1
|
Kibret GD, Demant D, Dawson A, Hayen A. Spatial patterns of maternal and neonatal continuum of care use and its correlations with women's empowerment. BMC Health Serv Res 2024; 24:1018. [PMID: 39227927 PMCID: PMC11373502 DOI: 10.1186/s12913-024-11453-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 08/19/2024] [Indexed: 09/05/2024] Open
Abstract
BACKGROUND The continuum of care (CoC) in maternal health refers to the continuity of individual reproductive health care across the antenatal, intrapartum, and postnatal periods. The CoC is an indicator of the quality of maternal and newborn health outcomes and women's empowerment is crucial to improving maternal and neonatal health service access and utilisation. OBJECTIVE To examine the spatial patterns of continuum of care use for maternal and neonatal health services and its correlation with women's empowerment. METHODS We analysed data from the Ethiopian Demographic and Health Surveys (EDHS) of 2011 and 2016. All women aged 15-49 who had live births in the preceding five years of the DHS surveys were included in the analysis. We measured the continuum of care using the modified co-coverage index (CoCI), which consisted of six indicators. Women's empowerment was assessed using a validated survey-based Women's Empowerment (SWPER) index. We used the Getis-Ord-Gi* spatial analysis tool to portray locations with clusters of CoC service use and spatial correlations between CoC use and women empowerment. RESULTS None of the newborn-mother pairs in the 2011 survey received the entire continuum of care and only 2.5% of newborn-mother pairs received the full range of continuum of care services in the 2016 survey. In 2016, 6.9% of mother-newborn pairs received the basic CoC services (four or more antenatal care [ANC] visits, skilled birth attendance [SBA], and postnatal care [PNC]), and no mother-newborn pair received all three services at the same time in 2011. The Amhara, Afar, and Somali regional states had the least CoC service use in both surveys. There was a positive spatial correlation between CoC use and women's empowerment domains. CONCLUSION Our analysis showed that the use of four or more ANC visits, SBS, newborn PNC, Bacillus Calmette-Guérin (BCG) vaccine uptake, and tetanus toxoid protection at birth were low in Ethiopia. Women empowerment domains were found to have a positive spatial correlation with CoC services use. To improve and preserve continuity of care, it is critical to leverage every maternal health facility encounter to encourage sustained service usage at each step of the continuum. Government policies should prioritise women's empowerment and raise public awareness of maternity services.
Collapse
Affiliation(s)
- Getiye Dejenu Kibret
- Department of Public Health, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia.
- School of Public Health, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia.
| | - Daniel Demant
- School of Public Health, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
- School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
| | - Angela Dawson
- School of Public Health, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
| | - Andrew Hayen
- School of Public Health, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
| |
Collapse
|
2
|
Baye K, Laillou A, Chitekwe S. Co-coverage of reproductive, maternal, newborn and child health interventions shows wide inequalities and is associated with child nutritional outcomes in Ethiopia (2005-2019). MATERNAL & CHILD NUTRITION 2024; 20 Suppl 5:e13452. [PMID: 36319604 PMCID: PMC11258776 DOI: 10.1111/mcn.13452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 10/13/2022] [Accepted: 10/17/2022] [Indexed: 02/17/2024]
Abstract
The health system is the primary vehicle for the delivery of nutrition-specific interventions that aim to reduce maternal and child malnutrition. The integration of nutrition interventions into existing health interventions is promising, but to ensure that no one is left behind requires that access to essential health services is equitably distributed. This study aims to assess trends and socioeconomic inequalities in coverage of reproductive, maternal, newborn and child health (RMNCH) and assess its association with child nutritional outcomes in Ethiopia. Using the Ethiopian Demographic and Health Survey (2005, 2011, 2016, and 2019), we estimated the coverage of RMNCH interventions in Ethiopia using the co-coverage index, which is a count of the number of interventions accessed. We assessed the trend and inequalities in co-coverage and evaluated its association with child nutritional outcomes like stunting, wasting, and minimum dietary diversity (MDD). The national co-coverage index has shown a significant increase over the 2005-2019 period. However, all of the RMNCH interventions constituting the co-coverage index showed a pro-rich and pro-urban distribution (p < 0.05). The highest inequality, based on the slope index of inequality (SII), was observed for skilled assistance during delivery (SII: 80.4%), followed by access to an improved source of drinking water (SII: 62.6%), and antenatal care visits (SII: 55.5%). The low coverage in RMNCH and the observed inequality were associated with stunting, wasting, and MDD. Reducing socioeconomic inequality in RMNCH is key to achieve the health, nutrition and equity-related goals of the Sustainable Development Goals.
Collapse
Affiliation(s)
- Kaleab Baye
- Center for Food Science and NutritionAddis Ababa UniversityAddis AbabaEthiopia
- Research Center for Inclusive Development in Africa (RIDA)Addis AbabaEthiopia
| | | | | |
Collapse
|
3
|
S R, Neethi Mohan V, Vaidyanathan G, Dash U, Muraleedharan VR. Wealth and education-related inequalities in the utilisation of reproductive, maternal, newborn, and child health interventions within scheduled tribes in India: an analysis of Odisha and Jharkhand. BMC Public Health 2024; 24:1605. [PMID: 38886705 PMCID: PMC11181544 DOI: 10.1186/s12889-024-18857-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 05/15/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND The utilisation of Reproductive, Maternal, Newborn and Child Health (RMNCH) services remains lower among the Scheduled Tribes (ST) in India than among the rest of the country's population. The tribal population's poorest and least-educated households are further denied access to RMNCH care due to the intersection of their social status, wealth, and education levels. The study analyses the wealth- and education-related inequalities in the utilisation of RMNCH services within the ST population in Odisha and Jharkhand. METHODOLOGY We have constructed two summary measures, namely, the Co-coverage indicator and a modified Composite Coverage Index (CC), to determine wealth- and education-related inequalities in the utilisation of RMNCH indicators within the ST population in Odisha and Jharkhand. The absolute and relative inequalities with respect to wealth and education within the ST population are estimated by employing the Slope Index of Inequality (SII) and the Relative Index of Inequality (RII). RESULTS The results of the study highlight that access to RMNCH services is easier for women who are better educated and belong to wealthier households. The SII and RII values in the co-coverage indicator and modified CCI exhibit an increase in wealth-related inequalities in Odisha between NFHS-4 (2015-16) and NFHS-5 (2019-21) whereas in Jharkhand, the wealth- and education-related absolute and relative inequalities present a reduction between 2016 and 2021. Among the indicators, utilisation of vaccination was high, while the uptake of Antenatal Care Centre Visits and Vitamin A supplementation should be improved. INTERPRETATION The study results underscore the urgent need of targeted policies and interventions to address the inequalities in accessing RMNCH services among ST communities. A multi-dimensional approach that considers the socioeconomic, cultural and geographical factors affecting healthcare should be adopted while formulating health policies to reduce inequalities in access to healthcare.
Collapse
Affiliation(s)
- Rekha S
- Department of Humanities and Social Sciences (DoHSS), Indian Institute of Technology (IIT), Madras, India.
| | - Varshini Neethi Mohan
- Department of Humanities and Social Sciences (DoHSS), Indian Institute of Technology (IIT), Madras, India
| | - Girija Vaidyanathan
- Department of Humanities and Social Sciences (DoHSS), Indian Institute of Technology (IIT), Madras, India
| | - Umakant Dash
- Department of Humanities and Social Sciences (DoHSS), Indian Institute of Technology (IIT), Madras, India
- Institute of Rural Management Anand, Anand, Gujarat, India
| | - V R Muraleedharan
- Department of Humanities and Social Sciences (DoHSS), Indian Institute of Technology (IIT), Madras, India
| |
Collapse
|
4
|
Amouzou A, Melesse DY, Wehrmeister FC, Ferreira LZ, Jiwani SS, Kassegne S, Maïga A, Faye CM, Ca T, Boerma T. Erosion of the Capital City Advantage in Child Survival and Reproductive, Maternal, Newborn, and Child Health Intervention Coverage in Sub-Saharan Africa. J Urban Health 2024:10.1007/s11524-023-00820-0. [PMID: 38767766 DOI: 10.1007/s11524-023-00820-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/08/2023] [Indexed: 05/22/2024]
Abstract
The place of residence is a major determinant of RMNCH outcomes, with rural areas often lagging in sub-Saharan Africa. This long-held pattern may be changing given differential progress across areas and increasing urbanization. We assessed inequalities in child mortality and RMNCH coverage across capital cities and other urban and rural areas. We analyzed mortality data from 163 DHS and MICS in 39 countries with the most recent survey conducted between 1990 and 2020 and RMNCH coverage data from 39 countries. We assessed inequality trends in neonatal and under-five mortality and in RMNCH coverage using multilevel linear regression models. Under-five mortality rates and RMNCH service coverage inequalities by place of residence have reduced substantially in sub-Saharan Africa, with rural areas experiencing faster progress than other areas. The absolute gap in child mortality between rural areas and capital cities and that between rural and other urban areas reduced respectively from 41 and 26 deaths per 1000 live births in 2000 to 23 and 15 by 2015. Capital cities are losing their primacy in child survival and RMNCH coverage over other urban areas and rural areas, especially in Eastern Africa where under-five mortality gap between capital cities and rural areas closed almost completely by 2015. While child mortality and RMNCH coverage inequalities are closing rapidly by place of residence, slower trends in capital cities and urban areas suggest gradual erosion of capital city and urban health advantage. Monitoring child mortality and RMNCH coverage trends in urban areas, especially among the urban poor, and addressing factors of within urban inequalities are urgently needed.
