Equity in maternal and child health in Thailand

Global health systems strengthening: FIGO's strategic view on reducing maternal and newborn mortality worldwide

OBJECTIVE

To demonstrate that successful health systems strengthening (HSS) projects have addressed disparities and inequities in maternal and perinatal care in low-income countries.

METHODS

A comprehensive literature review covered the period between 1980 and 2022, focusing on successful HSS interventions within health systems' seven core components that improved maternal and perinatal care.

RESULTS

The findings highlight the importance of integrating quality interventions into robust health systems, as this has been shown to reduce maternal and newborn mortality. However, several challenges, including service delivery gaps, poor data use, and funding deficits, continue to hinder the delivery of quality care. To improve maternal and newborn health outcomes, a comprehensive HSS strategy is essential, which should include infrastructure enhancement, workforce skill development, access to essential medicines, and active community engagement.

CONCLUSION

Effective health systems, leadership, and community engagement are crucial for a comprehensive HSS approach to catalyze progress toward universal health coverage and global improvements in maternal and newborn health.

Inequity of maternal-child health services in ASEAN member states from 1993 to 2021

INTRODUCTION

Inequity in maternal-child health services is a challenge to global health as it hinders the achievement of Sustainable Development Goals (SDGs) and Universal Health Coverage. Though the Association of Southeast Asian Nations (ASEAN) has made remarkable achievements in maternal-child health, there remain gaps in reaching global goals. This study aimed to compare and investigate the inequity in maternal-child health (MCH) services in ASEAN member states to help guide policy decisions to improve equitable health services in the SDG era and beyond.

METHODS

Using the WHO Health Inequality Monitor, we identified inequity summary measures for five MCH services in ASEAN member states from 1993 to 2021: antenatal care, births attended by skilled health personnel, diphtheria, tetanus and pertussis (DTP3) immunization, measles immunization, and polio immunization. We divided the analysis dimension of inequity into urban-rural inequity, economic status inequity, and sub-regional inequity. Trends of absolute and relative inequity in every dimension of MCH services in ASEAN member states were examined with the principal component analysis (PCA).

RESULTS

The mean coverages of MCH services are 98.80% (Thailand), 86.72% (Cambodia), 84.54% (Viet Nam), 78.52 (Indonesia), 76.94% (Timor-Leste), 72.40% (Lao PDR), 68.10% (Philippines) and 48.52% (Myanmar) in 2021. Thailand have the lowest MCH services absolute inequity indexes of -1.945, followed by Vietnam (-1.449). Lao PDR and Myanmar have relatively higher MCH services absolute inequity indexes of 0.852 and 0.054 respectively. The service in Cambodia, Indonesia, and the Philippines is pro-specific regions (with subnational region absolute inequity indexes of -0.02, 0.01, and 1.01 respectively). The service in Myanmar is pro-rich (with economic status absolute inequity index of 0.43). The service in Lao PDR and Timor-Leste is pro-urban areas, pro-rich, and pro-specific regions.

CONCLUSION

The inequity of MCH services in ASEAN persists but is in a declining trend. Thailand and Vietnam have performed well in ensuring MCH services equity, while Laos and Myanmar are still facing serious inequity dilemmas. The progress of MCH service equity in Myanmar, Cambodia, the Philippines, and Indonesia is uneven. It is acceptable to learn from the successful experiences of Thailand and Vietnam to improve the equities in other ASEAN countries. Policies should be developed according to the specific types of MCH inequity in member states to improve equity levels.

Inequalities of Infant Mortality in Ethiopia

(1) Background: Infant mortality is viewed as a core health indicator of overall community health. Although globally child survival has improved significantly over the years, Sub-Saharan Africa is still the region with the highest infant mortality in the world. In Ethiopia, infant mortality is still high, albeit substantial progress has been made in the last few decades. However, there is significant inequalities in infant mortalities in Ethiopia. Understanding the main sources of inequalities in infant mortalities would help identify disadvantaged groups, and develop equity-directed policies. Thus, the purpose of the study was to provide a diagnosis of inequalities of infant mortalities in Ethiopia from four dimensions of inequalities (sex, residence type, mother's education, and household wealth). (2) Methods: Data disaggregated by infant mortalities and infant mortality inequality dimensions (sex, residence type, mother's education, and household wealth) from the WHO Health Equity Monitor Database were used. Data were based on Ethiopia's Demographic and Health Surveys (EDHS) of 2000 (n = 14,072), 2005 (n = 14,500), 2011 (n = 17,817), and 2016 (n = 16,650) households. We used the WHO Health Equity Assessment Toolkit (HEAT) software to find estimates of infant mortalities along with inequality measures. (3) Results: Inequalities related to sex, residence type, mother's education, and household wealth still exist; however, differences in infant mortalities arising from residence type, mother's education, and household wealth were narrowing with the exception of sex-related inequality where male infants were markedly at a disadvantage. (4) Conclusions: Although inequalities of infant mortalities related to social groups still exist, there is a substantial sex related infant mortality inequality with disproportional deaths of male infants. Efforts directed at reducing infant mortality in Ethiopia should focus on improving the survival of male infants.

Vitamins and minerals, education, and self-care need during preconception to 1000 days of life in Southeast Asia: An expert panel opinion

Addressing maternal malnutrition and its drivers is paramount in Southeast Asia. This article summarizes the key clinical learnings and evidence-based opinions from the experts to understand the need for vitamins and minerals supplementation, education, and self-care from preconception to the first 1000 days of life, which warranted further attention since COVID-19 pandemic. Evidence describing the importance of vitamins and minerals during preconception, pregnancy, and lactation stages was identified using literature databases. A pre-meeting survey was conducted to determine the current practices and challenges in Southeast Asia. Based on the literature review and clinical experience, experts defined the topics, and an online meeting was held on 13th July 2021. During the meeting, nine experts from Southeast Asia provided evidence-based opinion on the vitamins and minerals supplementation, education, and self-care need during preconception, pregnancy, and lactation stages. The expert opinions underpin maternal malnutrition as a prevalent issue and discuss appropriate interventions and prevention strategies for women in Southeast Asia. The recent pandemic further impacted nutrition status, pregnancy, and neonatal health outcomes. The expert panel emphasized a need to improve existing inadequacies in education, self-care, and social support, and discussed the role of policymakers in addressing the barriers to dietary changes. As inadequacies in regular vitamins and minerals supplementation, education, and self-care for women of reproductive age implicate maternal and child health outcomes, there is an urgent need for addressing malnutrition concerns in this population. Thus, a strong partnership between policymakers, healthcare professionals, and other relevant sectors is required.

Factor associated with anthropometric failure among under-five Bengali children: A comparative study between Bangladesh and India

Background

Child undernutrition is a burden and the leading cause of child mortality in low-and middle-income countries like Bangladesh and India. Currently, this issue is a matter of great concern, inasmuch as achieving the Sustainable Development Goals (SDGs). The study intends to determine the factors of child undernutrition using a single composite index of anthropometric failure (CIAF) among the Bengali population.

Methods

Unit level data on 14055 under 5 children were extracted from the Bangladesh Demographic and Health Survey 2017–18 (BDHS) and the 4^th National Family Health Survey of India (NFHS-4). To understand child undernutrition and generate CIAF, data on height-for-age (stunting), weight-for-height (wasting), and weight-for-age (underweight) were used by WHO guidelines. These three undernutrition indicators were combined into a single undernutrition indicator called anthropometric failure (anth-failure) using the CIAF concept. Explanatory factors of anth-failure included data on maternal health, socio-demographic and birth-related variables. Differences of frequency were determined by Z-proportional and Chi-square tests; predictors of anth-failure were determined by binary logistic regression. Cut off point of p-value was taken as 0.05 to test the significance.

Results

Inter-country disparities were revealed, about half of Bengali children in India and two-fifths in Bangladesh being prone to anth-failure. Stunting and underweight were more prevalent in both countries than wasting. Maternal undernutrition, lack of maternal education, and poor wealth index were common factors of anth-failure for both countries. Children in Bangladesh developed anth-failure after the end of breastfeeding period, indicating a lack of nutritious food. Lack of antenatal care was another significant factor in Bangladesh. In India, the first child suffered from anth-failure due to lack of maternal education.

Conclusions

This study provides a better understanding of multifactorial impact on child undernutrition. It is proposed that the emphasis should be on initiatives that improve maternal education and nutrition, child food security, boost household wealth index, and enhance mothers’ access to health care. The study strongly recommends that the governments of Bangladesh and India invest financially in preventing child malnutrition, which will contribute to achieving the first four SDGs.

Vaccine equity in low and middle income countries: a systematic review and meta-analysis

BACKGROUND

Evidence to date has shown that inequality in health, and vaccination coverage in particular, can have ramifications to wider society. However, whilst individual studies have sought to characterise these heterogeneities in immunisation coverage at national level, few have taken a broad and quantitative view of the contributing factors to heterogeneity in immunisation coverage and impact, i.e. the number of cases, deaths, and disability-adjusted life years averted. This systematic review aims to highlight these geographic, demographic, and sociodemographic characteristics through a qualitative and quantitative approach, vital to prioritise and optimise vaccination policies.

