Healthcare in the Margins: A Qualitative Study of Healthcare Access and Utilization in Bangladesh's Informal Urban Settlements

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Utilizing data gathered from group discussions (N = 5) and case studies (N = 22) in five informal urban settlements, we uncover many important barriers to healthcare access, with those linked to economic and infrastructural shortcomings emerging as particularly critical. There is available healthcare, but public hospitals face overcrowding and long waiting lists, mistreating poorer patients, and the price of private health facilities is unaffordable for many residents. Culturally relevant alternatives, so-called informal healthcare providers, local pharmacies (unlicensed) in particular, and traditional birth attendants (TBAs) are important, although they often offer services that include risks such as over-prescribing and insufficient training. Factors including financial stress, low health literacy, and a fragmented health care system drive health inequities. This study underscore s the importance of enhancing health literacy and education to enable marginalized groups to make effective health choices. The study provides fresh insights into the healthcare needs and health inequities in these informal urban settlements. These findings reinforce the relevance of SDG 3 goals by emphasizing the need for inclusive, equitable, and community-oriented healthcare approaches to ensure healthy lives and promote well-being for all. Healthcare access urban health marginalized populations Informal urban settlements Health-seeking behavior Figures Figure 1 Figure 2 Introduction Urbanization is rapidly transforming health and well-being. Globally, 68% of the population is projected to live in urban areas by 2050, with the majority of this growth occurring in low- and middle-income countries 1 . The expansion has resulted in the spread of informal settlements, which are often overcrowded, poorly housed, lack sanitation and healthcare infrastructure. As a result residents face multifaceted health and well-being challenges, not only a high risk of both communicable and non-communicable diseases 2 , 3 but also exposure to environmental hazards, food insecurity, mental health stressors, and limited access to social protection and education. Over 52% of the urban population of Bangladesh lives in informal settlements, where health inequities increase due to endemic poverty, erratic jobs, lack of options, poor access to the primary health system, dependence on informal providers, and governance failures 4 , 5 . The health challenges in informal settlements extend beyond inadequate healthcare access. Socio-economic instability, environmental vulnerabilities, and systemic neglect by state institutions, urban planning authorities, and health governance bodies ensure that these populations are uniquely susceptible to malnutrition, maternal and child health risks, mental health stressors, and chronic diseases, such as diabetes and hypertension 6 , 7 . On top of that, the lack of social protection and universal health coverage in many countries, such as Bangladesh, often leads to high out-of-pocket (OOP) expenses that limit access to healthcare and add stress to the patient and their carers 8 , 9 . Although quantitative approaches have documented healthcare delivery systems and disease burden, they provide limited insights into the ways marginalised communities negotiate access in fragmented healthcare systems, the role of perceived provider trustworthiness in choices about care-seeking, and the adaptive strategies employed if burdened by service shortages. Yet, such insights are particularly relevant when discussing reliance on unlicensed pharmacies, traditional healers, and local birth attendants, which, although accessible and culturally acceptable, may enhance misdiagnosis, antibiotic resistance, and delays in accessing critical healthcare 10 , 11 . Ironically, in the face of limited options and weak governance, these informal providers become the primary source of support in the health care system for those who remain impoverished. This study applies the social determinants of health framework to explore how economic precarity, governance failures, and socio-cultural factors shape healthcare-seeking behavior in Bangladesh’s informal settlements. Adopting a community-based participatory research (CBPR) approach and centring the voices of socio-economically marginalised groups 12 , the study provides an in-depth understanding of the enablers and barriers to healthcare access and residents’ strategies to overcome these barriers across five informal urban settlements in Bangladesh, addressing a critical evidence gap. By holding up a mirror to the disconnect between formal healthcare provision and the everyday realities of informal settlement residents, this research generates policy-relevant insights to support more equitable and responsive urban health interventions. Ultimately, it aims to inform transformative, evidence-based approaches that enhance the accessibility, affordability, and accountability of healthcare for vulnerable urban populations. Methodology Study setting The research took place in five informal urban settlements across three city corporations (the highest tier of elected local government that manages all civic services in a metropolitan area) and one municipality (urban local government bodies) in Bangladesh, outlined in Table 1 . The settlements were purposively selected due to their setting, population, migration, and vulnerability to eviction, lack of WASH facilities, and recurrent climate events, for instance, floods, cyclones, heatwaves, etc. Table 1 Study sites characteristics Characteristics Kallyanpur Dholpur Shyampur Itagacha Greenland Established in 1988 1991 1996 1982 2001 Location Dhaka North City Corporation Dhaka South City Corporation Dhaka South City Corporation Itagacha Purbopara, Satkhira, Khulna City Corporation, Land Ownership Housing and Building Research Institute (Government) Dhaka North City Corporation Private and Bangladesh Railway (Government) Bangladesh Water Development Board (Government) Bangladesh Railway (Government) Number of residents (approx.) 15750 20000 6800 989 5146 Number of Divisions 10 10 4 1 6 Origin of residents Northern and southern Bangladesh Central and northern Bangladesh Central, north and southern Bangladesh Southern Bangladesh Southern Bangladesh Reason for settling Environmental Change (river erosion) Employment Employment (City corporation waste collection) Employment in nearby industrial areas. Environmental Change (cyclones and flooding, high water salinity, loss of land to climate events, loss of agricultural livelihood due to land erosion) Environmental Change (frequent cyclones and flooding, high water salinity, especially near the river, loss of land to river erosion, and better economic opportunities) Eviction The Housing and Building Research Institute made several attempts to evict residents. The High Court action has been successful in stopping evictions. Eight blocks were evicted in 2023 Evictions of households settled on the railway line in 2021 The Water Development Board has made several unsuccessful attempts in the past few years. No evictions. The Accountability and Responsiveness in Informal Settlements for Equity (ARISE) research consortium, in which this research is embedded, adopted a CBPR approach that centers the community researchers as equitable partners in the research process to document the lived experiences and challenges faced by residents living in informal settlements 13 . CBPR emphasises co-production of knowledge, equitable community–researcher collaboration, and reflexive engagement throughout the research process 14 . This research design and analysis approach is particularly appropriate for informal settlement contexts, where structural inequalities and social marginalisation necessitate participatory methods that amplify local voices and enable a nuanced understanding of how residents navigate a fragmented healthcare landscape shaped by both systemic constraints and informal coping mechanisms 12 . This study’s methods draw on participatory service mapping sessions in five informal settlements to identify locally available formal and informal healthcare providers, services, and access pathways. These maps were used to inform subsequent in-depth case studies (CS) ( N = 22) and group discussions (GD) ( N = 5), which explored healthcare-seeking behavior, perceived provider trustworthiness, and barriers to accessing care as shown in Table 2 . Data Collection and Co-Analysis Table 2 Data collection methods Data Collection Methods Timeline Shyampur Dholpur Kallyanpur Rangpur Itagacha Greenland Total Session Case Study (CS) In-person interview August 2022 – September 2022 5 0 (Evicted) 1 7 2 7 22 Group Discussion (GD) Service Mapping (SM) July 2022 – November 2022 1 1 1 0 1 1 5 Validation Session (VS) 1 1 1 0 1 1 5 All audio records of the group discussion were transcribed in Bangla by the researchers and community researchers who were present during the sessions. All transcripts were cross-checked by researchers who had led the sessions, ensured the accuracy of the transcriptions and imported them into NVivo 12. The BRAC James P Grant School of Public Health (BRAC JPSGH) research team adopted an inductive framework approach to analyse and organise data according to key concepts, themes, and sub-themes for comprehensive data interpretation 15 , 16 . During the first coding cycle, five research staff independently reviewed and coded the transcriptions of 22 case studies and 5 group discussions, and collectively assembled a codebook. MRH and FMN then reviewed and compared each other's code and used the comparative discussion to resolve disagreements and refine the codebook. During the second coding cycle, the researcher used memos to write down the key findings with their thoughts. We later created a data matrix with the coding outputs to analyse the findings, relations, and patterns. The findings were later shared and discussed and brought back to the communities through validation sessions (n = 5), ensuring that interpretations aligned with residents' lived realities and enhancing credibility through member checking. Recruitment ARISE Bangladesh research team partnered with 13 community researchers (eight female, five male) who live across the five study sites and actively participate in the research process, ensuring meaningful community engagement and amplifying local voices. Together, the research team and community researchers prepared a guideline for the service mapping group discussion activity and case studies. The community researchers reviewed the guidelines and provided feedback on the questions, prompts, wordings, and local understandings of healthcare and disease terminologies. THE BRAC JPSGH research team and community researchers decided