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Jacobs C, Musukuma M, Hamoonga R, Sikapande B, Chooye O, Wehrmeister FC, Michelo C, Blanchard AK. Trends and Inequalities in Maternal and Newborn Health Services for Unplanned Settlements of Lusaka City, Zambia. J Urban Health 2024:10.1007/s11524-024-00837-z. [PMID: 38459401 DOI: 10.1007/s11524-024-00837-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/07/2024] [Indexed: 03/10/2024]
Abstract
Living conditions and other factors in urban unplanned settlements present unique challenges for improving maternal and newborn health (MNH), yet MNH inequalities associated with such challenges are not well understood. This study examined trends and inequalities in coverage of MNH services in the last 20 years in unplanned and planned settlements of Lusaka City, Zambia. Geospatial information was used to map Lusaka's settlements and health facilities. Zambia Demographic Health Surveys (ZDHS 2001, 2007, 2013/2014, and 2018) were used to compare antenatal care (ANC), institutional delivery, and Cesarean section (C-section) coverage, and neonatal mortality rates between the poorer 60% and richer 40% households. Health Management Information System (HMIS) data from 2018 to 2021 were used to compute service volumes and coverage rates for ANC1 and ANC4, and institutional delivery and C-sections by facility level and type in planned and unplanned settlements. Although the correlation is not exact, our data analysis showed close alignment; and thus, we opted to use the 60% poorer and 40% richer groups as a proxy for households in unplanned versus planned settlements. Unplanned settlements were serviced by primary centers or first-level hospitals. ZDHS findings show that by 2018, at least one ANC visit and institutional delivery became nearly universal throughout Lusaka, but early and four or more ANC visits, C-sections, and neonatal mortality rates remained worse among poorer than richer women in ZDHS. In HMIS, ANC and institutional delivery volumes were highest in public facilities, especially in unplanned settlements. The volume of C-sections was much greater within facilities in planned than unplanned settlements. Our study exposed persistent gaps in timing and use of ANC and emergency obstetric care between unplanned and planned communities. Closing such gaps requires strengthening outreach early and consistently in pregnancy and increasing emergency obstetric care capacities and referrals to improve access to important MNH services for women and newborns in Lusaka's unplanned settlements.
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Affiliation(s)
- Choolwe Jacobs
- Department of Epidemiology and Biostatistics, School of Public Health, University of Zambia, Lusaka, Zambia.
| | - Mwiche Musukuma
- Department of Epidemiology and Biostatistics, School of Public Health, University of Zambia, Lusaka, Zambia
| | | | | | | | - Fernando C Wehrmeister
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
| | | | - Andrea K Blanchard
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
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Guerra S, Roope LS, Tsiachristas A. Assessing the relationship between coverage of essential health services and poverty levels in low- and middle-income countries. Health Policy Plan 2024; 39:156-167. [PMID: 38300510 PMCID: PMC10883664 DOI: 10.1093/heapol/czae002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 12/22/2023] [Accepted: 01/29/2024] [Indexed: 02/02/2024] Open
Abstract
Universal health coverage (UHC) aims to provide essential health services and financial protection to all. This study aimed to assess the relationship between the service coverage aspect of universal health coverage and poverty in low- and middle-income countries (LMICs). Using country-level data from 96 LMICs from 1990 to 2017, we employed fixed-effects and random-effects regressions to investigate the association of eight service coverage indicators (inpatient admissions; antenatal care; skilled birth attendance; full immunization; cervical and breast cancer screening rates; diarrhoea and acute respiratory infection treatment rates) with poverty headcount ratios and gaps at the $1.90, $3.20 and $5.50 poverty lines. Missing data were imputed using within-country linear interpolation or extrapolation. One-unit increases in seven service indicators (breast cancer screening being the only one with no significant associations) were associated with reduced poverty headcounts by 2.54, 2.46 and 1.81 percentage points at the $1.90, $3.20 and $5.50 lines, respectively. The corresponding reductions in poverty gaps were 0.99 ($1.90), 1.83 ($3.20) and 1.89 ($5.50) percentage points. Apart from cervical cancer screening, which was only significant in one poverty headcount model ($5.50 line), all other service indicators were significant in either the poverty headcount or gap models at both $1.90 and $3.20 poverty lines. In LMICs, higher service coverage rates are associated with lower incidence and intensity of poverty. Further research is warranted to identify the causal pathways and specific circumstances in which improved health services in LMICs might help to reduce poverty.
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Affiliation(s)
- Stefanny Guerra
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford OX3 7LF, United Kingdom
- Department of Population Health Sciences, King’s College London, Guy’s Campus, Great Maze Pond, London SE1 1UL, United Kingdom
| | - Laurence Sj Roope
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford OX3 7LF, United Kingdom
| | - Apostolos Tsiachristas
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG, United Kingdom
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Gausman J, Pingray V, Adanu R, Bandoh DAB, Berrueta M, Blossom J, Chakraborty S, Dotse-Gborgbortsi W, Kenu E, Khan N, Langer A, Nigri C, Odikro MA, Ramesh S, Saggurti N, Vázquez P, Williams CR, Jolivet RR. Validating indicators for monitoring availability and geographic distribution of emergency obstetric and newborn care (EmoNC) facilities: A study triangulating health system, facility, and geospatial data. PLoS One 2023; 18:e0287904. [PMID: 37708180 PMCID: PMC10501555 DOI: 10.1371/journal.pone.0287904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 06/15/2023] [Indexed: 09/16/2023] Open
Abstract
Availability of emergency obstetric and newborn care (EmONC) is a strong supply side measure of essential health system capacity that is closely and causally linked to maternal mortality reduction and fundamentally to achieving universal health coverage. The World Health Organization's indicator "Availability of EmONC facilities" was prioritized as a core indicator to prevent maternal death. The indicator focuses on whether there are sufficient emergency care facilities to meet the population need, but not all facilities designated as providing EmONC function as such. This study seeks to validate "Availability of EmONC" by comparing the value of the indicator after accounting for key aspects of facility functionality and an alternative measure of geographic distribution. This study takes place in four subnational geographic areas in Argentina, Ghana, and India using a census of all birthing facilities. Performance of EmONC in the 90 days prior to data collection was assessed by examining facility records. Data were collected on facility operating hours, staffing, and availability of essential medications. Population estimates were generated using ArcGIS software using WorldPop to estimate the total population, and the number of women of reproductive age (WRA), pregnancies and births in the study areas. In addition, we estimated the population within two-hours travel time of an EmONC facility by incorporating data on terrain from Open Street Map. Using these data sources, we calculated and compared the value of the indicator after incorporating data on facility performance and functionality while varying the reference population used. Further, we compared its value to the proportion of the population within two-hours travel time of an EmONC facility. Included in our study were 34 birthing facilities in Argentina, 51 in Ghana, and 282 in India. Facility performance of basic EmONC (BEmONC) and comprehensive EmONC (CEmONC) signal functions varied considerably. One facility (4.8%) in Ghana and no facility in India designated as BEmONC had performed all seven BEmONC signal functions. In Argentina, three (8.8%) CEmONC-designated facilities performed all nine CEmONC signal functions, all located in Buenos Aires Region V. Four CEmONC-designated facilities in Ghana (57.1%) and the three CEmONC-designated facilities in India (23.1%) evidenced full CEmONC performance. No sub-national study area in Argentina or India reached the target of 5 BEmONC-level facilities per 20,000 births after incorporating facility functionality yet 100% did in Argentina and 50% did in India when considering only facility designation. Demographic differences also accounted for important variation in the indicator's value. In Ghana, the total population in Tolon within 2 hours travel time of a designated EmONC facility was estimated at 99.6%; however, only 91.1% of women of reproductive age were within 2 hours travel time. Comparing the value of the indicator when calculated using different definitions reveals important inconsistencies, resulting in conflicting information about whether the threshold for sufficient coverage is met. This raises important questions related to the indicator's validity. To provide a valid measure of effective coverage of EmONC, the construct for measurement should extend beyond the most narrow definition of availability and account for functionality and geographic accessibility.