METHODS

A systematic review of two databases (PubMed and Web of Science) was undertaken using search terms and keywords to identify studies examining factors on immunisation inequality and heterogeneity in vaccination coverage. Inclusion criteria were applied independently by two researchers. Studies including data on key characteristics of interest were further analysed through a meta-analysis to produce a pooled estimate of the risk ratio using a random effects model for that characteristic.

RESULTS

One hundred and eight studies were included in this review. We found that inequalities in wealth, education, and geographic access can affect vaccine impact and vaccination dropout. We estimated those living in rural areas were not significantly different in terms of full vaccination status compared to urban areas but noted considerable heterogeneity between countries. We found that females were 3% (95%CI[1%, 5%]) less likely to be fully vaccinated than males. Additionally, we estimated that children whose mothers had no formal education were 28% (95%CI[18%,47%]) less likely to be fully vaccinated than those whose mother had primary level, or above, education. Finally, we found that individuals in the poorest wealth quintile were 27% (95%CI [16%,37%]) less likely to be fully vaccinated than those in the richest.

CONCLUSIONS

We found a nuanced picture of inequality in vaccination coverage and access with wealth disparity dominating, and likely driving, other disparities. This review highlights the complex landscape of inequity and further need to design vaccination strategies targeting missed subgroups to improve and recover vaccination coverage following the COVID-19 pandemic.

TRIAL REGISTRATION

Prospero, CRD42021261927.

Decomposing maternal socioeconomic inequalities in Zimbabwe; leaving no woman behind

Background

Several studies in the literature have shown the existence of large disparities in the use of maternal health services by socioeconomic status (SES) in developing countries. The persistence of the socioeconomic disparities is problematic, as the global community is currently advocating for not leaving anyone behind in attaining Sustainable Development Goals (SDGs). However, health care facilities in developing countries continue to report high maternal deaths. Improved accessibility and strengthening of quality in the uptake of maternal health services (skilled birth attendance, antenatal care, and postnatal care) plays an important role in reducing maternal deaths which eventually leads to the attainment of SDG 3, Good Health, and Well-being.

Methods

This study used the Zimbabwe Demographic Health Survey (ZDHS) of 2015. The ZDHS survey used the principal components analysis in estimating the economic status of households. We computed binary logistic regressions on maternal health services attributes (skilled birth attendance, antenatal care, and postnatal care) against demographic characteristics. Furthermore, concentration indices were then used to measure of socio-economic inequalities in the use of maternal health services, and the Erreygers decomposable concentration index was then used to identify the factors that contributed to the socio-economic inequalities in maternal health utilization in Zimbabwe.

Results

Overall maternal health utilization was skilled birth attendance (SBA), 93.63%; antenatal-care (ANC) 76.33% and postnatal-care (PNC) 84.27%. SBA and PNC utilization rates were significantly higher than the rates reported in the 2015 Zimbabwe Demographic Health Survey. Residence status was a significant determinant for antenatal care with rural women 2.25 times (CI: 1.55–3.27) more likely to utilize ANC. Richer women were less likely to utilize skilled birth attendance services [OR: 0.20 (CI: 0.08–0.50)] compared to women from the poorest households. While women from middle-income households [OR: 1.40 (CI: 1.03–1.90)] and richest households [OR: 2.36 (CI: 1.39–3.99)] were more likely to utilize antenatal care services compared to women from the poorest households. Maternal service utilization among women in Zimbabwe was pro-rich, meaning that maternal health utilization favoured women from wealthy households [SBA (0.05), ANC (0.09), PNC (0.08)]. Wealthy women were more likely to be assisted by a doctor, while midwives were more likely to assist women from poor households [Doctor (0.22), Midwife (− 0.10)].

Conclusion

Decomposition analysis showed household wealth, husband’s education, women’s education, and residence status as important positive contributors of the three maternal health service (skilled birth attendance, antenatal care, and postnatal care) utilization outcomes. Educating women and their spouses on the importance of maternal health services usage is significant to increase maternal health service utilization and consequently reduce maternal mortality.

Economic inequality in malnutrition: a global systematic review and meta-analysis

OBJECTIVE

To describe the evidence on global and regional economic inequality in malnutrition, and the associations between economic inequality and malnutrition.

METHODS

We conducted a systematic review and meta-analysis. Between 1 November 2020 and 22 January 2021, we searched Medline, Embase, Global Health, Eldis, Web of Science and EBSCO Discovery Service. We contacted 39 experts and tracked citations. We included any study reporting a concentration index (CIX) relating economic status and nutritional status and any multilevel study reporting an association between economic inequality and nutritional status. Nutritional status was measured as stunting, wasting, anaemia, or overweight in children (<5 years), or underweight, overweight or obesity, or anaemia in adults (15-49 years). We had no study date or language restriction. Quality was assessed using the Appraisal Tool for Cross-Sectional Studies (AXIS tool). We mapped estimates and pooled them using multilevel random-effects meta-analyses.

RESULTS

From 6185 results, 91 studies provided 426 CIX (>2.9 million people) and 47 associations (~3.9 million people). Stunting (CIX -0.15 (95% CI -0.19 to -0.11)) and wasting (-0.03 (95% CI -0.05 to -0.02)) are concentrated among poor households. Adult overweight and obesity is concentrated in wealthier households (0.08 (95% CI -0.00 to 0.17)), particularly in South Asia (0.26 (95% CI 0.19 to 0.34)), but not in Europe and Central Asia (-0.02 (95% CI -0.08 to 0.05)) or North America (-0.04 (95% CI -0.10 to 0.03)). We found no association between 0.1 increase in Gini coefficient and adult underweight (OR 1.03 (95% CI 0.94 to 1.12)) or overweight and obesity (0.92 (95% CI 0.80 to 1.05)).

CONCLUSIONS

There is good evidence that the prevalence of malnutrition varies by levels of absolute economic status. Undernutrition is concentrated in poor households, whereas concentration of overweight and obesity by economic status depends on region, and we lack information on economic inequalities in anaemia and child overweight. In contrast, links between malnutrition and relative economic status are less clear and should not be assumed; robust evidence on causal pathways is needed.

PROSPERO REGISTRATION NUMBER

CRD42020201572.

Can a Multi-Component Intervention Improve Pediatric Service Delivery in Guangzhou?

Background: Accessible, equitable, and efficient pediatric service is critical to achieve optimal child health. This study aimed to evaluate the effectiveness of a multi-component intervention on the pediatric health system over two different periods in Guangzhou. Methods: Based on the World Health Organization (WHO) "six building blocks" model and Donabedian's "Structure-Process-Outcomes" framework, an intervention package was developed to increase financial and human resouce investment to strengthen basic health care and strive for a better quality of pediatric care. This multi-component intervention package was conducted in Guangzhou to improve the pediatric service delivery during two stages (2011-2014 and 2016-2019). The main outcome indicators were the changes in the allocation of pediatricians and pediatric beds, pediatric service efficiency, and the impact of pediatricians on child mortality. Results: We found that pediatricians per 1,000 children (PPTC) and pediatric beds per 1,000 children (PBPTC) increased from 1.07 and 2.37 in 2010 to 1.37 and 2.39 in 2014, then to 1.47 and 2.93 in 2019, respectively. Infant mortality rate (IMR) and under-5 mortality rate (U5MR) dropped from 5.46‰ and 4.04‰ in 2010 to 4.35‰ and 3.30‰ in 2014 then to 3.26‰ and 2.37‰ in 2019. The Gini coefficients of PPTC and PBPTC decreased from 0.48 and 0.38 in 2010, to 0.35 and 0.28 in 2014, then to 0.35 and 0.22 in 2019, respectively, representing the improvement of pediatric resources distribution according to service population. However, equalities in the spatial distribution were not improved much. The average efficiency of pediatric service fluctuated from 2010 to 2019. A unit increase in PPTC was associated with an 11% reduction in IMR and a 16% reduction in U5MR. Conclusions: Findings suggest this multi-component intervention strategy is effective, particularly on the reduction of child mortality. In future, more rigorous and multi-faceted indicators should be integrated in a comprehensive evaluation of the intervention.

The Prevalence Rate of Malnutrition in Children Younger than 5 in Iran in 2018

Context:

The first stage of Universal Health Coverage (UHC) was founded Iran to achieve better access to needed health services.

Aims:

The aim of present study was to illustrate the prevalence rate of malnutrition's subtypes in under 5-year old children after UHC in comparison with before that.

Settings and Design:

In a cross-sectional study in 2018, anthropometric indices of 970 under 5 years old children in rural and small towns of Isfahan province were gathered from their health files by cluster randomized sampling method.

