Reaching the Unreachable: A mixed-method evaluation of multidimensional healthcare model addressing the healthcare service gaps in hard-to-reach Northern Riverine Bangladesh

Reaching the Unreachable: A mixed-method evaluation of multidimensional healthcare model addressing the healthcare service gaps in hard-to-reach Northern Riverine Bangladesh | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Reaching the Unreachable: A mixed-method evaluation of multidimensional healthcare model addressing the healthcare service gaps in hard-to-reach Northern Riverine Bangladesh Md Refat Uz Zaman Sajib, Kamrul Hasan, Tanvir Hayder, A M Rumayan Hasan, and 10 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4456479/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 14 Apr, 2025 Read the published version in Archives of Public Health → Version 1 posted 17 You are reading this latest preprint version Abstract Background Remote and hard-to-reach riverine communities of northern Bangladesh face unique challenges in health care services. Friendship, an international social purpose organization, has implemented a 3-tier health care model addressing these unique challenges over the past 20 years. This study evaluates Friendship’s 3-tier health care model, focusing on general health care service-seeking practices, beneficiary and stakeholder perspectives, and cost benefits. Methods A mixed-method approach was employed, including desk reviews, a cross-sectional quantitative survey, and qualitative interviews with service recipients, community representatives, health care providers, and health managers. Data were collected from five hard-to-reach riverine sub-districts across Kurigram, Gaibandha, Bogura, Sirajganj, and Jamalpur districts of Bangladesh between April 2022 and July 2023. Data analyses followed major thematic domains for a comprehensive and complementary understanding. Results A significant proportion (43.0%) of survey participants had no formal education, were aged 18–35 (57.5%), and earned less than 1,620 USD yearly (66.6%). Friendship's health care services at doorstep through satellite clinics and Female Community Medic Aides are widely accepted and preferred within the community for convenience, affordability (0.05–0.09 USD service charges), and superior quality, particularly the specialized treatments available on the hospital ships. Conclusion The 3-tier health care model offers a wide range of services, including ante- and post-natal care, family planning, and specialized treatment, complemented by nutrition demonstrations and community-based health awareness initiatives. With generalized acceptance among the target communities, Friendship's 3-tier health care model has made primary health care accessible and affordable. Upon implementing a robust referral mechanism and continuing collaboration with the Government of Bangladesh, this model has the potential to be effective in similar settings in Bangladesh and other developing countries, as well as during emergency responses. 3-tier health care model Comprehensive health care model Hard-to-reach Riverine low-resource setting Bangladesh Figures Figure 1 Figure 2 Contributions to the Literature The study highlights how Friendship’s (a Social Purpose Organization) 3-tier healthcare model addresses existing challenges in access to healthcare services from government facilities in the hard-to-reach riverine areas of northern Bangladesh. The model ensures primary, secondary and specialized healthcare through Hospital Ships, monthly temporary paramedic-led clinics and 24/7 trained community medic aids, as well as promotes nutrition with locally sourced ingredients and healthy lifestyle practices through courtyard sessions. Such a multidimensional approach can also be cost-effective in providing essential healthcare services for hard-to-reach populations, instilling confidence in its sustainability and implication for similar settings. Introduction In low-and middle-income countries (LMICs) like Bangladesh, the lack of health care resources and disparities in health care services are major challenges.[1] Such health care disparities impact the health indicators, delaying progress toward achieving Sustainable Development Goals (SDG).[2] Despite being a crucial component of development agendas, many developing countries continue to have significant concerns about the underutilization and limited reach of health care services.[3] Bangladesh, a densely populated country with a population of 164.7 million[4], faces significant challenges in meeting the rising health care needs of its diverse regions.[5] The persistent inequalities in health care access are mostly due to geographical diversity, including remote and hard-to-reach areas such as coastal, hilly, haor (wetland), and riverine or Char areas (shallow land mass rising within a water body).[6, 7] Despite constituting 5% of the total land with approximately 6.5 million people, these remote areas generally lack adequate public health infrastructures.[8] Moreover, these Char areas are particularly vulnerable to natural calamities like flooding, erosion, cyclones, etc., which regularly hamper essential services, including health care and transportation. This further worsens the overall scenario, leaving the health care needs of such hard-to-reach Char communities mostly unmet. Previous studies have reported that only 35% of the Char dwellers have access to public health care services, while 80% are ultra-poor.[8, 9] As a result, seeking health care services from informal and traditional health practitioners remains frequent.[9] To aid the people of these underserved areas, Friendship, an international Social Purpose organization, has been working for the last 20 years through a multidimensional 3-tier health care model. This includes Hospital Ships (Tier 1), Satellite Clinics and Static Clinics (Tier 2), and Friendship Community Medic Aides (FCMs) (Tier 3).[10–12] Currently, Friendship operates two hospital ships: Lifebuoy Friendship Hospital (LFH) and Emirates Friendship Hospital (EFH), providing primary, secondary, and specialized health care in distant climate-vulnerable areas where the government and other non-governmental organizations have little or no intervention. Also, paramedic-led Satellite and Static Clinics serve the target community monthly to provide basic medical services for communicable and non-communicable disease prevention, behavioral change communication, and general health care services. Moreover, it trains female community members as medic aides (FCMs) to provide primary health care services in their communities.[12] Given the gaps in public health care coverage in these hard-to-reach areas, such a multidimensional model utilizing a mobility-based community participatory approach possesses potential efficacy.[13] Exploring this comprehensive health care model can reveal insights about how it functions in such a hard-to-reach setting and helps the community in need, as well as possible scopes to reinforce/introduce additional initiatives. Thus, this study aims to evaluate this 3-tier health care model addressing the health care needs of this hard-to-reach riverine area of northern Bangladesh in light of general health care service-seeking practices, experience, and perception from beneficiaries and stakeholders, as well as cost benefits. Materials and Methods Study Design, Duration, and Site This study adheres to a mixed-method approach integrating desk reviews, cross-sectional quantitative surveys, facility assessments, and exploratory qualitative design to comprehensively investigate the research objective. It was conducted between April 2022 and July 2023 in five northern riverine districts (Kurigram, Gaibandha, Bogura, Sirajganj, and Jamalpur) of Bangladesh, where Friendship runs the 3-tier multidimensional health model. Chilmari, Sundarganj, Sariakandi, Kazipur, and Madarganj sub-districts were selected randomly among the nine sub-districts, each representing one district. Quantitative and qualitative data collection were conducted, focusing on the beneficiaries and stakeholders of this health care model. The quantitative survey explored the sociodemographic and economic domain, including the cost benefits, whereas the community's and stakeholders' perspectives on the health care model and the potential scope of further implications were explored using a qualitative approach. General health care service-seeking practices were explored using both quantitative and qualitative data. Sample Size and Sampling The sample size for the quantitative survey was determined considering a 76% estimated prevalence (based on coverage) of beneficiaries in the targeted areas.[14] The margin of error and confidence level were assumed to be 4% and 99%, respectively. The total sample size for the survey was around 757 (~760) who had received health care services from this model at the study sites. The desired sample size for each sub-district was 152, which was distributed equally among the selected sub-districts. Approximately 30-36 qualitative interviews were planned to be conducted with purposively selected participants of different backgrounds (beneficiaries, service providers, administrative officials, and other stakeholders- community representatives/gatekeepers, local government officials, and health managers). However, to reach data saturation, 56 qualitative interviews were conducted, including eight focus group discussions (FGDs) with both service providers and service recipients, 32 in-depth interviews (IDIs) with service recipients, service providers, community representatives/gatekeepers, etc., and 16 key informant interviews (KIIs) with officials and health managers from Friendships’ Central and Regional offices and local Government of Bangladesh (GoB). Also, to comprehensively support the findings, two facility assessments of the Friendship hospital ships and three case stories of the service recipients were conducted. Finally, two review and feedback workshops were conducted, comprising GoB officials and health managers, service providers of different levels, and service recipients from different areas, to validate the collected data as well as seek recommendations for further integration and improvement. Data Collection Considering the population context and study location, the study recruited experienced data collectors: two males and two females. The selected data collectors received a week of rigorous training, including practical and supervised data collection sessions. The study team physically supervised field data collection to ensure high-quality data gathering. We used open-ended guides for KIIs, FGDs, IDIs, and structured questionnaires for the survey, which were finalized following initial field testing. The beneficiaries only residing permanently in the communities and have taken/have been taking services from the Friendship 3-tier health care model within/during the last one year were considered for the survey or interviews. The KIIs were conducted face-to-face in convenient places for the respondents; FGDs and IDIs were held in the courtyards/households of the participants as they suggested. To ensure comfortable participation, no other people were allowed except the participants during the data collection process. For the survey, data were collected both from the satellite clinic and courtyard session participants and by visiting community households without separate scheduling rather than following regular satellite clinic schedules to different communities (venue-based data collection) [15]. Apart from these, observation notes of the field-site debriefing and review and feedback workshop were collected, and all previous reports and relevant records regarding each tier were collected from Friendship regional and head offices as well as from the ships. Data Analysis Quantitative data (survey, reports, records, and logbooks) was stored in Excel and analyzed using STATA 15.0. Descriptive statistics were used to explain the findings and presented coherently with the qualitative findings. The cost of key services of Friendship's 3-tier health care system was compared with nearby alternative facilities to calculate financial cost-benefit. For the value for money of the services from the organizational perspective, expenses to provide any specific services by Friendship (relative cost per beneficiary) were compared with nearby alternative private facilities. Qualitative data (IDIs, KIIs, FGDs, workshops) were audio-recorded and analyzed thematically.