Collapse
Affiliation(s)
- Agbessi Amouzou
- Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA.
| | - Dessalegn Y Melesse
- Institute for Global Public Health, Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Fernando C Wehrmeister
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
| | - Leonardo Z Ferreira
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
| | - Safia S Jiwani
- Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | | | - Abdoulaye Maïga
- Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Cheikh M Faye
- African Population and Health Research Center, Dakar, Senegal
| | - Tome Ca
- West African Health Organization, Bobo-Dioulasso, Burkina Faso
| | - Ties Boerma
- Institute for Global Public Health, Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| |
Collapse
|
5
|
Negash WD, Asmamaw DB, Wassie GT, Azene AG, Eshetu HB, Terefe B, Muchie KF, Bantie GM, Bogale KA, Belachew TB. Less than one in four mothers get quality intrapartum health care services in Ethiopia. Sci Rep 2024; 14:4194. [PMID: 38378838 PMCID: PMC10879093 DOI: 10.1038/s41598-024-54506-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 02/13/2024] [Indexed: 02/22/2024] Open
Abstract
Intrapartum care is a platform of comprehensive healthcare for pregnant women that is designed to improve birth outcomes for mother and child. However, complications during the intrapartum period continued to be the leading cause of death for women of reproductive age and newborns. Therefore, the aim of this study was to assess the prevalence of quality of intrapartum care and its associated factors among mothers in Ethiopia. A community based cross sectional study was conducted among 4469 mothers who gave birth in the last 2 years. Quality of intrapartum care was analyzed based on the assessment of health facility delivery, skilled birth attendants and early initiations of breast-feeding. Stata version 14 software was used for data cleaning and analysis. A mixed effect multilevel logistic regression was conducted to determine factors associated with quality of intrapartum care. An adjusted odds ratio with 95% confidence interval and a P value of less than or equal to 0.05 was used for the identification of both individual and community level factors. Overall, the prevalence of quality intrapartum care in Ethiopia was 23.8% (95% CI 22.6, 25.13). Primary education (AOR = 1.46, 95% CI = 1.14, 1.88), rich household class (AOR = 1.48, 95% CI = 1.10, 1.98), history of ANC (AOR = 2.91, 95% CI = 2.18, 3.86), perceived distance to the health facility as not a big issue (AOR = 1.63, 95% CI = 1.30, 2.05), urban residence (AOR = 2.97, 95% CI = 1.93, 5.09), Tigray region (AOR = 5.01, 95% CI = 1.25, 20.59), community level poverty (AOR = 0.63, 95% CI = 0.41, 0.97), and having 2-4 children (AOR = 0.74, 95% CI = 0.56, 0.97) were significantly associated with quality of intrapartum care. The finding conclude that less than one in four mothers received good quality intrapartum care. In order to optimize the quality of intrapartum care, the government should empower women through extensive education. It is also recommended for the Ministry of Health to evaluate the health facilities and community health workers to increase coverage of ANC and provide financial assistance to rural residents and the poor household class.
Collapse
Affiliation(s)
- Wubshet Debebe Negash
- Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, PO Box 196, Gondar, Ethiopia.
| | - Desale Bihonegn Asmamaw
- Department of Reproductive Health, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, PO Box 196, Gondar, Ethiopia
| | - Gizachew Tadesse Wassie
- Department of Epidemiology and Biostatistics, School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Abebaw Gedef Azene
- Department of Epidemiology and Biostatistics, School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Habitu Birhan Eshetu
- Department of Health Promotion and Health Behavior, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, PO Box 196, Gondar, Ethiopia
| | - Bewuketu Terefe
- Department of Community Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, PO Box 196, Gondar, Ethiopia
| | - Kindie Fentahun Muchie
- Department of Epidemiology and Biostatistics, School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | | | - Kassawmar Angaw Bogale
- Department of Epidemiology and Biostatistics, School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Tadele Biresaw Belachew
- Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, PO Box 196, Gondar, Ethiopia
| |
Collapse
|
6
|
Negero MG, Sibbritt D, Dawson A. Women's utilisation of quality antenatal care, intrapartum care and postnatal care services in Ethiopia: a population-based study using the demographic and health survey data. BMC Public Health 2023; 23:1174. [PMID: 37337146 DOI: 10.1186/s12889-023-15938-8] [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: 05/06/2022] [Accepted: 05/19/2023] [Indexed: 06/21/2023] Open
Abstract
OBJECTIVE This study sought to investigate the level and determinants of receiving quality antenatal care (ANC), intrapartum care, and postnatal care (PNC) services by women in Ethiopia. The quality of care a woman receives during ANC, intrapartum care, and PNC services affects the health of the woman and her child and her likelihood of seeking care in the future. METHODS Data from the nationally representative Ethiopia Mini Demographic and Health Survey 2019 were analysed for 5,527 mothers who gave birth within five years preceding the survey. We defined quality ANC as having: blood pressure measurement, urine and blood tests, informed of danger signs, iron supplementation, and nutritional counselling during ANC services; quality intrapartum care as having: a health facility birth, skilled birth assistance, and a newborn put to the breast within one hour of birth during intrapartum care services; and quality PNC as having: PNC within two days; cord examination; temperature measurement, and counselling on danger signs and breastfeeding of the newborn; and healthcare provider's observation of breastfeeding during PNC services. We used multilevel mixed-effects logistic regression analyses specifying three-level models: a woman/household, a cluster, and an administrative region to determine predictors of each care quality. The analyses employed sampling weights and were adjusted for sampling design. RESULTS Thirty-six percent (n = 1,048), 43% (n = 1,485), and 21% (n = 374) women received quality ANC, intrapartum care and PNC services, respectively. Private healthcare facilities provided higher-quality ANC and PNC but poor-quality intrapartum care, compared to public health facilities. Having four or more ANC visits, commencing ANC during the first trimester, and higher women's education levels and household wealth indices were positive predictors of quality ANC use. Government health posts were less likely to provide quality ANC. Wealthier, urban-residing women with education and four or more ANC contacts were more likely to receive quality intrapartum care. Women who received quality ANC and skilled birth assistance were more likely to receive quality PNC. Teenage mothers were more likely to receive quality intrapartum care, but were less likely to receive quality PNC than mothers aged 20-49. CONCLUSIONS We recommend standardizing the contents of ANC provided in all healthcare facilities; and promoting early and four or more ANC contacts, effectiveness, sensitivity and vigilance of care provided to teenage mothers, and women's education and economic empowerment.
Collapse
Affiliation(s)
- Melese Girmaye Negero
- School of Public Health, Institute of Health Sciences, Wollega University, Nekemte, Ethiopia.
- School of Public Health, Faculty of Health, University of Technology Sydney, Sydney, Australia.
| | - David Sibbritt
- School of Public Health, Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Angela Dawson
- School of Public Health, Faculty of Health, University of Technology Sydney, Sydney, Australia
| |
Collapse
|
7
|
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.
Collapse
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
| |
Collapse
|
8
|
Arhin K, Oteng-Abayie EF, Novignon J. Assessing the efficiency of health systems in achieving the universal health coverage goal: evidence from Sub-Saharan Africa. HEALTH ECONOMICS REVIEW 2023; 13:25. [PMID: 37129773 PMCID: PMC10152035 DOI: 10.1186/s13561-023-00433-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 03/27/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVE Universal health coverage (UHC) is a major pathway to save many people from catastrophic and impoverishing healthcare spending and address the inequality in health and healthcare. The objective of this paper is to assess the efficiency with which health systems in sub-Saharan Africa (SSA) are utilizing healthcare resources to progress towards achieving the UHC goal by 2030. METHODS The study followed the guidelines proposed by the World Health Organization (WHO) and World Bank joint UHC monitoring framework and the computational operationalization approach proposed by Wagstaff et al. (2015) to estimate the UHC index for each of the 30 selected SSA countries. The bootstrapping output-oriented data envelopment analysis (DEA) was used to estimate the bias-corrected technical efficiency scores and examine the environmental factors that influence health system efficiency. RESULTS The estimated UHC levels ranged from a minimum of 52% to a maximum of 81% [Formula: see text] with a median coverage of 66%. The average bias-corrected efficiency score was 0.81 [Formula: see text]. The study found that education, governance quality, public health spending, external health funding, and prepayment arrangements that pool funds for health had a positive significant effect on health system efficiency in improving UHC, while out-of-pocket payment had a negative impact. CONCLUSION The results show that health systems in SSA can potentially enhance UHC levels by at least 19% with existing healthcare resources if best practices are adopted. Policymakers should aim at improving education, good governance, and healthcare financing architecture to reduce out-of-pocket payments and over-reliance on donor funding for healthcare to achieve UHC.