together on the inclusion and exclusion criteria for study participants. The research participants for the case study and group discussion were separately identified based on migration history and vulnerability by asking community researchers to list 20–30 people from each site that are deemed essential to include, focusing on emphasizing social, economic, and gender diversity. The study deliberately included both new and older migrants to capture differences in social networks, financial stability, healthcare awareness, and health-seeking behavior. New immigrants (residents for ≤ 3 years) typically have weaker social networks, limited health literacy, and economic instability, and are more dependent on informal providers. On the other hand, older migrants (residents for ≥ 10 years) tend to have closer community ties and better healthcare awareness, enabling better system navigation. This study used two non-probability sampling procedures: purposive sampling and quota sampling. The potential categories of respondents for our group discussions included marginalised people such as daily wage earners, pregnant women or lactating mothers, single female-headed households, people over the age of 60, people living with disabilities, local community leaders/influential, and healthcare providers to include diverse experiences. The study comprised eligible community participants who met the following inclusion criteria: aged over eighteen, member of a marginalised group (as determined by discussions with stakeholders, community representatives, and a literature review), resident of the community for at least five years (for older migrants), being identified as a community leader or influential person by community researchers during the transect walk and being formal or informal healthcare providers providing services in the community. Community -researchers facilitated participant recruitment, organised group sessions, and provided access, increasing trust and rapport building. Ethical consideration All participants were compensated with 500 BDT (approx. 4.43 USD) and lunch as reimbursement for their opportunity cost. The study was approved by the Institutional Review Board (IRB) of BRAC JPGSPH (Research Number 2019-034-IR) (13), and the Research Ethics Committee of Liverpool School of Tropical Medicine, UK (Research Protocol 19–089) (14). We obtained informed written consent from all participants before conducting and recording the sessions. Personal identifiers were excluded from transcripts, and access to data was restricted to designated research team members following the project’s data management plan. In line with ARISE’s ethical guidance, we also integrated safeguarding measures throughout the study to ensure participant well-being and safety during all stages of data collection and engagement 17 . Results The results are structured around eight key themes that emerged from the data focusing on how residents of informal settlements navigate a pluralistic and fragmented healthcare landscape, namely: healthcare provision landscape, healthcare provider perception, access to healthcare, coping and adaptation strategies. A visual summary of the key themes is provided in Fig. 1 to guide the reader through the interlinked findings. Healthcare Provider Distribution Across Research Sites Participants across study sites identified and listed multiple healthcare providers, including government facilities, private clinics, NGO-run facilities, pharmacies (informal and unlicensed), and traditional healthcare providers, which are presented in Table 3 . However, availability did not ensure equitable access. Affordability, overcrowding, and inconsistent service quality remained key barriers. Table 3 Number and types of healthcare service availability across research sites Site Government hospital Private Clinic NGO-run facilities Pharmacy (informal) Traditional healthcare practitioner Number of Facilities Kallyanpur (Dhaka) 6 5 2 8 8 Dholpur (Dhaka) 7 8 8 5 2 Shyampur (Dhaka) 5 9 3 6 1 Greenland (Khulna) 5 2 5 2 4 Ittagacha (Satkhira) 3 4 2 5 1 A female participant from Dholpur highlighted this disparity: We have NGO clinics, a government hospital, pharmacies, and even a private diagnostic center near our community. The problem is not the availability of doctors, it’s accessing the services. (GD, housewife) City corporation areas, including Kallyanpur, Dholpur, Shyampur, and Greenland, offered more healthcare options. In contrast, municipality areas had fewer formal healthcare facilities, further restricting residents’ choices. Perceptions of Government Healthcare Services Government hospitals are considered essential for financially marginalized populations, particularly for emergencies, surgeries, and specialized treatments. A female participant from Kallyanpur emphasized: If you can access the doctor’s room in a government hospital, you will receive complete and perfect treatment. (GD, CDO member) Another male participant from Shyampur compared public and private hospitals: The treatment I receive at a private hospital for thousands of taka,(8 USD) I can get for just ten taka (0.082 USD) in a government hospital. (GD, day laborer) Despite confidence in treatment quality, systemic barriers undermine accessibility further. Participants cited long wait times, overcrowding, staff misconduct, and absent doctors. Many reported lack of accountability, leading to denied or delayed services. For example, a female participant from Kallyanpur expressed frustration: Government hospitals are important to us, but we are not important to them… I waited for hours at the National Heart Foundation, but the doctor never showed up. We can’t question them. (GD, housewife) Hidden costs also impacted access, especially in a setting where income is low and precarious with the average household income. Another male participant from Rangpur described informal payments: The emergency ticket costs 50 BDT (0.4 USD), but they charge 100 (0.8 USD) to 150 BDT (1.2 USD). If you pay, you get seen faster. If not, even if you're seriously ill, you wait. Trolleys should be free, but they charge another 300 (2.5 USD) to 400 BDT (3.2 USD). (CS, Harijan (Dalit)) Although government hospitals offer better treatment than many private facilities. Participants attributed the “better treatment” to the presence of highly qualified and experienced doctors, many of whom also practice in renowned private hospitals. Government facilities also provide access to essential surgical services, diagnostics, and hospitalization at minimal or no cost, making them a critical lifeline for low-income populations. However, community members often bypass government hospitals due to long wait times, overcrowding, high transportation and hidden costs, as well as negative experiences with staff behavior, including instances where bribes are requested for services that are officially meant to be free. As a result, pharmacies or informal providers become the preferred option for quicker and more accessible care, even if of lower quality. A female participant from Shyampur explained: Many people just buy medicine from a pharmacy without consulting a doctor. If the condition gets serious and local treatment doesn’t work, then we go to Dhaka Medical. (GD, ultra-poor) This reliance on unlicensed informal pharmacies over hospitals highlights the logistical and financial barriers deterring residents from accessing formal healthcare use. Perception of Private Healthcare Facilities Residents exhibited mixed perceptions of private healthcare. While some preferred established private clinics for efficiency and diagnostics, financial constraints prevented widespread access. However, private healthcare costs remained prohibitive. Private hospitals attempted to reduce costs through health card schemes, but these often served promotional purposes rather than offering real financial relief. A female participant from Satkhira noted: Private clinics came to our area, offering health cards so we wouldn’t have to pay high consultation fees. But they mostly want us to use their services. (GD, housewife) Despite high fees, private hospitals became the only choice during emergencies, when public hospitals fail due to corruption, inefficiency, or long delays. A pregnant woman from Shyampure explained: Even though private hospitals are expensive, they are our only choice when patients do not recover from informal or medical facilities. (CS, housewife) The Role of Informal Pharmacies Unlicensed pharmacies dominate the informal healthcare landscape, offering accessible, trusted, and often lifesaving services. Participants praised pharmacies for their affordability, availability of medicines, and willingness to provide medicine on credit. A female participant from Greenland highlighted their role: My daughter had a bad fever, but we had no money. A pharmacist gave me 300 taka (2.7 USD) worth of medicine on credit, which really helped my family in crisis. (CS, new migrant) For new migrants either affected/displaced by the climate crisis or needing to relocate, with limited networks, pharmacists serve as primary referral points to healthcare facilities, bridging gaps in healthcare knowledge. The low cost and convenience of pharmacies lead many residents to self-medicate rather than visit doctors. A male participant from Kallyanpur noted: When I have a fever or cold, I just tell the pharmacy, and they give me medicine. I don’t waste 500 taka on a doctor visit. (GD, street vendor) Although pharmacies provide crucial healthcare access, their unregulated status raises major concerns. Some unlicensed drug sellers hold disproportionate influence, creating unequal access to trusted providers. In addition, for daily wage laborers, long hospital wait times and lost wages make pharmacies the most viable healthcare option given the lack of overall choices for those who remain chronically marginalised. Reputation of NGO Clinics NGO clinics are highly trusted, particularly for maternal and child healthcare. Their community-based outreach reduces hospital visits and builds confidence. A female participant from Dholpur emphasised: Everyone knows the clinic because they have provided maternal and child care services and vaccines for a long time.