[16] The qualitative data analysis was performed using NVivo software (Version 12) in several stages. Initially, the purpose and plan of data analysis were outlined following listening to the tape-recorded interviews to identify discussed issues, emerging topics, and strengths and weaknesses of interview techniques. It helped to be familiarised with the data, enhanced future data quality, and initiated data analysis. The recorded interviews were then transcribed verbatim (conducted in the native language, Bengali), including all spoken content without alteration, and supplemented by field notes and interviewer’s observations. Subsequently, transcribed data were compared to identify data exploration gaps by assessing similar issues discussed by different types of interviewees. A set of a priori codes based on interview guidelines and study objectives was prepared before looking at the raw data and utilized to assign codes to each transcription. These codes were then condensed into a narrower set of codes and themes, ensuring comprehensive coverage of raw data. Next, emerging themes and sub-themes were identified, highlighting common ideas and recurrent themes grounded in actual data aligned with study objectives. Finally, data were systematically triangulated, indexed, synthesized, and interpreted to present findings comprehensively. Results Activities through the 3-tier Health care Model Friendship’s activities include various health care services but are not limited to antenatal care (ANC), postnatal care (PNC), family planning, respiratory tract infections, skin diseases, diarrhea, fever, cough, typhoid, and specialized services like cataract surgery, cleft lip and palate surgery, club foot surgery, etc. through the 3-tier health care model. It also involves monthly nutrition demonstration sessions, regular health and family care follow-ups (data tracking), assessment, treatment, and referral of malnutrition cases for under-5 children and pregnant and lactating mothers. Their hospital ships (Tier 1) provide primary, secondary, and specialized health care in distant climate-vulnerable areas where the government and other non-governmental organizations have little or no intervention, depending on the people’s needs and feasibility of moving, considering the navigability of the rivers. The paramedic-led Satellite and Static Clinics (Tier 2) run biweekly or monthly to provide basic medical services for communicable and non-communicable disease prevention, behavioral change communication, and general health care issues. Moreover, Friendship trains female community members as medic aides (FCMs) (Tier 3) to act as the first point of contact for Friendship health care initiative (Figure 1). FCMs with specialized training to be Community Skilled Birth Attendants (CSBAs) facilitate access to safe delivery, advanced family planning services, ANC, PNC, and basic infant/neonatal care for Char communities. Furthermore, some FCMs are equipped with mobile phones to enable m-health services for remote diagnosis and connecting patients with Friendship assigned doctors when needed, following the app's step-by-step instructions, ensuring comprehensive accessibility at any time. Sociodemographic and Economic Conditions A significant proportion (43.0%) of the quantitative survey participants had no formal education. Among others, 26.8% attended primary school, 20.4% attended high school, and only 4.5% pursued college education. The majority of service recipients were female (88.9%) and aged 18-35 years (57.5%). Most households have 5—10 members (45.8%), approximately two-thirds (66.6%) earning less than 1620 USD, and 14.4% reported unawareness about their income. Regarding water and sanitation, the majority of households had individual tube wells (66.7%) and used covered pit latrines (29.0%) (Table 1). Table 1: Sociodemographic and economic characteristics of survey respondents Characteristics n=760 N (%) Sex Male 84 (11.1%) Female 676 (88.9%) Age category 18-25 210 (27.6%) 26-35 227 (29.9%) 36- 45 111 (14.6%) 46- 60 139 (18.3%) 61- 90 34 (4.4%) Don't know 39 (5.1%) Religion Islam 731(96.2%) Hindu 29 (3.8%) Household size category 1 to 4 406 (53.4%) 5 to 10 348 (45.8%) >10 6 (0.8%) Years of schooling None 328 (43.1%) 1 – 5 204 (26.8%) 6 – 10 155 (20.4%) 10+ 33 (4.5%) Don't know 40 (5.2%) Occupation Housewife 585 (76.9%) Auto/ Van/Rickshaw Driver 10 (1.3%) Day Labour 12 (1.6%) Fisherman 3 (0.4%) Farmer 113 (14.9%) Service Holder 8 (1.1%) Small Business 18 (2.4%) Others 11 (1.4%) Source of Water Pipe(internal) 1 (0.1%) Pipe(yard) 2 (0.3%) Tube-well (Joint) 241 (31.7%) Tube-well (Individual) 507 (66.7%) Well (With coverage) 2 (0.3%) Well (Without coverage) 2 (0.3%) Geosphere (Pond/River/canal/fen) 1 (0.1%) Others 4 (0.5%) Latrine type With septic tank 59 (7.7%) With water seal 82 (10.8%) Without water seal 325 (42.8%) Covered pit 220 (29.0%) Open pit 16 (2.1%) Hanging latrine 2 (0.3%) No Latrine 33 (4.3%) Others 23 (3.0%) Yearly expenditure (USD)* 2700.01 4 (0.5%) Don't know 134 (17.6%) Yearly income (USD)* 2700 39 (5.1%) Don't know 109 (14.4%) *Converted using 01 BDT = 0.009 USD; OANDA currency converter as of 25 January 2023 According to the hospital ship register (2008 to 2022), for EFH and LFH, nearly 37-40% of beneficiaries were male, while around 59-62% were female, with over 70% of the beneficiaries aged between 26-60 years. General Health Service-Seeking Practices The Char people have been facing challenges in accessing government health services due to various factors such as geographical distance, transportation time, and cost associated with traveling to health care facilities. The 3-tier health care program provides convenient access to health care services in their neighborhood and enables them to get high-quality over-the-counter medicines at the most affordable price from the FCMs. The common health issues experienced by the residents of these areas included fever, common cold, diarrhea, dysentery, skin diseases, acidity, gastric pain, and worm infestation, among others. Over the last six months, 90.8% of the community people took health care services from the FCMs and Satellite Clinics, while 12.8% sought medical care from the hospital ships for common diseases. The hospital ships registers showed that approximately 551,289 and 647,090 individuals received services from the LFH and EFH, respectively, from 2008 to 2022. The geographical distribution of these beneficiaries (Figure 2) indicates patients coming from distant locations beyond the ships’ primary catchment area. This can be attributed to high praise and positive word-of-mouth recommendations from patients and their relatives, as well as the availability of free and advanced specialized care provided by national and international doctors during these special camps. Alongside Friendship services, they also received health care services from district hospitals (5.7%), Upazila Health Complexes (UHCs) (7.1%), Upazila Health and Family Welfare Centres (UH&FWCs) (0.7%), community clinics (1.6%), and community health workers (1.1%). Apart from these, 27.2% of people visited a village doctor/quack, while 19.8% purchased medicine based on recommendations from a drug seller/pharmacist. Furthermore, 6.2% sought treatment from a traditional healer. A 32y old female respondent (FGD) from the study area commented on FCMs services: "We can access the FCM at any time. It might be day or night, but we can call her for medical help. If she could not give us any suggestions, she contacted the MBBS doctor from Dhaka (capital of Bangladesh) over the phone." The community people are familiar with and used to receiving services from the Friendship hospital ships, satellite clinics, and FCMs. The satellite clinic team typically sets up in the courtyard of FCM's house to distribute medication and other services. The hospital ships provide routine basic and secondary health care services, including ANC, PNC, gynecology, pediatrics, family planning, obstetrics, etc. Friendship also organizes specialized health camps where volunteer doctors, both local and international, perform surgeries and medical consultations. These health camps offer consultations for a range of health conditions, as well as provide specialized treatments like cataract surgery, cleft lip repair, and club foot correction. One of the respondents (IDI, male, 36y) stated: “When the ship is accessible in this region, almost everyone prefers to visit the ship to reduce service expenses. We also receive quality services and medicines. Sometimes, they run camps for eye surgeries.” Experience and Perception of the Service Recipients and Stakeholders Community people are receiving specialized health care services from the Friendship hospital ships. In the past, people did not care much about their disabilities. Sometimes, they considered such disabilities as curses or "divine retribution." Following the implementation of the 3-tier health care system, the population has become well aware of cataract surgery, club foot treatment, cleft lip correction, etc. A participant (IDI, Male, 45y) from the study area stated: "We receive treatment for general health problems from satellite clinics. However, for more complex health issues, we are advised to visit the hospital ship. Once, I had a problem with my leg, and I was asked to visit the ship. There, I received treatment with check-ups, and it was very helpful for me. Also, I observed some people receiving spectacles after eye surgery there." A service provider (KII, Male, 46y) stated that, “The health services of hospital ship play an important role in reducing many complex diseases such as eye, uterine, dental, club foot, general, etc. Now char-living people feel relieved about their health problems”. The community people consider the Friendship hospital ships to be a blessing. A female respondent (IDI, 58y) expressed her opinion: "Perhaps I couldn't afford to go to a government or private hospital for my uterus problem; however, I received the operation at this ship with excellent care. The staff here carefully monitored me after the surgery." At the satellite clinics, the "paramedic(s)" provide individualized care to the patients, ensuring appropriate privacy. They also prescribe the permitted over-the-counter medicines, which are distributed by the "organizer(s)". If any medicines were not in stock on a given day, they advised the patients to buy them from nearby medicine stores. One of the service recipients (IDI, female, 43y) said, "The medicines we get from Friendship are better than what we buy from the local medicine shops. It worked, and we got better faster by taking the medicines from Friendship. But the types of medicines should be increased." The majority of the community people expressed satisfaction with the services provided by the FCMs and Satellite clinics, mostly due to convenient access and proximity to their residences. Now, they don't have to go on lengthy journeys to get medical advice and medicines. Overall, 83% of the community people were satisfied with the service, as well as, 82.4% were happy with the service environment of the satellite clinics. One of the recipients (IDI, female, 24y) shared the opinion: "We can avail health care in the courtyard of our house. We clean and arrange the courtyard where the clinic will take place ourselves. We don't need to go to Sadar (urban centers) for minor illnesses anymore". Apart from addressing the health care needs for different diseases, the nutrition sessions and the courtyard sessions create awareness and reinforce a nutrition drive. FCMs lead the nutrition sessions, where they discuss the nutritional facts of locally produced vegetables and demonstrate how to cut and clean the vegetables while preserving their nutritional value. They also prepare nutritious and delicious "Khichuri," a balanced diet, from locally sourced produce for the community children, as well as pregnant and lactating mothers. One of the community members (FGD, female, 35y) showed her satisfaction with the health care model and stated: "Friendship helps us to know the nutritional facts of vegetables. We had no idea that khichuri could be cooked using our locally available vegetables and be nutritious and delicious at the same time. Previously, we used to cook khichuri only with one type of lentil and no other vegetables or eggs. Now, we learned the whole procedure from the FCM Apa (sister)". Courtyard sessions are usually conducted in a similar setting where FCMs discuss various topics such as diarrhea, respiratory tract infection, skin disease, hygiene, safe water and sanitation, food and nutrition, primary health care, gender and reproductive health, family planning, Extended Programme of Immunization (EPI) activities, pregnant mother care, labor planning, safe labor and PNC, care of newborn and benefits of breastfeeding, STIs and STDs, child marriage and adolescent reproductive health care, etc. using flip charts. One of the participants (FGD, female, 35y) shared, "We attend the session regularly and learned a lot from those sessions. For example, why we should wash our hands and when we must wash our hands. Our babies also adopted this behavior and washed their hands before eating. FCM apa also discussed birth control and family planning methods in the sessions". A total of four courtyard sessions are conducted monthly in different locations throughout the community. Each session focuses on health awareness issues and offers opportunities for social interaction and education on health and wellbeing. A participant (FGD, Male, 46y) mentioned: "Community people are now more aware about maintaining their health issues and healthy lifestyles. For example, pregnant women were not aware of their health during pregnancy before Friendship arrived here. But now they have learned many things, such as the five danger signs, and are aware of the four check-ups." Friendship is the only Social Purpose Organization providing essential health care services in these hard-to-reach northern riverine Char communities. Though there were very few GoB Family Welfare Assistants (FWAs) in some districts (e.g., Jamalpur) to provide health care to the Char dwellers, the service was limited and insufficient considering the needs. One of the Upazila Health & Family Planning Officers (UH&FPO) (KII, Male, 42y) of the intervention area expressed his positive view and said, "By providing transportation support, Friendship made our work much easier. We have a very limited budget for transportation. Our EPI and Family Planning staffs use the boats of Friendship to go to the Char areas to implement and achieve the target set by the government. It's possible because they maintain a strong liaison with us, with the government. Their staffs are very supportive. I would like to add that they work based on community people's needs." Friendship’s efforts to prioritize public-private collaboration for sustainable intervention are also reflected in another government health manager’s (KII, Male, 44y) quote, "We expect continuous support from Friendship to meet the government goals collaboratively. Even if there are any possibilities of discontinuation for any funding or other issues, please inform us beforehand. Otherwise, a lot of programme will be largely affected." Cost Benefits Satellite clinics charge flat fees of 0.05 USD for females and children aged under 18 years, and 0.09 USD for males. In the absence of these clinics, community people would need to seek alternative outdoor services at a private clinic with an average registration fee of 2.79 USD. The net benefit for a beneficiary using a specific service is 2.75 USD. According to a quantitative survey, 43.4% of the community people expressed complete satisfaction with the service charge of a satellite clinic, while 40.8% expressed overall satisfaction. Moreover, they had to endure lengthy and expensive journeys to reach the sub-district or district city. One of the participants mentioned (IDI, Male, 27y), “Friendship team's efforts in our community are commendable. We no longer have to waste 2-3 hours travelling to reach the government Upazilla Health Complex for general illness. The best part is, they provide the services and medicine at a very minimal cost.” The transport cost by reserved boat to the nearby port ranged from 13.98 USD to 18.63 USD and could take 2:00 to 2:30 hours to reach the port. From there, it took a minimum of 30 minutes to 1 hour to reach the health care facilities. There were also local or shared boats but with limited operating hours and routes from the Chars to lands. The costs of these boats ranged from 0.46-1.40 USD depending on the distance and geographical area. Friendship's five key services, antenatal care (ANC), postnatal care (PNC), diarrhea, respiratory tract infections, and skin diseases, were considered for cost-effective analysis. The relative cost per beneficiary for each service