Collapse
Affiliation(s)
- Kwadwo Arhin
- Department of Economics, Ghana Institute of Management and Public Administration, Accra, Ghana
| | - Eric Fosu Oteng-Abayie
- Department of Economics, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Jacob Novignon
- Department of Economics, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| |
Collapse
|
9
|
Gebremedhin AF, Dawson A, Hayen A. Determinants of continuum of care for maternal, newborn, and child health services in Ethiopia: Analysis of the modified composite coverage index using a quantile regression approach. PLoS One 2023; 18:e0280629. [PMID: 36662768 PMCID: PMC9858465 DOI: 10.1371/journal.pone.0280629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 01/04/2023] [Indexed: 01/21/2023] Open
Abstract
Maternal and child mortality remain unacceptably high in the Sustainable Development Goals era. Continuum of care has become a key strategy for improving the health of mothers and newborns. Previous research on the continuum of care in Ethiopia is often limited to maternal health services. Maternal and child health services are inseparably linked, and an integrated approach to care is essential. This study assessed the continuum of maternal, newborn, and child health care and associated factors in Ethiopia. The analysis was based on the 2016 Ethiopian Demographic and Health Survey data. We restricted our analysis to women with their most recent children-alive and living with their mother- aged 12-23 months at the time of the survey (n = 1891). The modified composite coverage index, constructed from twelve maternal and child health services, was calculated as an indicator of the continuum of care. Bivariable and multivariable quantile regression were used to analyse the relationship between the predictors and specific quantiles of the composite coverage index. The effect of each variable was examined at the 10th, 25th, 50th, 75th, and 95th quantiles. The results showed that the average composite coverage index value was 39%. The overall completion rate of the continuum of care was low (2%). Four % of the women did not receive any of the services along the continuum of care. Postnatal care for newborns had the lowest coverage (12%). This study provides evidence that factors such as the educational status of women, region, residence, socio-economic status, perceived distance to a health facility, pregnancy intention, mode of delivery, parity, and early antenatal care initiation influence the continuum of care differently across levels of the composite coverage index. The findings call for integrated and targeted strategies that aim to improve the continuum of care considering the determinants.
Collapse
Affiliation(s)
- Aster Ferede Gebremedhin
- Department of Public Health, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
- School of Public Health, University of Technology Sydney, Sydney, Australia
| | - Angela Dawson
- School of Public Health, University of Technology Sydney, Sydney, Australia
| | - Andrew Hayen
- School of Public Health, University of Technology Sydney, Sydney, Australia
| |
Collapse
|
10
|
Ferreira LZ, Utazi CE, Huicho L, Nilsen K, Hartwig FP, Tatem AJ, Barros AJD. Geographic inequalities in health intervention coverage – mapping the composite coverage index in Peru using geospatial modelling. BMC Public Health 2022; 22:2104. [PMID: 36397019 PMCID: PMC9670533 DOI: 10.1186/s12889-022-14371-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 10/14/2022] [Indexed: 11/18/2022] Open
Abstract
Background The composite coverage index (CCI) provides an integrated perspective towards universal health coverage in the context of reproductive, maternal, newborn and child health. Given the sample design of most household surveys does not provide coverage estimates below the first administrative level, approaches for achieving more granular estimates are needed. We used a model-based geostatistical approach to estimate the CCI at multiple resolutions in Peru. Methods We generated estimates for the eight indicators on which the CCI is based for the departments, provinces, and areas of 5 × 5 km of Peru using data from two national household surveys carried out in 2018 and 2019 plus geospatial covariates. Bayesian geostatistical models were fit using the INLA-SPDE approach. We assessed model fit using cross-validation at the survey cluster level and by comparing modelled and direct survey estimates at the department-level. Results CCI coverage in the provinces along the coast was consistently higher than in the remainder of the country. Jungle areas in the north and east presented the lowest coverage levels and the largest gaps between and within provinces. The greatest inequalities were found, unsurprisingly, in the largest provinces where populations are scattered in jungle territory and are difficult to reach. Conclusions Our study highlighted provinces with high levels of inequality in CCI coverage indicating areas, mostly low-populated jungle areas, where more attention is needed. We also uncovered other areas, such as the border with Bolivia, where coverage is lower than the coastal provinces and should receive increased efforts. More generally, our results make the case for high-resolution estimates to unveil geographic inequities otherwise hidden by the usual levels of survey representativeness. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-022-14371-7.
Collapse
|
11
|
Socioeconomic inequalities in the continuum of care across women’s reproductive life cycle in Bangladesh. Sci Rep 2022; 12:15618. [PMID: 36114413 PMCID: PMC9481551 DOI: 10.1038/s41598-022-19888-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 09/06/2022] [Indexed: 11/24/2022] Open
Abstract
We examined the association between socioeconomic status (SES) and continuum of care (CoC) completion rate in maternal, neonatal, and child health among mothers in Bangladesh. We used data from the Bangladesh Demographic Health Survey (BDHS) from 2017 to 2018. Our findings were based on the responses of 1527 married women who had at least one child aged 12 to 23 months at the time of the survey. As a measure of SES, we focused on the standard of living (hereinafter referred to as wealth). The CoC for maternal and child health (MNCH) services is the study's outcome variable. The CoC was calculated using seven MNCH interventions: four or more antenatal care (ANC) visits with a skilled practitioner, delivery by a skilled birth attendant, post-natal care for mothers (PNCM) within two days of giving birth, post-natal care for newborns (PNCM) within two days of birth, immunization, age-appropriate breastfeeding, and maternal current use of modern family planning (FP) methods. Only 18.1% of Bangladeshi women completed all seven MNCH care interventions during the reproductive life span. Participants in the high SES group were 2.30 times (95% confidence interval [CI] 1.61–3.28) more likely than those in the low SES group to have higher composite care index (CCI) scores. Women with secondary or higher secondary education, as well as women who were exposed to mass media at least once a week, women who lived in an urban setting, women who had an intended pregnancy, and women with one parity, are associated with high CCI scores when other sociodemographic variables are considered. The complete CoC for MNCH reveals an extremely low completion rate, which may suggest that Bangladeshi mothers, newborns, and children are not receiving the most out of their present health care. Participants in the high SES group displayed higher CCI values than those in the low SES group, indicating that SES is one of the primary drivers of completion of CoC for MNCH services.
Collapse
|
12
|
Kachoria AG, Mubarak MY, Singh AK, Somers R, Shah S, Wagner AL. The association of religion with maternal and child health outcomes in South Asian countries. PLoS One 2022; 17:e0271165. [PMID: 35819940 PMCID: PMC9275688 DOI: 10.1371/journal.pone.0271165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 06/24/2022] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Theological beliefs play an important role in cultural norms and could impact women's prenatal and postpartum decisions in South Asia, which has a high burden of disease in children and pregnant women. The aim of this study is to identify any associations religion may have in affecting a woman's decision-making ability, and how that in turn affects maternal and child health, at a group level in multiple South Asian countries. STUDY DESIGN Cross-sectional study utilizing secondary data analysis. METHODS We used Demographic and Health Surveys (DHS) between 2014 and 2018 in Afghanistan, Bangladesh, India, Maldives, Myanmar, Nepal, and Pakistan. Not every country's survey asked about religion, so we imputed these results based on Census data. We assessed maternal and child health through a composite coverage index (CCI), which accounts for family planning, attendance of a skilled attendant at birth, antenatal care, BCG vaccinations, 3 doses of diphtheria-tetanus-pertussis vaccine, measles vaccine, oral rehydration therapy, and seeking care if the child has pneumonia. The relationship between religion, women's empowerment, and CCI was assessed through linear regression models. RESULTS The sample included 57,972 mothers who had children aged 12-23 months. CCI is observed to be affected by family income, in addition to religion and country. CCI was higher in Hindus (2.8%, 95% CI: 2.4%, 3.1%) and Buddhists (2.0%, 95% CI: 1.2%, 2.9%) than Muslims. Mother's age, education, income, decision-making autonomy, and attitude towards beatings were all related to CCI. In a model stratified by religion, age, education, and income were significant predictors of CCI for both Muslims and non-Muslims, but were more impactful among Muslims. CONCLUSION Though multiple imputation had to be used to fill in gaps in religion data, this study demonstrates that maternal and child health outcomes continue to be a concern in South Asia, especially for Muslim women. Given the importance of religious beliefs, utilizing a simple indicator, such as the CCI could be helpful for monitoring these outcomes and provides a tangible first step for communities to address gaps in care resulting from disparities in maternal empowerment.