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Affiliation(s)
- Jewel Gausman
- Department of Global Health and Population, Women and Health Initiative, Harvard University T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Verónica Pingray
- Institute for Clinical Effectiveness and Health Policy (Instituto de Efectividad Clínica y Sanitaria (IECS)), Buenos Aires, Argentina
| | - Richard Adanu
- Department of Population, Family, and Reproductive Health, University of Ghana School of Public Health, Accra, Ghana
| | - Delia A. B. Bandoh
- Department of Epidemiology and Disease Control, University of Ghana School of Public Health, Accra, Ghana
| | - Mabel Berrueta
- Institute for Clinical Effectiveness and Health Policy (Instituto de Efectividad Clínica y Sanitaria (IECS)), Buenos Aires, Argentina
| | - Jeff Blossom
- Center for Geographic Analysis, Harvard University T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | | | - Winfred Dotse-Gborgbortsi
- School of Geography and Environmental Science, University of Southampton, Southampton, United Kingdom
| | - Ernest Kenu
- Department of Epidemiology and Disease Control, University of Ghana School of Public Health, Accra, Ghana
| | | | - Ana Langer
- Department of Global Health and Population, Women and Health Initiative, Harvard University T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Carolina Nigri
- Institute for Clinical Effectiveness and Health Policy (Instituto de Efectividad Clínica y Sanitaria (IECS)), Buenos Aires, Argentina
| | - Magdalene A. Odikro
- Department of Epidemiology and Disease Control, University of Ghana School of Public Health, Accra, Ghana
| | | | | | - Paula Vázquez
- Institute for Clinical Effectiveness and Health Policy (Instituto de Efectividad Clínica y Sanitaria (IECS)), Buenos Aires, Argentina
- Department of Health Science, Kinesiology, and Rehabilitation, Universidad Nacional de La Matanza, Buenos Aires, Argentina
| | - Caitlin R. Williams
- Institute for Clinical Effectiveness and Health Policy (Instituto de Efectividad Clínica y Sanitaria (IECS)), Buenos Aires, Argentina
- Department of Maternal & and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - R. Rima Jolivet
- Department of Global Health and Population, Women and Health Initiative, Harvard University T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
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Blanchard AK, Jacobs C, Musukuma M, Chooye O, Sikapande B, Michelo C, Boerma T, Wehrmeister FC. Going deeper with health equity measurement: how much more can surveys reveal about inequalities in health intervention coverage and mortality in Zambia? Int J Equity Health 2023; 22:109. [PMID: 37268969 DOI: 10.1186/s12939-023-01901-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 04/27/2023] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND Although Zambia has achieved notable improvements in reproductive, maternal, newborn and child health (RMNCH), continued efforts to address gaps are essential to reach the Sustainable Development Goals by 2030. Research to better uncover who is being most left behind with poor health outcomes is crucial. This study aimed to understand how much more demographic health surveys can reveal about Zambia's progress in reducing inequalities in under-five mortality rates and RMNCH intervention coverage. METHODS Using four nationally-representative Zambia Demographic Health Surveys (2001/2, 2007, 2013/14, 2018), we estimated under-five mortality rates (U5MR) and RMNCH composite coverage indices (CCI) comparing wealth quintiles, urban-rural residence and provinces. We further used multi-tier measures including wealth deciles and double disaggregation between wealth and region (urban residence, then provinces). These were summarised using slope indices of inequality, weighted mean differences from overall mean, Theil and concentration indices. RESULTS Inequalities in RMNCH coverage and under-five mortality narrowed between wealth groups, residence and provinces over time, but in different ways. Comparing measures of inequalities over time, disaggregation with multiple socio-economic and geographic stratifiers was often valuable and provided additional insights compared to conventional measures. Wealth quintiles were sufficient in revealing mortality inequalities compared to deciles, but comparing CCI by deciles provided more nuance by showing that the poorest 10% were left behind by 2018. Examining wealth in only urban areas helped reveal closing gaps in under-five mortality and CCI between the poorest and richest quintiles. Though challenged by lower precision, wealth gaps appeared to close in every province for both mortality and CCI. Still, inequalities remained higher in provinces with worse outcomes. CONCLUSIONS Multi-tier equity measures provided similarly plausible and precise estimates as conventional measures for most comparisons, except mortality among some wealth deciles, and wealth tertiles by province. This suggests that related research could readily use these multi-tier measures to gain deeper insights on inequality patterns for both health coverage and impact indicators, given sufficient samples. Future household survey analyses using fit-for-purpose equity measures are needed to uncover intersecting inequalities and target efforts towards effective coverage that will leave no woman or child behind in Zambia and beyond.
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Affiliation(s)
- Andrea K Blanchard
- Institute for Global Public Health, University of Manitoba, R070-771 McDermot Ave, Winnipeg, R3E 0T6, Canada.
| | - Choolwe Jacobs
- School of Public Health, University of Zambia, Lusaka, Zambia
| | - Mwiche Musukuma
- School of Public Health, University of Zambia, Lusaka, Zambia
| | - Ovost Chooye
- Monitoring and Evaluation Division, Ministry of Health, Lusaka, Zambia
| | - Brivine Sikapande
- Monitoring and Evaluation Division, Ministry of Health, Lusaka, Zambia
| | - Charles Michelo
- School of Public Health, University of Zambia, Lusaka, Zambia
| | - Ties Boerma
- Institute for Global Public Health, University of Manitoba, R070-771 McDermot Ave, Winnipeg, R3E 0T6, Canada
| | - Fernando C Wehrmeister
- Institute for Global Public Health, University of Manitoba, R070-771 McDermot Ave, Winnipeg, R3E 0T6, Canada
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
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Marthias T, McPake B, Carvalho N, Millett C, Anindya K, Saputri NS, Trisnantoro L, Lee JT. Associations between Indonesia's national health insurance, effective coverage in maternal health and neonatal mortality: a multilevel interrupted time-series analysis 2000-2017. J Epidemiol Community Health 2022; 76:jech-2021-217213. [PMID: 36288996 DOI: 10.1136/jech-2021-217213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 09/14/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND We assessed the effect of Indonesia's national health insurance programme (Jaminan Kesehatan Nasional (JKN)) on effective coverage for maternal and child health across geographical regions and population groups. METHODS We used four waves of the Indonesia Demographic and Health Survey from 2000 to 2017, which included 38 880 women aged 15-49 years and 144 000 birth records. Key outcomes included antenatal and delivery care, caesarean section and neonatal and infant mortality. We used multilevel interrupted time-series regression to examine changes in outcomes after the introduction of the JKN in January 2014. FINDINGS JKN introduction was associated with significant level increases in (1) antenatal care (ANC) crude coverage (adjusted OR (aOR) 1.81, 95% CI 1.44 to 2.27); (2) ANC quality-adjusted coverage (aOR 1.66, 95% CI 1.38 to 1.98); (3) ANC user-adherence-adjusted coverage (aOR 1.80, 95% CI 1.45 to 2.25); (4) safe delivery service contact (aOR 1.83, 95% CI 1.42 to 2.36); and (5) safe delivery crude coverage (aOR 1.45, 95% CI 1.20 to 1.75). We did not find any significant level increase in ANC service contact or caesarean section. Interestingly, increases in ANC service contact and crude coverage, and safe delivery crude coverage were larger among the poorest compared with the most affluent. No statistically significant associations were found between JKN introduction and neonatal and infant mortality (p>0.05) in the first 3 years following implementation. INTERPRETATION Expansion of social health insurance led to substantial improvements in quality of care for maternal health services but not in child mortality. Concerted efforts are required to equitably improve service quality and child mortality across the population in Indonesia.
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Affiliation(s)
- Tiara Marthias
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Health Policy and Management, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Barbara McPake
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Natalie Carvalho
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Christopher Millett
- Department of Primary Care and Public Health, Imperial College London, London, UK
- Comprehensive Health Research Center and Public Health Research Centre, National School of Public Health, NOVA University Lisbon, Lisbon, Portugal
| | - Kanya Anindya
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | | | - Laksono Trisnantoro
- Department of Health Policy and Management, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - John Tayu Lee
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Primary Care and Public Health, Imperial College London, London, UK
- Department of Health Service Research and Policy, Australia National University, Canberra, Canberra, Australia
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Ferede Gebremedhin A, Dawson A, Hayen A. Evaluations of effective coverage of maternal and child health services: A systematic review. Health Policy Plan 2022; 37:895-914. [PMID: 35459943 PMCID: PMC9347022 DOI: 10.1093/heapol/czac034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 03/25/2022] [Accepted: 04/21/2022] [Indexed: 11/27/2022] Open
Abstract
Conventionally used coverage measures do not reflect the quality of care. Effective coverage (EC) assesses the extent to which health care services deliver potential health gains to the population by integrating concepts of utilization, need and quality. We aimed to conduct a systematic review of studies evaluating EC of maternal and child health services, quality measurement strategies and disparities across wealth quantiles. A systematic search was performed in six electronic databases [MEDLINE, EMBASE, Cumulative Index of Nursing and Allied Health (CINAHL), Scopus, Web of Science and Maternity and Infant Care] and grey literature. We also undertook a hand search of references. We developed search terms having no restrictions based on publication period, country or language. We included studies which reported EC estimates based on the World Health Organization framework of measuring EC. Twenty-seven studies, all from low- and middle-income settings (49 countries), met the criteria and were included in the narrative synthesis of the results. Maternal and child health intervention(s) and programme(s) were assessed either at an individual level or as an aggregated measure of health system performance or both. The EC ranged from 0% for post-partum care to 95% for breastfeeding. When crude coverage measures were adjusted to account for the quality of care, the EC values turned lower. The gap between crude coverage and EC was as high as 86%, and it signified a low quality of care. The assessment of the quality of care addressed structural, process and outcome domains individually or combined. The wealthiest 20% had higher EC of services than the poorest 20%, an inequitable distribution of coverage. More efforts are needed to improve the quality of maternal and child health services and to eliminate the disparities. Moreover, considering multiple dimensions of quality and the use of standard measurements are recommended to monitor coverage effectively.