(GD, housewife) However, despite their widespread acceptance, NGO clinics face resource constraints, leading to service disruptions. Many participants expressed concerns about clinics closing, reducing operations or charging service fees that were previously free due to funding shortages. A pregnant woman from Shyampur described unexpected expenses in NGO-affiliated private programs: SMC gave me a free birth control implant, but now it costs 270 taka (2.22USD). That’s too expensive for us. (CS, housewife) This is directly tied to funding cuts in the North. During the pandemic, there were severe cuts to funding by Western countries, which led to NGOs pulling out of informal settlements, creating disruption and havoc for those poorer families who had become reliant on their services and support. Since then, there have been further cuts in global health in 2025, which have severely impacted local NGOs ' ability to provide services. Traditional Healthcare Providers Traditional/Indigenous healers, including Traditional Birth Attendants (TBAs), Imams (religious leaders), and herbal healers, play a critical role, especially in maternal and newborn care. While institutional deliveries have increased in urban areas, especially due to the rise in cesarean births and greater awareness, TBAs and traditional healers remain a critical option for ultra-poor households who cannot afford hospital costs or new migrants with a lack of social networks to navigate formal care and among older caregivers due to their affordability, accessibility, and social familiarity. A female CDC member from Greenland emphasized: They come whenever we call, at midnight or any time. We rate them 10/10 for their service. (GD, Local committee member) For ultra-poor families, TBAs remain indispensable, with payments typically 1,000–1,500 taka (USD 8–12) or in-kind. Given the hidden costs in formal facilities, rising costly cesarean surgeries push on poor women in the country, a TBA offers cheap service for those who cannot afford the limited and expensive options available. Religious leaders (Imans) also play a significant role in treating perceived supernatural illnesses for newborn and/or young children. A female participant from Greenland shared: When our children cry excessively, we take them to a Hujur or Boiddo, and their treatment works. (GD, small business owner) When families suspected illnesses, such as unexplained fevers, seizures, or bad health of newborns, new mothers, and pregnant mothers, caused by evil eyes (nazar) or spiritual influences, they sought spiritual and or traditional healers. These healers are embedded in communities, offer flexible payment (often in-kind), and provide immediate care with prayers (dua), amulets (ta’wiz), and herbal remedies (kobiraji), giving psychological comfort, even if ineffective for biomedical conditions. Discussion To illustrate the interplay between various factors influencing healthcare access in informal urban settlements, we present the following Fig. 2 . It highlights the structural challenges, barriers to access, and fragmentation within the healthcare system, alongside the role of informal providers. The study investigated health-seeking behavior dynamics in five informal urban settlements in Bangladesh, focusing on healthcare access and availability across different healthcare provider sectors (government, private, NGO, and informal). The results underline that whilst health care services exist across all sites, as the residents face substantial challenges in accessing healthcare, including economic precarity, governance crisis, and socio-cultural factors constrain health-seeking practice. From precarious backgrounds, such as ultra-poor households and new migrants were particularly affected by these barriers. For these groups, the high cost of transportation, long wait times, negative attitudes towards patients and informal payments often prevented access to government services 18 , 19 . Many participants, particularly those from slightly better-off households or those with regular incomes, preferred private facilities for faster and more reliable care, often at an additional cost. The financial burden associated with access to both government and private facilities is exacerbated by inadequate health insurance coverage and limited private health insurance options, forcing families to make difficult trade-offs between healthcare and basic necessities. In Bangladesh, OOP expenditures account for approximately 73% of total health expenditure 20 . Despite the existence of government programs like the Shasthyo Surokhsha Karmasuchi (SSK) aimed at providing health insurance for slum dwellers, low enrollment persists due to limited coverage, awareness gaps, complex registration processes, and funding constraints 21 . This leads vulnerable populations to lean toward cheaper alternatives, such as local pharmacies and informal providers 9 , 22 , or choose between health care and other necessities, including food and shelter 23 . Residents in city corporation areas such as Kallyanpur and Dholpur which are informal settlements have access to more healthcare options but encounter system inefficiencies such as transport cost, fees and hidden costs, bad experiences, etc. indicating that urban location alone does not guarantee equitable access to healthcare 24 , 25 . Our findings are consistent with a growing body of evidence describing a fragmented healthcare system within informal urban settlements in LMICs, where residents experience inadequate healthcare services marked with suboptimal healthcare delivery 26 , 27 . For example, a wide variety of healthcare providers (public, private, NGO) can be present in the same informal settlements. Still, the lack of coordination and integration between these providers can provide a very fragmented care experience 28 . This fragmentation may result in duplicate services and gaps in care 29 . It may amplify the economic costs for polypharmacy patients-individuals who are prescribed and consume multiple medications especially when they visit multiple service providers to receive quality care 30 , 31 . This fragmentation, along with low levels of health literacy, renders many people in Bangladesh unable to seek care and worsens existing health inequities One of the findings of this study was that informal health providers, most notably local pharmacies and TBAs, were relied upon by residents of informal settlements to fulfil their health needs. Pharmacies operate without regulatory oversight and are generally considered both accessible and affordable, as well as reliable, for treating minor ailments. These healthcare providers are vital in the community, particularly those who are economically disadvantaged, since they can extend credit, dispense limited quantities of medications, and refer to other healthcare providers 10 . TBAs continue to play a critical role in maternal and newborn care, especially in ultra-poor households within informal urban settlements, where the opportunity cost of accessing formal healthcare is prohibitive. TBAs are valued for their accessibility, cultural relevance, and the holistic nature of their care, which often includes both emotional and spiritual support 32 . Despite their significance, TBAs are not formally trained, and traditional practices such as using spiritual artefacts, herbs and physical examination or mustard oil on premature babies raise concerns about safety and care quality, particularly when complications arise 33 . To mitigate these risks, programs like BRAC’s MANOSHI have engaged TBAs by providing training and monitoring from Skilled Birth Attendants (SBAs) 34 . This approach ensures safe childbirth while maintaining cultural alignment with the community’s healthcare preferences. Trust and acceptability of TBAs are enhanced through these initiatives, as they bridge the gap between traditional and modern healthcare practices. Our findings suggest that although informal healthcare providers are filling a necessary service delivery gap, they are often contributing to poor care. They are culturally embedded and immediately accessible when formalized healthcare is perceived as too expensive or unavailable 10 . However, services that are in principle available to informal settlements, such as government facilities, are often underregulated, poorly managed, or politicised, leading to inadequate services and corruption, and patients choosing alternative healthcare pathways. In the absence of regulation, informal care providers can inadvertently create health risks including an oversupply of medications or delayed diagnoses 35 . It underscores the need for overall reforms of the system to strengthen the governance of personal care at all levels, formal and informal. Limitations The study was conducted in five informal settlements that each have unique characteristics; hence, these results may not be generalisable to other settings, but some of the findings do replicate findings from studies in the country. Furthermore, the use of self-reported qualitative data may be biased by recall and social desirability effects. We limited these constraints by including a broad range of participants and contexts, engaging community researchers in data collection to increase its accuracy, and comparing findings across multiple sources. Conclusion This study underscores the complex dynamics of healthcare access in informal urban settlements, revealing that while healthcare services are available, significant financial, logistical, and informational barriers hinder equitable access to care. The findings demonstrate a reliance on informal healthcare providers, such as pharmacies and TBAs, to fill critical gaps, but also highlight the risks associated with their unregulated practices. The study calls for policy reforms that include pro-poor healthcare financing models, better integration of informal providers into the formal health system, and targeted health education initiatives to improve health literacy. Future interventions must address social, cultural factors that influence healthcare seeking behavior. In addition the socio-economic factors that prevent equitable healthcare access, and interventions must foster a more inclusive healthcare environment for marginalized populations. Declarations Acknowledgements: We acknowledge local knowledge contributed by research participants, local stakeholders and project partners, and appreciate their contributions in terms of allow us in the community and share their experiences Authors contribution: All authors listed made substantial contributions to the conception or design of this work, including the acquisition, analysis or interpretation of data for the work and gave final approval of the version. All authors agreed to be accountable for all aspects of the work. MRH, NWG, FMN, BA, SFR conceptualised the study and designed the approach. JK facilitated the workshops and JK, BA, ST, SFR feedback. MRH, FMN, and NJ conducted the initial analysis of the data and MRH, NWG, and FMN wrote the first draft of the manuscript. All authors reviewed and provided feedback on draft manuscripts. SFR is the guarantor for this study. Conflict of interest: The authors declare no conflicts of interest. Data availability: The data that support the findings of this study are available on request from the supervising author, SFR. The data are not publicly available due to their containing information that could compromise the privacy of research participants. Funding: This research was funded by the UK Research and Innovation (UKRI). The GCRF Accountability for Informal Urban Equity Hub ('ARISE') is a UKRI Collective Fund award with award reference ES/S00811X/1. For the purpose of open access, the author has applied a CC BY public copyright licence (where permitted by UKRI, ‘Open Government License’ or ‘CC BY-ND public copyright license may be stated instead) to any Author Accepted Manuscript version arising Disclaimer: The funder had no role in study design, data collection, data analysis, data interpretation or writing of the manuscript. References Habitat UN. Envisaging the future of cities: World cities report 2022. UN Habitat: Nairobi, Kenya . Published online 2022. 