Methods:

Children whose weight for age, height for age, and weight for height were lower than -2SD based on Z score, were marked as underweight, stunting, and wasting, respectively. Children, whose weight for age was upper than +2SD, were marked as overweight.

Statistical Analysis Used:

The T-test, Chi-square, and logistic regression tests were used for determination of association between malnutrition's subtypes and demographic variables.

Results:

A total of 78 (8.04%) of under 5 years old children were wasting, 74 (7.63%) were underweight, and 82 (8.45%) were stunting. Also, 12 (1.23%) of the children from the same group were overweight.

Conclusions:

The prevalence rate of underweight and stunting in under 5 years old children were less than before UHC implementation period. The prevalence rate of overweight children below 5 in Isfahan province's villages and small towns was low.

Participatory and responsive governance in universal health coverage: an analysis of legislative provisions in Thailand

Participatory and responsive governance in universal health coverage (UHC) systems synergistically ensure the needs of citizens are protected and met. In Thailand, UHC constitutes of three public insurance schemes: Civil Servant Medical Benefit Scheme, Social Health Insurance and Universal Coverage Scheme. Each scheme is governed through individual laws. This study aimed to identify, analyse and compare the legislative provisions related to participatory and responsive governance within the three public health insurance schemes and draw lessons that can be useful for other low-income and middle-income countries in their legislative process for UHC. The legislative provisions in each policy document were analysed using a conceptual framework derived from key literature. The results found that overall the UHC legislative provisions promote citizen representation and involvement in UHC governance, implementation and management, support citizens’ ability to voice concerns and improve UHC, protect citizens’ access to information as well as ensure access to and provision of quality care. Participatory governance is legislated in 33 sections, of which 23 are in the Universal Coverage Scheme, 4 in the Social Health Insurance and none in the Civil Servant Medical Benefit Scheme. Responsive governance is legislated in 24 sections, of which 18 are in the Universal Coverage Scheme, 2 in the Social Health Insurance and 4 in the Civil Servant Medical Benefit Scheme. Therefore, while several legislative provisions on both participatory and responsive governance exist in the Thai UHC, not all schemes equally bolster citizen participation and government responsiveness. In addition, as legislations are merely enabling factors, adequate implementation capacity and commitment to the legislative provisions are equally important.

Progress towards Achieving the Recommendations of the Commission on Ending Childhood Obesity: A Comprehensive Review and Analysis of Current Policies, Actions and Implementation Gaps in Thailand

Despite a significant commitment to tackling childhood overweight and obesity, questions remain about the progress the Thai Government has made in implementing childhood obesity prevention policies and actions. This study aimed to review and assess the implementation of the government's policies and actions for childhood obesity prevention in Thailand compared with the recommendations of the Commission on Ending Childhood Obesity and to identify the implementation gaps. Policy data were collected from governmental and NGO websites and publications and via direct contact with government officials. Stakeholder meetings were held to seek further information and advice on implementation gaps and to give recommendations. The analysis of each policy was conducted against pre-determined criteria formulated from literature assessments and stakeholder consultations. The policies and actions that were implemented by the Government were consistent with 33 broad policy actions and 55 specific policy actions. Preconception and pregnancy care was the policy area that was most implemented. Six broad policy actions were assessed as 'high' performance, these were: sugar-sweetened beverage taxation, nutrient labeling, nutrition guidance for preconception and pregnancy care, the International Code of Marketing of Breast-milk Substitutes, regulatory measures for supporting maternal breastfeeding, and regulations on the marketing of complementary foods and beverages. Policy coherence and monitoring and evaluation (M&E) were identified as major implementation gaps. Increasing the effectiveness of childhood obesity prevention in Thailand will require national immediate attention towards building infrastructure to enhance coherence among the policies and to put in place M&E mechanisms for each policy.

Economic-related inequalities in child health interventions: An analysis of 65 low- and middle-income countries

To achieve Sustainable Development Goal targets related to child health and well-being, it is important to quantify inequalities in the essential child health interventions. We used the latest available Demographic and Health Surveys from 65 low-income and middle-income countries between 2005 and 2018. We examined economic-related inequalities in 15 essential child health interventions spanning across four domains: nutrition, behavioral health, household environment, and maternal factors. In the pooled analysis, we observed significant inequalities in all child health interventions, except in the use of oral rehydration therapy (ORT) for child diarrhea. The interventions with the largest adjusted difference between the richest (Q5) and the poorest (Q1) groups were in household environment domain: improved sanitation at 55.6 percentage points [PPs] (95% confidence interval [CI]: 54.7, 56.6), low indoor pollution at 43.5 PPs (95% CI: 41.4, 45.9), and safe stool disposal at 39.8 PPs (95% CI: 38.7, 41.0). In 35 countries, the adjusted difference between Q5 and Q1 groups in improved sanitation was found to be larger than 50 PPs. At the same time, country-specific analyses revealed substantial heterogeneity in the extent of inequalities in child health interventions. An inverted-U shape curve was identified between the mean intervention coverage rate and the magnitude of inequalities for household environmental and maternal interventions. This suggests an initial exacerbation of inequality in child health interventions as the coverage increases until it reaches an inflection point at which inequality begins to decline even as the coverage continues to improve. Our findings call for more systematic monitoring of economic-related inequalities in child health interventions to develop equity-oriented policies and programmes in global health.

Multiple anthropometric and nutritional deficiencies in young children in Ethiopia: a multi-level analysis based on a nationally representative data

BACKGROUND

In Ethiopia, child undernutrition and anemia are major public health concerns, resulting in increased childhood morbidity and mortality. Despite progress made to reduce the prevalence of malnutrition (especially stunting) from 50% in 2000 to 38% in 2016, little is known about the magnitude and risk factors for concurrent nutritional deficiencies in Ethiopia.

METHODS

Analysis for this study was based on a total sample of 9218 children aged 6-59 months drawn from the Ethiopian Demographic and Health Survey (EDHS) conducted in the year 2016. The study used two outcome variables: Multiple nutrition deficit index formed by combining stunting, underweight, wasting and anemia status; and a concurrent stunting and anemia (CAS) index. Two mixed effect regression models, Poisson and Logistic, were used to identify the key risk factors of the two outcome variables, respectively.

RESULTS

The proportion of children with stunting (length-for-age), underweight (weight-for-age) and wasting children (weight-for-length) was 38%, 25.2% and 9.4%, respectively. About 58% of the children had anemia. The prevalence of children with concurrent stunting and anemia children was 24.8%. Our results showed that the risks of multiple nutritional problems were determined by a range of individual, household and behavioral factors including: sex of the child, age of the child, birth order, parity, parental education, religion, household wealth index and type of family structure. The proximate variables (hygiene and sanitation score, feeding practice, and child health service utilization score) were also found to exert a strong influence on the risk of multiple nutritional deficiencies. The likelihood of co-occurrence of stunting and anemia was determined by certain individual and household factors, including sex of the child, age of the child, maternal education, household asset based wealth, religion and household hygiene and sanitation.

CONCLUSIONS

This study underscores the importance of improving parental education, household wealth, hygiene and sanitation conditions, promoting feeding practice and child health service utilization. Also, any nutrition sensitive and specific intervention should consider a child's characteristics such as his/her age, gender and birth order.

Equity and Efficiency of Health Resource Allocation of Chinese Medicine in Mainland China: 2013-2017

Background: In this study, we aimed to estimate the equity and efficiency of traditional Chinese medicine (TCM) health resource allocation, utilization, and trend in mainland China from 2013 to 2017. Methods: The data were downloaded from the China Health Statistical Yearbook (2014-2018) and the China Statistical Yearbook (2018). The equity of TCM health resource allocation was evaluated through the Lorenz curve, Gini coefficient (G), and Theil index (T) based on population size and geographical area. The efficiency and productivity of TCM health resource utilization were assessed using the data envelopment analysis-based Malmquist productivity index. Results: TCM health resource had an increasing trend every year. The equity allocated by population (G ranging from 0.1 to 0.3) was better than that by geographic region (G > 0.5). T in the intra-groups was higher than those in the inter-groups. The equity of TCM resource allocation was the middle region > eastern region > western region. Most provinces (29 out of 31) had negative productivity changes, suggesting deterioration in productivity. Moreover, the middle region with higher scale sizes had more redundant inputs than the other two regions. However, the low technological development (all technical values <1) might hinder productive progress. Conclusion: The equity of TCM health allocated by the population was better than that by the geographic region. The intra-regional difference was the main reason for inequity sources. Productivities in more than 97% of provinces are inefficient. The frequency distribution of scale efficiency (score > 1) had increased since 2015. However, the frequency distribution of technical change (score > 1) decreased every year. The slow technological progress and low scale size might be the main reasons for low productivity.