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Affiliation(s)
- Aster Ferede Gebremedhin
- Department of Public Health, College of Health Sciences, Debre Markos University, PO Box 269, Debre Markos, Ethiopia
- School of Public Health, University of Technology Sydney, PO Box 123, Broadway NSW 2007, Sydney, Australia
| | - Angela Dawson
- School of Public Health, University of Technology Sydney, PO Box 123, Broadway NSW 2007, Sydney, Australia
| | - Andrew Hayen
- School of Public Health, University of Technology Sydney, PO Box 123, Broadway NSW 2007, Sydney, Australia
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Toolan M, Barnard K, Lynch M, Maharjan N, Thapa M, Rai N, Lavender T, Larkin M, Caldwell DM, Burden C, Manandhar DS, Merriel A. A systematic review and narrative synthesis of antenatal interventions to improve maternal and neonatal health in Nepal. AJOG GLOBAL REPORTS 2022; 2:100019. [PMID: 35252905 PMCID: PMC8883503 DOI: 10.1016/j.xagr.2021.100019] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Anindya K, Marthias T, Vellakkal S, Carvalho N, Atun R, Morgan A, Zhao Y, Hulse ESG, McPake B, Lee JT. Socioeconomic inequalities in effective service coverage for reproductive, maternal, newborn, and child health: a comparative analysis of 39 low-income and middle-income countries. EClinicalMedicine 2021; 40:101103. [PMID: 34527893 PMCID: PMC8430373 DOI: 10.1016/j.eclinm.2021.101103] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 08/10/2021] [Accepted: 08/11/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Reducing socioeconomic inequalities in access to good quality health care is key for countries to achieve Universal Health Coverage. This study aims to assess socioeconomic inequalities in effective coverage of reproductive, maternal, newborn and child health (RMNCH) in low- and middle-income countries (LMICs). METHODS Using the most recent national health surveys from 39 LMICs (between 2014 and 2018), we calculated coverage indicators using effective coverage care cascade that consists of service contact, crude coverage, quality-adjusted coverage, and user-adherence-adjusted coverage. We quantified wealth-related and education-related inequality using the relative index of inequality, slope index of inequality, and concentration index. FINDINGS The quality-adjusted coverage of RMNCH services in 39 countries was substantially lower than service contact, in particular for postnatal care (64 percentage points [pp], p-value<0·0001), family planning (48·7 pp, p<0·0001), and antenatal care (43·6 pp, p<0·0001) outcomes. Upper-middle-income countries had higher effective coverage levels compared with low- and lower-middle-income countries in family planning, antenatal care, delivery care, and postnatal care. Socioeconomic inequalities tend to be wider when using effective coverage measurement compared with crude and service contact measurements. Our findings show that upper-middle-income countries had a lower magnitude of inequality compared with low- and lower-middle-income countries. INTERPRETATION Reliance on the average contact coverage tends to underestimate the levels of socioeconomic inequalities for RMNCH service use in LMICs. Hence, the effective coverage measurement using a care cascade approach should be applied. While RMNCH coverages vary considerably across countries, equitable improvement in quality of care is particularly needed for lower-middle-income and low-income countries. FUNDING None.
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Affiliation(s)
- Kanya Anindya
- Nossal Institute for Global Health, The University of Melbourne, Melbourne, Australia
| | - Tiara Marthias
- Nossal Institute for Global Health, The University of Melbourne, Melbourne, Australia
- Department of Public Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
- Corresponding author at: IKM Building, Faculty of Medicine, Public Health and Nursing, Gadjah Mada University, Farmako Street, Sekip Utara, Sleman, Yogyakarta, Indonesia
| | - Sukumar Vellakkal
- Department of Economic Sciences, Indian Institute of Technology Kanpur, Kalyanpur, Uttar Pradesh, India
| | - Natalie Carvalho
- Center for Health Policy, School of Population and Global Health, The University of Melbourne, Melbourne, Australia
| | - Rifat Atun
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, United States
| | - Alison Morgan
- Nossal Institute for Global Health, The University of Melbourne, Melbourne, Australia
- Global Financing Facility, The World Bank Group, Washington, DC, United States
| | - Yang Zhao
- WHO Collaborating Centre on Implementation Research for Prevention and Control of Noncommunicable Diseases, Melbourne, VIC, Australia
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China
| | - Emily SG Hulse
- Center for Health Policy, School of Population and Global Health, The University of Melbourne, Melbourne, Australia
| | - Barbara McPake
- Nossal Institute for Global Health, The University of Melbourne, Melbourne, Australia
| | - John Tayu Lee
- Nossal Institute for Global Health, The University of Melbourne, Melbourne, Australia
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, United Kingdom
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Taniguchi H, Rahman MM, Swe KT, Islam MR, Rahman MS, Parsell N, Hussain A, Shibuya K, Hashizume M. Equity and determinants in universal health coverage indicators in Iraq, 2000-2030: a national and subnational study. Int J Equity Health 2021; 20:196. [PMID: 34461904 PMCID: PMC8404248 DOI: 10.1186/s12939-021-01532-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 08/11/2021] [Indexed: 11/26/2022] Open
Abstract
Background Equity is one of three dimensions of universal health coverage (UHC). However, Iraq has had capital-focused health services and successive conflicts and political turmoil have hampered health services around the country. Iraq has embarked on a new reconstruction process since 2018 and it could be time to aim for equitable healthcare access to realise UHC. We aimed to examine inequality and determinants associated with Iraq’s progress towards UHC targets. Methods We assessed the progress toward UHC in the context of equity using six nationally representative population-based household surveys in Iraq in 2000–2018. We included 14 health service indicators and two financial risk protection indicators in our UHC progress assessment. Bayesian hierarchical regression model was used to estimate the trend, projection, and determinant analyses. Slope and relative index of inequality were used to assess wealth-based inequality. Results In the national-level health service indicators, inequality indices decreased substantially from 2000 to 2030. However, the wide inequalities are projected to remain in DTP3, measles, full immunisations, and antenatal care in 2030. The pro-rich inequality gap in catastrophic health expenditure increased significantly in all governorates except Sulaimaniya from 2007 to 2012. The higher increases in pro-rich inequality were found in Missan, Karbala, Erbil, and Diala. Mothers’ higher education and more antenatal care visits were possible factors for increased coverage of health service indicators. The higher number of children and elderly population in the households were potential risk factors for an increased risk of catastrophic and impoverishing health payment in Iraq. Conclusions To reduce inequality in Iraq, urgent health-system reform is needed, with consideration for vulnerable households having female-heads, less educated mothers, and more children and/or elderly people. Considering varying inequity between and within governorates in Iraq, reconstruction of primary healthcare across the country and cross-sectoral targeted interventions for women should be prioritised. Supplementary Information The online version contains supplementary material available at 10.1186/s12939-021-01532-0.