was -0.96, -0.95, -1.02, - 0.74, and -0.79 USD, respectively. The negative values indicate that the relative cost of providing the service by Friendship was lower than that of alternative private facilities. Challenges Despite Friendship's 3-tier health care model being well regarded for its cost-effective provision of essential health care services and higher satisfaction levels, there are still areas where improvements are crucial. The providers experienced a heavy workload and expressed the necessity for additional training in communication, counseling, management, and networking skills, as well as increasing the number of trained FCMS as CSBAs. Moreover, there was an immediate requirement to increase the number of providers, which was reflected in the quote from one of the project officers (KII, Male, 38y): “We are always overwhelmed with lots of work compared to our salary. Also, we only receive the necessary training to perform our jobs. But it is crucial to get additional training to enhance our job performance and develop our skills. However, we do get verbal appreciation and motivation from our supervisors often.” For the recipients, the primary barriers were long waiting periods to receive services at satellite clinics and limited mobility of the hospital ships due to poor navigability in dry seasons. Finally, despite providing support to the referred patients to government facilities or hospital ships for critical illness and specialized care, the absence of a formal and structured referral mechanism poses a significant challenge. Generally, patients are referred to Hospital Ships and government facilities (if hospital ships are not stationed nearby) for specialized care. However, there is a lack of systematic tracking of referred patients. This includes insufficient follow-up and record keeping by FCMS or satellite clinics, as well as the lack of systematic tracking of referral status in hospital ships, even though the ship is considered the higher level of service point in this 3-tier model. Discussion This evaluation study has shown the utilization of Friendship's 3-tier health care model to establish accessible health care services within the existing system in the hard-to-reach riverine areas of northern Bangladesh. Friendship’s 3-tier health care model presents similarities with a 3-tier health care system in rural China.[17] The Chinese 3-tier health service delivery was established to connect villages, townships, and counties and implemented rapidly due to strong political commitment. [18] [19] In this model, the village clinic was the primary institution for health care delivery. However, village clinics were unlikely to succeed due to shrinking health care resources and gaps, along with an absence of market mechanism interaction and administrative village mergers. Hence, Chinese VCs faced obstacles and concerns regarding access and engagement; however, FCMs from Friendship's health care model made this easier due to having local people as FCMs as well as ample experiences and knowledge of the local populations.[17] Another review study demonstrated two-tier health care systems that involve transferring patients from a comprehensive hospital provider (CHP) to a primary hospital provider (PHP) and highlights the importance of effective coordination between the two providers to address the challenges of the referral system.[20] Although Friendship’s 3-tier health care model supports the patients seeking health care services at the government facilities (transportation, attendance and financial), it doesn’t have any formal referral mechanism between satellite clinics and hospital ships, the highest tier for specialized care within the system. Nevertheless, one study from Bangladesh revealed that rural people are often discouraged from visiting government hospitals due to their formal atmosphere and the unfriendly behaviour of health care staff, which leads to feelings of uncertainty and fear.[21] However, within the Friendship 3-tier health care model, as FCMs are females and from their own community, community members feel comfortable communicating with them as their first point of contact. Another study discovered social, organizational, and physical barriers that hindered access to maternal health care services. The barriers included early marriage, perception of pregnancy and childbirth, high financial cost, lack of female health staff, lack of a guiding principle in the health sector, in/exclusion errors in benefit distribution, low-quality services, distance and waiting time, etc.[21] According to this study, the Char people face similar challenges when it comes to obtaining health care from both government and private health care facilities. Hence, the participants urged that government health care staff and other health services be made available in the Char communities. Prior interventions in Bangladesh (Reach Up, Thinking Healthy, and general nutrition advice) created and piloted a culturally adapted integrated curriculum for pregnant and lactating women employing courtyard group sessions and household visits.[22] Friendship's health care model incorporated nutrition sessions facilitated by FCMs to educate them on nutritious foods appropriate for their needs, as well as live demonstrations and distributions of nutritious 'khichuri' using locally available vegetables and eggs. These sessions possess high beneficence in promoting health awareness, as mentioned by the community people. Another floating hospital initiative in Bangladesh, “Jibon Tari,” covers 27 locations in 18 districts, specially the riverine areas. Compared to Friendship’s Hospital Ships, the “Jibon Tari” provided general health care on prevention, cure, and awareness, addressing disabilities, as well as outdoor consultations and specialized surgeries for cataracts, club feet, post-polio deformities, loss of hearing, cleft lip, orthopedic, and ear, nose, and throat (ENT).[23] However, the key distinction lies in portable clinic setup and permanent community representatives (FCMs) as well as implementing the 3-tier health care model coherently for comprehensive health care to the community. Moreover, Friendship health care system prioritizes public-private collaboration, which contributes to the sustainability of such intervention, reflected by high praise from government officials. In Indonesia, a similar remote situation persists due to territorial geography. There are 7,500 government health centers (puskesmas) along with floating hospital referral ships to improve public health services and address the challenge of unequal access to medical facilities.[24] Here, in the northern riverine areas of Bangladesh, the government and other health facilities are very limited. Friendship hospital ships, satellite clinics, and FCMs are addressing these service gaps, increasing health literacy and awareness, and possessing high satisfaction among community people (83%). Thus, this comprehensive model has great potential to be utilized in other hard-to-reach areas (e.g., the southern coastal belt) in Bangladesh as well as in other similar low-resource settings. Moreover, during natural calamities or emergencies, the flexibility of the hospital ships can be highly effective in providing emergency health care services. Therefore, hospital ships can be a great addition to disaster preparedness programs in such climate-vulnerable regions like Bangladesh. Furthermore, the low-cost and mobile nature of the interventions eliminate the need for permanent infrastructure in the community, making it particularly suitable for riverine areas prone to erosion and frequent displacement of communities. Transportation and cost hinder Char people from visiting sub-district and/or district hospitals. The reserved boats from the Char required 2:00 to 2:30 hours to reach the nearby port and an additional 30–60 minutes to the health care facilities from there. A previous study on these populations revealed that 50% of the rich people traveled 30 minutes to receive services, while the corresponding percentage for the poorest was 23%.[25] However, through this 3-tier health care model, they have received health care services in their community for no to minimal cost. With Friendship's addressing transportation and cost barriers, the willingness to seek health care among Char people ultimately increased, as revealed in our exploration. Moreover, this study explored the usage of integrated mHealth approaches along with regular 3-tier health care delivery, comparable to m-tika, an android-based solution for hard-to-reach areas ensuring full vaccination coverage for children in Bangladesh.[26] FCMs use mobile phones to connect with remote physicians, improving health care and overcoming the obstacles and challenges of overall Telemedicine services, as evidenced in previous studies.[27] One of the strengths of this study lies in its unique methodology. Due to the absence of prior data, the researchers relied on community members' perceptions, revealing community opinions about their health management in rural areas as well as proxy indicators for the successful implementation of Friendship’s 3-tier health care model. Additionally, the relevant stakeholders, as well as government representatives, were included in the data collection process, providing a comprehensive view of the riverine population in Northern Bangladesh and revealing the actual state of affairs of health for the community people. Despite the best possible efforts, a limitation could be the potential inclusion of some non-permanent residents in some locations as beneficiaries due to riverine displacements. Moreover, the findings from this study may not be generalizable to general communities, considering the unique geographical and demographic characteristics of this region. Furthermore, due to a lack of sufficient information for the long intervention period, a complete economic evaluation was not feasible. Instead, a financial cost-benefit analysis for both providers and beneficiaries was carried out to provide a financial understanding. Finally, within the current study scope, the internal and external dynamics of the community could not be considered, which might have an impact on both health-seeking behaviors as well as health care delivery. Thus, future researches should consider such interplays of influencing social factors while evaluating health care models for hard-to-reach areas. Conclusion For the hard-to-reach riverine areas in northern Bangladesh, Friendship's multidimensional 3-tier health care model exhibits vital roles in terms of accessibility, lower cost, and improving health care service-seeking behavior. However, comprehensive training on emergency delivery procedures, mental health, and gender-based violence for the providers and implementing a digital inventory tracking and patient referral system are necessary to streamline the services and patient management. Additionally, efforts should focus on expanding community awareness sessions to include topics such as mental health, and disaster response. Furthermore, the coordination and cooperation with the government health care system can contribute to the sustainability of such interventions and be appreciated by the government and relevant stakeholders. Given its perceived effectiveness and efficiency from both beneficiaries' and stakeholders' sides, this multi-tier model has immense potential to be implemented in similar hard-to-reach riverine settings in other areas of Bangladesh as well as in other developing countries. Abbreviations ANC Antenatal care CSBA Community Skilled Birth Attendant EFH Emirates Friendship Hospital EPI Extended Programme of Immunization FCMs Friendship Community Medic Aides FGD Focused Group Discussions FWA Family Welfare Assistants GoB Government of Bangladesh IDI In-Depth Interview KII Key Informant Interviews LFH Lifebuoy Friendship Hospital LMICs Low-and middle-income countries PNC Postnatal care SDGs Sustainable Development Goals UH&FPO Upazila Health and Family Planning Officer UH&FWCs Upazila Health and Family Welfare Centres UHCs Upazila Health Complexes USD United States Dollar Declarations Ethics approval and consent to participate The study protocol was reviewed and approved by the Institutional Review Board of icddr,b that includes a Research Review Committee and an Ethics Review Committee (Protocol No.: PR-22060). Written informed consent was obtained from each participant, describing the goals, benefits, and risks of the study. The anonymity and privacy of the participants were maintained, and their data was kept secret, with only the study team having access. Participants were allowed to withdraw themselves at any time and choose not to answer any question. Consent for publication Not applicable Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding statement The research described in this study received financial support from Friendship Luxembourg through a grant (Grant No.: GR-02235). The funders did not play any role in the study design, data collection and analysis, publication decision, or manuscript preparation. Author contributions Md Refat Uz Zaman Sajib contributed as the focal for the study, overseeing the design and implementation, contributing to conceptualization, conducting the analysis, writing the initial draft, and editing the manuscript. Kamrul Hasan, Tanvir Hayder, Atia Rahman and Tania Sultana Tanwi participated in data collection, conducted the analysis, contributed to the initial draft, and edited the manuscript. A M Rumayan Hasan, Md. Musfikur Rahman, Saraban Ether, Fariya Rahman, Abu Sayeed, Syed Moshfiqur Rahman, and Sanwarul Bari contributed by providing review and feedback. Shams El Arifeen contributed to the study design and implementation and provided review and feedback. Anisuddin Ahmed contributed as the Principal Investigator for the study, overseeing the study design and implementation and providing review and feedback. Acknowledgements icddr,b is grateful to its core donors, the governments of Bangladesh and Global Affairs Canada for providing unrestricted support. We extend our gratitude to the 9 government officials who participated in the interview and to Friendship Bangladesh officials who contributed to the smooth operation of this study. We also sincerely appreciate the health care providers and community people who actively participated in this research. References Quinn SC, Kumar S: Health inequalities and infectious disease epidemics: a challenge for global health security . Biosecur Bioterror 2014, 12 (5):263-273. Khalid AM, Sharma S, Dubey AK: Concerns of developing countries and the sustainable development goals: case for India . International Journal of Sustainable