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Accessed July 13, 2025. https://cpd.org.bd/resources/2024/08/Health-Budget-of-Bangladesh-Optimising-Resources-for-Improved-Health-Outcomes.pdf Hasan MZ, Ahmed MW, Mehdi GG, et al. Factors affecting the healthcare utilization from Shasthyo Suroksha Karmasuchi scheme among the below-poverty-line population in one subdistrict in Bangladesh: a cross sectional study. BMC Health Serv Res. 2022;22(1):885. 10.1186/S12913-022-08254-1 . Watson S. Pharmacies in informal settlements: a retrospective, cross-sectional household and health facility survey in four countries. BMC Health Serv Res. 2021;21(1):1–10. Mishra KG, Patnaik N, Harshitha B, Mohandas A, Roy A, Patnaik S. Food insecurity: A formidable barrier to medication adherence in a vulnerable population with chronic diseases. Clin Epidemiol Glob Health. 2025;33:102033. 10.1016/J.CEGH.2025.102033 . Sapkota S, Tiwary MR, Zare MKB, Kumar P. Access to Healthcare Facilities and Social Well-being in Urban Areas. J Appl Bioanal. 2024;10(2):243–51. Corburn J. Urban Place and Health Equity: Critical Issues and Practices. Int J Environ Res Public Health 2017. 2017;14(2):117. 10.3390/IJERPH14020117 . Witter S, Sheikh K, Schleiff M. Learning health systems in low-income and middle-income countries: exploring evidence and expert insights. BMJ Glob Health. 2022;7(Suppl 7):e008115. Bitton A, Fifield J, Ratcliffe H, et al. Primary healthcare system performance in low-income and middle-income countries: a scoping review of the evidence from 2010 to 2017. BMJ Glob Health. 2019;4(Suppl 8):e001551. Langlois EV, McKenzie A, Schneider H, Mecaskey JW. Measures to strengthen primary health-care systems in low- and middle-income countries. Bull World Health Organ. 2020;98(11):781. 10.2471/BLT.20.252742 . Gibbings R, Wickramasinghe N. Technology’s Enabling Role to Improve Care Coordination. Handbook of Research on Optimizing Healthcare Management Techniques. IGI Global Scientific Publishing; 2020. pp. 358–65. Ohnishi Y, Watanuki S. The definition and evaluation of uncoordinated involvement of multiple healthcare providers;Polydoctoring as a component of care fragmentation among patients which multimorbidity. J Gen Fam Med. 2024;25(2):114. Matthias AT, Fernando GVMC, Somathilake BGGK, Prathapan S. Predictors and patterns of polypharmacy in chronic diseases in a middle-income country. Int J Physiol Pathophysiol Pharmacol. 2021;13(6):158. Falle TY, Mullany LC, Thatte N, et al. Potential Role of Traditional Birth Attendants in Neonatal Healthcare in Rural Southern Nepal. J Health Popul Nutr. 2009;27(1):53. 10.3329/JHPN.V27I1.3317 . Aziato L, Omenyo CN. Initiation of traditional birth attendants and their traditional and spiritual practices during pregnancy and childbirth in Ghana. BMC Pregnancy Childbirth. 2018;18(1):1–10. 10.1186/S12884-018-1691-7/PEER-REVIEW . Bender H, Peter T, Annie K, Jacquelyn C, Ana L. The Manoshi Project: Bringing Quality Maternal Care to Poor Women in Urban Bangladesh. Harvard School of Public Health and Maternal Health Task Force . Published online 2014. Roberts LW, Kim JP. Informal health care practices of residents:Curbside consultation and self-diagnosis and treatment. Acad Psychiatry. 2015;39(1):22–30. Cite Share Download PDF Status: Published Journal Publication published 18 Dec, 2025 Read the published version in Journal of Urban Health → Version 1 posted Editorial decision: Revise and resubmit 24 Sep, 2025 Reviewers agreed at journal 21 Aug, 2025 Reviewers invited by journal 21 Aug, 2025 Editor assigned by journal 14 Jul, 2025 First submitted to journal 14 Jul, 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. 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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-7123814","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":485354251,"identity":"6a14b81d-1ccf-489e-a2db-4406559bc573","order_by":0,"name":"Muhammad Riaz Hossain","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABD0lEQVRIiWNgGAWjYDACZjCCMBgkGCR42NgbgCwDC6K1WMjx8RwAaZEgZBEcVBjLSSQwgHXjAubtzI8/F1TU2fO38x5gsGyTSGyTfH51w48CCQb+9u4EbFpkDrMZGM84czhxxmG+BAZJkBbpnLKbPUCHSZw5uwGbFglmBoNk3rYDCQyHeQxgWtJu8AC1GEjk4tDC/uEwb1udvTxci+SZtJt/8GrhMWzmbWNm3ADVYswmwX7sNn5beIqZeYB+2QjUckDinIQcG08O220ZAwkenH7hP775Mw8wxOTOnzF8LFFWxyPffvzZzTd/bOT423uxakEBhyGRAXQhiCSoHAQYP4Ap9gdEqR4Fo2AUjIIRAwAgXFRUB2LVsAAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0002-5584-6201","institution":"BRAC University James P Grant School of Public Health","correspondingAuthor":true,"prefix":"","firstName":"Muhammad","middleName":"Riaz","lastName":"Hossain","suffix":""},{"id":485354252,"identity":"1767eeb1-c946-4678-a74f-24f9c253619c","order_by":1,"name":"Neele Wiltgen Georgi","email":"","orcid":"","institution":"LSTM: Liverpool School of Tropical Medicine","correspondingAuthor":false,"prefix":"","firstName":"Neele","middleName":"Wiltgen","lastName":"Georgi","suffix":""},{"id":485354253,"identity":"19b30edc-c928-4112-8b8a-e6b3dc804812","order_by":2,"name":"Farha Musharrat Noor","email":"","orcid":"","institution":"BRAC University James P Grant School of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Farha","middleName":"Musharrat","lastName":"Noor","suffix":""},{"id":485354254,"identity":"4021bc46-4d58-4ead-aac3-dd4d0875ad21","order_by":3,"name":"Bachera Aktar","email":"","orcid":"","institution":"BRAC University James P Grant School of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Bachera","middleName":"","lastName":"Aktar","suffix":""},{"id":485354255,"identity":"14b15b4c-903e-427d-9fc9-ad2ffd299687","order_by":4,"name":"Jiban Karki","email":"","orcid":"","institution":"LSTM: Liverpool School of Tropical Medicine","correspondingAuthor":false,"prefix":"","firstName":"Jiban","middleName":"","lastName":"Karki","suffix":""},{"id":485354256,"identity":"1670f914-f01e-468a-96b9-bd6ab9e83ab3","order_by":5,"name":"Mst. Nusrat Jahan","email":"","orcid":"","institution":"BRAC University James P Grant School of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Mst.","middleName":"Nusrat","lastName":"Jahan","suffix":""},{"id":485354257,"identity":"ced80c51-8064-4153-b130-87236dacf38a","order_by":6,"name":"Sally Theobald","email":"","orcid":"","institution":"LSTM: Liverpool School of Tropical Medicine","correspondingAuthor":false,"prefix":"","firstName":"Sally","middleName":"","lastName":"Theobald","suffix":""},{"id":485354258,"identity":"eaa50956-0d6c-419d-830b-389644e67add","order_by":7,"name":"Sabina Faiz Rashid","email":"","orcid":"","institution":"BRAC University James P Grant School of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Sabina","middleName":"Faiz","lastName":"Rashid","suffix":""}],"badges":[],"createdAt":"2025-07-14 18:31:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7123814/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7123814/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s11524-025-01042-2","type":"published","date":"2025-12-18T15:58:06+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":87044777,"identity":"69b532af-f131-4998-b170-494b001baaeb","added_by":"auto","created_at":"2025-07-18 14:25:03","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":26858,"visible":true,"origin":"","legend":"\u003cp\u003eFlow chart showing the key themes discussed in this section\u003c/p\u003e","description":"","filename":"OnlineFig1.png","url":"https://assets-eu.researchsquare.com/files/rs-7123814/v1/e8897b3f7e19af9f6f9809d2.png"},{"id":87044783,"identity":"5632cd97-3941-43fc-8b6d-d789dbe90c8e","added_by":"auto","created_at":"2025-07-18 14:25:03","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":20769,"visible":true,"origin":"","legend":"\u003cp\u003eThis chart shows the interplay between barriers, structural challenges, and the role of informal providers.\u003c/p\u003e","description":"","filename":"OnlineFig2.png","url":"https://assets-eu.researchsquare.com/files/rs-7123814/v1/772be38406e90d6f11b13562.png"},{"id":98814137,"identity":"153f3970-84ff-4f73-8a21-1dab99051f85","added_by":"auto","created_at":"2025-12-22 16:11:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":828802,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7123814/v1/a41c41e6-719f-41e1-8cef-9dabf7715668.pdf"}],"financialInterests":"","formattedTitle":"Healthcare in the Margins: A Qualitative Study of Healthcare Access and Utilization in Bangladesh's Informal Urban Settlements","fulltext":[{"header":"Introduction","content":"\u003cp\u003eUrbanization is rapidly transforming health and well-being. Globally, 68% of the population is projected to live in urban areas by 2050, with the majority of this growth occurring in low- and middle-income countries\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. The expansion has resulted in the spread of informal settlements, which are often overcrowded, poorly housed, lack sanitation and healthcare infrastructure. As a result residents face multifaceted health and well-being challenges, not only a high risk of both communicable and non-communicable diseases\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e but also exposure to environmental hazards, food insecurity, mental health stressors, and limited access to social protection and education. Over 52% of the urban population of Bangladesh lives in informal settlements, where health inequities increase due to endemic poverty, erratic jobs, lack of options, poor access to the primary health system, dependence on informal providers, and governance failures\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. The health challenges in informal settlements extend beyond inadequate healthcare access. Socio-economic instability, environmental vulnerabilities, and systemic neglect by state institutions, urban planning authorities, and health governance bodies ensure that these populations are uniquely susceptible to malnutrition, maternal and child health risks, mental health stressors, and chronic diseases, such as diabetes and hypertension\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. On top of that, the lack of social protection and universal health coverage in many countries, such as Bangladesh, often leads to high out-of-pocket (OOP) expenses that limit access to healthcare and add stress to the patient and their carers\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eAlthough quantitative approaches have documented healthcare delivery systems and disease burden, they provide limited insights into the ways marginalised communities negotiate access in fragmented healthcare systems, the role of perceived provider trustworthiness in choices about care-seeking, and the adaptive strategies employed if burdened by service shortages. Yet, such insights are particularly relevant when discussing reliance on unlicensed pharmacies, traditional healers, and local birth attendants, which, although accessible and culturally acceptable, may enhance misdiagnosis, antibiotic resistance, and delays in accessing critical healthcare\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Ironically, in the face of limited options and weak governance, these informal providers become the primary source of support in the health care system for those who remain impoverished.