Collapse
Affiliation(s)
- Aparna G. Kachoria
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | | | - Awnish K. Singh
- National Technical Advisory Group on Immunization Secretariat, Ministry of Health and Family Welfare, National Institute of Health and Family Welfare, New Delhi, India
| | - Rachael Somers
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | | | - Abram L. Wagner
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, United States of America
| |
Collapse
|
13
|
Ramadan M, Tappis H, Brieger W. Primary Healthcare Quality in Conflict and Fragility: a subnational analysis of disparities using Population Health surveys. Confl Health 2022; 16:36. [PMID: 35706012 PMCID: PMC9202222 DOI: 10.1186/s13031-022-00466-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 05/24/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Recent global reports highlighted the importance of addressing the quality of care in all settings including fragile and conflict-affected situations (FCS), as a central strategy for the attainment of sustainable development goals and universal health coverage. Increased mortality burden in FCS reflects the inability to provide routine services of good quality. There is also paucity of research documenting the impact of conflict on the quality of care within fragile states including disparities in service delivery. This study addresses this measurement gap by examining disparities in the quality of primary healthcare services in four conflict-affected fragile states using proxy indicators. METHODS A secondary analysis of publicly available data sources was performed in four conflict-affected fragile states: Cameroon, the Democratic Republic of Congo, Mali, and Nigeria. Two main databases were utilized: the Demographic Health Survey and the Uppsala Conflict Data Program for information on components of care and conflict events, respectively. Three equity measures were computed for each country: absolute difference, concentration index, and coefficients of mixed-effects logistic regression. Each computed measure was then compared according to the intensity of organized violence events at the neighborhood level. RESULTS Overall, the four studied countries had poor quality of PHC services, with considerable subnational variation in the quality index. Poor quality of PHC services was not only limited to neighborhoods where medium or high intensity conflict was recorded but was also likely to be observed in neighborhoods with no or low intensity conflict. Both economic and educational disparities were observed in individual quality components in both categories of conflict intensity. CONCLUSION Each of the four conflict-affected countries had an overall poor quality of PHC services with both economic and educational disparities in the individual components of the quality index, regardless of conflict intensity. Multi-sectoral efforts are needed to improve the quality of care and disparities in these settings, without a limited focus on sub-national areas where medium or high intensity conflict is recorded.
Collapse
Affiliation(s)
- Marwa Ramadan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
- Department of Community Medicine and Public Health, Alexandria University, Alexandria, Egypt.
| | - Hannah Tappis
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Technical leadership and Innovations Office, Jhpiego, Baltimore, MD, USA
| | - William Brieger
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| |
Collapse
|
14
|
Nguyen PH, Singh N, Scott S, Neupane S, Jangid M, Walia M, Murira Z, Bhutta ZA, Torlesse H, Piwoz E, Heidkamp R, Menon P. Unequal coverage of nutrition and health interventions for women and children in seven countries. Bull World Health Organ 2022; 100:20-29. [PMID: 35017754 PMCID: PMC8722629 DOI: 10.2471/blt.21.286650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 09/25/2021] [Accepted: 10/05/2021] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To examine inequalities and opportunity gaps in co-coverage of health and nutrition interventions in seven countries. METHODS We used data from the most recent (2015-2018) demographic and health surveys of mothers with children younger than 5 years in Afghanistan (n = 19 632), Bangladesh (n = 5051), India (n = 184 641), Maldives (n = 2368), Nepal (n = 3998), Pakistan (n = 8285) and Sri Lanka (n = 7138). We estimated co-coverage for a set of eight health and eight nutrition interventions and assessed within-country inequalities in co-coverage by wealth and geography. We examined opportunity gaps by comparing coverage of nutrition interventions with coverage of their corresponding health delivery platforms. FINDINGS Only 15% of 231 113 mother-child pairs received all eight health interventions (weighted percentage). The percentage of mother-child pairs who received no nutrition interventions was highest in Pakistan (25%). Wealth gaps (richest versus poorest) for co-coverage of health interventions were largest for Pakistan (slope index of inequality: 62 percentage points) and Afghanistan (38 percentage points). Wealth gaps for co-coverage of nutrition interventions were highest in India (32 percentage points) and Bangladesh (20 percentage points). Coverage of nutrition interventions was lower than for associated health interventions, with opportunity gaps ranging from 4 to 54 percentage points. CONCLUSION Co-coverage of health and nutrition interventions is far from optimal and disproportionately affects poor households in south Asia. Policy and programming efforts should pay attention to closing coverage, equity and opportunity gaps, and improving nutrition delivery through health-care and other delivery platforms.
Collapse
Affiliation(s)
- Phuong Hong Nguyen
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, 1201 I Street, NW, Washington DC, 20005, United States of America (USA)
| | - Nishmeet Singh
- International Food Policy Research Institute, New Delhi, India
| | - Samuel Scott
- International Food Policy Research Institute, New Delhi, India
| | - Sumanta Neupane
- International Food Policy Research Institute, Kathmandu, Nepal
| | - Manita Jangid
- International Food Policy Research Institute, New Delhi, India
| | - Monika Walia
- International Food Policy Research Institute, New Delhi, India
| | - Zivai Murira
- United Nations Children’s Fund, Regional Office for South Asia, Kathmandu, Nepal
| | | | - Harriet Torlesse
- United Nations Children’s Fund, Regional Office for South Asia, Kathmandu, Nepal
| | | | - Rebecca Heidkamp
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Purnima Menon
- International Food Policy Research Institute, New Delhi, India
| |
Collapse
|
15
|
Peven K, Day LT, Bick D, Purssell E, Taylor C, Akuze J, Mallick L. Household Survey Measurement of Newborn Postnatal Care: Coverage, Quality Gaps, and Internal Inconsistencies in Responses. GLOBAL HEALTH, SCIENCE AND PRACTICE 2021; 9:737-751. [PMID: 34933972 PMCID: PMC8691891 DOI: 10.9745/ghsp-d-21-00209] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 07/20/2021] [Indexed: 11/17/2022]
Abstract
Reliable measurement of postnatal content of care is currently lacking despite the critical importance of care in this vulnerable period. We found that there is a large quality-coverage gap with missed opportunities for quality care as well as internal inconsistencies in responses to newborn questions. Background: Reliable measurement of newborn postnatal care is essential to understand gaps in coverage and quality and thereby improve outcomes. This study examined gaps in coverage and measurement of newborn postnatal care in the first 2 days of life. Methods: We analyzed Demographic and Health Survey data from 15 countries for 71,366 births to measure the gap between postnatal contact coverage and content coverage within 2 days of birth. Coverage was a contact with the health system in the first 2 days (postnatal check or newborn care intervention), and quality was defined as reported receipt of 5 health worker-provided interventions. We examined internal consistency between interrelated questions regarding examination of the umbilical cord. Results: Reported coverage of postnatal check ranged from 13% in Ethiopia to 78% in Senegal. Report of specific newborn care interventions varied widely by intervention within and between countries. Quality-coverage gaps were high, ranging from 26% in Malawi to 89% in Burundi. We found some internally inconsistent reporting of newborn care. The percentage of women who reported that a health care provider checked their newborn's umbilical cord but responded “no” to the postnatal check question was as high as 16% in Malawi. Conclusion: Reliable measurement of coverage and content of early postnatal newborn care is essential to track progress in improving quality of care. Postnatal contact coverage is challenging to measure because it may be difficult for women to distinguish postnatal care from intrapartum care and it is a less recognizable concept than antenatal care. Co-coverage measures may provide a useful summary of contact and content, reflecting both coverage and an aspect of quality.