Development & World Ecology 2020, 28 (4):303-315. Angele MN, Abel NM, Jacques OM, Henri MT, Francoise MK: Social and economic consequences of the cost of obstetric and neonatal care in Lubumbashi, Democratic Republic of Congo: a mixed methods study . BMC Pregnancy Childbirth 2021, 21 (1):315. Amjath-Babu TS, Krupnik TJ, Thilsted SH, McDonald AJ: Key indicators for monitoring food system disruptions caused by the COVID-19 pandemic: Insights from Bangladesh towards effective response . Food Secur 2020, 12 (4):761-768. Ahmadi-Javid A, Seyedi P, Syam SS: A survey of healthcare facility location . Computers & Operations Research 2017, 79 :223-263. Iqbal MH: Disparities of health service for the poor in the coastal area: does Universal health coverage reduce disparities? J Mark Access Health Policy 2019, 7 (1):1575683. Kamal F, Chowdhury MM, Masud M: Challenges of Char People in Northern Bangladesh: A Study on Dimla, Nilphamari . International Journal of Innovative Science and Research Technology 2021, 6 (2):620-629. Islam MR: Climate Change, Natural Disasters and Socioeconomic Livelihood Vulnerabilities: Migration Decision Among the Char Land People in Bangladesh . Social Indicators Research 2017, 136 (2):575-593. Paul S, Islam MR: Ultra-poor char people's rights to development and accessibility to public services: A case of Bangladesh . Habitat International 2015, 48 :113-121. Ahmed JU, Rahanaz M, Rubaiyat i S: Friendship Floating Hospitals: Healthcare for the Riverine People of Bangladesh . Journal of Developing Societies 2019, 35 (1):175-194. Khan R: Friendship's 3-Tier Healthcare System: An Innovative Approach to Delivering Healthcare to Geographically and Socially Remote Areas . In: Social Space. Lien Centre; 2010: 114-119. Lira Huq N, Ahmed A, Tahrin Islam T, Rahman F, Hanson M, Sayeed A, Nusrat N, Mazumder T, Golam Rasul K, Rahman Turza M et al : Community-based integrated intervention for skilled maternal health care utilization in riverine remote areas, Bangladesh . Sex Reprod Healthc 2023, 37 :100892. Tangermann U, Kleij K-S, Krauth C, Amelung VE: Primary healthcare provision and introduction of new models of Care in Hard to serve regions: a population survey . Gesundheitswesen (Bundesverband der Arzte des Offentlichen Gesundheitsdienstes (Germany)) 2018, 81 (6):498-504. Bangladesh F: Integrated Community Based Primary Health Care Model Program (ICBPHCMP) – North Progress Report . In . ; 2021. Ott MA, Campbell J, Imburgia TM, Yang Z, Tu W, Auerswald CL: Community Engagement and Venue-Based Sampling in Adolescent Male Sexually Transmitted Infection Prevention Research . Journal of Adolescent Health 2018, 62 (3, Supplement):S58-S64. Braun V, Clarke V: Using thematic analysis in psychology . Qualitative Research in Psychology 2006, 3 (2):77-101. Ao Y, Feng Q, Zhou Z, Chen Y, Wang T: Resource Allocation Equity in the China's Rural Three-Tier Healthcare System . Int J Environ Res Public Health 2022, 19 (11). Feng XL, Martinez-Alvarez M, Zhong J, Xu J, Yuan B, Meng Q, Balabanova D: Extending access to essential services against constraints: the three-tier health service delivery system in rural China (1949-1980) . Int J Equity Health 2017, 16 (1):49. Meng Q, Mills A, Wang L, Han Q: What can we learn from China's health system reform? BMJ 2019, 365 :l2349. Wang J-J, Li Z-P, Shi J, Chang A-C: Hospital referral and capacity strategies in the two-tier healthcare systems . Omega 2021, 100 . Banik BK: Barriers to access in maternal healthcare services in the Northern Bangladesh . South East Asia Journal of Public Health 2017, 6 (2):23-36. Akter F, Rahman M, Pitchik HO, Winch PJ, Fernald LCH, Nurul Huda TM, Jahir T, Amin R, Das JB, Hossain K et al : Adaptation and Integration of Psychosocial Stimulation, Maternal Mental Health and Nutritional Interventions for Pregnant and Lactating Women in Rural Bangladesh . Int J Environ Res Public Health 2020, 17 (17). Uddin Ahmed J, Sadat Shimul A, Sen P, Nuren Khan N: Jibon Tari: A Floating Hospital to Serve Distressed Humanity . Business Perspectives and Research 2015, 3 (2):146-160. Abdillah 1 HN, Masroeri 1 AA, Artana 1 KB, Edfi 1 RD: Hospital Ship Design for Public Health Services in the Foremost, Outermost, and Remote (FOR) Areas in Indonesia . IOP Conference Series: Earth and Environmental Science 2020:9. Chowdhury MAK, Karim F, Hasan MM, Ali NB, Khan ANS, Siraj MS, Ahasan SMM, Hoque DME: Bottleneck analysis of maternal and newborn health services in hard-to-reach areas of Bangladesh using ‘TANAHASHI’ framework’: An explanatory mixed-method study . PLoS One 2022. Uddin MJ, Shamsuzzaman M, Horng L, Labrique A, Vasudevan L, Zeller K, Chowdhury M, Larson CP, Bishai D, Alam N: Use of mobile phones for improving vaccination coverage among children living in rural hard-to-reach areas and urban streets of Bangladesh . Vaccine 2016, 34 (2):276-283. Zobair KM, Sanzogni L, Sandhu K: Telemedicine Healthcare Service Adoption Barriers in Rural Bangladesh . Australasian Journal of Information Systems 2020, 24 :1-24. Additional Declarations No competing interests reported. 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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-4456479","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":310305351,"identity":"ea430a56-eaea-464c-9185-3961f68a1e5b","order_by":0,"name":"Md Refat Uz Zaman Sajib","email":"","orcid":"","institution":"University of Illinois Urbana- Champaign","correspondingAuthor":false,"prefix":"","firstName":"Md","middleName":"Refat Uz Zaman","lastName":"Sajib","suffix":""},{"id":310305356,"identity":"65cc793d-8761-4016-a017-4ba7b1e22dfd","order_by":1,"name":"Kamrul Hasan","email":"","orcid":"","institution":"International Centre for Diarrhoeal Disease Research","correspondingAuthor":false,"prefix":"","firstName":"Kamrul","middleName":"","lastName":"Hasan","suffix":""},{"id":310305358,"identity":"83f9a08f-00e0-466f-a882-3db12a0cf003","order_by":2,"name":"Tanvir Hayder","email":"","orcid":"","institution":"International Centre for Diarrhoeal Disease Research","correspondingAuthor":false,"prefix":"","firstName":"Tanvir","middleName":"","lastName":"Hayder","suffix":""},{"id":310305360,"identity":"37859113-f68e-43b6-b2ea-67fd1f9ca8e8","order_by":3,"name":"A M Rumayan Hasan","email":"","orcid":"","institution":"International Centre for Diarrhoeal Disease Research","correspondingAuthor":false,"prefix":"","firstName":"A","middleName":"M Rumayan","lastName":"Hasan","suffix":""},{"id":310305361,"identity":"80668ad0-e5df-4084-9f41-d97e31adfa81","order_by":4,"name":"Md. 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17:47:59","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4456479/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4456479/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13690-025-01592-6","type":"published","date":"2025-04-14T15:57:19+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":58153134,"identity":"a1c9e672-0b19-47f4-84a0-cff3a774305f","added_by":"auto","created_at":"2024-06-11 20:25:50","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":260542,"visible":true,"origin":"","legend":"\u003cp\u003e3-tier multidimensional health care model\u003c/p\u003e","description":"","filename":"Figure1Multidimensionalhealthcaremode.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4456479/v1/01b1660e2c5fe7d2cbf8a687.jpg"},{"id":58153132,"identity":"7e8c868f-3c38-4ad2-b38e-72a3a408922e","added_by":"auto","created_at":"2024-06-11 20:25:50","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":363021,"visible":true,"origin":"","legend":"\u003cp\u003eGeographical distribution of patients who received LFH and EFH services (2008-2022)\u003c/p\u003e","description":"","filename":"Figure2Multidimensionalhealthcaremode.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4456479/v1/742b8972e66ced02f80b305a.jpg"},{"id":81050798,"identity":"3cc25923-1360-488e-b860-a5a5106a8af4","added_by":"auto","created_at":"2025-04-21 16:05:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2659914,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4456479/v1/cebaab6e-757c-46bc-a4e3-9e87d8c005be.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Reaching the Unreachable: A mixed-method evaluation of multidimensional healthcare model addressing the healthcare service gaps in hard-to-reach Northern Riverine Bangladesh","fulltext":[{"header":"Contributions to the Literature","content":"\u003cul\u003e\n \u003cli\u003eThe study highlights how Friendship\u0026rsquo;s (a Social Purpose Organization) 3-tier healthcare model addresses existing challenges in access to healthcare services from government facilities in the hard-to-reach riverine areas of northern Bangladesh.\u003c/li\u003e\n \u003cli\u003eThe model ensures primary, secondary and specialized healthcare through Hospital Ships, monthly temporary paramedic-led clinics and 24/7 trained community medic aids, as well as promotes nutrition with locally sourced ingredients and healthy lifestyle practices through courtyard sessions.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSuch a multidimensional approach can also be cost-effective in providing essential healthcare services for hard-to-reach populations, instilling confidence in its sustainability and implication for similar settings.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Introduction","content":"\u003cp\u003eIn low-and middle-income countries (LMICs) like Bangladesh, the lack of health care resources and disparities in health care services are major challenges.[1] Such health care disparities impact the health indicators, delaying progress toward achieving Sustainable Development Goals (SDG).[2] Despite being a crucial component of development agendas, many developing countries continue to have significant concerns about the underutilization and limited reach of health care services.[3]\u003c/p\u003e \u003cp\u003eBangladesh, a densely populated country with a population of 164.7 million[4], faces significant challenges in meeting the rising health care needs of its diverse regions.[5] The persistent inequalities in health care access are mostly due to geographical diversity, including remote and hard-to-reach areas such as coastal, hilly, haor (wetland), and riverine or Char areas (shallow land mass rising within a water body).[6, 7] Despite constituting 5% of the total land with approximately 6.5\u0026nbsp;million people, these remote areas generally lack adequate public health infrastructures.[8] Moreover, these Char areas are particularly vulnerable to natural calamities like flooding, erosion, cyclones, etc., which regularly hamper essential services, including health care and transportation. This further worsens the overall scenario, leaving the health care needs of such hard-to-reach Char communities mostly unmet. Previous studies have reported that only 35% of the Char dwellers have access to public health care services, while 80% are ultra-poor.[8, 9] As a result, seeking health care services from informal and traditional health practitioners remains frequent.[9]\u003c/p\u003e \u003cp\u003eTo aid the people of these underserved areas, Friendship, an international Social Purpose organization, has been working for the last 20 years through a multidimensional 3-tier health care model. This includes Hospital Ships (Tier 1), Satellite Clinics and Static Clinics (Tier 2), and Friendship Community Medic Aides (FCMs) (Tier 3).[10\u0026ndash;12] Currently, Friendship operates two hospital ships: Lifebuoy Friendship Hospital (LFH) and Emirates Friendship Hospital (EFH), providing primary, secondary, and specialized health care in distant climate-vulnerable areas where the government and other non-governmental organizations have little or no intervention. Also, paramedic-led Satellite and Static Clinics serve the target community monthly to provide basic medical services for communicable and non-communicable disease prevention, behavioral change communication, and general health care services. Moreover, it trains female community members as medic aides (FCMs) to provide primary health care services in their communities.[12]\u003c/p\u003e \u003cp\u003eGiven the gaps in public health care coverage in these hard-to-reach areas, such a multidimensional model utilizing a mobility-based community participatory approach possesses potential efficacy.[13] Exploring this comprehensive health care model can reveal insights about how it functions in such a hard-to-reach setting and helps the community in need, as well as possible scopes to reinforce/introduce additional initiatives. Thus, this study aims to evaluate this 3-tier health care model addressing the health care needs of this hard-to-reach riverine area of northern Bangladesh in light of general health care service-seeking practices, experience, and perception from beneficiaries and stakeholders, as well as cost benefits.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStudy Design, Duration, and Site\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study adheres to a mixed-method approach integrating desk reviews, cross-sectional quantitative surveys, facility assessments, and exploratory qualitative design to comprehensively investigate the research objective. It was conducted between April 2022 and July 2023 in five northern riverine districts (Kurigram, Gaibandha, Bogura, Sirajganj, and Jamalpur) of Bangladesh, where Friendship runs the 3-tier multidimensional health model. Chilmari, Sundarganj, Sariakandi, Kazipur, and Madarganj sub-districts were selected randomly among the nine sub-districts, each representing one district. Quantitative and qualitative data collection were conducted, focusing on the beneficiaries and stakeholders of this health care model. The quantitative survey explored the sociodemographic and economic domain, including the cost benefits, whereas the community\u0026apos;s and stakeholders\u0026apos; perspectives on the health care model and the potential scope of further implications were explored using a qualitative approach. General health care service-seeking practices were explored using both quantitative and qualitative data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSample Size and Sampling\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe sample size for the quantitative survey was determined considering a 76% estimated prevalence (based on coverage) of beneficiaries in the targeted areas.