Financial risk protection of Thailand's universal health coverage: results from series of national household surveys between 1996 and 2015

BACKGROUND

Thailand, an upper-middle income country, has demonstrated exemplary outcomes of Universal Health Coverage (UHC). The country achieved full population coverage and a high level of financial risk protection since 2002, through implementing three public health insurance schemes. UHC has two explicit goals of improved access to health services and financial protection where use of these services does not create financial hardship. Prior studies in Thailand do not provide evidence of long-term UHC financial risk protection. This study assessed financial risk protection as measured by the incidence of catastrophic health spending and impoverishment in Thai households prior to and after UHC in 2002.

METHODS

We used data from a 15-year series of annual national household socioeconomic surveys (SES) between 1996 and 2015, which were conducted by the National Statistic Office (NSO). The survey covered about 52,000 nationally representative households in each round. Descriptive statistics were used to assess the incidence of catastrophic payment as measured by the share of out-of-pocket payment (OOP) for health by households exceeding 10 and 25% of household total consumption expenditure, and the incidence of impoverishment as determined by the additional number of non-poor households falling below the national and international poverty lines after making health payments.

RESULTS

Using the 10% threshold, the incidence of catastrophic spending dropped from 6.0% in 1996 to 2% in 2015. This incidence reduced more significantly when the 25% threshold was applied from 1.8 to 0.4% during the same period. The incidence of impoverishment against the national poverty line reduced considerably from 2.2% in 1996 to approximately 0.3% in 2015. When the international poverty line of US$ 3.1 per capita per day was applied, the incidence of impoverishment was 1.4 and 0.4% in 1996 and 2015 respectively; and when US$ 1.9 per day was applied, the incidence was negligibly low.

CONCLUSION

The significant decline in the incidence of catastrophic health spending and impoverishment was attributed to the deliberate design of Thailand's UHC, which provides a comprehensive benefits package and zero co-payment at point of services. The well-founded healthcare delivery system and favourable benefits package concertedly support the achievement of UHC goals of access and financial risk protection.

Assessing and decomposing inequality of opportunity in access to child health and nutrition in sub-Saharan Africa: evidence from three countries with low human development index

Background

Inequality of opportunity in health and nutrition is a major public health issue in the developing regions. This study analyzed the patterns and extent of inequality of opportunity in health and nutrition among children under-five across three countries sub-Saharan Africa with low Human development index (HDI).

Methods

We used data from the Multiple Indicator Cluster Survey of the Democratic Republic of Congo (20,792 households, 21,756 women aged 15 to 49 and 21,456 children under five), Guinea Bissau (6601 households, 10,234 women aged 15–49 and 7573 children under five) and Mali (11,830 households, 18,409 women in 15–49 years and 16,468 children under five) to compute the human opportunity index (HOI) and the dissimilarity index (D-index). Secondly, the Shapley decomposition method was used to estimate the relative contribution of circumstances that are beyond the control of children under-five and affecting their development outcomes in later life stages.

Results

The study revealed that children belonging to the most favorable group had higher access rates for immunization (93.64%) and water and sanitation facilities (73.59%) in Guinea Bissau. In Congo DR, the access rate was high for immunization (93.9%) for children in the most favorable group. In Mali, access rates stood at 6.56% for children in the most favorable group. In Guinea Bissau, the inequality of opportunity was important in access to health services before and after delivery (43.85%). In Congo DR, the inequality of opportunity was only high for the immunization composite indicator (83.79%) while in Mali, inequality of opportunity was higher for access to health services before and after delivery (41.67%).

Conclusion

The results show that there are efforts in some places to promote access to health and nutrition services in order to make access equal without distinction linked to the socio-economic and demographic characteristics in which the children live. However, the inequalities of opportunity observed between the children of the most favorable group and those of the least favorable group, remain in general at significant levels and call on government of these countries to implement policies taking them into account.

Inequality in dental expenditures among Iranian households: A cross-sectional survey using the National Health Accounts

BACKGROUND

Recently, inequality in dental care has become increasingly popular in both developed and developing countries as a matter of health policy. Thus, the aims of this study were examining inequality in dental care expenditures and assessing the effects of insurance coverage and other variables on these services.

MATERIALS AND METHODS

In this cross-sectional and descriptive-analytical study, we used secondary data of the National Health Accounts that has been conducted in 2008 in Iran. The sample size was 17,239 households in all over the country. All analyses were performed by Stata software using Mann-Whitney test and logistic regression. P < 0.05 was considered statistically significant. To determine inequality in dental services, the concentration index (CI) was used.

RESULTS

CI for total dental expenditures was 0.315 and for orthodontics was 0.6. Findings showed that out-of-pocket expenditure for dental care was progressive and there was a significant relationship between total dental expenditure with residence areas (odds ratio [OR] =1.3; P > 0.001), complementary insurance coverage (OR = 1.3; P > 0.001), family size (OR = 1.46; P > 0.001), and income (OR = 1.3; P > 0.001).

CONCLUSION

Dental expenditures were progressive in Iran, and the rich have paid more share for these services. It seems that implementing insurance programs, changes in the financing of dental care, development of insurance basic benefits package, supporting programs for the poor, adopting educational policies, and promoting oral health for vulnerable people can have an effective role in decreasing inequality in using dental services.

Maternal stature, maternal education and child growth in Pakistan: a cross-sectional study

Pakistan has a significantly higher prevalence of stunted children under five years old compared with other countries with a similar income level. Given maternal education is a modifiable factor, we analyzed whether education has a larger marginal effect on improving children's growth for shorter stature mothers. Pakistan Demographic and Health Survey of 2012–13 was analyzed, with a total of 3,883 of children under five years of age (belonged to 2,327 mothers). The results showed that the overall prevalence of stunting, underweight, wasting, and overweight in our sample was 45%, 26.2%, 9.9%, and 9.5%, respectively. Short stature mothers have a higher number of malnourished children as compared to taller mothers. Compared to tall stature mothers, short stature mothers at all education levels have a higher number of stunted and underweight children. Maternal education has a significant positive effect on children's growth. However, we did not find significant differences in the marginal effect of maternal education among mothers with different statures. Policies providing specialized care to children born to short stature mothers are crucial, along with emphasizing mothers' education. Moreover, a poverty elevation program is necessary as a significant fraction of childhood malnutrition is attributed to the wealth index.

Comparing Regional Distribution Equity among Doctors in China before and after the 2009 Medical Reform Policy: A Data Analysis from 2002 to 2017

Background: Although China began implementing medical reforms in 2009 aimed at fair allocation of the regional distribution of doctors, little is known of their impact. This study analyzed the geographic distribution of doctors from 2002 to 2017. Methods: This study calculated the Gini coefficient and Theil index among doctors in the eastern, central, and western regions (Category 1) of China, and in urban and rural areas (Category 2). The statistical significance of fairness changes was analyzed using the Mann–Whitney U test. Results: The annual growth rates of the number of doctors for the periods from 2002 to 2009 and 2010 to 2017 were 2.38% and 4.44%. The Gini coefficients among Category 1 were lower than those in Category 2, and statistically decreased after the medical reforms (P < 0.01) but continued to increase in Category 2 (P = 0.463). In 2017, the Theil decomposition result of Category 1 was 74.33% for the between-group, and in Category 2, it was 95.22% for the within-group. Conclusions: The fairness among the regional distribution of doctors in Category 1 is now at a high level and is better than that before the reforms. While the fairness in Category 2 is worse than that before the reforms, it causes moderate inequality and is continually decreasing. Overall unfairness was found to be derived from the between-group.

Equity of health workforce distribution in Thailand: an implication of concentration index

Background

Geographical maldistribution has been a critical concern of health workforce planning in Thailand for years. This study aimed to assess the equity of health workforce distribution in public hospitals affiliated to the Office of Permanent Secretary (OPS) of the Ministry of Public Health (MOPH) through the application of “concentration index” (CI).

Methods

A cross sectional quantitative design was employed. The dataset comprised 1) health workforce data from the OPS, MOPH in 2016, 2) regional and provincial-level economic data from the National Economic and Social Development Board in 2015, and 3) population data from the Ministry of Interior in 2015. Descriptive statistics, Spearman’s rank correlation, and CI analysis were performed.

Results

Thailand had 2.04 health professionals working in public facilities per 1,000 population. Spearman’s correlation found positive relationship in all health professionals. Yet, statistical significance was not found in most health professionals but doctors (P<0.001). Positive correlation was observed in all health cadres at regional and provincial hospitals (r_s=0.348, P=0.002). In the CI analysis, the distribution of health professionals across provincial income was relatively equitable in all cadres. Significant CIs were found in doctor density (CI =0.055, P=0.001), all professionals density at district hospitals (CI =–0.049, P=0.012), and all professionals density at provincial and regional hospitals (CI =0.078, P=0.003).

Conclusion

The positive CIs implied that the distribution of all health professionals, especially doctors, at provincial and regional hospitals slightly favored the richer provinces. In contrast, the distribution at district hospitals was slightly more concentrated in less well-off provinces. From a macro-view, the distribution of all health professionals in Thailand was relatively equitable across provincial economic status. This might be due to the extensive health infrastructure development and rural retention policies over the past four decades.

