Intersecting Inequities in Healthcare Utilisation among Persons with Disabilities in Bangladesh

Imagine a world where the simple act of seeking medical help is not just a matter of needing care, but a complex negotiation with your own body, your bank account, your gender, and the way society treats you. For millions of people living with disabilities, this negotiation is often a daily struggle. In many parts of the world, including low- and middle-income nations, the health system is designed for the average person, often leaving those with physical or cognitive differences behind. This creates a gap where the very people who need care the most are the ones who face the highest walls to get it. Researchers have long known that disability and poverty often feed into each other, creating a cycle where being poor makes disability more likely, and having a disability makes it harder to earn money. But a critical question remains: when a person with a disability in a place like Bangladesh finally tries to access a doctor, what actually stops them or helps them? Is it just the cost? Is it the distance? Or is it something deeper, like the way a woman with a disability is treated differently than a man with a disability?

A team of researchers from the Australian National University decided to look closely at this question using a massive, newly collected dataset from Bangladesh. They turned to a framework called the Andersen Behavioural Model, which is a standard way scientists organize the reasons why people go to the doctor. This model usually looks at three things: who you are (like your age or education), what resources you have (like money or living in a city), and how sick you are. However, the researchers realized that for people with disabilities, this standard list might be missing crucial pieces. They added a new layer to their investigation, looking at how people feel about their ability to get care, whether they face discrimination, and how their social or religious lives might help or hinder them. By combining this standard model with a perspective called intersectionality—which understands that different parts of a person's identity, like being a woman and being disabled, overlap to create unique challenges—they set out to see if the rules of healthcare access work the same way for everyone.

The researchers analyzed data from over 136,000 people, including more than 4,000 individuals with disabilities, collected in a comprehensive national survey in 2021. This was the first time such a large, representative group had been studied together in this way. When they looked at the raw numbers, they found a surprising starting point: people with disabilities in Bangladesh were actually visiting doctors more often than those without disabilities. Nearly 91 percent of people with disabilities had used some form of healthcare in the past year, compared to about 78 percent of those without disabilities. At first glance, this might look like a success story, suggesting that the system is working. But the researchers knew that high usage numbers could be misleading. They dug deeper to understand why these numbers were high and who was being left out within that group.

The first major discovery was that the high usage was driven by sheer necessity. People with disabilities in the study were far more likely to suffer from multiple chronic conditions, such as heart disease, diabetes, or high blood pressure, often having two or more serious health issues at once. Their visits were not optional; they were a response to a heavy burden of illness. However, when the researchers broke down the data by gender, a stark and troubling pattern emerged. In the general population, women were slightly more likely to visit a doctor than men. But among people with disabilities, this trend flipped completely. Women with disabilities were significantly less likely to seek care than men with disabilities. The researchers found that a woman with a disability had much lower odds of visiting a doctor compared to a man with a disability. This suggests that in the context of Bangladesh, being a woman and having a disability creates a double barrier that prevents access to care in a way that does not affect men with disabilities. It appears that cultural norms and household dynamics restrict the mobility and decision-making power of women with disabilities far more than they do for men.

Money played a complex role in this story. The researchers found that wealth mattered, but not in a simple, steady way. For people without disabilities, having more money generally meant a higher chance of seeing a doctor. For people with disabilities, the effect was much sharper. Only those in the very richest group saw a significant boost in their ability to get care. Those in the middle-income groups were not much better off than the poorest. This suggests a "threshold" effect, where a certain level of wealth is required just to overcome the extra costs and barriers of disability, and anything less than that leaves a person struggling. Furthermore, the study revealed that the feeling of being able to access care was the single most powerful factor. When a person with a disability believed they could get the help they needed, their likelihood of actually going to a doctor jumped dramatically. This feeling of accessibility was so strong that it seemed to explain much of the difference that wealth usually makes. In other words, money helps primarily because it makes care feel reachable; if care feels unreachable, money alone may not be enough.

The study also highlighted the heavy weight of social attitudes. People with disabilities who reported experiencing discrimination were far less likely to use healthcare services. This effect was so strong that it cut their chances of seeking help by more than half. Interestingly, the researchers found that having some money could slightly soften this blow. A person with a disability who faced discrimination but had moderate wealth was still able to seek care more often than the poorest person facing the same discrimination. This suggests that while money cannot erase discrimination, it can provide a small buffer, perhaps by allowing a person to travel further to find a kinder doctor or pay for private help. The study also found that religious participation was a powerful positive force. People with disabilities who were active in their religious communities were twice as likely to use healthcare services. This points to the idea that religious groups in Bangladesh act as a vital support network, offering trust, information, and encouragement that helps people navigate the health system.

Perhaps the most surprising finding was about location. In many countries, living in a big city like Dhaka usually means better access to hospitals. But for people with disabilities in Bangladesh, living in the capital city did not give them a significant advantage over living in rural areas. The researchers found that people with disabilities in Dhaka were not more likely to get care than those in other regions. This suggests that even in the most developed part of the country, the physical infrastructure of hospitals and clinics remains inaccessible to many. The buildings may be there, but if they cannot be entered or used by someone with a mobility impairment, the location offers no real benefit. This finding challenges the assumption that urbanization automatically solves access problems for everyone.

The researchers concluded that the story of healthcare in Bangladesh for people with disabilities is not just about having a disease or having money. It is about how different parts of a person's life intersect to create unique barriers. A woman with a disability faces a different set of obstacles than a man with a disability. A poor person with a disability faces a different set of obstacles than a rich one. The study showed that simply counting how many people visit a doctor hides these deep inequalities. The high overall number of visits is driven by the urgent, unmet needs of a population that is often ignored. To fix this, the researchers suggest that policies need to move beyond general solutions. They need to specifically address the barriers that women face, ensure that physical spaces are truly accessible, and create systems that hold healthcare providers accountable for discrimination. The study also highlights that faith-based communities are already doing important work to connect people with care, and these networks could be better supported by the health system. Ultimately, the research paints a picture of a system where the path to a doctor is paved with more than just a road; it is paved with attitudes, resources, and the very design of the society itself.