\u003c/p\u003e\u003cp\u003eThis study applies the social determinants of health framework to explore how economic precarity, governance failures, and socio-cultural factors shape healthcare-seeking behavior in Bangladesh\u0026rsquo;s informal settlements. Adopting a community-based participatory research (CBPR) approach and centring the voices of socio-economically marginalised groups\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e, the study provides an in-depth understanding of the enablers and barriers to healthcare access and residents\u0026rsquo; strategies to overcome these barriers across five informal urban settlements in Bangladesh, addressing a critical evidence gap. By holding up a mirror to the disconnect between formal healthcare provision and the everyday realities of informal settlement residents, this research generates policy-relevant insights to support more equitable and responsive urban health interventions. Ultimately, it aims to inform transformative, evidence-based approaches that enhance the accessibility, affordability, and accountability of healthcare for vulnerable urban populations.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003eStudy setting\u003c/p\u003e\u003cp\u003eThe research took place in five informal urban settlements across three city corporations (the highest tier of elected local government that manages all civic services in a metropolitan area) and one municipality (urban local government bodies) in Bangladesh, outlined in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The settlements were purposively selected due to their setting, population, migration, and vulnerability to eviction, lack of WASH facilities, and recurrent climate events, for instance, floods, cyclones, heatwaves, etc.\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\u003eStudy sites characteristics\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eKallyanpur\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDholpur\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eShyampur\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eItagacha\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eGreenland\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEstablished in\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1988\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1991\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1996\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1982\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLocation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDhaka North City Corporation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDhaka South City Corporation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDhaka South City Corporation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eItagacha Purbopara, Satkhira,\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eKhulna City Corporation,\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLand Ownership\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHousing and Building Research Institute (Government)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDhaka North City Corporation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePrivate and Bangladesh Railway (Government)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eBangladesh Water Development Board (Government)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eBangladesh Railway (Government)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of residents (approx.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15750\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6800\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e989\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5146\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of Divisions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOrigin of residents\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNorthern and southern Bangladesh\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCentral and northern Bangladesh\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCentral, north and southern Bangladesh\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSouthern Bangladesh\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eSouthern\u003c/p\u003e\u003cp\u003eBangladesh\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReason for settling\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEnvironmental Change (river erosion) Employment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEmployment (City corporation waste collection)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eEmployment in nearby\u0026nbsp;industrial areas.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eEnvironmental Change (cyclones and flooding, high water salinity, loss of land to climate events, loss of agricultural livelihood due to land erosion)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eEnvironmental Change (frequent cyclones and flooding, high water salinity, especially near the river, loss of land to river erosion, and better economic opportunities)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEviction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe Housing and Building Research Institute made several attempts to evict residents. The High Court action has been successful in stopping evictions.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEight blocks were evicted in 2023\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eEvictions of households settled on the railway line in 2021\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eThe Water Development Board has made several unsuccessful attempts in the past few years.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNo evictions.\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 Accountability and Responsiveness in Informal Settlements for Equity (ARISE) research consortium, in which this research is embedded, adopted a CBPR approach that centers the community researchers as equitable partners in the research process to document the lived experiences and challenges faced by residents living in informal settlements\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. CBPR emphasises co-production of knowledge, equitable community\u0026ndash;researcher collaboration, and reflexive engagement throughout the research process\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. This research design and analysis approach is particularly appropriate for informal settlement contexts, where structural inequalities and social marginalisation necessitate participatory methods that amplify local voices and enable a nuanced understanding of how residents navigate a fragmented healthcare landscape shaped by both systemic constraints and informal coping mechanisms\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003e This study\u0026rsquo;s methods draw on participatory service mapping sessions in five informal settlements to identify locally available formal and informal healthcare providers, services, and access pathways. These maps were used to inform subsequent in-depth case studies (CS) (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;22) and group discussions (GD) (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;5), which explored healthcare-seeking behavior, perceived provider trustworthiness, and barriers to accessing care as shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cb\u003eData Collection and Co-Analysis\u003c/b\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\u003eData collection methods\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"10\"\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=\"char\" char=\".\" 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=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eData Collection Methods\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTimeline\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eShyampur\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eDholpur\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eKallyanpur\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eRangpur\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eItagacha\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eGreenland\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u003cp\u003eTotal Session\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCase Study (CS)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIn-person interview\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAugust 2022 \u0026ndash;\u003c/p\u003e\u003cp\u003eSeptember 2022\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0 (Evicted)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eGroup Discussion (GD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eService Mapping (SM)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eJuly 2022 \u0026ndash; November 2022\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eValidation Session (VS)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e5\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\u003eAll audio records of the group discussion were transcribed in Bangla by the researchers and community researchers who were present during the sessions. All transcripts were cross-checked by researchers who had led the sessions, ensured the accuracy of the transcriptions and imported them into NVivo 12. The BRAC James P Grant School of Public Health (BRAC JPSGH) research team adopted an inductive framework approach to analyse and organise data according to key concepts, themes, and sub-themes for comprehensive data interpretation\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. During the first coding cycle, five research staff independently reviewed and coded the transcriptions of 22 case studies and 5 group discussions, and collectively assembled a codebook. MRH and FMN then reviewed and compared each other's code and used the comparative discussion to resolve disagreements and refine the codebook. During the second coding cycle, the researcher used memos to write down the key findings with their thoughts. We later created a data matrix with the coding outputs to analyse the findings, relations, and patterns.