Collapse
Affiliation(s)
- Kimberly Peven
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, United Kingdom. .,Maternal and Newborn Health Group, Department of Infectious Disease Epidemiology and Centre for Maternal, Adolescent, Reproductive, & Child Health (MARCH), London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Louise Tina Day
- Maternal and Newborn Health Group, Department of Infectious Disease Epidemiology and Centre for Maternal, Adolescent, Reproductive, & Child Health (MARCH), London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Debra Bick
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | | | - Cath Taylor
- School of Health Sciences, University of Surrey, Guildford, United Kingdom
| | - Joseph Akuze
- Maternal and Newborn Health Group, Department of Infectious Disease Epidemiology and Centre for Maternal, Adolescent, Reproductive, & Child Health (MARCH), London School of Hygiene & Tropical Medicine, London, United Kingdom.,Department of Health Policy, Planning and Management and Centre of Excellence for Maternal, Newborn and Child Health, Makerere University School of Public Health, Kampala, Uganda
| | - Lindsay Mallick
- Department of Family Science, School of Public Health, University of Maryland, College Park, MD, USA.,Avenir Health, Glastonbury, CT, USA
| |
Collapse
|
16
|
Gandhi S, Maharatha TM, Dash U, Babu M. S. Level of inequality and the role of governance indicators in the coverage of reproductive maternal and child healthcare services: Findings from India. PLoS One 2021; 16:e0258244. [PMID: 34767556 PMCID: PMC8589169 DOI: 10.1371/journal.pone.0258244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 09/23/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Diligent monitoring of inequalities in the coverage of essential reproductive, maternal, new-born and child health related (RMNCH) services becomes imperative to smoothen the journey towards Sustainable Development Goals (SDGs). In this study, we aim to measure the magnitude of inequalities in the coverage of RMNCH services. We also made an attempt to divulge the relationship between the various themes of governance and RMNCH indices. METHODS We used National Family Health Survey dataset (2015-16) and Public Affairs Index (PAI), 2016 for the analysis. Two summative indices, namely Composite Coverage Index (CCI) and Co-Coverage (Co-Cov) indicator were constructed to measure the RMNCH coverage. Slope Index of Inequality (SII) and Relative Index of Inequality (RII) were employed to measure inequality in the distribution of coverage of RMNCH. In addition, we have used Spearman's rank correlation matrix to glean the association between governance indicator and coverage indices. RESULTS & CONCLUSIONS Our study indicates an erratic distribution in the coverage of CCI and Co-Cov across wealth quintiles and state groups. We found that the distribution of RII values for Punjab, Tamil Nadu, and West Bengal hovered around 1. Whereas, RII values for Haryana was 2.01 indicating maximum inequality across wealth quintiles. Furthermore, the essential interventions like adequate antenatal care services (ANC4) and skilled birth attendants (SBA) were the most inequitable interventions, while tetanus toxoid and Bacilli Calmette- Guerin (BCG) were least inequitable. The Spearman's rank correlation matrix demonstrated a strong and positive correlation between governance indicators and coverage indices.
Collapse
Affiliation(s)
- Sumirtha Gandhi
- Bengaluru Dr. B.R. Ambedkar School of Economics, Karnataka, India
| | - Tulasi Malini Maharatha
- Department of Humanities and Social Sciences, Indian Institute of Technology, Chennai, India
| | - Umakant Dash
- Department of Humanities and Social Sciences, Indian Institute of Technology, Chennai, India
| | - Suresh Babu M.
- Department of Humanities and Social Sciences, Indian Institute of Technology, Chennai, India
| |
Collapse
|
17
|
Bouilly R, Gatica-Domínguez G, Mesenburg M, Cáceres Ureña FI, Leventhal DGP, Barros AJD, Victora CG, Wehrmeister FC. [Maternal and child health inequalities among migrants: the case of Haiti and the Dominican RepublicDesigualdades na saúde materno-infantil entre migrantes: o caso do Haiti e da República Dominicana]. Rev Panam Salud Publica 2021; 45:e100. [PMID: 34539764 PMCID: PMC8442708 DOI: 10.26633/rpsp.2021.100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 10/19/2020] [Indexed: 11/24/2022] Open
Abstract
Objective To assess coverage and inequalities in maternal and child health interventions among Haitians, Haitian migrants in the Dominican Republic and Dominicans. Methods Cross-sectional study using data from nationally representative surveys carried out in Haiti in 2012 and in the Dominican Republic in 2014. Nine indicators were compared: demand for family planning satisfied with modern methods, antenatal care, delivery care (skilled birth attendance), child vaccination (BCG, measles and DPT3), child case management (oral rehydration salts for diarrhea and careseeking for suspected pneumonia), and the composite coverage index. Wealth was measured through an asset-based index, divided into tertiles, and place of residence (urban or rural) was established according to the country definition. Results Haitians showed the lowest coverage for demand for family planning satisfied with modern methods (44.2%), antenatal care (65.3%), skilled birth attendance (39.5%) and careseeking for suspected pneumonia (37.9%), and the highest for oral rehydration salts for diarrhea (52.9%), whereas Haitian migrants had the lowest coverage in DPT3 (44.1%) and oral rehydration salts for diarrhea (38%) and the highest in careseeking for suspected pneumonia (80.7%). Dominicans presented the highest coverage for most indicators, except oral rehydration salts for diarrhea and careseeking for suspected pneumonia. The composite coverage index was 79.2% for Dominicans, 69.0% for Haitian migrants, and 52.6% for Haitians. Socioeconomic inequalities generally had pro-rich and pro-urban pattern in all analyzed groups. Conclusion Haitian migrants presented higher coverage than Haitians, but lower than Dominicans. Both countries should plan actions and policies to increase coverage and address inequalities of maternal health interventions.
Collapse
Affiliation(s)
- Roberta Bouilly
- Universidad Federal de Pelotas Pelotas Brasil Universidad Federal de Pelotas, Pelotas, Brasil
| | | | - Marilia Mesenburg
- Universidad Federal de Pelotas Pelotas Brasil Universidad Federal de Pelotas, Pelotas, Brasil.,Universidad Federal de Ciencias de la Salud Porto Alegre Brasil Universidad Federal de Ciencias de la Salud, Porto Alegre, Brasil
| | - Francisco I Cáceres Ureña
- Universidad Autónoma de Santo Domingo Santo Domingo República Dominicana Universidad Autónoma de Santo Domingo, Santo Domingo, República Dominicana.,Oficina Nacional de Estadística Santo Domingo República Dominicana Oficina Nacional de Estadística, Santo Domingo, República Dominicana
| | - Daniel G P Leventhal
- Universidad Federal de Pelotas Pelotas Brasil Universidad Federal de Pelotas, Pelotas, Brasil
| | - Aluísio J D Barros
- Universidad Federal de Pelotas Pelotas Brasil Universidad Federal de Pelotas, Pelotas, Brasil
| | - Cesar G Victora
- Universidad Federal de Pelotas Pelotas Brasil Universidad Federal de Pelotas, Pelotas, Brasil
| | - Fernando C Wehrmeister
- Universidad Federal de Pelotas Pelotas Brasil Universidad Federal de Pelotas, Pelotas, Brasil
| |
Collapse
|
18
|
Garchitorena A, Miller AC, Cordier LF, Randriamanambintsoa M, Razanadrakato HTR, Randriamihaja M, Razafinjato B, Finnegan KE, Haruna J, Rakotonirina L, Rakotozafy G, Raharimamonjy L, Atwood S, Murray MB, Rich M, Loyd T, Solofomalala GD, Bonds MH. District-level health system strengthening for universal health coverage: evidence from a longitudinal cohort study in rural Madagascar, 2014-2018. BMJ Glob Health 2021; 5:bmjgh-2020-003647. [PMID: 33272943 PMCID: PMC7716667 DOI: 10.1136/bmjgh-2020-003647] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 11/03/2020] [Accepted: 11/10/2020] [Indexed: 12/13/2022] Open
Abstract
Introduction Despite renewed commitment to universal health coverage and health system strengthening (HSS) to improve access to primary care, there is insufficient evidence to guide their design and implementation. To address this, we conducted an impact evaluation of an ongoing HSS initiative in rural Madagascar, combining data from a longitudinal cohort and primary health centres. Methods We carried out a district representative household survey at the start of the HSS intervention in 2014 in over 1500 households in Ifanadiana district, and conducted follow-up surveys at 2 and 4 years. At each time point, we estimated maternal, newborn and child health coverage; economic and geographical inequalities in coverage; and child mortality rates; both in the HSS intervention and control catchments. We used logistic regression models to evaluate changes associated with exposure to the HSS intervention. We also estimated changes in health centre per capita utilisation during 2013 to 2018. Results Child mortality rates decreased faster in the HSS than in the control catchment. We observed significant improvements in care seeking for children under 5 years of age (OR 1.23; 95% CI 1.05 to 1.44) and individuals of all ages (OR 1.37, 95% CI 1.19 to 1.58), but no significant differences in maternal care coverage. Economic inequalities in most coverage indicators were reduced, while geographical inequalities worsened in nearly half of the indicators. Conclusion The results demonstrate improvements in care seeking and economic inequalities linked to the early stages of a HSS intervention in rural Madagascar. Additional improvements in this context of persistent geographical inequalities will require a stronger focus on community health.
