Abstract
<title>Abstract</title> <p>The demographic aging in low-and middle-income countries is increasingly complicating governance challenges for which their health systems are ill-equipped. Such is the case of Bangladesh, where the proportion of the elderly age group (aged 60 years or more) is expected to increase from 9.5% of the total population in 2023 to around 21.5% in 2050, whereas the public health administration system continues to suffer from fragmentation, unevenness, and lack of reform to suit the requirements of older persons. The present systematic scoping review argues that spatial inequality in healthcare service access for older Bangladeshis does not come about mainly due to a lack of resources but rather governance failures throughout the various hierarchical layers of the public administration system. Following the five-stage methodology of Arksey and O’Malley (2005) and using the PRISMA-ScR criteria checklist by Tricco et al. (2018), the study systematically analyzes 58 articles, both peer-reviewed and grey literature, published from 2013 to 2025. Governance failures identified in the review include the absence of geriatric care policy requirements in the organizational structure of the health system, unequal distribution of doctors and high absenteeism at Upazila Health Complexes, unequal access to facilities and poor transportation infrastructure in rural versus urban areas, decline of the system of informal caregiving at home, and intersectoral coordination between the Ministry of Health and Family Welfare, local governments, and the Department of Social Services. An analytical model in which spatial inequality is viewed as the spatial expression of governance failure is put forth, applicable to other LMICs in addition to Bangladesh. The proposed governance reform strategy, informed by institutional theory, involves the incorporation of spatial equity considerations into the Health, Population and Nutrition Sector Programme of Bangladesh as an immediate measure.</p>