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Affiliation(s)
- Hiroko Taniguchi
- Department of Global Health Policy, School of International Health, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.
| | - Md Mizanur Rahman
- Department of Global Health Policy, School of International Health, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.,Hitotsubashi Institute for Advanced Study (HIAS), Hitotsubashi University, 2-1, Naka, Kunitachi, Tokyo, 186-8601, Japan
| | - Khin Thet Swe
- Department of Global Health Policy, School of International Health, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.,Hitotsubashi Institute for Advanced Study (HIAS), Hitotsubashi University, 2-1, Naka, Kunitachi, Tokyo, 186-8601, Japan
| | - Md Rashedul Islam
- Department of Global Health Policy, School of International Health, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Md Shafiur Rahman
- Research Center for Child Mental Development, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu, Shizuoka, 431-3192, Japan.,United Graduate School of Child Development, Osaka University, Kanazawa University, Hamamatsu University School of Medicine, Chiba University and University of Fukui, Osaka, Japan
| | - Nadia Parsell
- Department of Global Health Policy, School of International Health, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Ashraf Hussain
- Department of Family and Community Medicine, College of Medicine, University of Babylon, Babil, Iraq
| | - Kenji Shibuya
- Soma COVID Vaccination Medical Center, Soma City Hall, 63-3, Kitamachi, Nakamura, Soma, Fukushima, 976-8601, Japan
| | - Masahiro Hashizume
- Department of Global Health Policy, School of International Health, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
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10
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Alhassan JAK, Wariri O, Onuwabuchi E, Mark G, Kwarshak Y, Dase E. Access to skilled attendant at birth and the coverage of the third dose of diphtheria-tetanus-pertussis vaccine across 14 West African countries - an equity analysis. Int J Equity Health 2020; 19:78. [PMID: 32487158 PMCID: PMC7268225 DOI: 10.1186/s12939-020-01204-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 05/26/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Universal Health Coverage (UHC) remains a critical public health goal that continues to elude many countries of the global south. As countries strive for its attainment, it is important to track progress in various subregions of the world to understand current levels and mechanisms of progress for shared learning. Our aim was to compare multidimensional equity gaps in access to skilled attendant at birth (SAB) and coverage of the third dose of Diphtheria-Tetanus-Pertussis (DTP3) across 14 West African countries. METHODS The study was a cross sectional comparative analysis that used publicly available, nationally representative health surveys. We extracted data from Demographic and Health Surveys, and Multiple Indicator Cluster Surveys conducted between 2010 and 2017 in Benin, Burkina Faso, Cote d' Ivoire, The Gambia, Ghana, Guinea, Guinea Bissau, Liberia, Mali, Niger, Nigeria, Senegal, Sierra Leone and Togo. The World Health Organization's Health Equity Assessment Toolkit (HEAT Plus) software was used to evaluate current levels of intra-country equity in access to SAB and DTP3 coverage across four equity dimensions (maternal education, location of residence, region within a country and family wealth status). RESULTS There was a general trend of higher levels of coverage for DTP3 compared to access to SAB in the subregion. Across the various dimensions of equity, more gaps appear to have been closed in the subregion for DTP3 compared to SAB. The analysis revealed that countries such as Sierra Leone, Liberia and Ghana have made substantial progress towards equitable access for the two outcomes compared to others such as Nigeria, Niger and Guinea. CONCLUSION In the race towards UHC, equity should remain a priority and comparative progress should be consistently tracked to enable the sharing of lessons. The West African subregion requires adequate government financing and continued commitment to move toward UHC and close health equity gaps.
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Affiliation(s)
- Jacob Albin Korem Alhassan
- Department of Community Health and Epidemiology, College of Medicine, University of Saskatchewan, Saskatoon, Canada
- African Population and Health Policy Initiative, Gombe, Nigeria
| | - Oghenebrume Wariri
- African Population and Health Policy Initiative, Gombe, Nigeria
- Medical Research Council (MRC) Unit The Gambia, London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Egwu Onuwabuchi
- African Population and Health Policy Initiative, Gombe, Nigeria
- Department of Obstetrics and Gynaecology, Federal Teaching Hospital, Gombe, Nigeria
| | - Godwin Mark
- Department of One Health, The University of Edinburgh, Royal (Dick) School of Veterinary Studies, Edinburgh, Scotland UK
| | - Yakubu Kwarshak
- Department of Global Health and Management, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, Scotland UK
| | - Eseoghene Dase
- African Population and Health Policy Initiative, Gombe, Nigeria
- Department of Obstetrics and Gynaecology, Federal Teaching Hospital, Gombe, Nigeria
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11
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Amouzou A, Jiwani SS, da Silva ICM, Carvajal-Aguirre L, Maïga A, Vaz LME. Closing the inequality gaps in reproductive, maternal, newborn and child health coverage: slow and fast progressors. BMJ Glob Health 2020; 5:e002230. [PMID: 32133181 PMCID: PMC7042586 DOI: 10.1136/bmjgh-2019-002230] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 12/18/2019] [Indexed: 11/04/2022] Open
Abstract
Introduction Universal Health Coverage (UHC) is a critical goal under the Sustainable Development Goals (SDGs) for health. Achieving this goal for reproductive, maternal, newborn and child health (RMNCH) service coverage will require an understanding of national progress and how socioeconomic and demographic subgroups of women and children are being reached by health interventions. Methods We accessed coverage databases produced by the International Centre for Equity in Health, which were based on reanalysis of Demographic and Health Surveys, Multiple Indicator Cluster Surveys and Reproductive and Health Surveys. We limited the data to 58 countries with at least two surveys since 2008. We fitted multilevel linear regressions of coverage of RMNCH, divided into four main components-reproductive health, maternal health, child immunisation and child illness treatment-to estimate the average annual percentage point change (AAPPC) in coverage for the period 2008-2017 across these countries and for subgroups defined by maternal age, education, place of residence and wealth quintiles. We also assessed change in the pace of coverage progress between the periods 2000-2008 and 2008-2017. Results Progress in RMNCH coverage has been modest over the past decade, with statistically significant AAPPC observed only for maternal health (1.25, 95% CI 0.90 to 1.61) and reproductive health (0.83, 95% CI 0.47 to 1.19). AAPPC was not statistically significant for child immunisation and illness treatment. Progress, however, varied largely across countries, with fast or slow progressors spread throughout the low-income and middle-income groups. For reproductive and maternal health, low-income and lower middle-income countries appear to have progressed faster than upper middle-income countries. For these two components, faster progress was also observed in older women and in traditionally less well-off groups such as non-educated women, those living in rural areas or belonging to the poorest or middle wealth quintiles than among groups that are well off. The latter groups however continue to maintain substantially higher coverage levels over the former. No acceleration in RMNCH coverage was observed when the periods 2000-2008 and 2008-2017 were compared. Conclusion At the dawn of the SDGs, progress in coverage in RMNCH remains insufficient at the national level and across equity dimensions to accelerate towards UHC by 2030. Greater attention must be paid to child immunisation to sustain the past gains and to child illness treatment to substantially raise its coverage across all groups.
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Affiliation(s)
- Agbessi Amouzou
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Safia S Jiwani
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | | | - Abdoulaye Maïga
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Lara M E Vaz
- Global Health, Save the Children, Washington DC, District of Columbia, USA
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12
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Wuneh AD, Medhanyie AA, Bezabih AM, Persson LÅ, Schellenberg J, Okwaraji YB. Wealth-based equity in maternal, neonatal, and child health services utilization: a cross-sectional study from Ethiopia. Int J Equity Health 2019; 18:201. [PMID: 31870447 PMCID: PMC6929360 DOI: 10.1186/s12939-019-1111-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 12/11/2019] [Indexed: 12/03/2022] Open
Abstract
Background Despite the pro-poor health policies in Ethiopia, the utilization of maternal, neonatal, and child health services remains a challenge for the country. Health equity became central in the post-2015 Sustainable Development Goals globally and is a priority for Ethiopia. The aim of this study was to assess equity in utilization of a range of maternal and child health services by applying absolute and relative equity indices. Methods Data on maternal and child health utilization emanated from a baseline survey conducted for a large project ‘Optimizing the Health Extension Program from December 2016 to February 2017 in four regions of Ethiopia. The utilization of four or more antenatal care visits; skilled birth attendance; postnatal care within 2 days after childbirth; immunization with BCG, polio 3, pentavalent 3, measles and full immunization of children aged 12–23 months; and vitamin A supplementation for 6–23 months old children were stratified by wealth quintiles. The socioeconomic status of the household was assessed by household assets and measured by constructing a wealth index using principal component analysis. Equity was assessed by applying two absolute inequity indices (Wealth index [quintile 5- quintile 1] and slope index of inequality) and two relative inequity indices (Wealth index [quintile5: quintile1] and concentration index). Results The maternal health services utilization was low and inequitably distributed favoring the better-off women. About 44, 71, and 18% of women from the better-off households had four or more antenatal visits, utilized skilled birth attendance and postnatal care within two days compared to 20, 29, and 8% of women from the poorest households, respectively. Skilled birth attendance was the most inequitably distributed maternal health service. All basic immunizations: BCG, polio 3, pentavalent 3, measles, and full immunization in children aged 12–23 months and vitamin A supplementation were equitably distributed. Conclusion Utilization of maternal health services was low, inequitable, and skewed against women from the poorest households. In contrast, preventive child health services were equitably distributed. Efforts to increase utilization and reinforcement of pro-poor and pro-rural strategies for maternal, newborn and immunization services in Ethiopia should be strengthened.