Collapse
Affiliation(s)
- Andres Garchitorena
- MIVEGEC, Univ. Montpellier, CNRS, IRD, Montpellier, France .,PIVOT, Ifanadiana, Madagascar
| | - Ann C Miller
- PIVOT, Ifanadiana, Madagascar.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Marius Randriamanambintsoa
- Direction de la Démographie et des Statistiques Sociales, Institut National de la Statistique, Antananarivo, Madagascar
| | - Hery-Tiana R Razanadrakato
- Direction de la Démographie et des Statistiques Sociales, Institut National de la Statistique, Antananarivo, Madagascar
| | | | | | - Karen E Finnegan
- PIVOT, Ifanadiana, Madagascar.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | | | | | - Sidney Atwood
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Megan B Murray
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Rich
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Matthew H Bonds
- PIVOT, Ifanadiana, Madagascar.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
19
|
Mothupi MC, De Man J, Tabana H, Knight L. Development and testing of a composite index to monitor the continuum of maternal health service delivery at provincial and district level in South Africa. PLoS One 2021; 16:e0252182. [PMID: 34033670 PMCID: PMC8148336 DOI: 10.1371/journal.pone.0252182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 05/11/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION The continuum of care is a recommended framework for comprehensive health service delivery for maternal health, and it integrates health system and social determinants of health. There is a current lack of knowledge on a measurement approach to monitor performance on the framework. In this study we aim to develop and test a composite index for assessing the maternal health continuum in a province in South Africa with the possibility of nationwide use. MATERIALS AND METHODS The composite index was computed as a geometric mean of four dimensions of adequacy of the continuum of care. Data was sourced from the district health information system, household surveys and the census. The index formula was tested for robustness when alternative inputs for indicators and standardization methods were used. The index was used to assess performance in service delivery in the North West province of South Africa, as well as its four districts over a five-year period (2013-2017). The index was validated by assessing associations with maternal health and other outcomes. And factor analysis was used to assess the statistical dimensions of the index. RESULTS The provincial level index score increased from 62.3 in 2013 to 74 in 2017, showing general improvement in service delivery over time. The district level scores also improved over time, and our analysis identified areas for performance improvement. These include social determinants of health in some districts, and access and linkages to care in others. The provincial index was correlated with institutional maternal mortality rates (rs = -0.90, 90% CI = (-1.00, -0.25)) and the Human Development Index (r = 0.97, 95% CI = (0.63, 0.99). It was robust to alternative approaches including z-score standardization of indicators. Factor analysis showed three groupings of indicators for the health system and social determinants of health. CONCLUSIONS This study demonstrated the development and testing of a composite index to monitor and assess service delivery on the continuum of care for maternal health. The index was shown to be robust and valid, and identified potential areas for service improvement. A contextualised version can be tested in other settings within and outside of South Africa.
Collapse
Affiliation(s)
- Mamothena Carol Mothupi
- School of Public Health, Faculty of Community and Health Sciences, University of the Western Cape, Cape Town, South Africa
| | - Jeroen De Man
- Department of Primary and Interdisciplinary Care, Centre for General Practice, University of Antwerp, Antwerp, Belgium
| | - Hanani Tabana
- School of Public Health, Faculty of Community and Health Sciences, University of the Western Cape, Cape Town, South Africa
| | - Lucia Knight
- School of Public Health & Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
20
|
Ewerling F, Wehrmeister FC, Victora CG, Raj A, McDougal L, Barros AJD. Is women's empowerment associated with coverage of RMNCH interventions in low- and middle-income countries? An analysis using a survey-based empowerment indicator, the SWPER. J Glob Health 2021; 11:04015. [PMID: 33791094 PMCID: PMC7979155 DOI: 10.7189/jogh.11.04015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Women's empowerment has a strong potential to promote sustainable development. We evaluate the association between women's empowerment and the Composite Coverage Index (CCI), a weighted average of coverage of eight interventions in reproductive, maternal, newborn and child health (RMNCH). We also assess whether these effects are modified by wealth. METHODS We used Demographic and Health Survey data from 62 low- and middle-income countries. Women's empowerment was measured using the three domains (attitude to violence, social independence and decision making) of the survey-based indicator of women's empowerment (SWPER). Analyses followed an ecological design. Meta-regression models were used to account for within-country uncertainty in the CCI. We also carried out meta-regression with wealth quintiles of households as the units of analyses and tested for interaction between wealth and each empowerment domain. RESULTS We found positive associations between the three domains of SWPER and CCI at the country level. One standard deviation change in empowerment increased the CCI by 14.2 percentage points (attitude to violence), 15.3 percentage points (decision-making), and 16.3 percentage points (social independence). The association between social independence and CCI was modified by wealth: each additional standard deviation was associated with 21.8 (95% confidence interval (CI) = 14.0-29.6) and 8.7 (95% CI = 5.4-12.0) percentage points increase in the CCI among the poorest and the richest quintiles, respectively. CONCLUSIONS Our findings suggest that efforts toward the achievement of SDG5 (Achieve gender equality and empower all women and girls) may support improvements in RMNCH in low- and middle-income countries, especially among the poorest women and children.
Collapse
Affiliation(s)
- Fernanda Ewerling
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
| | - Fernando C Wehrmeister
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
- Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
| | - Cesar G Victora
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
- Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
| | - Anita Raj
- Center on Gender Equity and Health, University of California San Diego, San Diego, California, USA
| | - Lotus McDougal
- Center on Gender Equity and Health, University of California San Diego, San Diego, California, USA
| | - Aluisio JD Barros
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
- Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
| |
Collapse
|
21
|
Colomé-Hidalgo M, Campos JD, de Miguel ÁG. Exploring wealth-related inequalities in maternal and child health coverage in Latin America and the Caribbean. BMC Public Health 2021; 21:115. [PMID: 33423659 PMCID: PMC7798299 DOI: 10.1186/s12889-020-10127-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 12/23/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Maternal and child health have shown important advances in the world in recent years. However, national averages indicators hide large inequalities in access and quality of care in population subgroups. We explore wealth-related inequalities affecting health coverage and interventions in reproductive, maternal, newborn, and child health in Latin America and the Caribbean. METHODS We analyzed representative national surveys from 15 countries conducted between 2001 and 2016. We estimated maternal-child health coverage gaps using the Composite Coverage Index - a weighted average of interventions that include family planning, maternal and newborn care, immunizations, and treatment of sick children. We measured absolute and relative inequality to assess gaps by wealth quintile. Pearson's correlation coefficient was used to test the association between the coverage gap and population attributable risk. RESULTS The Composite Coverage Index showed patterns of inequality favoring the wealthiest subgroups. In eight countries the national coverage was higher than the global median (78.4%; 95% CI: 73.1-83.6) and increased significantly as inequality decreased (Pearson r = 0.9; p < 0.01). CONCLUSIONS There are substantial inequalities between socioeconomic groups. Reducing inequalities will improve coverage indicators for women and children. Additional health policies, programs, and practices are required to promote equity.
Collapse
Affiliation(s)
| | | | - Ángel Gil de Miguel
- Instituto Tecnológico de Santo Domingo, Universidad Rey Juan Carlos, Madrid, Spain
| |
Collapse
|
22
|
Shah N, Mathew S, Pereira A, Nakaima A, Sridharan S. The role of evaluation in iterative learning and implementation of quality of care interventions. Glob Health Action 2021; 14:1882182. [PMID: 34148508 PMCID: PMC8216261 DOI: 10.1080/16549716.2021.1882182] [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: 05/17/2020] [Accepted: 12/22/2020] [Indexed: 11/01/2022] Open
Abstract
Background: The Lancet Global Health Commission (LGHC) has argued that quality of care (QoC) is an emergent property that requires an iterative process to learn and implement. Such iterations are required given that health systems are complex adaptive systems.Objective: This paper explores the multiple roles that evaluations need to play in order to help with iterative learning and implementation. We argue evaluation needs to shift from a summative focus toward an approach that promotes learning in complex systems. A framework is presented to help guide the iterative learning, and includes the dimensions of clinical care, person-centered care, continuum of care, and 'more than medicine. Multiple roles of evaluation corresponding to each of the dimensions are discussed.Methods: This paper is informed by reviews of the literature on QoC and the roles of evaluation in complex systems. The proposed framework synthesizes the multiple views of QoC. The recommendations of the roles of evaluation are informed both by review and experience in evaluating multiple QoC initiatives.Results: The specific roles of different evaluation approaches, including summative, realist, developmental, and participatory, are identified in relationship to the dimensions in our proposed framework. In order to achieve the potential of LGHC, there is a need to discuss how different evaluation approaches can be combined in a coherent way to promote iterative learning and implementation of QoC initiatives.Conclusion: One of the implications of the QoC framework discussed in the paper is that time needs to be spent upfront in recognizing areas in which knowledge of a specific intervention is not complete at the outset. This, of course, implies taking stock of areas of incompleteness in knowledge of context, theory of change, support structures needed in order for the program to succeed in specific settings. The role of evaluation should not be limited to only providing an external assessment, but an important goal in building evaluation capacity should be to promote adaptive management among planners and practitioners. Such iterative learning and adaptive management are needed to achieve the goals of sustainable development goals.