[14]\u0026nbsp;The margin of error and confidence level were assumed to be 4% and 99%, respectively. The total sample size for the survey was around 757 (~760) who had received health care services from this model at the study sites. The desired sample size for each sub-district was 152, which was distributed equally among the selected sub-districts. Approximately 30-36 qualitative interviews were planned to be conducted with purposively selected participants of different backgrounds (beneficiaries, service providers, administrative officials, and other stakeholders- community representatives/gatekeepers, local government officials, and health managers). However, to reach data saturation, 56 qualitative interviews were conducted, including eight focus group discussions (FGDs) with both service providers and service recipients, 32 in-depth interviews (IDIs) with service recipients, service providers, community representatives/gatekeepers, etc., and 16 key informant interviews (KIIs) with officials and health managers from Friendships\u0026rsquo; Central and Regional offices and local Government of Bangladesh (GoB). Also, to comprehensively support the findings, two facility assessments of the Friendship hospital ships and three case stories of the service recipients were conducted. Finally, two review and feedback workshops were conducted, comprising GoB officials and health managers, service providers of different levels, and service recipients from different areas, to validate the collected data as well as seek recommendations for further integration and improvement.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData Collection\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConsidering the population context and study location, the study recruited experienced data collectors: two males and two females. The selected data collectors received a week of rigorous training, including practical and supervised data collection sessions. The study team physically supervised field data collection to ensure high-quality data gathering. We used open-ended guides for KIIs, FGDs, IDIs, and structured questionnaires for the survey, which were finalized following initial field testing. The beneficiaries only residing permanently in the communities and have taken/have been taking services from the Friendship 3-tier health care model within/during the last one year were considered for the survey or interviews. The KIIs were conducted face-to-face in convenient places for the respondents; FGDs and IDIs were held in the courtyards/households of the participants as they suggested. To ensure comfortable participation, no other people were allowed except the participants during the data collection process. For the survey, data were collected both from the satellite clinic and courtyard session participants and by visiting community households without separate scheduling rather than following regular satellite clinic schedules to different communities (venue-based data collection)\u0026nbsp;[15]. Apart from these, observation notes of the field-site debriefing and review and feedback workshop were collected, and all previous reports and relevant records regarding each tier were collected from Friendship regional and head offices as well as from the ships.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData Analysis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQuantitative data (survey, reports, records, and logbooks) was stored in Excel and analyzed using STATA 15.0. Descriptive statistics were used to explain the findings and presented coherently with the qualitative findings. The cost of key services of Friendship\u0026apos;s 3-tier health care system was compared with nearby alternative facilities to calculate financial cost-benefit. For the value for money of the services from the organizational perspective, expenses to provide any specific services by Friendship (relative cost per beneficiary) were compared with nearby alternative private facilities.\u003c/p\u003e\n\u003cp\u003eQualitative data (IDIs, KIIs, FGDs, workshops) were audio-recorded and analyzed thematically.[16] The qualitative data analysis was performed using NVivo software (Version 12) in several stages. Initially, the purpose and plan of data analysis were outlined following listening to the tape-recorded interviews to identify discussed issues, emerging topics, and strengths and weaknesses of interview techniques. It helped to be familiarised with the data, enhanced future data quality, and initiated data analysis. The recorded interviews were then transcribed verbatim (conducted in the native language, Bengali), including all spoken content without alteration, and supplemented by field notes and interviewer\u0026rsquo;s observations. Subsequently, transcribed data were compared to identify data exploration gaps by assessing similar issues discussed by different types of interviewees. A set of a priori codes based on interview guidelines and study objectives was prepared before looking at the raw data and utilized to assign codes to each transcription. These codes were then condensed into a narrower set of codes and themes, ensuring comprehensive coverage of raw data. Next, emerging themes and sub-themes were identified, highlighting common ideas and recurrent themes grounded in actual data aligned with study objectives. Finally, data were systematically triangulated, indexed, synthesized, and interpreted to present findings comprehensively.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eActivities through the 3-tier Health care Model\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFriendship\u0026rsquo;s activities include various health care services but are not limited to antenatal care (ANC), postnatal care (PNC), family planning, respiratory tract infections, skin diseases, diarrhea, fever, cough, typhoid, and specialized services like cataract surgery, cleft lip and palate surgery, club foot surgery, etc. through the 3-tier health care model. It also involves monthly nutrition demonstration sessions, regular health and family care follow-ups (data tracking), assessment, treatment, and referral of malnutrition cases for under-5 children and pregnant and lactating mothers. Their hospital ships (Tier 1) provide primary, secondary, and specialized health care in distant climate-vulnerable areas where the government and other non-governmental organizations have little or no intervention, depending on the people\u0026rsquo;s needs and feasibility of moving, considering the navigability of the rivers. The paramedic-led Satellite and Static Clinics (Tier 2) run biweekly or monthly to provide basic medical services for communicable and non-communicable disease prevention, behavioral change communication, and general health care issues. Moreover, Friendship trains female community members as medic aides (FCMs) (Tier 3) to act as the first point of contact for Friendship health care initiative (Figure 1). FCMs with specialized training to be Community Skilled Birth Attendants (CSBAs) facilitate access to safe delivery, advanced family planning services, ANC, PNC, and basic infant/neonatal care for Char communities. Furthermore, some FCMs are equipped with mobile phones to enable m-health services for remote diagnosis and connecting patients with Friendship assigned doctors when needed, following the app\u0026apos;s step-by-step instructions, ensuring comprehensive accessibility at any time.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSociodemographic and Economic Conditions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA significant proportion (43.0%) of the quantitative survey participants had no formal education. Among others, 26.8% attended primary school, 20.4% attended high school, and only 4.5% pursued college education. The majority of service recipients were female (88.9%) and aged 18-35 years (57.5%). Most households have 5\u0026mdash;10 members (45.8%), approximately two-thirds (66.6%) earning less than 1620 USD, and 14.4% reported unawareness about their income. Regarding water and sanitation, the majority of households had individual tube wells (66.7%) and used covered pit latrines (29.0%) (Table 1).\u003c/p\u003e\n\u003cp\u003eTable 1: Sociodemographic and economic characteristics of survey respondents\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003en=760\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e84 (11.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e676 (88.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge category\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e18-25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e210 (27.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e26-35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e227 (29.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e36- 45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e111 (14.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e46- 60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e139 (18.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e61- 90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e34 (4.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eDon\u0026apos;t know\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e39 (5.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eReligion\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eIslam\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e731(96.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eHindu\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e29 (3.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHousehold size category\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e1 to 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e406 (53.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e5 to 10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e348 (45.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026gt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e6 (0.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eYears of schooling\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e328 (43.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e1 \u0026ndash; 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e204 (26.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e6 \u0026ndash; 10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e155 (20.4%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e10+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e33 (4.5%) \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eDon\u0026apos;t know\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e40 (5.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOccupation\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eHousewife\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e585 (76.9%) \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eAuto/ Van/Rickshaw Driver\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e10 (1.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eDay Labour\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e12 (1.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eFisherman\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e3 (0.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eFarmer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e113 (14.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eService Holder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e8 (1.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eSmall Business\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e18 (2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e11 (1.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSource of Water\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003ePipe(internal)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e1 (0.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003ePipe(yard)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e2 (0.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eTube-well (Joint)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e241 (31.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eTube-well (Individual)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e507 (66.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eWell (With coverage)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e2 (0.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eWell (Without coverage)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e2 (0.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eGeosphere (Pond/River/canal/fen)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e1 (0.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e4 (0.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLatrine type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eWith septic tank\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e59 (7.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eWith water seal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e82 (10.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eWithout water seal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e325 (42.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eCovered pit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e220 (29.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eOpen pit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e16 (2.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eHanging latrine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e2 (0.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eNo Latrine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e33 (4.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e23 (3.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eYearly expenditure (USD)*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;=108\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e8 (1.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e108.01- 540\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e172 (22.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e540.01- 1080\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e256 (33.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e1080.01- 1620\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e132 (17.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e1620.01- 2160\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e46 (6.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e2160.01- 2700\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e8 (1.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026gt;2700.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e4 (0.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eDon\u0026apos;t know\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e134 (17.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eYearly income (USD)*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;=108\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e4 (0.