\u003c/p\u003e\u003cp\u003eThe findings were later shared and discussed and brought back to the communities through validation sessions (n\u0026thinsp;=\u0026thinsp;5), ensuring that interpretations aligned with residents' lived realities and enhancing credibility through member checking.\u003c/p\u003e\u003cp\u003e\u003cb\u003eRecruitment\u003c/b\u003e ARISE Bangladesh research team partnered with 13 community researchers (eight female, five male) who live across the five study sites and actively participate in the research process, ensuring meaningful community engagement and amplifying local voices. Together, the research team and community researchers prepared a guideline for the service mapping group discussion activity and case studies. The community researchers reviewed the guidelines and provided feedback on the questions, prompts, wordings, and local understandings of healthcare and disease terminologies.\u003c/p\u003e\u003cp\u003eTHE BRAC JPSGH research team and community researchers decided together on the inclusion and exclusion criteria for study participants. The research participants for the case study and group discussion were separately identified based on migration history and vulnerability by asking community researchers to list 20\u0026ndash;30 people from each site that are deemed essential to include, focusing on emphasizing social, economic, and gender diversity. The study deliberately included both new and older migrants to capture differences in social networks, financial stability, healthcare awareness, and health-seeking behavior. New immigrants (residents for \u0026le;\u0026thinsp;3 years) typically have weaker social networks, limited health literacy, and economic instability, and are more dependent on informal providers. On the other hand, older migrants (residents for \u0026ge;\u0026thinsp;10 years) tend to have closer community ties and better healthcare awareness, enabling better system navigation.\u003c/p\u003e\u003cp\u003eThis study used two non-probability sampling procedures: purposive sampling and quota sampling. The potential categories of respondents for our group discussions included marginalised people such as daily wage earners, pregnant women or lactating mothers, single female-headed households, people over the age of 60, people living with disabilities, local community leaders/influential, and healthcare providers to include diverse experiences. The study comprised eligible community participants who met the following inclusion criteria: aged over eighteen, member of a marginalised group (as determined by discussions with stakeholders, community representatives, and a literature review), resident of the community for at least five years (for older migrants), being identified as a community leader or influential person by community researchers during the transect walk and being formal or informal healthcare providers providing services in the community. Community -researchers facilitated participant recruitment, organised group sessions, and provided access, increasing trust and rapport building.\u003c/p\u003e\u003cp\u003e\u003cb\u003eEthical consideration\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAll participants were compensated with 500 BDT (approx. 4.43 USD) and lunch as reimbursement for their opportunity cost. The study was approved by the Institutional Review Board (IRB) of BRAC JPGSPH (Research Number 2019-034-IR) (13), and the Research Ethics Committee of Liverpool School of Tropical Medicine, UK (Research Protocol 19\u0026ndash;089) (14). We obtained informed written consent from all participants before conducting and recording the sessions. Personal identifiers were excluded from transcripts, and access to data was restricted to designated research team members following the project\u0026rsquo;s data management plan. In line with ARISE\u0026rsquo;s ethical guidance, we also integrated safeguarding measures throughout the study to ensure participant well-being and safety during all stages of data collection and engagement\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe results are structured around eight key themes that emerged from the data focusing on how residents of informal settlements navigate a pluralistic and fragmented healthcare landscape, namely: healthcare provision landscape, healthcare provider perception, access to healthcare, coping and adaptation strategies. A visual summary of the key themes is provided in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e to guide the reader through the interlinked findings.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eHealthcare Provider Distribution Across Research Sites\u003c/b\u003e\u003c/p\u003e\u003cp\u003eParticipants across study sites identified and listed multiple healthcare providers, including government facilities, private clinics, NGO-run facilities, pharmacies (informal and unlicensed), and traditional healthcare providers, which are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. However, availability did not ensure equitable access. Affordability, overcrowding, and inconsistent service quality remained key barriers.\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\u003eNumber and types of healthcare service availability across research sites\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=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSite\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGovernment hospital\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePrivate Clinic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNGO-run facilities\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePharmacy (informal)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eTraditional healthcare practitioner\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e\u003cp\u003eNumber of Facilities\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKallyanpur (Dhaka)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDholpur (Dhaka)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eShyampur (Dhaka)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGreenland (Khulna)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIttagacha (Satkhira)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1\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\u003eA female participant from Dholpur highlighted this disparity:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWe have NGO clinics, a government hospital, pharmacies, and even a private diagnostic center near our community. The problem is not the availability of doctors, it\u0026rsquo;s accessing the services. (GD, housewife)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eCity corporation areas, including Kallyanpur, Dholpur, Shyampur, and Greenland, offered more healthcare options. In contrast, municipality areas had fewer formal healthcare facilities, further restricting residents\u0026rsquo; choices.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePerceptions of Government Healthcare Services\u003c/b\u003e\u003c/p\u003e\u003cp\u003eGovernment hospitals are considered essential for financially marginalized populations, particularly for emergencies, surgeries, and specialized treatments. A female participant from Kallyanpur emphasized:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eIf you can access the doctor\u0026rsquo;s room in a government hospital, you will receive complete and perfect treatment. (GD, CDO member)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAnother male participant from Shyampur compared public and private hospitals:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe treatment I receive at a private hospital for thousands of taka,(8 USD) I can get for just ten taka (0.082 USD) in a government hospital. (GD, day laborer)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eDespite confidence in treatment quality, systemic barriers undermine accessibility further. Participants cited long wait times, overcrowding, staff misconduct, and absent doctors. Many reported lack of accountability, leading to denied or delayed services. For example, a female participant from Kallyanpur expressed frustration:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eGovernment hospitals are important to us, but we are not important to them\u0026hellip; I waited for hours at the National Heart Foundation, but the doctor never showed up. We can\u0026rsquo;t question them. (GD, housewife)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eHidden costs also impacted access, especially in a setting where income is low and precarious with the average household income. Another male participant from Rangpur described informal payments:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe emergency ticket costs 50 BDT (0.4 USD), but they charge 100 (0.8 USD) to 150 BDT (1.2 USD). If you pay, you get seen faster. If not, even if you're seriously ill, you wait. Trolleys should be free, but they charge another 300 (2.5 USD) to 400 BDT (3.2 USD). (CS, Harijan (Dalit))\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAlthough government hospitals offer better treatment than many private facilities. Participants attributed the \u0026ldquo;better treatment\u0026rdquo; to the presence of highly qualified and experienced doctors, many of whom also practice in renowned private hospitals. Government facilities also provide access to essential surgical services, diagnostics, and hospitalization at minimal or no cost, making them a critical lifeline for low-income populations. However, community members often bypass government hospitals due to long wait times, overcrowding, high transportation and hidden costs, as well as negative experiences with staff behavior, including instances where bribes are requested for services that are officially meant to be free. As a result, pharmacies or informal providers become the preferred option for quicker and more accessible care, even if of lower quality. A female participant from Shyampur explained:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eMany people just buy medicine from a pharmacy without consulting a doctor. If the condition gets serious and local treatment doesn\u0026rsquo;t work, then we go to Dhaka Medical. (GD, ultra-poor)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThis reliance on unlicensed informal pharmacies over hospitals highlights the logistical and financial barriers deterring residents from accessing formal healthcare use.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePerception of Private Healthcare Facilities\u003c/b\u003e\u003c/p\u003e\u003cp\u003eResidents exhibited mixed perceptions of private healthcare. While some preferred established private clinics for efficiency and diagnostics, financial constraints prevented widespread access. However, private healthcare costs remained prohibitive.