Collapse
Affiliation(s)
- Nikhil Shah
- The Evaluation Centre for Complex Health Interventions, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Sharon Mathew
- The Evaluation Centre for Complex Health Interventions, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Amanda Pereira
- The Evaluation Centre for Complex Health Interventions, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - April Nakaima
- The Evaluation Centre for Complex Health Interventions, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | | |
Collapse
|
23
|
Oh J, Moon J, Choi JW, Kim K. Factors associated with the continuum of care for maternal, newborn and child health in The Gambia: a cross-sectional study using Demographic and Health Survey 2013. BMJ Open 2020; 10:e036516. [PMID: 33243786 PMCID: PMC7692971 DOI: 10.1136/bmjopen-2019-036516] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To identify factors associated with the continuum of maternal, newborn and child health care in The Gambia. DESIGN A secondary statistical analysis using Demographic and Health Survey conducted in 2013. SETTING The Gambia. PARTICIPANTS 1308 married women (or with a partner) whose most recent children were aged 12-23 months at the time of the survey. OUTCOME MEASURES The main outcome was continuum of care for maternal, newborn and child health. The modified composite coverage index was calculated to express the completion level of continuum of care. RESULTS The following factors were associated with the continuum of maternal, newborn and child health care: women's autonomy in decision-making of her own healthcare (β=0.063, p=0.015), having higher educated husbands (β=0.138, p<0.001), listening to the radio at least once a week (β=0.078, p=0.006), having a child with birth order less than 5 (β=0.069, p=0.037), initiating the first antenatal care within 16 weeks of pregnancy (β=0.170, p<0.001), having been informed of signs of pregnancy complications (β=0.057, p=0.029), living in rural areas (β=-0.107, p=0.006) and having higher burden due to distance to health facility (β=-0.100, p<0.001), with an explanatory power of 15.5% (R2=0.155). CONCLUSIONS Efforts on future policies and programmes should focus on the concept of continuum of care considering the associated factors. In particular, more attention should be given to providing country-wide family planning and education to women, men and community members in The Gambia.
Collapse
Affiliation(s)
- Jiyoung Oh
- Department of Environmental and Global Health, Graduate School of Public Health, Korea University, Seoul, Republic of Korea
- Global Health Strategy Center, Institute for Environmental Health, Korea University, Seoul, Seongbuk-gu, Republic of Korea
| | - Juyoung Moon
- Department of Environmental and Global Health, Graduate School of Public Health, Korea University, Seoul, Republic of Korea
- Global Health Strategy Center, Institute for Environmental Health, Korea University, Seoul, Seongbuk-gu, Republic of Korea
| | - Jae Wook Choi
- Department of Environmental and Global Health, Graduate School of Public Health, Korea University, Seoul, Republic of Korea
- Global Health Strategy Center, Institute for Environmental Health, Korea University, Seoul, Seongbuk-gu, Republic of Korea
- Department of Preventive Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Kyunghee Kim
- Global Health Strategy Center, Institute for Environmental Health, Korea University, Seoul, Seongbuk-gu, Republic of Korea
| |
Collapse
|
24
|
Khan MN, Harris ML, Loxton D. Assessing the effect of pregnancy intention at conception on the continuum of care in maternal healthcare services use in Bangladesh: Evidence from a nationally representative cross-sectional survey. PLoS One 2020; 15:e0242729. [PMID: 33216799 PMCID: PMC7678970 DOI: 10.1371/journal.pone.0242729] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 11/06/2020] [Indexed: 11/18/2022] Open
Abstract
Background The Continuum of Care (CoC; defined as accessing the recommended healthcare services during pregnancy and the early postpartum period) is low in lower-middle-income countries (LMICs). This may be a major contributor to the high rates of pregnancy-related complications and deaths in LMICs, particularly among women who had an unintended pregnancy. With a lack of research on the subject in Bangladesh, we aimed to examine the effect of unintended pregnancy on CoC. Methods Data from 4,493 mother-newborn dyads who participated in the cross-sectional 2014 Bangladesh Demographic and Health Survey were analysed. Women’s level of CoC was generated from responses to questions on the use and non-use of three recommended services during the course of pregnancy: four or more antenatal care (ANC) visits, skilled birth attendance (SBA) during delivery, and at least one postnatal care (PNC) visit within 24 hours of giving birth. Global recommendations of service use were used to classify CoC as high (used each of the recommended services), moderate (used at least two of the three recommended services), and low/none (no PNC, no SBA, and ≤3 ANC visits). Women’s pregnancy intention at the time of conception of their last pregnancy (ending with a live birth) was the major exposure variable, classified as wanted, mistimed, and unwanted. Unadjusted and adjusted (with individual-, household-, and community-level factors) multilevel multinomial logistic regression models were used to assess the association between unintended pregnancy and level of CoC. Results In Bangladesh, the highest level of CoC occurred in only 12% of pregnancies that ended with live births. This figure was reduced to 5.6% if the pregnancy was unwanted at conception. The antenatal period saw the greatest drop in CoC, with 65.13% of women receiving at least one ANC visit and 26.32% having four or more ANC visits. Following the adjustment of confounders, an unwanted pregnancy was found to be associated with 39% and 62% reduced odds of women receiving moderate and high levels of CoC, respectively, than those with a wanted pregnancy. Having a mistimed pregnancy was found to be associated with a 31% reduction in odds of women achieving a high CoC than women with a wanted pregnancy. Conclusion Almost nine in ten women did not achieve CoC in their last pregnancy, which was even higher when the pregnancy was unintended. Given that the ANC period has been identified as a critical time for intervention for these women, it is necessary for policies to scale up current maternal healthcare services that provide in-home maternal healthcare services and to monitor the continuity of ANC, with a particular focus on women who have an unintended pregnancy. Integration of maternal healthcare services with family planning services is also required to ensure CoC.
Collapse
Affiliation(s)
- Md Nuruzzaman Khan
- Department of Population Sciences, Jatiya Kabi Kazi Nazrul Islam University, Trishal, Mymensingh, Bangladesh
- * E-mail: ,
| | - Melissa L. Harris
- Faculty of Health and Medicine, School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
| | - Deborah Loxton
- Faculty of Health and Medicine, Priority Research Centre for Generational Health and Ageing, School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
| |
Collapse
|
25
|
Bouilly R, Gatica-Domínguez G, Mesenburg M, Cáceres Ureña FI, Leventhal DGP, Barros AJD, Victora CG, Wehrmeister FC. Maternal and child health inequalities among migrants: the case of Haiti and the Dominican Republic. Rev Panam Salud Publica 2020; 44:e144. [PMID: 33245298 PMCID: PMC7679047 DOI: 10.26633/rpsp.2020.144] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 10/19/2020] [Indexed: 11/24/2022] Open
Abstract
Objective. To assess coverage and inequalities in maternal and child health interventions among Haitians, Haitian migrants in the Dominican Republic and Dominicans. Methods. Cross-sectional study using data from nationally representative surveys carried out in Haiti in 2012 and in the Dominican Republic in 2014. Nine indicators were compared: demand for family planning satisfied with modern methods, antenatal care, delivery care (skilled birth attendance), child vaccination (BCG, measles and DPT3), child case management (oral rehydration salts for diarrhea and careseeking for suspected pneumonia), and the composite coverage index. Wealth was measured through an asset-based index, divided into tertiles, and place of residence (urban or rural) was established according to the country definition. Results. Haitians showed the lowest coverage for demand for family planning satisfied with modern methods (44.2%), antenatal care (65.3%), skilled birth attendance (39.5%) and careseeking for suspected pneumonia (37.9%), and the highest for oral rehydration salts for diarrhea (52.9%), whereas Haitian migrants had the lowest coverage in DPT3 (44.1%) and oral rehydration salts for diarrhea (38%) and the highest in careseeking for suspected pneumonia (80.7%). Dominicans presented the highest coverage for most indicators, except oral rehydration salts for diarrhea and careseeking for suspected pneumonia. The composite coverage index was 79.2% for Dominicans, 69.0% for Haitian migrants, and 52.6% for Haitians. Socioeconomic inequalities generally had pro-rich and pro-urban pattern in all analyzed groups. Conclusion. Haitian migrants presented higher coverage than Haitians, but lower than Dominicans. Both countries should plan actions and policies to increase coverage and address inequalities of maternal health interventions.