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e108.01- 540\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e96 (12.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e540.01- 1080\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e217 (28.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e1080.01- 1620\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e189 (24.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e1620.01- 2160\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e80 (10.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e2160.01- 2700\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e26 (3.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026gt;2700\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e39 (5.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eDon\u0026apos;t know\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e109 (14.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*Converted using 01 BDT = 0.009 USD; OANDA currency converter as of 25 January 2023\u003c/p\u003e\n\u003cp\u003eAccording to the hospital ship register (2008 to 2022), for EFH and LFH, nearly 37-40% of beneficiaries were male, while around 59-62% were female, with over 70% of the beneficiaries aged between 26-60 years.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eGeneral Health Service-Seeking Practices\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Char people have been facing challenges in accessing government health services due to various factors such as geographical distance, transportation time, and cost associated with traveling to health care facilities. The 3-tier health care program provides convenient access to health care services in their neighborhood and enables them to get high-quality over-the-counter medicines at the most affordable price from the FCMs. The common health issues experienced by the residents of these areas included fever, common cold, diarrhea, dysentery, skin diseases, acidity, gastric pain, and worm infestation, among others. Over the last six months, 90.8% of the community people took health care services from the FCMs and Satellite Clinics, while 12.8% sought medical care from the hospital ships for common diseases. The hospital ships registers showed that approximately 551,289 and 647,090 individuals received services from the LFH and EFH, respectively, from 2008 to 2022. The geographical distribution of these beneficiaries (Figure 2)\u0026nbsp;indicates\u0026nbsp;patients coming from distant locations beyond the ships\u0026rsquo; primary catchment area. This can be attributed to high praise and positive word-of-mouth recommendations from patients and their relatives, as well as the availability of free and advanced specialized care provided by national and international doctors during these special camps.\u003c/p\u003e\n\u003cp\u003eAlongside Friendship services, they also received health care services from district hospitals (5.7%), Upazila Health Complexes (UHCs) (7.1%), Upazila Health and Family Welfare Centres (UH\u0026amp;FWCs) (0.7%), community clinics (1.6%), and community health workers (1.1%). Apart from these, 27.2% of people visited a village doctor/quack, while 19.8% purchased medicine based on recommendations from a drug seller/pharmacist. Furthermore, 6.2% sought treatment from a traditional healer. A 32y old female respondent (FGD) from the study area commented on FCMs services:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;We can access the FCM at any time. It might be day or night, but we can call her for medical help. If she could not give us any suggestions, she contacted the MBBS doctor from Dhaka (capital of Bangladesh) over the phone.\u0026quot;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe community people are familiar with and used to receiving services from the Friendship hospital ships, satellite clinics, and FCMs. The satellite clinic team typically sets up in the courtyard of FCM\u0026apos;s house to distribute medication and other services. The hospital ships provide routine basic and secondary health care services, including ANC, PNC, gynecology, pediatrics, family planning, obstetrics, etc. Friendship also organizes specialized health camps where volunteer doctors, both local and international, perform surgeries and medical consultations. These health camps offer consultations for a range of health conditions, as well as provide specialized treatments like cataract surgery, cleft lip repair, and club foot correction. One of the respondents (IDI, male, 36y) stated:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;When the ship is accessible in this region, almost everyone prefers to visit the ship to reduce service expenses. We also receive quality services and medicines. Sometimes, they run camps for eye surgeries.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExperience and Perception of the Service Recipients and Stakeholders\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCommunity people are receiving specialized health care services from the Friendship hospital ships. In the past, people did not care much about their disabilities. Sometimes, they considered such disabilities as curses or \u0026quot;divine retribution.\u0026quot; Following the implementation of the 3-tier health care system, the population has become well aware of cataract surgery, club foot treatment, cleft lip correction, etc. A participant (IDI, Male, 45y) from the study area stated:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;We receive treatment for general health problems from satellite clinics. However, for more complex health issues, we are advised to visit the hospital ship. Once, I had a problem with my leg, and I was asked to visit the ship. There, I received treatment with check-ups, and it was very helpful for me. Also, I observed some people receiving spectacles after eye surgery there.\u0026quot;\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA service provider (KII, Male, 46y) stated that,\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The health services of hospital ship play an important role in reducing many complex diseases such as eye, uterine, dental, club foot, general, etc. Now char-living people feel relieved about their health problems\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe community people consider the Friendship hospital ships to be a blessing. A female respondent (IDI, 58y) expressed her opinion:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Perhaps I couldn\u0026apos;t afford to go to a government or private hospital for my uterus problem; however, I received the operation at this ship with excellent care. The staff here carefully monitored me after the surgery.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAt the satellite clinics, the \u0026quot;paramedic(s)\u0026quot; provide individualized care to the patients, ensuring appropriate privacy. They also prescribe the permitted over-the-counter medicines, which are distributed by the \u0026quot;organizer(s)\u0026quot;. If any medicines were not in stock on a given day, they advised the patients to buy them from nearby medicine stores. One of the service recipients (IDI, female, 43y) said,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;The medicines we get from Friendship are better than what we buy from the local medicine shops. It worked, and we got better faster by taking the medicines from Friendship. But the types of medicines should be increased.\u0026quot;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe majority of the community people expressed satisfaction with the services provided by the FCMs and Satellite clinics, mostly due to convenient access and proximity to their residences. Now, they don\u0026apos;t have to go on lengthy journeys to get medical advice and medicines. Overall, 83% of the community people were satisfied with the service, as well as, 82.4% were happy with the service environment of the satellite clinics. One of the recipients (IDI, female, 24y) shared the opinion:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;We can avail health care in the courtyard of our house. We clean and arrange the courtyard where the clinic will take place ourselves. We don\u0026apos;t need to go to Sadar (urban centers) for minor illnesses anymore\u0026quot;.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eApart from addressing the health care needs for different diseases, the nutrition sessions and the courtyard sessions create awareness and reinforce a nutrition drive. FCMs lead the nutrition sessions, where they discuss the nutritional facts of locally produced vegetables and demonstrate how to cut and clean the vegetables while preserving their nutritional value. They also prepare nutritious and delicious \u0026quot;Khichuri,\u0026quot; a balanced diet, from locally sourced produce for the community children, as well as pregnant and lactating mothers. One of the community members (FGD, female, 35y) showed her satisfaction with the health care model and stated:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Friendship helps us to know the nutritional facts of vegetables. We had no idea that khichuri could be cooked using our locally available vegetables and be nutritious and delicious at the same time.\u0026nbsp;\u003c/em\u003e\u003cem\u003ePreviously, we used to cook khichuri only with one type of lentil and no other vegetables or eggs. Now, we learned the whole procedure from the FCM Apa (sister)\u0026quot;.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eCourtyard sessions are usually conducted in a similar setting where FCMs discuss various topics such as diarrhea, respiratory tract infection, skin disease, hygiene, safe water and sanitation, food and nutrition, primary health care, gender and reproductive health, family planning, Extended Programme of Immunization (EPI) activities, pregnant mother care, labor planning, safe labor and PNC, care of newborn and benefits of breastfeeding, STIs and STDs, child marriage and adolescent reproductive health care, etc. using flip charts. One of the participants (FGD, female, 35y) shared,\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;We attend the session regularly and learned a lot from those sessions. For example, why we should wash our hands and when we must wash our hands. Our babies also adopted this behavior and washed their hands before eating. FCM apa also discussed birth control and family planning methods in the sessions\u0026quot;.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA total of four courtyard sessions are conducted monthly in different locations throughout the community. Each session focuses on health awareness issues and offers opportunities for social interaction and education on health and wellbeing. A participant (FGD, Male, 46y) mentioned:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Community people are now more aware about maintaining their health issues and healthy lifestyles. For example, pregnant women were not aware of their health during pregnancy before Friendship arrived here. But now they have learned many things, such as the five danger signs, and are aware of the four check-ups.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFriendship is the only Social Purpose Organization providing essential health care services in these hard-to-reach northern riverine Char communities. Though there were very few GoB Family Welfare Assistants (FWAs) in some districts (e.g., Jamalpur) to provide health care to the Char dwellers, the service was limited and insufficient considering the needs. One of the Upazila Health \u0026amp; Family Planning Officers (UH\u0026amp;FPO) (KII, Male, 42y) of the intervention area expressed his positive view and said,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;By providing transportation support, Friendship made our work much easier. We have a very limited budget for transportation. Our EPI and Family Planning staffs use the boats of Friendship to go to the Char areas to implement and achieve the target set by the government. It\u0026apos;s possible because they maintain a strong liaison with us, with the government. Their staffs are very supportive. I would like to add that they work based on community people\u0026apos;s needs.\u0026quot; \u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFriendship\u0026rsquo;s efforts to prioritize public-private collaboration for sustainable intervention are also reflected in another government health manager\u0026rsquo;s (KII, Male, 44y) quote,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;We expect continuous support from Friendship to meet the government goals collaboratively. Even if there are any possibilities of discontinuation for any funding or other issues, please inform us beforehand. Otherwise, a lot of programme will be largely affected.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCost Benefits\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSatellite clinics charge flat fees of 0.05 USD for females and children aged under 18 years, and 0.09 USD for males. In the absence of these clinics, community people would need to seek alternative outdoor services at a private clinic with an average registration fee of 2.79 USD. The net benefit for a beneficiary using a specific service is 2.75 USD. According to a quantitative survey, 43.4% of the community people expressed complete satisfaction with the service charge of a satellite clinic, while 40.8% expressed overall satisfaction. Moreover, they had to endure lengthy and expensive journeys to reach the sub-district or district city. One of the participants mentioned (IDI, Male, 27y), \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Friendship team\u0026apos;s efforts in our community are commendable. We no longer have to waste 2-3 hours travelling to reach the government Upazilla Health Complex for general illness. The best part is, they provide the services and medicine at a very minimal cost.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe transport cost by reserved boat to the nearby port ranged from 13.98 USD to 18.63 USD and could take 2:00 to 2:30 hours to reach the port. From there, it took a minimum of 30 minutes to 1 hour to reach the health care facilities. There were also local or shared boats but with limited operating hours and routes from the Chars to lands. The costs of these boats ranged from 0.46-1.40 USD depending on the distance and geographical area.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFriendship\u0026apos;s five key services, antenatal care (ANC), postnatal care (PNC), diarrhea, respiratory tract infections, and skin diseases, were considered for cost-effective analysis. The relative cost per beneficiary for each service was -0.96, -0.95, -1.02, - 0.74, and -0.79 USD, respectively. The negative values indicate that the relative cost of providing the service by Friendship was lower than that of alternative private facilities.