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Affiliation(s)
- Alem Desta Wuneh
- School of Public Health, College of Health Sciences, Mekelle University, Mekelle, Ethiopia.
| | - Araya Abrha Medhanyie
- School of Public Health, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | | | - Lars Åke Persson
- London School of Hygiene &Tropical Medicine, London, UK.,Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | | | - Yemisrach Behailu Okwaraji
- London School of Hygiene &Tropical Medicine, London, UK.,Ethiopian Public Health Institute, Addis Ababa, Ethiopia
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13
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Victora C, Boerma T, Requejo J, Mesenburg MA, Joseph G, Costa JC, Vidaletti LP, Ferreira LZ, Hosseinpoor AR, Barros AJD. Analyses of inequalities in RMNCH: rising to the challenge of the SDGs. BMJ Glob Health 2019; 4:e001295. [PMID: 31297251 PMCID: PMC6590961 DOI: 10.1136/bmjgh-2018-001295] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 02/19/2019] [Accepted: 02/25/2019] [Indexed: 01/31/2023] Open
Abstract
The Sustainable Development Goal (SDG) 17.18 recommends efforts to increase the availability of data disaggregated by income, gender, age, race, ethnicity, migratory status, disability and geographic location in developing countries. Surveys will continue to be the leading data source for disaggregated data for most dimensions of inequality. We discuss potential advances in the disaggregation of data from national surveys, with a focus on the coverage of reproductive, maternal, newborn and child health indicators (RMNCH). Even though the Millennium Development Goals were focused on national-level progress, monitoring initiatives such as Countdown to 2015 reported on progress in RMNCH coverage according to wealth quintiles, sex of the child, women’s education and age, urban/rural residence and subnational geographic regions. We describe how the granularity of equity analyses may be increased by including additional stratification variables such as wealth deciles, estimated absolute income, ethnicity, migratory status and disability. We also provide examples of analyses of intersectionality between wealth and urban/rural residence (also known as double stratification), sex of the child and age of the woman. Based on these examples, we describe the advantages and limitations of stratified analyses of survey data, including sample size issues and lack of information on the necessary variables in some surveys. We conclude by recommending that, whenever possible, stratified analyses should go beyond the traditional breakdowns by wealth quintiles, sex and residence, to also incorporate the wider dimensions of inequality. Greater granularity of equity analyses will contribute to identify subgroups of women and children who are being left behind and monitor the impact of efforts to reduce inequalities in order to achieve the health SDGs.
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Affiliation(s)
- Cesar Victora
- Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil.,International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
| | - Ties Boerma
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | | | - Gary Joseph
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
| | - Janaína Calu Costa
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
| | - Luis Paulo Vidaletti
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
| | | | - Ahmad Reza Hosseinpoor
- Partnership for Maternal, Newborn & Child Health, World Health Organization, Geneva, Switzerland
| | - Aluisio J D Barros
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
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14
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Joseph G, da Silva ICM, Barros AJD, Victora CG. Socioeconomic inequalities in access to skilled birth attendance among urban and rural women in low-income and middle-income countries. BMJ Glob Health 2018; 3:e000898. [PMID: 30588340 PMCID: PMC6278921 DOI: 10.1136/bmjgh-2018-000898] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 08/01/2018] [Accepted: 08/31/2018] [Indexed: 11/17/2022] Open
Abstract
Introduction Rapid urbanisation is one of the greatest challenges for Sustainable Development Goals. We compared socioeconomic inequalities in urban and rural women’s access to skilled birth attendance (SBA) and to assess whether the poorest urban women have an advantage over the poorest rural women. Methods The latest available surveys (DemographicHealth Survey, Multiple Indicators Cluster Surveys) of 88 countries since 2010 were analysed. SBA coverage was calculated for 10 subgroups of women according to wealth quintile and urban-rural residence. Poisson regression was used to test interactions between wealth quintile index and urban-rural residence on coverage. The slope index of inequality (SII) and concentration index were calculated for urban and rural women. Results 37 countries had surveys with at least 25 women in each of the 10 cells. Average rural average coverage was 72.8 % (ranging from 17.2% % in South Sudan to 99.9 % in Jordan) and average urban coverage was 80.0% (from 23.6% in South Sudan to 99.7% in Guyana. In 33 countries, rural coverage was lower than urban coverage; the difference was significant (p<0.05) in 15 countries. The widest urban/rural coverage gap was in the Central African Republic (32.8% points; p<0.001). Most countries showed narrower socioeconomic inequalities in urban than in rural areas. The largest difference was observed in Panama, where the rural SII was 77.1% points larger than the urban SII (p<0.001). In 31 countries, the poorest rural women had lower coverage than the poorest urban women; in 20 countries, these differences were statistically significant (p<0.05). Conclusion In most countries studied, urban areas present a double advantage of higher SBA coverage and narrower wealth-related inequalities when compared with rural areas. Studies of the intersectionality of wealth and residence can support policy decisions about which subgroups require special efforts to reach universal coverage.
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Affiliation(s)
- Gary Joseph
- International Center for Equity in Health Post-Graduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
| | | | - Aluísio J D Barros
- International Center for Equity in Health Post-Graduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
| | - Cesar G Victora
- International Center for Equity in Health Post-Graduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
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15
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Benova L, Dennis ML, Lange IL, Campbell OMR, Waiswa P, Haemmerli M, Fernandez Y, Kerber K, Lawn JE, Santos AC, Matovu F, Macleod D, Goodman C, Penn-Kekana L, Ssengooba F, Lynch CA. Two decades of antenatal and delivery care in Uganda: a cross-sectional study using Demographic and Health Surveys. BMC Health Serv Res 2018; 18:758. [PMID: 30286749 PMCID: PMC6172797 DOI: 10.1186/s12913-018-3546-3] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 09/17/2018] [Indexed: 11/11/2022] Open
Abstract
Background Uganda halved its maternal mortality to 343/100,000 live births between 1990 and 2015, but did not meet the Millennium Development Goal 5. Skilled, timely and good quality antenatal (ANC) and delivery care can prevent the majority of maternal/newborn deaths and stillbirths. We examine coverage, equity, sector of provision and content of ANC and delivery care between 1991 and 2011. Methods We conducted a repeated cross-sectional study using four Uganda Demographic and Health Surveys (1995, 2000, 2006 and 2011).Using the most recent live birth and adjusting for survey sampling, we estimated percentage and absolute number of births with ANC (any and 4+ visits), facility delivery, caesarean sections and complete maternal care. We assessed socio-economic differentials in these indicators by wealth, education, urban/rural residence, and geographic zone on the 1995 and 2011 surveys. We estimated the proportions of ANC and delivery care provided by the public and private (for-profit and not-for-profit) sectors, and compared content of ANC and delivery care between sectors. Statistical significance of differences were evaluated using chi-square tests. Results Coverage with any ANC remained high over the study period (> 90% since 2001) but was of insufficient frequency; < 50% of women who received any ANC reported 4+ visits. Facility-based delivery care increased slowly, reaching 58% in 2011. While significant inequalities in coverage by wealth, education, residence and geographic zone remained, coverage improved for all indicators among the lowest socio-economic groups of women over time. The private sector market share declined over time to 14% of ANC and 25% of delivery care in 2011. Only 10% of women with 4+ ANC visits and 13% of women delivering in facilities received all measured care components. Conclusions The Ugandan health system had to cope with more than 30,000 additional births annually between 1991 and 2011. The majority of women in Uganda accessed ANC, but this contact did not result in care of sufficient frequency, content, and continuum of care (facility delivery). Providers in both sectors require quality improvements. Achieving universal health coverage and maternal/newborn SDGs in Uganda requires prioritising poor, less educated and rural women despite competing priorities for financial and human resources. Electronic supplementary material The online version of this article (10.1186/s12913-018-3546-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lenka Benova
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK. .,Institute of Tropical Medicine, Nationalestraat 155, 2000, Antwerp, Belgium.
