e\n \u003cp\u003eUH\u0026amp;FPO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83.0018%;\"\u003e\n \u003cp\u003eUpazila Health and Family Planning Officer\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.9982%;\"\u003e\n \u003cp\u003eCS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83.0018%;\"\u003e\n \u003cp\u003eCivil Surgeon\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.9982%;\"\u003e\n \u003cp\u003eSFTC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83.0018%;\"\u003e\n \u003cp\u003eSpecial Foundation Training Course\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.9982%;\"\u003e\n \u003cp\u003eBOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83.0018%;\"\u003e\n \u003cp\u003eBed Occupancy Rate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eEthical approval of the research protocol from the Institutional Review Board (IRB) of National Institute of Preventive and Social Medicine (NIPSOM) was taken prior to the commencement of the study (Memo No.: NIPSOM/IRB/2023/06 Date: 02/07/2023).\u003c/p\u003e\n\u003cp\u003eAll the procedures were conducted in accordance with guidelines of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003eInformed consent was taken from all the participants. The respondents were informed about their full freedom to participate or refuse to be involved in the study at any point in time.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot Applicable.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eThe datasets used and analysed during the study are available from the corresponding author on request.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThe study did not receive any funds or grants from any sources.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions\u003c/p\u003e\n\u003cp\u003eSA contributed to data collection, analysis and interpretation. DJ analysis and interpretation of collected data. SMA and MTM contributed to writing the manuscript. UA, MD took part in data collection and report writing. ANMSI contributed to writing the whole report as well as the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eShah Mehedi Bin Zahur was crucial in data collection in Khulna division. Md Abdullah Saeed Khan helped in writing this manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organization. Monitoring the building blocks of health systems : a handbook of indicators and their measurement strategies. World Health Organization; 2010. 92 p.\u003c/li\u003e\n\u003cli\u003eFigueroa CA, Harrison R, Chauhan A, Meyer L. Priorities and challenges for health leadership and workforce management globally: A rapid review. Vol. 19, BMC Health Services Research. BioMed Central Ltd.; 2019.\u003c/li\u003e\n\u003cli\u003eHenriksson DK, Ayebare F, Waiswa P, Peterson SS, Tumushabe EK, Fredriksson M. Enablers and barriers to evidence based planning in the district health system in Uganda; perceptions of district health managers. BMC Health Serv Res. 2017 Feb 2;17(1):1\u0026ndash;11.\u003c/li\u003e\n\u003cli\u003eShahen MA, Islam MR, Ahmed R. Challenges for Health Care Services in Bangladesh: An Overview. Issue 1 Ser I [Internet]. 2020;9(1):13\u0026ndash;24. Available from: www.iosrjournals.org\u003c/li\u003e\n\u003cli\u003eJoarder T, Rawal LB, Ahmed SM, Uddin A, Evans TG. Retaining doctors in rural Bangladesh: A policy analysis. Int J Health Policy Manag. 2018 Sep 1;7(9):847\u0026ndash;58.\u003c/li\u003e\n\u003cli\u003eOleribe OO, Momoh J, Uzochukwu BSC, Mbofana F, Adebiyi A, Barbera T, et al. Identifying key challenges facing healthcare systems in Africa and potential solutions. Int J Gen Med. 2019;12:395\u0026ndash;403.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Challenges health managers, Challenges healthcare delivery system, Challenges health managers of Bangladesh","lastPublishedDoi":"10.21203/rs.3.rs-6792321/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6792321/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eHealth managers in healthcare delivery systems in Bangladesh face several challenges that make it difficult for them to provide quality service to patients. Despite these challenges, there are also opportunities for improvement. The healthcare delivery system in Bangladesh can be improved by increasing health facilities, providing more skilled workforce, and allocating more financial resources. This research aimed to identify challenges the health managers face.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis cross-sectional study was conducted all over Bangladesh by conducting both online and physical data collection simultaneously. All 568 members of the study population were approached in several ways. In total, 140 health managers who had at least 6 months of work experience participated in this study. Face-to-face and web-based data were collected via a semi structured questionnaire. Data analysis was aimed at determining the prevalence and associations between different factors.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eWorkload-related challenges were reported by 65% of health managers, whereas target-driven stress affected 85% of them. The monthly target was the most stressful target (86.6%), which was made difficult by the suboptimal availability of resources (84%). Career progression-related challenges were reported by 70.7%, while approximately 70% perceived resource limitation-related challenges. In addition, 86.1% reported facing some sort of challenge in store management. At least 54.8% reported difficulties dealing with the local situation and with local government offices. Health workforce scarcity was perceived by 87.4% of the respondents.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eHealthcare delivery systems in any country trust health managers for their quality and efficiency. This study suggests prioritizing combating those challenges that may result in improved health service delivery and retention by health managers. The study results could provide policy makers and health administrators with a clearer picture of the measures to be taken to alleviate those problems. These findings will be especially helpful in creating and maintaining an environment in which health managers can express themselves in a way that could unlock the full potential of the health care delivery system and managers themselves alike.\u003c/p\u003e","manuscriptTitle":"Challenges Faced by Health Managers in Healthcare Delivery Systems in Bangladesh","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-25 06:15:26","doi":"10.21203/rs.3.rs-6792321/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-22T03:22:17+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"33376928995781926095963230075261331525","date":"2025-07-21T05:31:44+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-21T05:01:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"183557267422000387523905241552539560222","date":"2025-07-15T12:36:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"246246346117519069181659918218676346040","date":"2025-07-15T08:31:32+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-05T07:40:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"169302403343923484290049542711904291013","date":"2025-06-27T03:09:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"169149779326599549135773411517083287359","date":"2025-06-25T03:55:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"211924039811710719640093458622444961242","date":"2025-06-16T08:55:10+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-16T06:54:10+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-12T13:13:16+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-06-09T15:00:59+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-08T06:44:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-06-08T06:42:12+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d338b8b5-653a-4041-ab9c-ec99d19dc35c","owner":[],"postedDate":"June 25th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-10-14T10:08:32+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-25 06:15:26","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6792321","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6792321","identity":"rs-6792321","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}