Bangladesh is committed to achieving the United Nations Sustainable Development Goal 3 (SDG3) but faces growing challenges in meeting the healthcare needs of an aging population. The elderly in rural areas experience heightened vulnerability, including chronic diseases such as diabetes, cancer, and cardiovascular events, together with socioeconomic insecurity, loneliness, and inadequate local health facilities. Primary healthcare (PHC) is the frontline of the health system and generally the preferred point of care for older adults; however, rural elderly Bangladeshi people continue to encounter multiple obstacles that limit access and use. This systematic review aimed to identify and synthesize multilevel barriers to accessing and using primary healthcare among the rural Bangladeshi elderly, using the Social Ecological Model (SEM) to structure findings.
The review was registered in PROSPERO. Electronic searches were conducted in March 2026 across Scopus, PubMed, ProQuest Sociological Abstracts, Google Scholar and Google using keywords related to healthcare access, PHC services, aging, and barriers for older persons in rural Bangladesh. The initial search returned 2,099 records. After application of the review’s inclusion and exclusion criteria, 19 articles were retained for synthesis.
Included studies were screened and selected according to the pre-specified criteria reported in the review. The quality of the selected studies was appraised using established tools: the Critical Appraisal Skills Programme (CASP) and the Mixed Methods Appraisal Tool (MMAT). Thematic synthesis was used to extract and organize reported barriers, with the SEM guiding the identification of multilevel themes.
The review applied the SEM to classify barriers at five nested levels: individual, family, organizational, social and community, and policy. This approach was selected because SEM provides a multilevel perspective—addressing personal, interpersonal, institutional, community, and policy influences—rather than focusing solely on individual behavior or health outcomes.
Across included studies, prominent individual-level barriers were reported. These included reduced physical capability among older adults, which limits mobility and the ability to seek care; financial insolvency and limited economic resources that constrain the ability to pay for services and medicines; and poor awareness or lack of knowledge about available PHC services and how to use them. These factors individually and collectively reduced care-seeking from institutional PHC providers.
Family and household dynamics were repeatedly identified as important determinants of PHC use. Limited connectivity with family and relatives (for example, absent caregivers or reduced family support) impeded access. Family members often influenced healthcare decision-making, which could delay or prevent timely use of PHC. Gender disparities within families—such as differential prioritization of male over female health needs—were also reported as barriers for some older adults.
Organizational obstacles within PHC settings were common. The review identified limited infrastructural facilities at primary-level centers, dissatisfaction with healthcare providers’ attitudes and perceived lack of professionalism, and a preference among some elderly patients for gender-concordant providers. Direct treatment expenses and ancillary costs associated with facility visits were additional organizational-level deterrents. These service-level shortcomings reduced confidence in and use of institutional PHC.
At the community level, the review highlighted reliance on traditional healers as an alternative to formal PHC, which sometimes replaced or delayed use of formal services. Limited mobility within communities—owing to poor transport, geographic distance from facilities, or social constraints—further restricted access for rural elderly people.
Policy-related gaps included inadequate elderly-specific health programs within the Government of Bangladesh’s health framework and shortcomings in rural elderly health insurance or coverage schemes. Although the Ministry of Social Welfare formulated the National Policy on Elder Persons (2013), the review noted an absence of policy implementation details, attributed to limited funding, investment, and dedicated human resources. Overall, these policy-level deficiencies contributed to persistent access barriers.
The review emphasizes that barriers to PHC for the rural elderly are multifactorial and operate across individual, interpersonal, organizational, community, and policy domains. Addressing these barriers is relevant to Bangladesh’s pledge toward SDG3 and universal health coverage goals. The review notes that prior research on rural elderly PHC access in Bangladesh is limited and often focused on narrower subgroups, such as women, or on specific socioeconomic or cultural factors. Strengthened policy attention, improved implementation of existing elderly-related policies, and better resourcing of PHC are implied priorities.
Based on the synthesized evidence, the review recommends interventions across levels: PHC awareness campaigns to improve knowledge among older adults, measures to strengthen family support and decision-making in favor of elderly care, simplification and improvement of service-related procedures and infrastructure at PHC facilities, social assistance to reduce financial barriers, and development or expansion of health coverage programs targeting the rural elderly. The authors conclude that such multilevel actions are needed to improve PHC access and help Bangladesh progress toward SDG3 for its aging rural population.