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eChallenges\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDespite Friendship\u0026apos;s 3-tier health care model being well regarded for its cost-effective provision of essential health care services and higher satisfaction levels, there are still areas where improvements are crucial. The providers experienced a heavy workload and expressed the necessity for additional training in communication, counseling, management, and networking skills, as well as increasing the number of trained FCMS as CSBAs. Moreover, there was an immediate requirement to increase the number of providers, which was reflected in the quote from one of the project officers (KII, Male, 38y): \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We are always overwhelmed with lots of work compared to our salary. Also, we only receive the necessary training to perform our jobs. But it is crucial to get additional training to enhance our job performance and develop our skills. However, we do get verbal appreciation and motivation from our supervisors often.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFor the recipients, the primary barriers were long waiting periods to receive services at satellite clinics and limited mobility of the hospital ships due to poor navigability in dry seasons. Finally, despite providing support to the referred patients to government facilities or hospital ships for critical illness and specialized care, the absence of a formal and structured referral mechanism poses a significant challenge. Generally, patients are referred to Hospital Ships and government facilities (if hospital ships are not stationed nearby) for specialized care. However, there is a lack of systematic tracking of referred patients. This includes insufficient follow-up and record keeping by FCMS or satellite clinics, as well as the lack of systematic tracking of referral status in hospital ships, even though the ship is considered the higher level of service point in this 3-tier model.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis evaluation study has shown the utilization of Friendship's 3-tier health care model to establish accessible health care services within the existing system in the hard-to-reach riverine areas of northern Bangladesh. Friendship\u0026rsquo;s 3-tier health care model presents similarities with a 3-tier health care system in rural China.[17] The Chinese 3-tier health service delivery was established to connect villages, townships, and counties and implemented rapidly due to strong political commitment. [18] [19] In this model, the village clinic was the primary institution for health care delivery. However, village clinics were unlikely to succeed due to shrinking health care resources and gaps, along with an absence of market mechanism interaction and administrative village mergers. Hence, Chinese VCs faced obstacles and concerns regarding access and engagement; however, FCMs from Friendship's health care model made this easier due to having local people as FCMs as well as ample experiences and knowledge of the local populations.[17]\u003c/p\u003e \u003cp\u003eAnother review study demonstrated two-tier health care systems that involve transferring patients from a comprehensive hospital provider (CHP) to a primary hospital provider (PHP) and highlights the importance of effective coordination between the two providers to address the challenges of the referral system.[20] Although Friendship\u0026rsquo;s 3-tier health care model supports the patients seeking health care services at the government facilities (transportation, attendance and financial), it doesn\u0026rsquo;t have any formal referral mechanism between satellite clinics and hospital ships, the highest tier for specialized care within the system. Nevertheless, one study from Bangladesh revealed that rural people are often discouraged from visiting government hospitals due to their formal atmosphere and the unfriendly behaviour of health care staff, which leads to feelings of uncertainty and fear.[21] However, within the Friendship 3-tier health care model, as FCMs are females and from their own community, community members feel comfortable communicating with them as their first point of contact.\u003c/p\u003e \u003cp\u003eAnother study discovered social, organizational, and physical barriers that hindered access to maternal health care services. The barriers included early marriage, perception of pregnancy and childbirth, high financial cost, lack of female health staff, lack of a guiding principle in the health sector, in/exclusion errors in benefit distribution, low-quality services, distance and waiting time, etc.[21] According to this study, the Char people face similar challenges when it comes to obtaining health care from both government and private health care facilities. Hence, the participants urged that government health care staff and other health services be made available in the Char communities.\u003c/p\u003e \u003cp\u003ePrior interventions in Bangladesh (Reach Up, Thinking Healthy, and general nutrition advice) created and piloted a culturally adapted integrated curriculum for pregnant and lactating women employing courtyard group sessions and household visits.[22] Friendship's health care model incorporated nutrition sessions facilitated by FCMs to educate them on nutritious foods appropriate for their needs, as well as live demonstrations and distributions of nutritious 'khichuri' using locally available vegetables and eggs. These sessions possess high beneficence in promoting health awareness, as mentioned by the community people.\u003c/p\u003e \u003cp\u003eAnother floating hospital initiative in Bangladesh, \u0026ldquo;Jibon Tari,\u0026rdquo; covers 27 locations in 18 districts, specially the riverine areas. Compared to Friendship\u0026rsquo;s Hospital Ships, the \u0026ldquo;Jibon Tari\u0026rdquo; provided general health care on prevention, cure, and awareness, addressing disabilities, as well as outdoor consultations and specialized surgeries for cataracts, club feet, post-polio deformities, loss of hearing, cleft lip, orthopedic, and ear, nose, and throat (ENT).[23] However, the key distinction lies in portable clinic setup and permanent community representatives (FCMs) as well as implementing the 3-tier health care model coherently for comprehensive health care to the community. Moreover, Friendship health care system prioritizes public-private collaboration, which contributes to the sustainability of such intervention, reflected by high praise from government officials.\u003c/p\u003e \u003cp\u003eIn Indonesia, a similar remote situation persists due to territorial geography. There are 7,500 government health centers (puskesmas) along with floating hospital referral ships to improve public health services and address the challenge of unequal access to medical facilities.[24] Here, in the northern riverine areas of Bangladesh, the government and other health facilities are very limited. Friendship hospital ships, satellite clinics, and FCMs are addressing these service gaps, increasing health literacy and awareness, and possessing high satisfaction among community people (83%). Thus, this comprehensive model has great potential to be utilized in other hard-to-reach areas (e.g., the southern coastal belt) in Bangladesh as well as in other similar low-resource settings. Moreover, during natural calamities or emergencies, the flexibility of the hospital ships can be highly effective in providing emergency health care services. Therefore, hospital ships can be a great addition to disaster preparedness programs in such climate-vulnerable regions like Bangladesh. Furthermore, the low-cost and mobile nature of the interventions eliminate the need for permanent infrastructure in the community, making it particularly suitable for riverine areas prone to erosion and frequent displacement of communities.\u003c/p\u003e \u003cp\u003eTransportation and cost hinder Char people from visiting sub-district and/or district hospitals. The reserved boats from the Char required 2:00 to 2:30 hours to reach the nearby port and an additional 30\u0026ndash;60 minutes to the health care facilities from there. A previous study on these populations revealed that 50% of the rich people traveled 30 minutes to receive services, while the corresponding percentage for the poorest was 23%.[25] However, through this 3-tier health care model, they have received health care services in their community for no to minimal cost. With Friendship's addressing transportation and cost barriers, the willingness to seek health care among Char people ultimately increased, as revealed in our exploration.\u003c/p\u003e \u003cp\u003eMoreover, this study explored the usage of integrated mHealth approaches along with regular 3-tier health care delivery, comparable to m-tika, an android-based solution for hard-to-reach areas ensuring full vaccination coverage for children in Bangladesh.[26] FCMs use mobile phones to connect with remote physicians, improving health care and overcoming the obstacles and challenges of overall Telemedicine services, as evidenced in previous studies.[27]\u003c/p\u003e \u003cp\u003eOne of the strengths of this study lies in its unique methodology. Due to the absence of prior data, the researchers relied on community members' perceptions, revealing community opinions about their health management in rural areas as well as proxy indicators for the successful implementation of Friendship\u0026rsquo;s 3-tier health care model. Additionally, the relevant stakeholders, as well as government representatives, were included in the data collection process, providing a comprehensive view of the riverine population in Northern Bangladesh and revealing the actual state of affairs of health for the community people. Despite the best possible efforts, a limitation could be the potential inclusion of some non-permanent residents in some locations as beneficiaries due to riverine displacements. Moreover, the findings from this study may not be generalizable to general communities, considering the unique geographical and demographic characteristics of this region. Furthermore, due to a lack of sufficient information for the long intervention period, a complete economic evaluation was not feasible. Instead, a financial cost-benefit analysis for both providers and beneficiaries was carried out to provide a financial understanding. Finally, within the current study scope, the internal and external dynamics of the community could not be considered, which might have an impact on both health-seeking behaviors as well as health care delivery. Thus, future researches should consider such interplays of influencing social factors while evaluating health care models for hard-to-reach areas.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eFor the hard-to-reach riverine areas in northern Bangladesh, Friendship's multidimensional 3-tier health care model exhibits vital roles in terms of accessibility, lower cost, and improving health care service-seeking behavior. However, comprehensive training on emergency delivery procedures, mental health, and gender-based violence for the providers and implementing a digital inventory tracking and patient referral system are necessary to streamline the services and patient management. Additionally, efforts should focus on expanding community awareness sessions to include topics such as mental health, and disaster response. Furthermore, the coordination and cooperation with the government health care system can contribute to the sustainability of such interventions and be appreciated by the government and relevant stakeholders. Given its perceived effectiveness and efficiency from both beneficiaries' and stakeholders' sides, this multi-tier model has immense potential to be implemented in similar hard-to-reach riverine settings in other areas of Bangladesh as well as in other developing countries.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.434991974317818%\" valign=\"top\"\u003e\n \u003cp\u003eANC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.56500802568219%\" valign=\"top\"\u003e\n \u003cp\u003eAntenatal care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.434991974317818%\" valign=\"top\"\u003e\n \u003cp\u003eCSBA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.56500802568219%\" valign=\"top\"\u003e\n \u003cp\u003eCommunity Skilled Birth Attendant\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.434991974317818%\" valign=\"top\"\u003e\n \u003cp\u003eEFH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.56500802568219%\" valign=\"top\"\u003e\n \u003cp\u003eEmirates Friendship Hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.434991974317818%\" valign=\"top\"\u003e\n \u003cp\u003eEPI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.56500802568219%\" valign=\"top\"\u003e\n \u003cp\u003eExtended Programme of Immunization\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.434991974317818%\" valign=\"top\"\u003e\n \u003cp\u003eFCMs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.56500802568219%\" valign=\"top\"\u003e\n \u003cp\u003eFriendship Community Medic Aides\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.434991974317818%\" valign=\"top\"\u003e\n \u003cp\u003eFGD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.56500802568219%\" valign=\"top\"\u003e\n \u003cp\u003eFocused Group Discussions\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.434991974317818%\" valign=\"top\"\u003e\n \u003cp\u003eFWA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.56500802568219%\" valign=\"top\"\u003e\n \u003cp\u003eFamily Welfare Assistants\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.434991974317818%\" valign=\"top\"\u003e\n \u003cp\u003eGoB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.56500802568219%\" valign=\"top\"\u003e\n \u003cp\u003eGovernment of Bangladesh\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.434991974317818%\" valign=\"top\"\u003e\n \u003cp\u003eIDI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.56500802568219%\" valign=\"top\"\u003e\n \u003cp\u003eIn-Depth Interview\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.434991974317818%\" valign=\"top\"\u003e\n \u003cp\u003eKII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.56500802568219%\" valign=\"top\"\u003e\n \u003cp\u003eKey Informant Interviews\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.434991974317818%\" valign=\"top\"\u003e\n \u003cp\u003eLFH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.56500802568219%\" valign=\"top\"\u003e\n \u003cp\u003eLifebuoy Friendship Hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.434991974317818%\" valign=\"top\"\u003e\n \u003cp\u003eLMICs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.56500802568219%\" valign=\"top\"\u003e\n \u003cp\u003eLow-and middle-income countries\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.434991974317818%\" valign=\"top\"\u003e\n \u003cp\u003ePNC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.56500802568219%\" valign=\"top\"\u003e\n \u003cp\u003ePostnatal care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.434991974317818%\" valign=\"top\"\u003e\n \u003cp\u003eSDGs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.56500802568219%\" valign=\"top\"\u003e\n \u003cp\u003eSustainable Development Goals\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.434991974317818%\" valign=\"top\"\u003e\n \u003cp\u003eUH\u0026amp;FPO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.56500802568219%\" valign=\"top\"\u003e\n \u003cp\u003eUpazila Health and Family Planning Officer\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.434991974317818%\" valign=\"top\"\u003e\n \u003cp\u003eUH\u0026amp;FWCs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.56500802568219%\" valign=\"top\"\u003e\n \u003cp\u003eUpazila Health and Family Welfare Centres\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.434991974317818%\" valign=\"top\"\u003e\n \u003cp\u003eUHCs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.56500802568219%\" valign=\"top\"\u003e\n \u003cp\u003eUpazila Health Complexes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.434991974317818%\" valign=\"top\"\u003e\n \u003cp\u003eUSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.56500802568219%\" valign=\"top\"\u003e\n \u003cp\u003eUnited States Dollar\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was reviewed and approved by the Institutional Review Board of icddr,b that includes a Research Review Committee and an Ethics Review Committee (Protocol No.: PR-22060).