Childhood stunting in Thailand: when prolonged breastfeeding interacts with household poverty

BACKGROUND

Childhood stunting, defined as the height-for-age standardized score lower than minus two, is one of the key indicators for assessing well-being and health of a child; and can be used for monitoring child health inequalities. Thailand has been successful in improving health and providing financial protection for its population. A better understanding of the determinants of stunting will help fill both knowledge and policy gaps which promote children's health and well-being. This study assesses the factors contributing to stunting among Thai children aged less than five years.

METHODS

This study obtained data from the Multiple Indicator Cluster Survey Round 4 (MICS4), conducted in Thailand in 2012. Data analysis consisted of three steps. First, descriptive statistics provided an overview of data. Second, a Chi-square test determined the association between each covariate and stunting. Finally, multivariable logistic regression assessed the likelihood of stunting from all independent variables. Interaction effects between breastfeeding and household economy were added in the multivariable logistic regression.

RESULTS

In the analysis without interaction effects, while the perceived size of children at birth as 'small' were positively associated with stunting, children in the well-off households were less likely to experience stunting. The analysis of the interactions between 'duration of breastfeeding' and 'household's economic level' found that the odds of stunting in children who were breastfed longer than 12 months in the poorest household quintile were 1.8 fold (95% Confidence interval: 1.3-2.6) higher than the odds found in mothers from the same poorest quintiles, but without prolonged breastfeeding. However prolonged breastfeeding in most well-off households (those between the second quintile and the fifth wealth quintile) did not show a tendency towards stunting.

CONCLUSIONS

Childhood stunting was significantly associated with several factors. Prolonged breastfeeding beyond 12 months when interacting with poor economic status of a household potentiated stunting. Children living in the least well-off households were more prone to stunting than others. We recommend that the MICS survey questionnaire be amended to capture details on quantity, quality and practices of supplementary feeding. Multi-sectoral nutrition policies targeting poor households are required to address stunting challenges.

Impoverishment and catastrophic expenditures due to out-of-pocket payments for antenatal and delivery care in Yangon Region, Myanmar: a cross-sectional study

OBJECTIVES

(1) To assess the levels of impoverishment and catastrophic expenditure due to out-of-pocket (OOP) payments for antenatal care (ANC) and delivery care in Yangon Region, Myanmar; and (2) to explore the determinants of impoverishment and catastrophic expenditure.

DESIGN, SETTING AND PARTICIPANTS

A community-based cross-sectional survey among women giving birth within the past 12 months in Yangon, Myanmar, was conducted during October to November 2016 using three-stage cluster sampling procedure.

OUTCOME MEASURES

Poverty headcount ratio, normalised poverty gap and catastrophic expenditure incidence due to OOP payments in the utilisation of ANC and delivery care as well as the determinants of impoverishment and catastrophic expenditure.

RESULTS

Of 759 women, OOP payments were made by 75% of the women for ANC and 99.6% for delivery care. The poverty headcount ratios after payments increased to 4.3% among women using the ANC services, to 1.3% among those using delivery care and to 6.1% among those using both ANC and delivery care. The incidences of catastrophic expenditure after payments were found to be 12% for ANC, 9.1% for delivery care and 20.9% for both ANC and delivery care. The determinants of impoverishment and catastrophic expenditure were women's occupation, number of household members, number of ANC visits and utilisation of skilled health personnel and health facilities. The associations of the outcomes with these variables bear both negative and positive signs.

CONCLUSIONS

OOP payments for all ANC and delivery care services are a challenge to women, as one of fifteen women become impoverished and a further one-fifth incur catastrophic expenditures after visiting facilities that offer these services.

Assessing levels and trends of child health inequality in 88 developing countries: from 2000 to 2014

Background: Reducing child mortality was one of the Millennium Development Goals. In the current Sustainable Development Goals era, achieving equity is prioritized as a major aim.

Objective: This study aims to provide a comprehensive and updated picture of inequalities in child health intervention coverage and child health outcomes by wealth status, as well as their trends between 2000 and 2014.

Methods: Using data from Demographic Health Surveys and Multiple Indicator Cluster Surveys, we adopted three measures of inequality, including one absolute inequality indicator and two relative inequality indicators, to estimate the level and trends of inequalities in three child health outcome variables and 17 intervention coverages in 88 developing countries.

Results: While improvements in child health outcomes and coverage of interventions have been observed between 2000 and 2014, large inequalities remain. There was a high level of variation between countries’ progress toward reducing child health inequalities, with some countries significantly improving, some deteriorating, and some remaining statistically unchanged. Among child health interventions, the least equitable one was access to improved sanitation (The absolute difference in coverages between the richest quintile and the poorest quintile reached 49.5% [42.7, 56.2]), followed by access to improved water (34.1% [29.5, 38.6]), and skilled birth attendant (SBA) (34.1% [28.8, 39.4]). The most equitable intervention coverage was insecticide-treated bed net for children (1.0% [−3.9, 5.9]), followed by oral rehydration therapy for diarrhea ((8.0% [5.2, 10.8]), and vitamin A supplement (8.4% [5.1, 11.7]). These findings were robust to various inequality measurements.

Conclusions: Although child health outcomes and coverage of interventions have improved largely over the study period for almost all wealth quintiles, insufficient progress was made in reducing child health inequalities between the poorest and richest wealth quintiles. Future efforts should focus on reaching the poorest children by increasing investments toward expanding the coverage of interventions in resource-limited settings.

Inequalities in maternal health care utilization in Benin: a population based cross-sectional study

BACKGROUND

Ensuring equitable access to maternal health care including antenatal, delivery, postnatal services and fertility control methods, is one of the most critical challenges for public health sector. There are significant disparities in maternal health care indicators across many geographical locations, maternal, economic, socio-demographic factors in many countries in sub-Sahara Africa. In this study, we comparatively explored the utilization level of maternal health care, and examined disparities in the determinants of major maternal health outcomes.

METHODS

This paper used data from two rounds of Benin Demographic and Health Survey (BDHS) to examine the utilization and disparities in factors of maternal health care indicators using logistic regression models. Participants were 17,794 and 16,599 women aged between15-49 years in 2006 and 2012 respectively. Women's characteristics were reported in percentage, mean and standard deviation.

RESULTS

Mean (±SD) age of the participants was 29.0 (±9.0) in both surveys. The percentage of at least 4 ANC visits was approximately 61% without any change between the two rounds of surveys, facility based delivery was 93.5% in 2012, with 4.9% increase from 2006; postnatal care was currently 18.4% and contraceptive use was estimated below one-fifth. The results of multivariable logistic regression models showed disparities in maternal health care service utilization, including antenatal care, facility-based delivery, postnatal care and contraceptive use across selected maternal factors. The current BHDS showed age, region, religion were significantly associated with maternal health care services. Educated women, those from households of high wealth index and women currently working were more likely to utilize maternal health care services, compared to women with no formal education, from poorest households or not currently employed. Women who watch television (TV) were 1.31 (OR = 1.31; 95% CI = 1.13-1.52), 1.69 (OR = 1.69; 95% CI = 1.20-2.37) and 1.38 (OR = 1.38; 95% CI = 1.16-1.65) times as likely to utilize maternal health care services after adjusting for other covariates.

CONCLUSION

The findings would guide stakeholders to address inequalities in maternal health care services. More so, health care programmes and policies should be strengthened to enhance accessibility as well as improve the utilization of maternal care services, especially for the disadvantaged, uneducated and those who live in hard-to-reach rural areas in Benin. The Benin government needs to create strategies that cover both the supply and demand side factors at attain the universal health coverage.

Inequity in the utilization of antenatal and delivery care in Yangon region, Myanmar: a cross-sectional study

BACKGROUND

Equity of access to and utilization of healthcare across socio-economic groups is important to achieve universal health coverage. Although the utilization of antenatal and delivery care has been increasing in low- and middle-income countries, inequities in the utilization of antenatal and delivery care have been reported in many countries, but have not yet been studied in Myanmar. This study aimed to determine whether inequities in the utilization of antenatal and delivery care existed in Yangon region, Myanmar.

METHODS

A community-based cross-sectional survey using multistage sampling was conducted from October to November 2016. A wealth index was selected as the main socioeconomic parameter for measuring inequities with respect to early initiation of antenatal care (ANC), number of antenatal care visits, delivery by a skilled birth attendant (SBA) and delivery by cesarean section (CS). Inequities were evaluated using concentration curves and concentration indexes.

RESULTS

Of the 762 women who gave birth within the 12-month survey period, there was no evidence of inequity in utilization of ANC; however, inequity of at least one antenatal visit among women aged less than 20 years was found with a concentration index of 0.04. The concentration indexes for delivery by SBA and CS were 0.05 and 0.14, respectively. Delivery by CS was disproportionately higher in adolescents and women with higher education than middle school.