\u003c/p\u003e\u003cp\u003ePrivate hospitals attempted to reduce costs through health card schemes, but these often served promotional purposes rather than offering real financial relief. A female participant from Satkhira noted:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003ePrivate clinics came to our area, offering health cards so we wouldn\u0026rsquo;t have to pay high consultation fees. But they mostly want us to use their services. (GD, housewife)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eDespite high fees, private hospitals became the only choice during emergencies, when public hospitals fail due to corruption, inefficiency, or long delays. A pregnant woman from Shyampure explained:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eEven though private hospitals are expensive, they are our only choice when patients do not recover from informal or medical facilities. (CS, housewife)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eThe Role of Informal Pharmacies\u003c/b\u003e\u003c/p\u003e\u003cp\u003eUnlicensed pharmacies dominate the informal healthcare landscape, offering accessible, trusted, and often lifesaving services. Participants praised pharmacies for their affordability, availability of medicines, and willingness to provide medicine on credit. A female participant from Greenland highlighted their role:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eMy daughter had a bad fever, but we had no money. A pharmacist gave me 300 taka (2.7 USD) worth of medicine on credit, which really helped my family in crisis. (CS, new migrant)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eFor new migrants either affected/displaced by the climate crisis or needing to relocate, with limited networks, pharmacists serve as primary referral points to healthcare facilities, bridging gaps in healthcare knowledge. The low cost and convenience of pharmacies lead many residents to self-medicate rather than visit doctors. A male participant from Kallyanpur noted:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWhen I have a fever or cold, I just tell the pharmacy, and they give me medicine. I don\u0026rsquo;t waste 500 taka on a doctor visit. (GD, street vendor)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAlthough pharmacies provide crucial healthcare access, their unregulated status raises major concerns. Some unlicensed drug sellers hold disproportionate influence, creating unequal access to trusted providers.\u003c/p\u003e\u003cp\u003eIn addition, for daily wage laborers, long hospital wait times and lost wages make pharmacies the most viable healthcare option given the lack of overall choices for those who remain chronically marginalised.\u003c/p\u003e\u003cp\u003e\u003cb\u003eReputation of NGO Clinics\u003c/b\u003e\u003c/p\u003e\u003cp\u003eNGO clinics are highly trusted, particularly for maternal and child healthcare. Their community-based outreach reduces hospital visits and builds confidence. A female participant from Dholpur emphasised:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eEveryone knows the clinic because they have provided maternal and child care services and vaccines for a long time.(GD, housewife)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eHowever, despite their widespread acceptance, NGO clinics face resource constraints, leading to service disruptions. Many participants expressed concerns about clinics closing, reducing operations or charging service fees that were previously free due to funding shortages. A pregnant woman from Shyampur described unexpected expenses in NGO-affiliated private programs:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eSMC gave me a free birth control implant, but now it costs 270 taka (2.22USD). That\u0026rsquo;s too expensive for us. (CS, housewife)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThis is directly tied to funding cuts in the North. During the pandemic, there were severe cuts to funding by Western countries, which led to NGOs pulling out of informal settlements, creating disruption and havoc for those poorer families who had become reliant on their services and support. Since then, there have been further cuts in global health in 2025, which have severely impacted local NGOs ' ability to provide services.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTraditional Healthcare Providers\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTraditional/Indigenous healers, including Traditional Birth Attendants (TBAs), Imams (religious leaders), and herbal healers, play a critical role, especially in maternal and newborn care. While institutional deliveries have increased in urban areas, especially due to the rise in cesarean births and greater awareness, TBAs and traditional healers remain a critical option for ultra-poor households who cannot afford hospital costs or new migrants with a lack of social networks to navigate formal care and among older caregivers due to their affordability, accessibility, and social familiarity. A female CDC member from Greenland emphasized:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThey come whenever we call, at midnight or any time. We rate them 10/10 for their service. (GD, Local committee member)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eFor ultra-poor families, TBAs remain indispensable, with payments typically 1,000\u0026ndash;1,500 taka (USD 8\u0026ndash;12) or in-kind. Given the hidden costs in formal facilities, rising costly cesarean surgeries push on poor women in the country, a TBA offers cheap service for those who cannot afford the limited and expensive options available.\u003c/p\u003e\u003cp\u003eReligious leaders (Imans) also play a significant role in treating perceived supernatural illnesses for newborn and/or young children. A female participant from Greenland shared:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWhen our children cry excessively, we take them to a Hujur or Boiddo, and their treatment works. (GD, small business owner)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eWhen families suspected illnesses, such as unexplained fevers, seizures, or bad health of newborns, new mothers, and pregnant mothers, caused by evil eyes (nazar) or spiritual influences, they sought spiritual and or traditional healers. These healers are embedded in communities, offer flexible payment (often in-kind), and provide immediate care with prayers (dua), amulets (ta\u0026rsquo;wiz), and herbal remedies (kobiraji), giving psychological comfort, even if ineffective for biomedical conditions.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo illustrate the interplay between various factors influencing healthcare access in informal urban settlements, we present the following Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. It highlights the structural challenges, barriers to access, and fragmentation within the healthcare system, alongside the role of informal providers.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe study investigated health-seeking behavior dynamics in five informal urban settlements in Bangladesh, focusing on healthcare access and availability across different healthcare provider sectors (government, private, NGO, and informal). The results underline that whilst health care services exist across all sites, as the residents face substantial challenges in accessing healthcare, including economic precarity, governance crisis, and socio-cultural factors constrain health-seeking practice. From precarious backgrounds, such as ultra-poor households and new migrants were particularly affected by these barriers. For these groups, the high cost of transportation, long wait times, negative attitudes towards patients and informal payments often prevented access to government services\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eMany participants, particularly those from slightly better-off households or those with regular incomes, preferred private facilities for faster and more reliable care, often at an additional cost. The financial burden associated with access to both government and private facilities is exacerbated by inadequate health insurance coverage and limited private health insurance options, forcing families to make difficult trade-offs between healthcare and basic necessities. In Bangladesh, OOP expenditures account for approximately 73% of total health expenditure \u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. Despite the existence of government programs like the Shasthyo Surokhsha Karmasuchi (SSK) aimed at providing health insurance for slum dwellers, low enrollment persists due to limited coverage, awareness gaps, complex registration processes, and funding constraints\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. This leads vulnerable populations to lean toward cheaper alternatives, such as local pharmacies and informal providers\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e, or choose between health care and other necessities, including food and shelter\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eResidents in city corporation areas such as Kallyanpur and Dholpur which are informal settlements have access to more healthcare options but encounter system inefficiencies such as transport cost, fees and hidden costs, bad experiences, etc. indicating that urban location alone does not guarantee equitable access to healthcare\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eOur findings are consistent with a growing body of evidence describing a fragmented healthcare system within informal urban settlements in LMICs, where residents experience inadequate healthcare services marked with suboptimal healthcare delivery\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. For example, a wide variety of healthcare providers (public, private, NGO) can be present in the same informal settlements. Still, the lack of coordination and integration between these providers can provide a very fragmented care experience\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e. This fragmentation may result in duplicate services and gaps in care\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. It may amplify the economic costs for polypharmacy patients-individuals who are prescribed and consume multiple medications especially when they visit multiple service providers to receive quality care\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e,\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e. This fragmentation, along with low levels of health literacy, renders many people in Bangladesh unable to seek care and worsens existing health inequities\u003c/p\u003e\u003cp\u003eOne of the findings of this study was that informal health providers, most notably local pharmacies and TBAs, were relied upon by residents of