| | - Mardieh L Dennis
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Isabelle L Lange
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Oona M R Campbell
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Peter Waiswa
- School of Public Health, Makerere University, P.O Box 7072, Kampala, Uganda
| | - Manon Haemmerli
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Yolanda Fernandez
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Kate Kerber
- Saving Newborn Lives, Save the Children, 899 North Capitol Street, Suite 900, Washington, DC, 20002, USA.,Indigenous & Global Health Research Group, Department of Medicine, University of Alberta, University Terrace, 8303-112 Street, Edmonton, AB, T6G 2T4, Canada
| | - Joy E Lawn
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Andreia Costa Santos
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Fred Matovu
- School of Economics, Makerere University Kampala, Uganda and Policy Analysis & Development Research Institute (PADRI), Kampala, Uganda
| | - David Macleod
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Catherine Goodman
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Loveday Penn-Kekana
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Freddie Ssengooba
- School of Public Health, Makerere University, P.O Box 7072, Kampala, Uganda
| | - Caroline A Lynch
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
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16
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Han SM, Rahman MM, Rahman MS, Swe KT, Palmer M, Sakamoto H, Nomura S, Shibuya K. Progress towards universal health coverage in Myanmar: a national and subnational assessment. LANCET GLOBAL HEALTH 2018; 6:e989-e997. [PMID: 30056050 DOI: 10.1016/s2214-109x(18)30318-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 05/31/2018] [Accepted: 06/21/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Attainment of universal health coverage is a global health priority. The Myanmar Government has committed to attainment of universal health coverage by 2030, but progress so far has not been assessed. We aimed to estimate national and subnational health service coverage and financial risk protection. METHODS We used nationally representative data from the Myanmar Demographic and Health Survey (2016) and the Integrated Household Living Condition Assessment (2010) to examine 26 health service indicators and explored the incidence of catastrophic health payment and impoverishment caused by out-of-pocket payments. We used logistic regression models of inequalities in, and risk factors for, indicators of universal health coverage. FINDINGS Nationally, the coverage of health service indicators ranged from 18·4% (95% CI 14·9-21·9) to 96·2% (95·9-96·5). Coverage of most health services indicators was below the universal health coverage target of 80%. 14·6% (95% CI 13·9-15·3) of households that used health services faced catastrophic health-care payments. 2·0% (95% CI 1·7-2·3) of non-poor households became poor because of out-of-pocket payments for health. Health service coverage and financial risk protection varied substantially by region. Although the richest quintiles had better access to health services than the poorest quintiles, they also had a higher incidence of financial catastrophe as a result of payments for health care. Of the indicators included in the study, coverage of adequate sanitation, no indoor use of solid fuels, at least four antenatal care visits, postnatal care for mothers, skilled birth attendance, and institutional delivery were the most inequitable by wealth quintile. INTERPRETATION Attainment of universal health coverage in Myanmar in the immediate future will be very challenging as a result of the low health service coverage, high financial risk, and inequalities in access to care. Health service coverage and financial risk protection for vulnerable, disadvantaged populations should be prioritised. FUNDING Japanese Ministry of Health, Labour and Welfare, Ministry of Education, Culture, Sports, Science and Technology of Japan.
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Affiliation(s)
- Su Myat Han
- Department of Global Health Policy, Graduate School of Medicine, University of Tokyo, Tokyo, Japan.
| | - Md Mizanur Rahman
- Department of Global Health Policy, Graduate School of Medicine, University of Tokyo, Tokyo, Japan; Global Public Health Research Foundation, Dhaka, Bangladesh
| | - Md Shafiur Rahman
- Department of Global Health Policy, Graduate School of Medicine, University of Tokyo, Tokyo, Japan; Global Public Health Research Foundation, Dhaka, Bangladesh
| | - Khin Thet Swe
- Department of Global Health Policy, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Matthew Palmer
- Department of Global Health Policy, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Haruka Sakamoto
- Department of Global Health Policy, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Shuhei Nomura
- Department of Global Health Policy, Graduate School of Medicine, University of Tokyo, Tokyo, Japan; Institute for Global Health Policy Research, Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo, Japan
| | - Kenji Shibuya
- Department of Global Health Policy, Graduate School of Medicine, University of Tokyo, Tokyo, Japan; Institute for Global Health Policy Research, Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo, Japan
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17
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Pulok MH, Uddin J, Enemark U, Hossin MZ. Socioeconomic inequality in maternal healthcare: An analysis of regional variation in Bangladesh. Health Place 2018; 52:205-214. [PMID: 29960144 DOI: 10.1016/j.healthplace.2018.06.004] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 06/17/2018] [Accepted: 06/19/2018] [Indexed: 11/25/2022]
Abstract
Socioeconomic inequality in the utilisation of maternal healthcare services is well-documented in Bangladesh. However, the spatial dimension of this inequality is largely unexplored in the literature. This study examined the regional variation of wealth-related inequality in the utilisation of maternal healthcare services using data from Bangladesh Demographic and Health Survey, 2014. The highest extent of pro-wealthy inequality was found in Chittagong and Sylhet for ANC services compared to Khulna and Rangpur where inequality was the lowest. Pro-wealthy inequality was the lowest in Rangpur while Dhaka and Barisal tended to have the greatest degree of inequality for delivery care services. Policy efforts aiming to tackle socioeconomic inequality in maternal healthcare should consider this spatial dimension of inequality in Bangladesh.
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Affiliation(s)
- Mohammad Habibullah Pulok
- Centre for Health Economics Research and Evaluation (CHERE), UTS Business School, University of Technology, Sydney (UTS), PO Box 123, Broadway, NSW 2007, Australia; CMCRC Health Market Quality Research Program, GPO Box 970, Sydney, NSW 2001, Australia; The Canadian Centre for Health Economics (CCHE), the University of Toronto, 155 College Street, 4th Floor, Toronto, ON, Canada M5T 3M6.
| | - Jalal Uddin
- Department of Sociology, University of Alabama at Birmingham, Heritage Hall 460E, 1401 University Blvd., Birmingham, AL 35233, USA.
| | - Ulrika Enemark
- Department of Public Health, Aarhus University, Bartholins Allé 2 - Building 1260, DK-8000 Aarhus C, Denmark.
| | - Muhammad Zakir Hossin
- Department of Public Health Sciences, Karolinska Institute, Tomtebodavägen 18B, Solna, 17165 Stockholm, Sweden.
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18
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Yan LD, Mwale J, Straitz S, Biemba G, Bhutta Z, Ross JF, Mwananyanda L, Nambao M, Ngwakum P, Genovese E, Banda B, Akseer N, Yeboah-Antwi K, Rockers PC, Hamer DH. Equity dimensions of the availability and quality of reproductive, maternal and neonatal health services in Zambia. Trop Med Int Health 2018; 23:433-445. [PMID: 29457318 DOI: 10.1111/tmi.13043] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To assess how quality and availability of reproductive, maternal, neonatal (RMNH) services vary by district wealth and urban/rural status in Zambia. METHODS We conducted a retrospective analysis of data from the Millennium Development Goal Acceleration Initiative baseline assessment of 117 health facilities in 9 districts. Quality was assessed through a composite score of 23 individual RMNH indicators, ranging from 0 to 1. Availability was evaluated by density of providers and facilities. Districts were divided into wealth groups based on the multidimensional poverty index (MPI). Relative inequity was calculated using the concentration index for quality indicators (positive favours rich, negative favours poor). Multivariable linear regression was performed for the dependent variable composite quality indicator using MPI, urban/rural, and facility level of care as independent variables. RESULTS 13 hospitals, 85 health centres and 19 health posts were included. The RMNH composite quality indicator was 0.64. Availability of facilities and providers was universally low. The concentration index for the composite quality indicator was -0.015 [-0.043, 0.013], suggesting no clustering to favour either rich or poor districts. Rich districts had the highest absolute numbers of health facilities and providers, but lowest numbers per facility per 1 000 000 population. Urban districts had slightly better service quality, but not availability. Using regression analysis, only facility level of care was significantly associated with quality outcome. CONCLUSIONS Composite quality of RMNH services did not vary by district wealth, but was slightly higher in urban districts. The availability data suggest that the higher population in richer districts outpaces health infrastructure.