CONCLUSION

There was no overall inequity in the utilization of ANC but substantial inequities in delivery by CS and SBA were shown. Social determinants of health, particularly age and education, were associated with inequities in the utilization of delivery care. Adolescent pregnant women were found to be particularly vulnerable, and thus should be a target group for strategic plans to reduce inequities in utilization of delivery care.

Inequality in early childhood neurodevelopment in six poor rural counties of China: a decomposition analysis

BACKGROUND

Previous studies about inequality in children's health focused more on physical health than the neurodevelopment. In this study, we aimed to evaluate the inequality in early childhood neurodevelopment in poor rural China and explore the contributions of socioeconomic factors to the inequality.

METHOD

Information of 2120 children aged 0 to 35 months and their households in six poor rural counties of China was collected during July - September, 2013. Age and Stages Questionnaire-Chinese version, concentration index and decomposition analysis were used to assess the neurodevelopment of early childhood, measure its inequality and evaluate the contributions of socioeconomic factors to the inequality, respectively.

RESULT

The prevalence of suspected developmental delay in children under 35 months of age in six poor rural counties of China was nearly 40%, with the concentration index of -0.0877. Household economic status, caregivers' depressive symptoms, learning material and family support for learning were significantly associated with children's suspected developmental delay, and explained 34.1, 14.1, 8.9 and 7.0% of the inequality in early childhood neurodevelopment, respectively.

CONCLUSION

The early childhood neurodevelopment in the surveyed area is poor and unfair. Factors including household economic status, caregivers' depressive symptoms, learning material and family support for learning are significantly associated with children's suspected developmental delay and early developmental inequality. The results highlight the urgent need of monitoring child neurodevelopment in poor rural areas. Interventions targeting the caregivers' depressive symptoms, providing learning material and developmental appropriate stimulating activities may help improve early childhood neurodevelopment and reduce its inequality.

Measurement and analysis of inequality of opportunity in access of maternal and child health care in Togo

BACKGROUND

Access to maternal and child health care in low- and middle-income countries such as Togo is characterized by significant inequalities. Most studies in the Togolese context have examined the total inequality of health and the determinants of individuals' health. Few empirical studies in Togo have focused on inequalities of opportunity in maternal and child health. To fill this gap, we estimated changes in inequality of opportunity in access to maternal and child health services between 1998 and 2013 using data from Togo Demographic and Health Surveys (DHS).

METHOD

We computed the Human Opportunity Index (HOI)-a measure of how individual, household, and geographic characteristics like sex and place of residence can affect individuals' access to services or goods that should be universal-using five indicators of access to healthcare and one composite indicator of access to adequate care for children. The five indicators of access were: birth in a public or private health facility; whether the child had received any vaccinations; access to prenatal care; prenatal care given by qualified staff; and having at least four antenatal visits. We then examined differences across the two years.

RESULTS

Between 1998 and 2013, inequality of opportunities decreased for four out of six indicators. However, inequalities increased in access to antenatal care provided by qualified staff (5.9% to 12.5%) and access to adequate care (27.7% to 28.6%).

CONCLUSIONS

Although inequality of opportunities reduced between 1998 and 2013 for some of the key maternal and child health indicators, the average coverage and access rates underscore the need for sustained efforts to ensure equitable access to primary health care for mothers and children.

Socioeconomic inequalities in the uptake of maternal healthcare services in Ethiopia

Background

The progress in coverage of maternal health services in Ethiopia has been rather slow over the past decade and consequently the maternal mortality ratio was very high (673 per 100,000 live births) among the countries in Sub-Saharan Africa and remained constant during 2005–11 period. Earlier studies have mostly focused on determinants of maternal health seeking behavior in Ethiopia. However, little is known about the inequality aspects. This study intends to examine socioeconomic inequalities in the uptake of maternal health services and to identify factors that contribute to such inequalities.

Methods

Data for the study is drawn from three rounds (year 2000, 2005 and 2011) of the Ethiopian Demographic and Health Surveys (EDHS). Concentration curves and the related concentration index (CI) were used to capture inequalities across the full range of socioeconomic status and highlight trends in the uptake of maternal health services in the country. Decomposition analysis was also employed to identify dominant factors that contribute to inequalities in the uptake of maternal healthcare services.

Results

In this study, there is a general improvement in the uptake of maternal health services in Ethiopia over the past decade which is inequitable to the disadvantage of the poor. Inequalities are much larger in care during giving birth than in other maternal healthcare indicators. Furthermore, despite the progress made in reducing inequalities in the uptake of four antenatal care consultation (ANC) and tetanus toxoid (TT) injection, inequalities in access to health facilities for delivery and skilled assistance during delivery have rather widened over the same period. In all the survey years, inequalities in education and media access significantly contribute to inequalities in maternal health service utilization favoring the non-poor.

Conclusion

The challenges to improving the uptake of maternal healthcare services in Ethiopia go beyond improving coverage of the maternal health services. Thus, addressing socioeconomic inequalities in accessing maternal health services is central to resolving challenges of maternal health. Furthermore, as Ethiopia moves forward with the sustainable development agenda, socioeconomic inequalities in uptake of maternal health services should also be continuously monitored.

Factors Associated with Stunting among Children Aged 0 to 59 Months from the Central Region of Mozambique

The objective of this study was to identify the major socio-demographic, health, and environmental determinants of stunting among children aged 0-59 months from the Tete province (Mozambique) and offering useful information for future healthcare strategies and interventions. A case-control study was conducted among 282 (162 boys; 120 girls) children under five years of age from the central region of Mozambique between 1 May and 3 June 2014. Children with stunting (HAZ < -2 SD according to the WHO Child Growth Standards in 2006) were considered as cases and those who had a Z-score < -2 SD were considered as controls. We collected data related to mothers and children and their environment, and they were assessed in two groups to find a possible association. The software used for data analysis was the SPSS®(version, 21.0) using descriptive statistics, t-test, ANOVA, chi-square analyses, bivariate comparisons, and stepwise multiple logistic regression analysis. The results showed that birth weight, mother's educational status, maternal occupation, living in a rural area, family size, number of children under five years of age in the household, cooking with charcoal, inhabiting wooden or straw housing or housing without proper floors, overall duration of breastfeeding as well as duration of exclusive breastfeeding, and time of initiation of complementary feeding were significantly related to stunting. Thus, appropriate nutritional intervention programmes considering these determinants and the dissemination of knowledge at the population level related to undernutrition are necessary to ameliorate the children´s nutritional status.

The equity of China's emergency medical services from 2010-2014

Background

With the depth development of health care system reform in China, emergency medical services (EMS) is confronted with challenges as well as opportunities. This study aimed to analyze the equity of China’s EMS needs, utilization, and resources distribution, and put forward proposal to improve the equity.

Method

Three emergency needs indicators (mortality rate of cardiovascular and cerebrovascular diseases, harm, and digestive system disease), two utilization indicators (emergency outpatient visits and rate of utilization) and one resource allocation indicator (number of EMS facilities) were collected after the review of the China Statistical Yearbook and the National Disease Surveillance System. Next, EMS related indicators were compared among 31 provinces from the eastern, central, and western regions of the country. Concentration Index (CI) were used to measure the equity of EMS needs and utilization among the western, central, and eastern regions. The Gini coefficient of demographic and geographic distribution of facilities represented the equity of resource allocation.

Result

During 2010–2014, the CI of cardiovascular and cerebrovascular disease mortality changed from positive to negative, which indicates that the concentrated trend transferred from richer regions to the poorer area. Injury mortality (CI: range from − 0.1241to −0.1504) and digestive disease mortality (CI: range from − 0.1921 to − 0.2279) consistently concentrated in the poorer region, and the inequity among regions became more obviously year-by-year. The utilization of EMS (CI: range from 0.1074 to 0.0824) showed an improvement; however, the inequity reduced gradually. The EMS facilities distribution by population (Gini coefficient: range from 0.0922 to 0.1200) showed high equitability but the EMS facilities distribution by geography (Gini coefficient: range from 0.0922 to 0.1200) suggested a huge gap between regions because the Gini coefficients were greater than 0.5 in the past 5 years.

Conclusion

There are some inequities of needs, utilization, and resource allocation in the China EMS. The government needs to stick to the principle of increasing investment in poorer regions, perfecting ambulance configuration and improving health workers’ professional skills to improve the equity and quality of EMS.

Post universal health coverage trend and geographical inequalities of mortality in Thailand

Background

Thailand has achieved remarkable improvement in health status since the achievement of universal health coverage in 2002. Health equity has improved significantly. However, challenges on health inequity still remain.This study aimed to determine the trends of geographical inequalities in disease specific mortality in Thailand after the country achieved universal health coverage.

