The predictive power of health system environments: a novel approach for explaining inequalities in access to maternal healthcare

How Zambia reduced inequalities in under-five mortality rates over the last two decades: a mixed-methods study

BACKGROUND

Zambia experienced a major decline in under-five mortality rates (U5MR), with one of the fastest declines in socio-economic disparities in sub-Saharan Africa in the last two decades. We aimed to understand the extent to which, and how, Zambia has reduced socio-economic inequalities in U5MR since 2000.

METHODS

Using nationally-representative data from Zambia Demographic Health Surveys (2001/2, 2007, 2013/14 and 2018), we examined trends and levels of inequalities in under-five mortality, intervention coverage, household water and sanitation, and fertility. This analysis was integrated with an in-depth review of key policy and program documents relevant to improving child survival in Zambia between 1990 and 2020.

RESULTS

The under-five mortality rate (U5MR) declined from 168 to 64 deaths per 1000 live births between 2001/2 and 2018 ZDHS rounds, particularly in the post-neonatal period. There were major reductions in U5MR inequalities between wealth, education and urban-rural residence groups. Yet reduced gaps between wealth groups in estimated absolute income or education levels did not simultaneously occur. Inequalities reduced markedly for coverage of reproductive, maternal, newborn and child health (RMNCH), malaria and human immunodeficiency virus interventions, but less so for water or sanitation and fertility levels. Several policy and health systems drivers were identified for reducing RMNCH inequalities: policy commitment to equity in RMNCH; financing with a focus on disadvantaged groups; multisectoral partnerships and horizontal programming; expansion of infrastructure and human resources for health; and involvement of community stakeholders and service providers.

CONCLUSION

Zambia's major progress in reducing inequalities in child survival between the poorest and richest people appeared to be notably driven by government policies and programs that centrally valued equity, despite ongoing gaps in absolute income and education levels. Future work should focus on sustaining these gains, while targeting families that have been left behind to achieve the sustainable development goal targets.

Understanding maternal choices and experiences of care by skilled providers: Voices of mothers who delivered at home in selected communities of Lusaka city, Zambia

Background

Significant proportions of women living in urban areas including the capital cities continue to deliver at home. We aimed to understand why mothers in a selected densely populated community of Lusaka city in Zambia deliver from home without assistance from a skilled provider during childbirth.

Methods

Using a phenomenological case study design, we conducted Focus Group Discussions and In-depth Interviews with mothers who delivered at home without assistance from a skilled provider. The study was conducted between November 2020 and January 2021 among 19 participants. Data were analysed using content analysis.

Results

Individual-related factors including the belief that childbirth is a natural and easy process that did not require assistance, lack of transport to get to the health facility, influence and preference for care from older women who were perceived to have the experience and better care, failure to afford baby supplies, and waiting for partner to provide the supplies that were required at the health facility influenced mothers' choices to seek care from skilled providers. Health system-related factors included mistreatment and disrespectful care such as verbal and physical abuse by skilled healthcare providers, stigma and discrimination, institutional fines, and guidelines such as need to attend antenatal care with a spouse and need to provide health facility demanded supplies.

Conclusion

Individual and health system access related factors largely drive the choice to involve skilled providers during childbirth. The socioeconomic position particularly contributes to limited decision-making autonomy of mothers, thus, creating challenges to accessing care in health facilities. The health system-related factors found in this study such as mistreatment and disrespectful care suggests the need for redesigning effective and sustainable urban resource-limited context maternal health strategies that are culturally acceptable, non-discriminatory, and locally responsive and inclusive. Rethinking these strategies this way has the potential to strengthening equitable responsive health systems that could accelerate attainment of sustainable developmental goal (SDG) 3 targets.

Intersectional social identities and loneliness: Evidence from a municipality in Switzerland

We examined the extent to which intersectional social identities combine to shape risks of loneliness and identified the specific social clusters that are most at risk of loneliness for more precise and targeted interventions to reduce loneliness in a Swiss municipality. Based on data collected using participatory action research, we used the novel multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) to estimate the predictive power of intersectional social attributes on risk of loneliness. We found that 56% of the between-strata variance was captured by intersectional interaction but was not explained by the additive effect of social identities. We also found that nationality and education had the strongest predictive power for loneliness. Interventions to reduce loneliness may benefit from understanding the resident population's intersectional identities given that individuals with the same combinations of social identities face a common set of social exposures relating to loneliness.

Universal health coverage and the poor: to what extent are health financing policies making a difference? Evidence from a benefit incidence analysis in Zambia

Background

Zambia has invested in several healthcare financing reforms aimed at achieving universal access to health services. Several evaluations have investigated the effects of these reforms on the utilization of health services. However, only one study has assessed the distributional incidence of health spending across different socioeconomic groups, but without differentiating between public and overall health spending and between curative and maternal health services. Our study aims to fill this gap by undertaking a quasi-longitudinal benefit incidence analysis of public and overall health spending between 2006 and 2014.