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Affiliation(s)
- Lily D Yan
- Department of Medicine, Boston Medical Center, Boston, MA, USA.,Department of Global Health and Center for Global Health and Development, Boston University School of Public Health, Boston, MA, USA
| | | | - Samantha Straitz
- Department of Global Health and Center for Global Health and Development, Boston University School of Public Health, Boston, MA, USA
| | - Godfrey Biemba
- National Health Research Authority, Ministry of Health, Lusaka, Zambia
| | - Zulfiqar Bhutta
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan.,Centre for Global Child Health, SickKids Hospital, Toronto, ON, Canada
| | - Julia F Ross
- Delegation of the European Union in Zambia, Lusaka, Zambia
| | | | - Mary Nambao
- Maternal and Child Health, Ministry of Health, Lusaka, Zambia
| | | | | | - Bowen Banda
- Zambian Centre for Applied Health Research and Development, Lusaka, Zambia
| | - Nadia Akseer
- Centre for Global Child Health, SickKids Hospital, Toronto, ON, Canada
| | - Kojo Yeboah-Antwi
- Department of Global Health and Center for Global Health and Development, Boston University School of Public Health, Boston, MA, USA
| | - Peter C Rockers
- Department of Global Health and Center for Global Health and Development, Boston University School of Public Health, Boston, MA, USA
| | - Davidson H Hamer
- Department of Medicine, Boston Medical Center, Boston, MA, USA.,Department of Global Health and Center for Global Health and Development, Boston University School of Public Health, Boston, MA, USA.,Zambian Centre for Applied Health Research and Development, Lusaka, Zambia
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19
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Rahman MS, Rahman MM, Gilmour S, Swe KT, Krull Abe S, Shibuya K. Trends in, and projections of, indicators of universal health coverage in Bangladesh, 1995-2030: a Bayesian analysis of population-based household data. LANCET GLOBAL HEALTH 2018; 6:e84-e94. [PMID: 29241620 DOI: 10.1016/s2214-109x(17)30413-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 09/22/2017] [Accepted: 10/02/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Many countries are implementing health system reforms to achieve universal health coverage (UHC) by 2030. To understand the progress towards UHC in Bangladesh, we estimated trends in indicators of the health service and of financial risk protection. We also estimated the probability of Bangladesh's achieving of UHC targets of 80% essential health-service coverage and 100% financial risk protection by 2030. METHODS We estimated the coverage of UHC indicators-13 prevention indicators and four treatment indicators-from 19 nationally representative population-based household surveys done in Bangladesh from Jan 1, 1991, to Dec 31, 2014. We used a Bayesian regression model to estimate the trend and to predict the coverage of UHC indicators along with the probabilities of achieving UHC targets of 80% coverage of health services and 100% coverage of financial risk protection from catastrophic and impoverishing health payments by 2030. We used the concentration index and relative index of inequality to assess wealth-based inequality in UHC indicators. FINDINGS If the current trends remain unchanged, we estimated that coverage of childhood vaccinations, improved water, oral rehydration treatment, satisfaction with family planning, and non-use of tobacco will achieve the 80% target by 2030. However, coverage of four antenatal care visits, facility-based delivery, skilled birth attendance, postnatal checkups, care seeking for pneumonia, exclusive breastfeeding, non-overweight, and adequate sanitation were not projected to achieve the target. Quintile-specific projections showed wide wealth-based inequality in access to antenatal care, postnatal care, delivery care, adequate sanitation, and care seeking for pneumonia, and this inequality was projected to continue for all indicators. The incidence of catastrophic health expenditure and impoverishment were projected to increase from 17% and 4%, respectively, in 2015, to 20% and 9%, respectively, by 2030. Inequality analysis suggested that wealthiest households would disproportionately face more financial catastrophe than the most disadvantaged households. INTERPRETATION Despite progress, Bangladesh will not achieve the 2030 UHC targets unless the country scales up interventions related to maternal and child health services, and reforms health financing systems to avoid high dependency on out-of-pocket payments. The introduction of a national health insurance system, increased public funding for health care, and expansion of community-based clinics in rural areas could help to move the country towards UHC. FUNDING Japan Ministry of Health, Labour, and Welfare.
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Affiliation(s)
- Md Shafiur Rahman
- Department of Global Health Policy, Graduate School of Medicine, University of Tokyo, Tokyo, Japan; Global Public Health Research Foundation, Dhaka, Bangladesh.
| | - Md Mizanur Rahman
- Department of Global Health Policy, Graduate School of Medicine, University of Tokyo, Tokyo, Japan; Global Public Health Research Foundation, Dhaka, Bangladesh; Department of Population Science and Human Resource Development, University of Rajshahi, Rajshahi, Bangladesh; Institute for Global Health Policy Research, National Center for Global Health and Medicine, Tokyo, Japan
| | - Stuart Gilmour
- Department of Global Health Policy, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Khin Thet Swe
- Department of Global Health Policy, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Sarah Krull Abe
- Department of Global Health Policy, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Kenji Shibuya
- Department of Global Health Policy, Graduate School of Medicine, University of Tokyo, Tokyo, Japan; Institute for Global Health Policy Research, National Center for Global Health and Medicine, Tokyo, Japan
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20
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Jacobs C, Michelo C, Chola M, Oliphant N, Halwiindi H, Maswenyeho S, Baboo KS, Moshabela M. Evaluation of a community-based intervention to improve maternal and neonatal health service coverage in the most rural and remote districts of Zambia. PLoS One 2018; 13:e0190145. [PMID: 29337995 PMCID: PMC5770027 DOI: 10.1371/journal.pone.0190145] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Accepted: 12/09/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND A community-based intervention comprising both men and women, known as Safe Motherhood Action Groups (SMAGs), was implemented in four of Zambia's poorest and most remote districts to improve coverage of selected maternal and neonatal health interventions. This paper reports on outcomes in the coverage of maternal and neonatal care interventions, including antenatal care (ANC), skilled birth attendance (SBA) and postnatal care (PNC) in the study areas. METHODOLOGY Three serial cross-sectional surveys were conducted between 2012 and 2015 among 1,652 mothers of children 0-5 months of age using a 'before-and-after' evaluation design with multi-stage sampling, combining probability proportional to size and simple random sampling. Logistic regression and chi-square test for trend were used to assess effect size and changes in measures of coverage for ANC, SBA and PNC during the intervention. RESULTS Mothers' mean age and educational status were non-differentially comparable at all the three-time points. The odds of attending ANC at least four times (aOR 1.63; 95% CI 1.38-1.99) and SBA (aOR 1.72; 95% CI 1.38-1.99) were at least 60% higher at endline than baseline surveillance. A two-fold and four-fold increase in the odds of mothers receiving PNC from an appropriate skilled provider (aOR 2.13; 95% CI 1.62-2.79) and a SMAG (aOR 4.87; 95% CI 3.14-7.54), respectively, were observed at endline. Receiving birth preparedness messages from a SMAG during pregnancy (aOR 1.76; 95% CI, 1.20-2.19) and receiving ANC from a skilled provider (aOR 4.01; 95% CI, 2.88-5.75) were significant predictors for SBA at delivery and PNC. CONCLUSIONS Strengthening community-based action groups in poor and remote districts through the support of mothers by SMAGs was associated with increased coverage of maternal and newborn health interventions, measured through ANC, SBA and PNC. In remote and marginalised settings, where the need is greatest, context-specific and innovative task-sharing strategies using community health volunteers can be effective in improving coverage of maternal and neonatal services and hold promise for better maternal and child survival in poorly-resourced parts of sub-Saharan Africa.
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Affiliation(s)
- Choolwe Jacobs
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- Strategic Centre for Health Systems Metrics and Evaluations (SCHEME), School of Public Health, University of Zambia, Lusaka, Zambia
- Department of Epidemiology & Biostatistics, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Charles Michelo
- Strategic Centre for Health Systems Metrics and Evaluations (SCHEME), School of Public Health, University of Zambia, Lusaka, Zambia
- Department of Epidemiology & Biostatistics, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Mumbi Chola
- Department of Epidemiology & Biostatistics, School of Public Health, University of Zambia, Lusaka, Zambia
| | | | - Hikabasa Halwiindi
- Department of Global Health, School of Public Health, University of Zambia, Lusaka, Zambia
| | | | - Kumar Sridutt Baboo
- Department of Global Health, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Mosa Moshabela
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- Africa Health Research Institute, Kwa-Zulu Natal, Durban, South Africa
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21
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Tesfaye B, Mathewos T, Kebede M. Skilled delivery inequality in Ethiopia: to what extent are the poorest and uneducated mothers benefiting? Int J Equity Health 2017; 16:82. [PMID: 28511657 PMCID: PMC5434546 DOI: 10.1186/s12939-017-0579-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 05/08/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The fifth Millennium Development Goal (MDG) targeted at improving maternal health. In this regard, Ethiopia has shown substantial progresses in the past two decades. Nonetheless, these impressive gains are unevenly distributed among Ethiopian women with different socio-economic characteristics. This study aimed at investigating levels and trends of skilled delivery service, and wealth and education related inequalities from 2000 to 16. METHODS Longitudinal data analysis was conducted on Ethiopian Demographic and Health Survey (EDHS) data of 2000, 2005, 2011 and 2016. The outcome variable was skilled delivery, while data on economic status and education level were used as dimensions of inequality. Rate Ratio (RR) and Rate Difference (RD) inequality measures were applied. STATA for windows version 10.1 statistical software was utilized for data analysis and presentation. The strength of association of inequality dimensions with the outcome variable was assessed using a 95% confidence interval. RESULTS From total deliveries, 5.62%, 6.3%, 10.8% and 28% of them were attended by skilled birth attendant in 2000, 2005, 2011 and 2016 respectively. In the most recent survey (EDHS 2016), proportion of births attended by skilled birth attendance among women who completed secondary and above education was about 5.42 [95% CI (4.53, 6.09)] times more when compared to women with no formal education. Proportion of births attended by skilled birth attendance among women in the richest quintile was about 5.11 [95% CI (3.98, 6.12)] times higher than that of women in the poorest quintile. Moreover, gap of inequality on receiving skilled delivery service has increased substantially from 24.2 (2000) to 53.8 (2016) percentage points between women in the richest and poorest quintiles; and from 44.9 (2000) to 76.0 (2016) percentage points between women who completed secondary and above education and women with no formal education. CONCLUSIONS Skilled birth attendance remained low and virtually unchanged during the period 2000-2011, but increased substantially in 2016. Gap on wealth and education related inequalities increased linearly during 2000-16. Most pronounced inequalities were observed in women's level of education revealing women with no formal education were the most underserved subgroups. Encouraging women in education and economic development programs should be strengthened as part of the effort to attain Universal Health Coverage (UHC) of Sustainable Development Goals (SDGs) in Ethiopia.