informal settlements to fulfil their health needs. Pharmacies operate without regulatory oversight and are generally considered both accessible and affordable, as well as reliable, for treating minor ailments. These healthcare providers are vital in the community, particularly those who are economically disadvantaged, since they can extend credit, dispense limited quantities of medications, and refer to other healthcare providers\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. TBAs continue to play a critical role in maternal and newborn care, especially in ultra-poor households within informal urban settlements, where the opportunity cost of accessing formal healthcare is prohibitive. TBAs are valued for their accessibility, cultural relevance, and the holistic nature of their care, which often includes both emotional and spiritual support\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e. Despite their significance, TBAs are not formally trained, and traditional practices such as using spiritual artefacts, herbs and physical examination or mustard oil on premature babies raise concerns about safety and care quality, particularly when complications arise\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e. To mitigate these risks, programs like BRAC\u0026rsquo;s MANOSHI have engaged TBAs by providing training and monitoring from Skilled Birth Attendants (SBAs)\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e. This approach ensures safe childbirth while maintaining cultural alignment with the community\u0026rsquo;s healthcare preferences. Trust and acceptability of TBAs are enhanced through these initiatives, as they bridge the gap between traditional and modern healthcare practices.\u003c/p\u003e\u003cp\u003eOur findings suggest that although informal healthcare providers are filling a necessary service delivery gap, they are often contributing to poor care. They are culturally embedded and immediately accessible when formalized healthcare is perceived as too expensive or unavailable\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. However, services that are in principle available to informal settlements, such as government facilities, are often underregulated, poorly managed, or politicised, leading to inadequate services and corruption, and patients choosing alternative healthcare pathways. In the absence of regulation, informal care providers can inadvertently create health risks including an oversupply of medications or delayed diagnoses\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e. It underscores the need for overall reforms of\u0026ensp;the system to strengthen the governance of personal care at all levels, formal and informal.\u003c/p\u003e\u003cp\u003e\u003cb\u003eLimitations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe study was conducted in five informal settlements that each have unique characteristics; hence, these results may not be generalisable to other settings, but some of the findings do replicate findings from studies in the country. Furthermore, the use of self-reported qualitative data may be biased by recall and social desirability effects. We limited these constraints by including a broad range of participants and contexts, engaging community researchers in data collection to increase its accuracy, and comparing findings across multiple sources.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study underscores the complex dynamics of healthcare access in informal urban settlements, revealing that while healthcare services are available, significant financial, logistical, and informational barriers hinder equitable access to care. The findings demonstrate a reliance on informal healthcare providers, such as pharmacies and TBAs, to fill critical gaps, but also highlight the risks associated with their unregulated practices. The study calls for policy reforms that include pro-poor healthcare financing models, better integration of informal providers into the formal health system, and targeted health education initiatives to improve health literacy. Future interventions must address social, cultural factors that influence healthcare seeking behavior. In addition the socio-economic factors that prevent equitable healthcare access, and interventions must foster a more inclusive healthcare environment for marginalized populations.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements: \u003c/strong\u003eWe acknowledge local knowledge contributed by research participants, local stakeholders and project partners, and appreciate their contributions in terms of\u0026nbsp; allow us in the community and share their experiences\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors contribution:\u003c/strong\u003e\u0026nbsp;All authors listed made substantial contributions to the conception or design of this work, including the acquisition, analysis or interpretation of data for the work and gave final approval of the version. All authors agreed to be accountable for all aspects of the work. MRH, NWG, FMN, BA, SFR conceptualised the study and designed the approach. JK facilitated the workshops and JK, BA, ST, SFR feedback. MRH, FMN, and NJ conducted the initial analysis of the data and MRH, NWG, and FMN wrote the first draft of the manuscript. All authors reviewed and provided feedback on draft manuscripts. SFR is the guarantor for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest: \u003c/strong\u003eThe authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability:\u003c/strong\u003e The data that support the findings of this study are available on request from the supervising author, SFR. The data are not publicly available due to their containing information that could compromise the privacy of research participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u0026nbsp;This research was funded by the UK Research and Innovation (UKRI). The GCRF Accountability for Informal Urban Equity Hub ('ARISE') is a UKRI Collective Fund award with award reference ES/S00811X/1. For the purpose of open access, the author has applied a CC BY public copyright licence (where permitted by UKRI, \u0026lsquo;Open Government License\u0026rsquo; or \u0026lsquo;CC BY-ND public copyright license may be stated instead) to any Author Accepted Manuscript version arising\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclaimer:\u003c/strong\u003e The funder had no role in study design, data collection, data analysis, data interpretation or writing of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHabitat UN. Envisaging the future of cities: World cities report 2022. \u003cem\u003eUN Habitat: Nairobi, Kenya\u003c/em\u003e. Published online 2022.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRahaman MA, Kalam A, Al-Mamun M. 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Acad Psychiatry. 2015;39(1):22\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-urban-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jurh","sideBox":"Learn more about [Journal of Urban Health](https://www.springer.com/journal/11524)","snPcode":"11524","submissionUrl":"https://www.editorialmanager.com/jurh","title":"Journal of Urban Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Healthcare access, urban health, marginalized populations, Informal urban settlements, Health-seeking behavior","lastPublishedDoi":"10.21203/rs.3.rs-7123814/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7123814/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThis study investigates healthcare access and health-seeking behavior in informal urban settlements of Bangladesh, focusing on the roles played by key stakeholders, public, private, NGO, and informal sectors, toward positive health outcomes. Utilizing data gathered from group discussions (N\u0026thinsp;=\u0026thinsp;5) and case studies (N\u0026thinsp;=\u0026thinsp;22) in five informal urban settlements, we uncover many important barriers to healthcare access, with those linked to economic and infrastructural shortcomings emerging as particularly critical. There is available healthcare, but public hospitals face overcrowding and long waiting lists, mistreating poorer patients, and the price of private health facilities is unaffordable for many residents. Culturally relevant alternatives, so-called informal healthcare providers, local pharmacies (unlicensed) in particular, and traditional birth attendants (TBAs) are important, although they often offer services that include\u0026ensp;risks such as over-prescribing and insufficient training. Factors including financial stress, low health literacy, and a fragmented health care system drive health inequities. This study underscore\u003cb\u003es\u003c/b\u003e the importance of enhancing health literacy and education to enable marginalized groups to make effective health choices. The study provides fresh insights into the healthcare needs and health inequities in these informal urban settlements. These findings reinforce the relevance of SDG 3 goals by emphasizing the need for inclusive, equitable, and community-oriented healthcare approaches to ensure healthy lives and promote well-being for all.\u003c/p\u003e","manuscriptTitle":"Healthcare in the Margins: A Qualitative Study of Healthcare Access and Utilization in Bangladesh's Informal Urban Settlements","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-18 14:24:58","doi":"10.21203/rs.3.rs-7123814/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revise and resubmit","date":"2025-09-24T16:39:11+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2025-08-21T20:52:32+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-21T16:42:39+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-14T19:23:36+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Urban Health","date":"2025-07-14T14:30:46+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-urban-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jurh","sideBox":"Learn more about [Journal of Urban Health](https://www.springer.com/journal/11524)","snPcode":"11524","submissionUrl":"https://www.editorialmanager.com/jurh","title":"Journal of Urban Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"4ea52c6f-48f6-43e7-a37c-6f3cacff4a63","owner":[],"postedDate":"July 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-22T16:05:56+00:00","versionOfRecord":{"articleIdentity":"rs-7123814","link":"https://doi.org/10.1007/s11524-025-01042-2","journal":{"identity":"journal-of-urban-health","isVorOnly":false,"title":"Journal of Urban Health"},"publishedOn":"2025-12-18 15:58:06","publishedOnDateReadable":"December 18th, 2025"},"versionCreatedAt":"2025-07-18 14:24:58","video":"","vorDoi":"10.1007/s11524-025-01042-2","vorDoiUrl":"https://doi.org/10.1007/s11524-025-01042-2","workflowStages":[]},"version":"v1","identity":"rs-7123814","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7123814","identity":"rs-7123814","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}