Methods

National vital registration data from 2001 to 2014 were used to calculate age-adjusted mortality rate and standardized mortality ratio (SMR). To minimize large variations in mortality across administrative districts, the adjacent districts were systematically grouped into “super-districts” by taking into account the population size and proximity. Geographical mortality inequality among super-districts was measured by the coefficient of variation. Mixed effects modeling was used to test the difference in trends between super-districts.

Results

The overall SMR steadily declined from 1.2 in 2001 to 0.9 in 2014. The upper north and upper northeast regions had higher SMR whereas Greater Bangkok achieved the lowest SMR. Decreases in SMR were mostly seen in Greater Bangkok and the upper northern region. Coefficient of variation of SMR rapidly decreased from 20.0 in 2001 to 12.5 in 2007 and remained close to this value until 2014. The mixed effects modelling revealed significant differences in trends of SMR across super-districts. Inequality in mortality declined among adults (≥15 years old) but increased in children (0–14 years old). A declining trend in inequality of mortality was seen in almost all regions except Greater Bangkok where the inequality in SMR remained high throughout the study period.

Conclusions

A decline in the adult mortality inequality across almost all regions of Thailand followed universal health coverage. Inequalities in child mortality rates and among residents of Greater Bangkok need further exploration.

Medical care ideals among urban and rural residents in Thailand: a qualitative study

Background

Health care is generally considered to be more highly valued in urban areas than in rural areas. However, studies have reported that there is no difference in the health care values of urban and rural areas in the Kingdom of Thailand, with some studies even indicating that these values are stronger in rural areas. We, therefore, conducted interviews and implemented a qualitative investigation and analysis aimed at elucidating ideals relating to the medical environment among the Kingdom’s urban and rural citizens.

Methods

The study targeted Thai citizens residing in urban and rural areas. The city of Khon Kaen, located in Khon Kaen Province in northeastern Thailand, was selected as the urban area for the study. We selected Donyang village, located in the same province, as the rural study area. In July 2014, we conducted semi-structured group interviews, applying the Constructivist Grounded Theory (CGT) analytical approach.

Results

We interviewed ten people in Khon Kaen (the urban area) and seven people from Donyang village (the rural area). Five major and distinctive themes emerged from the interviews. These were: locally appropriate standards of medical care, support for local lifestyles, satisfaction with local medical personnel, healthy lifestyles that do not rely on medical services, and desire for regional autonomy/desire to serve the region in terms of medical care. All of these themes were evident in both study areas. Thus, rather than relying on advanced medical services, both urban and rural Thai citizens expressed the desire to continue living within communities (considered as “families”), contributing to them, and tending to all of their health care needs within their communities.

Conclusions

This study revealed five common themes relating to forms of medical care regarded as ideal among urban and rural citizens of Thailand. Its findings could potentially have important implications for areas characterized by urban–rural inequities relating to the accessibility and utilization of medical services.

Analysis of the equity of emergency medical services: a cross-sectional survey in Chongqing city

Background

Due to reform of the economic system and the even distribution of available wealth, emergency medical services (EMS) experienced greater risks in equity. This study aimed to assess the equity of EMS needs, utilisation, and distribution of related resources, and to provide evidence for policy-makers to improve such services in Chongqing city, China.

Methods

Five emergency needs variables (mortality rate of maternal, neonatal, cerebrovascular, cardiovascular, injury and poisoning) from the death surveillance, and two utilisation variables (emergency room visits and rate of utilisation) were collected from Chongqing Health Statistical Year Book 2008 to 2012. We used a concentration index (CI) to assess equality in the distribution of needs and utilisation among three areas with different per-head gross domestic product (GDP). In each area, we randomly chose two districts as sample areas and selected all the medical institutions with emergency services as subjects. We used the Gini coefficient (G) to measure equity in population and geographic distribution of facilities and human resources related EMS.

Results

Maternal-caused (CI: range −0.213 to −0.096) and neonatal-caused (CI: range −0.161 to −0.046)deaths declined in 2008–12, which focusing mainly on the less developed area. The maternal deaths were less equitably distributed than neonatal, and the gaps between areas gradually become more noticeable. For cerebrovascular (CI: range 0.106 to 0.455), cardiovascular (CI: range 0.101 to 0.329), injury and poisoning (CI: range 0.001 to 0.301) deaths, we documented a steady improvement of mortality; the overall equity of these mortalities was lower than those of maternal and neonatal mortalities, but distinct decreases were seen over time. The patients in developed area were more likely to use EMS (CI: range 0.296 to 0.423) than those in less developed area, and the CI increased over the 5-year period, suggesting that gaps in equity were increasing. The population distribution of facilities, physicians and nurses (G: range 0.2 to 0.3) was relatively equitable; the geographic distribution (G: range 0.4 to 0.5) showed a big gap between areas.

Conclusions

In Chongqing city, equity of needs, utilization, and resources allocation of EMS is low, and the provision of such services has not met the needs of patients. To narrow the gap of equity, improvement in the capability of EMS to decrease cerebrovascular, cardiovascular, injury and poisoning cases, should be regarded as a top priority. In poor areas, allocation of facilities and human resources needs to be improved, and the economy should also be enhanced.

Immunization Equity

Health inequities are the unjust differences in health among different social groups. Unfortunately, inequities are the norm, both in terms of health status and access to, and use of, health services. Childhood immunizations reduce the incidence of vaccine-preventable diseases and represent a cost-effective way to foster health equity. This paper reflects a 2015 review of data from surveys conducted in developing countries from 2005 to 2011 that show significant inequities in immunization coverage and discusses several initiatives currently underway (including Gavi, the Vaccine Alliance) that are directed at increasing childhood immunizations or reducing or abolishing overall health inequities. These initiatives have already had a significant impact on disease burden and childhood mortality and give rise to optimism that health disparities may further be reduced and health equity achieved as a result of investments made in immunization.

Equity in maternal health care service utilization: a systematic review for developing countries

OBJECTIVES

The objective was to explore progress of equity in the utilization of maternal health care services in developing countries since maternal care is a crucial factor in reducing maternal mortality, which is targeted by the Millennium Development Goal 5.

METHODS

A systematic review of quantitative studies was done. PubMed Central, Web of Science, and Science Direct databases were searched for peer-reviewed and English-language articles published between 2005 and 2015.

RESULTS

Thirty-six articles were included in the review. The results reveal the lack of equity in the utilization of maternal health care in developing countries. Thirty-three out of 36 studies found evidence supporting severe inequities while three studies found evidence of equity or at least improvement in terms of equity.

CONCLUSIONS

Most of the literature devoted to utilization of maternal health care generally provides information on the level of maternal care used and ignore the equity problem. Research in this area should focus not only on the level of maternal care used but also on the most disadvantaged segments of the population in terms of utilization of maternal care in order to reach the set targets.

Decomposing socioeconomic inequality in child vaccination: results from Ireland

BACKGROUND

There is limited knowledge of the extent of or factors underlying inequalities in uptake of childhood vaccination in Ireland. This paper aims to measure and decompose socioeconomic inequalities in childhood vaccination in the Republic of Ireland.

METHODS

The analysis was performed using data from the first wave of the Growing Up in Ireland survey, a nationally representative survey of the carers of over 11,000 nine-month old babies collected in 2008 and 2009. Multivariate analysis was conducted to explore the child and parental factors, including socioeconomic factors that were associated with non-vaccination of children. A concentration index was calculated to measure inequality in childhood vaccination. Subsequent decomposition analysis identified key factors underpinning observed inequalities.

RESULTS

Overall the results confirm a strong socioeconomic gradient in childhood vaccination in the Republic of Ireland. Concentration indices of vaccination (CI=-0.19) show a substantial pro-rich gradient. Results from the decomposition analysis suggest that a substantial proportion of the inequality is explained by household level variables such as socioeconomic status, household structure, income and entitlement to publicly funded care (29.9%, 24% 30.6% and 12.9% respectively). Substantial differences are also observed between children of Irish mothers and immigrant mothers from developing countries.

CONCLUSIONS

Vaccination was less likely in lower than in higher income households. Access to publicly funded services was an important factor in explaining inequalities.

Measuring and decomposing the inequality of maternal health services utilization in western rural China

BACKGROUND

To measure socioeconomic inequalities in maternal health services in rural western China and to analyze the determinants' contributions of inequalities.

STUDY DESIGN

a cross-sectional study.

METHODS

The data utilized in this study were obtained from a cross-sectional study from 10 provinces in rural Western China in 2005. Wealth index of household socioeconomic status was developed by using principle component analysis. Concentration index, concentration curve and decomposition of the concentration index were employed to measure socioeconomic inequality in maternal health services utilization.

RESULTS

For more than four times prenatal visits, the concentration index was 0.0605 (95% CI: 0.0603, 0.0607). The concentration index of hospital delivery was 0.0230 (95% CI: 0.0210, 0.0240) and the concentration index of more than 2 times postnatal visits was 0.0842 (95% CI: 0.0836, 0.0847). Han ethnicity woman, particularly in conjunction with high school education and rich wealth status, was the main contributor to inequality in maternal health services utilization.