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Affiliation(s)
- Brook Tesfaye
- Health Policy and Planning Directorate, Ethiopian Federal Ministry of Health, Sudan Street, Lideta Sub-city, Addis Ababa, Ethiopia
| | - Tsedeke Mathewos
- John Snow Incorporated Research and Training Institute, Health Management Information System Scale-up Project, Addis Ababa, Ethiopia
- Technical Assistant to Director of Health Policy and Planning Directorate, Ethiopian Federal Ministry of Health, Addis Ababa, Ethiopia
| | - Mihiretu Kebede
- Department of Health Informatics, College of Medicine and Health Sciences, Institute of Public Health, University of Gondar, Gondar, Ethiopia
- Leibniz Institute for Prevention Research and Epidemiology – BIPS, Achterstraße 30, Bremen, Germany
- University of Bremen, Health Sciences, Bremen, Germany
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22
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Andrade MV, Noronha KVMDS, Queiroz Barbosa AC, Souza MN, Calazans JA, Carvalho LRD, Rocha TAH, Silva NC. Family health strategy and equity in prenatal care: a population based cross-sectional study in Minas Gerais, Brazil. Int J Equity Health 2017; 16:24. [PMID: 28109194 PMCID: PMC5251278 DOI: 10.1186/s12939-016-0503-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 12/25/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Prenatal care coverage is still not universal or adequately provided in many low and middle income countries. One of the main barriers regards the presence of socioeconomic inequalities in prenatal care utilization. In Brazil, prenatal care is supplied for the entire population at the community level as part of the Family Health Strategy (FHS), which is the main source of primary care provided by the public health system. Brazil has some of the greatest income inequalities in the world, and little research has been conducted to investigate prenatal care utilization of FHS across socioeconomic groups. This paper addresses this gap investigating the socioeconomic and regional differences in the utilization of prenatal care supplied by the FHS in the state of Minas Gerais, Brazil. METHODS Data comes from a probabilistic household survey carried out in 2012 representative of the population living in urban areas in the state of Minas Gerais. The sample size comprises 1,420 women aged between 13 and 45 years old who had completed a pregnancy with a live born in the last five years prior to the survey. The outcome variables are received prenatal care, number of antenatal visits, late prenatal care, antenatal tests, tetanus immunization and low birthweight. A descriptive analysis and logistic models were estimated for the outcome variables. RESULTS The coverage of prenatal care is almost universal in catchment urban areas of FHT of Minas Gerais state including both antenatal visits and diagnostic procedures. Due to this high level of coverage, socioeconomic inequalities were not observed. FHS supplied care for around 80% of the women without private insurance and 90% for women belonging to lower socioeconomic classes. Women belonging to lower socioeconomic classes were at least five times more likely to receive antenatal visits and any of the antenatal tests by the FHS compared to those belonging to the highest classes. Moreover, FHS was effective in reducing low birthweight. Women who had prenatal care through FHS were 40% less likely to have a child with low birthweight. CONCLUSION This paper presents strong evidence that FHS promotes equity in antenatal care in Minas Gerais, Brazil.
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Affiliation(s)
- Mônica Viegas Andrade
- CEDEPLAR, Federal University of Minas Gerais - UFMG, Av. Antônio Carlos 6627, sala 3006, Belo Horizonte, MG, 31270-901, Brazil. .,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | | | - Allan Claudius Queiroz Barbosa
- CEPEAD, Federal University of Minas Gerais - UFMG, Av. Antônio Carlos 6627, sala 3040, Belo Horizonte, MG, 31270-901, Brazil
| | - Michelle Nepomuceno Souza
- CEDEPLAR, Federal University of Minas Gerais - UFMG, Av. Antônio Carlos 6627, sala 3006, Belo Horizonte, MG, 31270-901, Brazil
| | - Júlia Almeida Calazans
- CEDEPLAR, Federal University of Minas Gerais - UFMG, Av. Antônio Carlos 6627, sala 3006, Belo Horizonte, MG, 31270-901, Brazil
| | - Lucas Resende de Carvalho
- CEDEPLAR, Federal University of Minas Gerais - UFMG, Av. Antônio Carlos 6627, sala 3006, Belo Horizonte, MG, 31270-901, Brazil
| | - Thiago Augusto Hernandes Rocha
- CEPEAD, Federal University of Minas Gerais - UFMG, Av. Antônio Carlos 6627, sala 3040, Belo Horizonte, MG, 31270-901, Brazil
| | - Núbia Cristina Silva
- CEPEAD, Federal University of Minas Gerais - UFMG, Av. Antônio Carlos 6627, sala 3040, Belo Horizonte, MG, 31270-901, Brazil
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Joseph G, da Silva ICM, Wehrmeister FC, Barros AJD, Victora CG. Inequalities in the coverage of place of delivery and skilled birth attendance: analyses of cross-sectional surveys in 80 low and middle-income countries. Reprod Health 2016; 13:77. [PMID: 27316970 PMCID: PMC4912761 DOI: 10.1186/s12978-016-0192-2] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Accepted: 06/06/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Having a health worker with midwifery skills present at delivery is one of the key interventions to reduce maternal and newborn mortality. We sought to estimate the frequencies of (a) skilled birth attendant coverage, (b) institutional delivery, and (c) the combination of place of delivery and type of attendant, in LMICs. METHODS National surveys (DHS and MICS) performed in 80 LMICs since 2005 were analyzed to estimate these four categories of delivery care. Results were stratified by wealth quintile based on asset indices, and by urban/rural residence. The combination of place of delivery and type of attendant were also calculated for seven world regions. RESULTS The proportion of institutional SBA deliveries was above 90 % in 25 of the 80 countries, and below 40 % in 11 countries. A strong positive correlation between SBA and institutional delivery coverage (rho: 0.97, p <0,001) was observed. Eight countries had over 10 % of home SBA deliveries, and two countries had over 10 % of institutional non-SBA deliveries. Except for South Asia, all regions had over 80 % of urban deliveries in the institutional SBA category, but in rural areas, only two regions (CEE & CIS, Middle East & North Africa) presented average coverage above 80 %. In all regions, institutional SBA deliveries were over 80 % in the richest quintile. Home SBA deliveries were more common in rural than in urban areas, and in the poorest quintiles in all regions. Facility non-SBA deliveries also tended to be more common in rural areas and among the poorest. CONCLUSION Four different categories of delivery assistance were identified worldwide. Pro-urban and pro-rich inequalities were observed for coverage of institutional SBA deliveries.
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Affiliation(s)
- Gary Joseph
- International Center for Equity in Health, Post-Graduate Program in Epidemiology, Federal University of Pelotas, Rua Marechal Deodoro, 1160, 3o andar, Pelotas, RS 96020-220 Brazil
| | - Inácio Crochemore Mohnsam da Silva
- International Center for Equity in Health, Post-Graduate Program in Epidemiology, Federal University of Pelotas, Rua Marechal Deodoro, 1160, 3o andar, Pelotas, RS 96020-220 Brazil
| | - Fernando C. Wehrmeister
- International Center for Equity in Health, Post-Graduate Program in Epidemiology, Federal University of Pelotas, Rua Marechal Deodoro, 1160, 3o andar, Pelotas, RS 96020-220 Brazil
| | - Aluísio J. D. Barros
- International Center for Equity in Health, Post-Graduate Program in Epidemiology, Federal University of Pelotas, Rua Marechal Deodoro, 1160, 3o andar, Pelotas, RS 96020-220 Brazil
| | - Cesar G. Victora
- International Center for Equity in Health, Post-Graduate Program in Epidemiology, Federal University of Pelotas, Rua Marechal Deodoro, 1160, 3o andar, Pelotas, RS 96020-220 Brazil
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