\u0026nbsp;Written informed consent was obtained from each participant, describing the goals, benefits, and risks of the study. The anonymity and privacy of the participants were maintained, and their data was kept secret, with only the study team having access. Participants were allowed to withdraw themselves at any time and choose not to answer any question.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research described in this study received financial support from Friendship Luxembourg through a grant (Grant No.: GR-02235). The funders did not play any role in the study design, data collection and analysis, publication decision, or manuscript preparation.\u003cstrong\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMd Refat Uz Zaman Sajib contributed as the focal for the study, overseeing the design and implementation, contributing to conceptualization, conducting the analysis, writing the initial draft, and editing the manuscript. Kamrul Hasan, Tanvir Hayder, Atia Rahman and Tania Sultana Tanwi participated in data collection, conducted the analysis, contributed to the initial draft, and edited the manuscript. A M Rumayan Hasan, Md. Musfikur Rahman, Saraban Ether, Fariya Rahman, Abu Sayeed, Syed Moshfiqur Rahman, and Sanwarul Bari contributed by providing review and feedback. Shams El Arifeen contributed to the study design and implementation and provided review and feedback. Anisuddin Ahmed contributed as the Principal Investigator for the study, overseeing the study design and implementation and providing review and feedback.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eicddr,b is grateful to its core donors, the governments of Bangladesh and Global Affairs Canada for providing unrestricted support. We extend our gratitude to the 9 government officials who participated in the interview and to Friendship Bangladesh officials who contributed to the smooth operation of this study. We also sincerely appreciate the health care providers and community people who actively participated in this research.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eQuinn SC, Kumar S: \u003cstrong\u003eHealth inequalities and infectious disease epidemics: a challenge for global health security\u003c/strong\u003e. \u003cem\u003eBiosecur Bioterror \u003c/em\u003e2014, \u003cstrong\u003e12\u003c/strong\u003e(5):263-273.\u003c/li\u003e\n\u003cli\u003eKhalid AM, Sharma S, Dubey AK: \u003cstrong\u003eConcerns of developing countries and the sustainable development goals: case for India\u003c/strong\u003e. \u003cem\u003eInternational Journal of Sustainable Development \u0026amp; World Ecology \u003c/em\u003e2020, \u003cstrong\u003e28\u003c/strong\u003e(4):303-315.\u003c/li\u003e\n\u003cli\u003eAngele MN, Abel NM, Jacques OM, Henri MT, Francoise MK: \u003cstrong\u003eSocial and economic consequences of the cost of obstetric and neonatal care in Lubumbashi, Democratic Republic of Congo: a mixed methods study\u003c/strong\u003e. \u003cem\u003eBMC Pregnancy Childbirth \u003c/em\u003e2021, \u003cstrong\u003e21\u003c/strong\u003e(1):315.\u003c/li\u003e\n\u003cli\u003eAmjath-Babu TS, Krupnik TJ, Thilsted SH, McDonald AJ: \u003cstrong\u003eKey indicators for monitoring food system disruptions caused by the COVID-19 pandemic: Insights from Bangladesh towards effective response\u003c/strong\u003e. \u003cem\u003eFood Secur \u003c/em\u003e2020, \u003cstrong\u003e12\u003c/strong\u003e(4):761-768.\u003c/li\u003e\n\u003cli\u003eAhmadi-Javid A, Seyedi P, Syam SS: \u003cstrong\u003eA survey of healthcare facility location\u003c/strong\u003e. \u003cem\u003eComputers \u0026amp; Operations Research \u003c/em\u003e2017, \u003cstrong\u003e79\u003c/strong\u003e:223-263.\u003c/li\u003e\n\u003cli\u003eIqbal MH: \u003cstrong\u003eDisparities of health service for the poor in the coastal area: does Universal health coverage reduce disparities?\u003c/strong\u003e \u003cem\u003eJ Mark Access Health Policy \u003c/em\u003e2019, \u003cstrong\u003e7\u003c/strong\u003e(1):1575683.\u003c/li\u003e\n\u003cli\u003eKamal F, Chowdhury MM, Masud M: \u003cstrong\u003eChallenges of Char People in Northern Bangladesh: A Study on Dimla, Nilphamari\u003c/strong\u003e. \u003cem\u003eInternational Journal of Innovative Science and Research Technology \u003c/em\u003e2021, \u003cstrong\u003e6\u003c/strong\u003e(2):620-629.\u003c/li\u003e\n\u003cli\u003eIslam MR: \u003cstrong\u003eClimate Change, Natural Disasters and Socioeconomic Livelihood Vulnerabilities: Migration Decision Among the Char Land People in Bangladesh\u003c/strong\u003e. \u003cem\u003eSocial Indicators Research \u003c/em\u003e2017, \u003cstrong\u003e136\u003c/strong\u003e(2):575-593.\u003c/li\u003e\n\u003cli\u003ePaul S, Islam MR: \u003cstrong\u003eUltra-poor char people\u0026apos;s rights to development and accessibility to public services: A case of Bangladesh\u003c/strong\u003e. \u003cem\u003eHabitat International \u003c/em\u003e2015, \u003cstrong\u003e48\u003c/strong\u003e:113-121.\u003c/li\u003e\n\u003cli\u003eAhmed JU, Rahanaz M, Rubaiyat i S: \u003cstrong\u003eFriendship Floating Hospitals: Healthcare for the Riverine People of Bangladesh\u003c/strong\u003e. \u003cem\u003eJournal of Developing Societies \u003c/em\u003e2019, \u003cstrong\u003e35\u003c/strong\u003e(1):175-194.\u003c/li\u003e\n\u003cli\u003eKhan R: \u003cstrong\u003eFriendship\u0026apos;s 3-Tier Healthcare System: An Innovative Approach to Delivering Healthcare to Geographically and Socially Remote Areas\u003c/strong\u003e. 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framework\u0026rsquo;: An explanatory mixed-method study\u003c/strong\u003e. \u003cem\u003ePLoS One \u003c/em\u003e2022.\u003c/li\u003e\n\u003cli\u003eUddin MJ, Shamsuzzaman M, Horng L, Labrique A, Vasudevan L, Zeller K, Chowdhury M, Larson CP, Bishai D, Alam N: \u003cstrong\u003eUse of mobile phones for improving vaccination coverage among children living in rural hard-to-reach areas and urban streets of Bangladesh\u003c/strong\u003e. \u003cem\u003eVaccine \u003c/em\u003e2016, \u003cstrong\u003e34\u003c/strong\u003e(2):276-283.\u003c/li\u003e\n\u003cli\u003eZobair KM, Sanzogni L, Sandhu K: \u003cstrong\u003eTelemedicine Healthcare Service Adoption Barriers in Rural Bangladesh\u003c/strong\u003e. \u003cem\u003eAustralasian Journal of Information Systems \u003c/em\u003e2020, \u003cstrong\u003e24\u003c/strong\u003e:1-24.\u003c/li\u003e\n\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":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"archives-of-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aoph","sideBox":"Learn more about [Archives of Public Health](http://archpublichealth.biomedcentral.com/)","snPcode":"13690","submissionUrl":"https://submission.nature.com/new-submission/13690/3","title":"Archives of Public Health","twitterHandle":"@Archpubhealth","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"3-tier health care model, Comprehensive health care model, Hard-to-reach, Riverine low-resource setting, Bangladesh","lastPublishedDoi":"10.21203/rs.3.rs-4456479/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4456479/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eRemote and hard-to-reach riverine communities of northern Bangladesh face unique challenges in health care services. Friendship, an international social purpose organization, has implemented a 3-tier health care model addressing these unique challenges over the past 20 years. This study evaluates Friendship\u0026rsquo;s 3-tier health care model, focusing on general health care service-seeking practices, beneficiary and stakeholder perspectives, and cost benefits.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA mixed-method approach was employed, including desk reviews, a cross-sectional quantitative survey, and qualitative interviews with service recipients, community representatives, health care providers, and health managers. Data were collected from five hard-to-reach riverine sub-districts across Kurigram, Gaibandha, Bogura, Sirajganj, and Jamalpur districts of Bangladesh between April 2022 and July 2023. Data analyses followed major thematic domains for a comprehensive and complementary understanding.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA significant proportion (43.0%) of survey participants had no formal education, were aged 18\u0026ndash;35 (57.5%), and earned less than 1,620 USD yearly (66.6%). Friendship's health care services at doorstep through satellite clinics and Female Community Medic Aides are widely accepted and preferred within the community for convenience, affordability (0.05\u0026ndash;0.09 USD service charges), and superior quality, particularly the specialized treatments available on the hospital ships.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe 3-tier health care model offers a wide range of services, including ante- and post-natal care, family planning, and specialized treatment, complemented by nutrition demonstrations and community-based health awareness initiatives. With generalized acceptance among the target communities, Friendship's 3-tier health care model has made primary health care accessible and affordable. Upon implementing a robust referral mechanism and continuing collaboration with the Government of Bangladesh, this model has the potential to be effective in similar settings in Bangladesh and other developing countries, as well as during emergency responses.\u003c/p\u003e","manuscriptTitle":"Reaching the Unreachable: A mixed-method evaluation of multidimensional healthcare model addressing the healthcare service gaps in hard-to-reach Northern Riverine Bangladesh","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-11 20:25:45","doi":"10.21203/rs.3.rs-4456479/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-02-22T18:22:42+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-02-21T18:46:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"80737566699733578311955653965194025220","date":"2025-02-14T12:27:54+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-02-11T10:13:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"96616816142663853594969131501539378507","date":"2025-02-10T13:06:32+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-02-10T07:55:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"254176908423825097941198247512693380703","date":"2025-02-10T07:41:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"250747094780031711896420709783805990094","date":"2025-02-10T04:16:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"115680532528601000319799647269563156597","date":"2025-02-09T14:38:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"225189154098939354691856415431242302658","date":"2025-02-09T14:13:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"57034395995869333229781076660881313448","date":"2025-02-09T14:10:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"71071453901357798231371249930984222653","date":"2025-02-09T12:37:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"29973086447912613395451884756036972504","date":"2024-08-22T07:02:51+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-02T20:14:38+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-27T06:37:51+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-05-27T06:37:51+00:00","index":"","fulltext":""},{"type":"submitted","content":"Archives of Public Health","date":"2024-05-21T17:46:49+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"archives-of-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aoph","sideBox":"Learn more about [Archives of Public Health](http://archpublichealth.biomedcentral.com/)","snPcode":"13690","submissionUrl":"https://submission.nature.com/new-submission/13690/3","title":"Archives of Public Health","twitterHandle":"@Archpubhealth","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"df6d079a-933c-4ef2-9169-59b635802709","owner":[],"postedDate":"June 11th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-04-21T15:59:56+00:00","versionOfRecord":{"articleIdentity":"rs-4456479","link":"https://doi.org/10.1186/s13690-025-01592-6","journal":{"identity":"archives-of-public-health","isVorOnly":false,"title":"Archives of Public Health"},"publishedOn":"2025-04-14 15:57:19","publishedOnDateReadable":"April 14th, 2025"},"versionCreatedAt":"2024-06-11 20:25:45","video":"","vorDoi":"10.1186/s13690-025-01592-6","vorDoiUrl":"https://doi.org/10.1186/s13690-025-01592-6","workflowStages":[]},"version":"v1","identity":"rs-4456479","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4456479","identity":"rs-4456479","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}