Methods

We conducted a Benefit Incidence Analysis (BIA) to measure the socioeconomic inequality of public and overall health spending on curative services and institutional delivery across different health facility typologies at three time points. We combined data from household surveys and National Health Accounts.

Results

Results showed that public (concentration index of − 0.003; SE 0.027 in 2006 and − 0.207; SE 0.011 in 2014) and overall (0.050; SE 0.033 in 2006 and − 0.169; SE 0.011 in 2014) health spending on curative services tended to benefit the poorer segments of the population while public (0.241; SE 0.018 in 2007 and 0.120; SE 0.007 in 2014) and overall health spending (0.051; SE 0.022 in 2007 and 0.116; SE 0.007 in 2014) on institutional delivery tended to benefit the least-poor. Higher inequalities were observed at higher care levels for both curative and institutional delivery services.

Conclusion

Our findings suggest that the implementation of UHC policies in Zambia led to a reduction in socioeconomic inequality in health spending, particularly at health centres and for curative care. Further action is needed to address existing barriers for the poor to benefit from health spending on curative services and at higher levels of care.

Physically Constructed and Socially Shaped: Sociomaterial Environment and Walking for Transportation in Later Life

The predictive power of three intersecting environmental dimensions (built structures, social infrastructure, and social capital) on late-life walking was investigated, conceptually based on the ecological framework of place, which posits that a living environment is simultaneously a physical place, a social place, and a set of social bonds. Multilevel models were used to examine the extent to which environments, defined as interactions of the social and material environmental dimensions, reliably predicted walking for transportation among U.S. adults aged 60 years or older in the 2015 National Health Interview Survey (n = 11,180). Random intercepts representing 221 environments showed an intraclass correlation of 21%, indicating high levels of between-environment variance in walking. Social infrastructure had the highest predictive power for walking, followed by material structures and social capital. Synergistic interventions that incorporate the intersecting nature of the sociomaterial environment may be most effective in promoting physical activity in later life.

Challenging categorical thinking: A mixed methods approach to explaining health inequalities

"Categorical thinking" in social science research has been widely criticised by feminist scholars for conceptualising social categories as natural, de-contextualised, and internally homogeneous. This paper develops and applies a mixed-methods approach to the study of health inequalities, using social categories meaningfully in order to challenge categorical thinking. The approach is demonstrated through a case study of socio-economic (SES) inequalities in maternal healthcare access in Zambia. This paper's approach responds to the research agenda set by intersectional social epidemiologists by considering potential heterogeneity within categories, but also by exploring the context-specific meaning of categories, examining explanations at multiple levels, and interpreting results according to mutually constitutive social processes. The study finds that meso-level institutions, "health service environments", explain a large share of SES inequalities in maternal healthcare access. Women's work, marital status, and levels of "autonomy" have heterogeneous implications for healthcare access across SES categories. Disadvantaged categories and their reproductive behaviours are stigmatised as 'backwards', in contrast to advantaged categories and their behaviours, which are associated with 'modernity' and 'development'. Challenging categorical thinking has important implications for social justice and health, by rejecting framings of a specific category as problematic or non-compliant, highlighting the possibility of change, and emphasising the political and structural nature of progress.

Assessment of health facility quality improvements, United Republic of Tanzania

Objective

To identify contextual factors associated with quality improvements in primary health-care facilities in the United Republic of Tanzania between two star rating assessments, focusing on local district administration and proximity to other facilities.

Methods

Facilities underwent star rating assessments in 2015 and between 2017 and 2018; quality was rated from zero to five stars. The consolidated framework for implementation research, adapted to a low-income context, was used to identify variables associated with star rating improvements between assessments. Facility data were obtained from several secondary sources. The proportion of the variance in facility improvement observed at facility and district levels and the influence of nearby facilities and district administration were estimated using multilevel regression models and a hierarchical spatial autoregressive model, respectively.

Findings

Star ratings improved at 4028 of 5595 (72%) primary care facilities. Factors associated with improvement included: (i) star rating in 2015; (ii) facility type (e.g. hospital) and ownership (e.g. public); (iii) participation in, or eligibility for, a results-based financing programme; (iv) local population density; and (v) distance from a major road. Overall, 20% of the variance in facility improvement was associated with district administration. Geographical clustering indicated that improvement at a facility was also associated with improvements at nearby facilities.

Conclusion

Although the majority of facilities improved their star rating, there were substantial variations between facilities. Both district administration and proximity to high-performing facilities influenced improvements. Quality improvement interventions should take advantage of factors operating above the facility level, such as peer learning and peer pressure.