CONCLUSIONS

There is a strong pro-rich inequality of maternal health services in rural western China. This study suggests that an effective way to reduce the inequality is not only to narrow the gap of income between the rich and poor, but focus education on ethnic minority woman in rural remote areas.

Improving women's health through universal health coverage

Jonathan Quick and colleagues discuss how women's health world-wide can be improved through universal health coverage.

Safe Delivery Posts: an intervention to provide equitable childbirth care services to vulnerable groups in Zahedan, Iran

BACKGROUND

Recently, there has been a shift towards alternative childbirth services to increase access to skilled care during childbirth.

OBJECTIVE

This study aims to assess the past 10 years of experience of the first Safe Delivery Posts (SDPs) established in Zahedan, Iran to determine the number of deliveries and the intrapartum transfer rates, and to examine the reasons why women choose to give birth at a Safe Delivery Post and not in one of the four large hospitals in Zahedan.

DESIGN

A mixed-methods research strategy was used for this study. In the quantitative phase, an analysis was performed on the existing data that are routinely collected in the health-care sector. In the qualitative phase, a grounded theory approach was used to collect and analyse narrative data from in-depth interviews with women who had given birth to their children at the Safe Delivery Posts.

SETTING

Women were selected from two Safe Delivery Posts in Zahedan city in southeast Iran.

PARTICIPANTS

Nineteen mothers who had given birth in the Safe Delivery Posts were interviewed.

FINDINGS

During the 10-year period, 22,753 low-risk women gave birth in the Safe Delivery Posts, according to the records. Of all the women who were admitted to the Safe Delivery Posts, on average 2.1% were transferred to the hospital during labour or the postpartum period. Three key categories emerged from the analysis: barriers to hospital use, opposition to home birth and finally, reasons for choosing the childbirth care provided by the SDPs.

KEY CONCLUSION AND IMPLICATIONS FOR PRACTICE

Implementing a model of midwifery care that offers the benefits of modern medical care and meets the needs of the local population is feasible and sustainable. This model of care reduces the cost of giving birth and ensures equitable access to care among vulnerable groups in Zahedan.

Maternal health care utilization in Viet Nam: increasing ethnic inequity

OBJECTIVE

To investigate changes that took place between 2006 and 2010 in the inequity gap for antenatal care attendance and delivery at health facilities among women in Viet Nam.

METHODS

Demographic, socioeconomic and obstetric data for women aged 15-49 years were extracted from Viet Nam's Multiple Indicator Cluster Survey for 2006 (MICS3) and 2010-2011 (MICS4). Multivariate logistic regression was performed to determine if antenatal care attendance and place of delivery were significantly associated with maternal education, maternal ethnicity (Kinh/Hoa versus other), household wealth and place of residence (urban versus rural). These independent variables correspond to the analytical framework of the Commission on Social Determinants of Health.

FINDINGS

Large discrepancies between urban and rural populations were found in both MICS3 and MICS4. Although antenatal care attendance and health facility delivery rates improved substantially between surveys (from 86.3 to 92.1% and from 76.2 to 89.7%, respectively), inequities increased, especially along ethnic lines. The risk of not giving birth in a health facility increased significantly among ethnic minority women living in rural areas. In 2006 this risk was nearly five times higher than among women of Kinh/Hoa (majority) ethnicity (odds ratio, OR: 4.67; 95% confidence interval, CI: 2.94-7.43); in 2010-2011 it had become nearly 20 times higher (OR: 18.8; 95% CI: 8.96-39.2).

CONCLUSION

Inequity in maternal health care utilization has increased progressively in Viet Nam, primarily along ethnic lines, and vulnerable groups in the country are at risk of being left behind. Health-care decision-makers should target these groups through affirmative action and culturally sensitive interventions.

Inequalities in reproductive, maternal, newborn and child health in Vietnam: a retrospective study of survey data for 1997-2006

Background

Vietnam has achieved considerable success in economic development, poverty reduction, and health over a relatively short period of time. However, there is concern that inequalities in health outcomes and intervention coverage are widening. This study explores if inequalities in reproductive, maternal, newborn and child health and nutrition changed over time in Vietnam in 1997–2006, and if inequalities were different depending on the type of stratifying variable used to measure inequalities and on the type of outcome studied.

Methods

Using data from four nationally representative household surveys conducted in 1997–2006, we study inequalities in reproductive, maternal, newborn and child health and nutrition outcomes and intervention coverage by computing concentration indices by living standards, maternal education, ethnicity, region, urban/rural residence, and sex of child.

Results

Inequalities in maternal, newborn and child health persisted in 1997–2006. Inequalities were largest by living standards, but not trivial by the other stratifying variables. Inequalities in health outcomes generally increased over time, while inequalities in intervention coverage generally declined. The most equitably distributed interventions were family planning, exclusive breastfeeding, and immunizations. The most inequitably distributed interventions were those requiring multiple service contacts, such as four or more antenatal care visits, and those requiring significant support from the health system, such as skilled birth attendance.

Conclusions

Three main policy implications emerge. First, persistent inequalities suggest the need to address financial and other access barriers, for example by subsidizing health care for the poor and ethnic minorities and by support from other sectors, for example in strengthening transportation networks. This should be complemented by careful monitoring and evaluation of current program design and implementation to ensure effective and efficient use of resources. Second, greater inequalities for interventions that require multiple service contacts imply that inequalities could be reduced by strengthening information and service provision by community and village health workers to promote and sustain timely care-seeking. Finally, larger inequalities for interventions that require a fully functioning health system suggest that investments in health facilities and human resources, particularly in areas that are disproportionately inhabited by the poor and ethnic minorities, may contribute to reducing inequalities.

Inequality in oral health-care utilisation exists among older Thais despite a universal coverage policy

AIM

To assess socioeconomic-related inequality in oral health-care utilisation among older Thais.

METHOD

The data on 8951 and 11,402 older Thais (≥60 years) from national representative Thailand Health and Welfare Surveys (HWS) of 2003 and 2009, respectively, were analysed. Descriptive analyses were performed on oral health-care utilisation, and a concentration index (CI) quantified the extent of socioeconomic-related inequality in oral health-care utilisation.

RESULTS

Analyses indicated that socioeconomic-related inequalities in oral health-care utilisation among older Thais existed, and tended to favour those of higher socioeconomic status. However, the older poor were more likely to utilise oral health care at public facilities, particularly primary care facilities, than those of higher socioeconomic status.

CONCLUSION

Despite universal coverage policy, socioeconomic-related inequalities in oral health-care utilisations exist among the older Thais. To alleviate these, strengthening the primary health-care system deserves particular attention.

The comparative cost-effectiveness of an equity-focused approach to child survival, health, and nutrition: a modelling approach

Progress on child mortality and undernutrition has seen widening inequities and a concentration of child deaths and undernutrition in the most deprived communities, threatening the achievement of the Millennium Development Goals. Conversely, a series of recent process and technological innovations have provided effective and efficient options to reach the most deprived populations. These trends raise the possibility that the perceived trade-off between equity and efficiency no longer applies for child health--that prioritising services for the poorest and most marginalised is now more effective and cost effective than mainstream approaches. We tested this hypothesis with a mathematical-modelling approach by comparing the cost-effectiveness in terms of child deaths and stunting events averted between two approaches (from 2011-15 in 14 countries and one province): an equity-focused approach that prioritises the most deprived communities, and a mainstream approach that is representative of current strategies. We combined some existing models, notably the Marginal Budgeting for Bottlenecks Toolkit and the Lives Saved Tool, to do our analysis. We showed that, with the same level of investment, disproportionately higher effects are possible by prioritising the poorest and most marginalised populations, for averting both child mortality and stunting. Our results suggest that an equity-focused approach could result in sharper decreases in child mortality and stunting and higher cost-effectiveness than mainstream approaches, while reducing inequities in effective intervention coverage, health outcomes, and out-of-pocket spending between the most and least deprived groups and geographic areas within countries. Our findings should be interpreted with caution due to uncertainties around some of the model parameters and baseline data. Further research is needed to address some of these gaps in the evidence base. Strategies for improving child nutrition and survival, however, should account for an increasing prioritisation of the most deprived communities and the increased use of community-based interventions.

Universal access: making health systems work for women

Universal coverage by health services is one of the core obligations that any legitimate government should fulfil vis-à-vis its citizens. However, universal coverage may not in itself ensure universal access to health care. Among the many challenges to ensuring universal coverage as well as access to health care are structural inequalities by caste, race, ethnicity and gender. Based on a review of published literature and applying a gender-analysis framework, this paper highlights ways in which the policies aimed at promoting universal coverage may not benefit women to the same extent as men because of gender-based differentials and inequalities in societies. It also explores how 'gender-blind' organisation and delivery of health care services may deny universal access to women even when universal coverage has been nominally achieved. The paper then makes recommendations for addressing these.