Collapse
Affiliation(s)
| | | | - Marilia Mesenburg
- Federal University of Pelotas, Pelotas, Brazil
- Federal University of Health Science, Porto Alegre, Brazil
| | - Francisco I. Cáceres Ureña
- Autonomous University of Santo Domingo, Santo Domingo, Dominican Republic
- National Statistics Office, Censuses and Surveys, Santo Domingo, Dominican Republic
| | | | | | | | | |
Collapse
|
26
|
Macharia PM, Joseph NK, Okiro EA. A vulnerability index for COVID-19: spatial analysis at the subnational level in Kenya. BMJ Glob Health 2020; 5:e003014. [PMID: 32839197 PMCID: PMC7447114 DOI: 10.1136/bmjgh-2020-003014] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 06/22/2020] [Accepted: 07/15/2020] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Response to the coronavirus disease 2019 (COVID-19) pandemic calls for precision public health reflecting our improved understanding of who is the most vulnerable and their geographical location. We created three vulnerability indices to identify areas and people who require greater support while elucidating health inequities to inform emergency response in Kenya. METHODS Geospatial indicators were assembled to create three vulnerability indices; Social VulnerabilityIndex (SVI), Epidemiological Vulnerability Index (EVI) and a composite of the two, that is, Social Epidemiological Vulnerability Index (SEVI) resolved at 295 subcounties in Kenya. SVI included 19 indicators that affect the spread of disease; socioeconomic deprivation, access to services and population dynamics, whereas EVI comprised 5 indicators describing comorbidities associated with COVID-19 severe disease progression. The indicators were scaled to a common measurement scale, spatially overlaid via arithmetic mean and equally weighted. The indices were classified into seven classes, 1-2 denoted low vulnerability and 6-7, high vulnerability. The population within vulnerabilities classes was quantified. RESULTS The spatial variation of each index was heterogeneous across Kenya. Forty-nine northwestern and partly eastern subcounties (6.9 million people) were highly vulnerable, whereas 58 subcounties (9.7 million people) in western and central Kenya were the least vulnerable for SVI. For EVI, 48 subcounties (7.2 million people) in central and the adjacent areas and 81 subcounties (13.2 million people) in northern Kenya were the most and least vulnerable, respectively. Overall (SEVI), 46 subcounties (7.0 million people) around central and southeastern were more vulnerable, whereas 81 subcounties (14.4 million people) were least vulnerable. CONCLUSION The vulnerability indices created are tools relevant to the county, national government and stakeholders for prioritisation and improved planning. The heterogeneous nature of the vulnerability indices underpins the need for targeted and prioritised actions based on the needs across the subcounties.
Collapse
Affiliation(s)
- Peter M Macharia
- Population Health Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Noel K Joseph
- Population Health Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Emelda A Okiro
- Population Health Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| |
Collapse
|
27
|
Wehrmeister FC, Fayé CM, da Silva ICM, Amouzou A, Ferreira LZ, Jiwani SS, Melesse DY, Mutua M, Maïga A, Ca T, Sidze E, Taylor C, Strong K, Carvajal-Aguirre L, Porth T, Hosseinpoor AR, Barros AJD, Boerma T. Wealth-related inequalities in the coverage of reproductive, maternal, newborn and child health interventions in 36 countries in the African Region. Bull World Health Organ 2020; 98:394-405. [PMID: 32514213 PMCID: PMC7265922 DOI: 10.2471/blt.19.249078] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 03/06/2020] [Accepted: 03/09/2020] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To investigate whether sub-Saharan African countries have succeeded in reducing wealth-related inequalities in the coverage of reproductive, maternal, newborn and child health interventions. METHODS We analysed survey data from 36 countries, grouped into Central, East, Southern and West Africa subregions, in which at least two surveys had been conducted since 1995. We calculated the composite coverage index, a function of essential maternal and child health intervention parameters. We adopted the wealth index, divided into quintiles from poorest to wealthiest, to investigate wealth-related inequalities in coverage. We quantified trends with time by calculating average annual change in index using a least-squares weighted regression. We calculated population attributable risk to measure the contribution of wealth to the coverage index. FINDINGS We noted large differences between the four regions, with a median composite coverage index ranging from 50.8% for West Africa to 75.3% for Southern Africa. Wealth-related inequalities were prevalent in all subregions, and were highest for West Africa and lowest for Southern Africa. Absolute income was not a predictor of coverage, as we observed a higher coverage in Southern (around 70%) compared with Central and West (around 40%) subregions for the same income. Wealth-related inequalities in coverage were reduced by the greatest amount in Southern Africa, and we found no evidence of inequality reduction in Central Africa. CONCLUSION Our data show that most countries in sub-Saharan Africa have succeeded in reducing wealth-related inequalities in the coverage of essential health services, even in the presence of conflict, economic hardship or political instability.
Collapse
Affiliation(s)
- Fernando C Wehrmeister
- International Center for Equity in Health, Federal University of Pelotas, Rua Marechal Deodoro, 1160, 3 piso, Pelotas, Brazil
| | - Cheikh Mbacké Fayé
- African Population and Health Research Centre, West Africa Regional Office, Dakar, Senegal
| | - Inácio Crochemore M da Silva
- International Center for Equity in Health, Federal University of Pelotas, Rua Marechal Deodoro, 1160, 3 piso, Pelotas, Brazil
| | - Agbessi Amouzou
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, United States of America (USA)
| | - Leonardo Z Ferreira
- International Center for Equity in Health, Federal University of Pelotas, Rua Marechal Deodoro, 1160, 3 piso, Pelotas, Brazil
| | - Safia S Jiwani
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, United States of America (USA)
| | | | - Martin Mutua
- African Population and Health Research Center, Central Office, Nairobi, Kenya
| | - Abdoulaye Maïga
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, United States of America (USA)
| | - Tome Ca
- Health Information System, West African Health Organization, Bobo-Dioulasso, Burkina Faso
| | - Estelle Sidze
- African Population and Health Research Center, Central Office, Nairobi, Kenya
| | - Chelsea Taylor
- Department of Data and Analytics, World Health Organization, Geneva, Switzerland
| | - Kathleen Strong
- Department of Maternal, Newborn, Child, and Adolescent Health and Aging, World Health Organization, Geneva, Switzerland
| | - Liliana Carvajal-Aguirre
- Division of Data, Analytics, Planning and Monitoring, United Nations Children’s Fund, New York, USA
| | - Tyler Porth
- Division of Data, Analytics, Planning and Monitoring, United Nations Children’s Fund, New York, USA
| | | | - Aluisio J D Barros
- International Center for Equity in Health, Federal University of Pelotas, Rua Marechal Deodoro, 1160, 3 piso, Pelotas, Brazil
| | - Ties Boerma
- Centre for Global Public Health, University of Manitoba, Canada
| | - on the behalf of the Countdown to 2030 for Women’s, Children’s and Adolescents’ Health regional collaboration in sub-Saharan Africa
- International Center for Equity in Health, Federal University of Pelotas, Rua Marechal Deodoro, 1160, 3 piso, Pelotas, Brazil
- African Population and Health Research Centre, West Africa Regional Office, Dakar, Senegal
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, United States of America (USA)
- Centre for Global Public Health, University of Manitoba, Canada
- African Population and Health Research Center, Central Office, Nairobi, Kenya
- Health Information System, West African Health Organization, Bobo-Dioulasso, Burkina Faso
- Department of Data and Analytics, World Health Organization, Geneva, Switzerland
- Department of Maternal, Newborn, Child, and Adolescent Health and Aging, World Health Organization, Geneva, Switzerland
- Division of Data, Analytics, Planning and Monitoring, United Nations Children’s Fund, New York, USA
| |
Collapse
|
28
|
Altare C, Malembaka EB, Tosha M, Hook C, Ba H, Bikoro SM, Scognamiglio T, Tappis H, Pfaffmann J, Balaluka GB, Boerma T, Spiegel P. Health services for women, children and adolescents in conflict affected settings: experience from North and South Kivu, Democratic Republic of Congo. Confl Health 2020; 14:31. [PMID: 32514296 PMCID: PMC7254646 DOI: 10.1186/s13031-020-00265-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 03/02/2020] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Insecurity has characterized the Eastern regions of the Democratic Republic of Congo for decades. Providing health services to sustain women's and children's health during protracted conflict is challenging. This mixed-methods case study aimed to describe how reproductive, maternal, newborn, child, adolescent health and nutrition (RMNCAH+N) services have been offered in North and South Kivu since 2000 and how successful they were. METHODS We conducted a case study using a desk review of publicly available literature, secondary analysis of survey and health information system data, and primary qualitative interviews. The qualitative component provides insights on factors shaping RMNCAH+N design and implementation. We conducted 49 interviews with government officials, humanitarian agency staff and facility-based healthcare providers, and focus group discussions with community health workers in four health zones (Minova, Walungu, Ruanguba, Mweso). We applied framework analysis to investigate key themes across informants.The quantitative component used secondary data from nationwide surveys and the national health facility information system to estimate coverage of RMNCAH+N interventions at provincial and sub-provincial level. The association between insecurity on service provision was examined with random effects generalized least square models using health facility data from South Kivu. RESULTS Coverage of selected preventive RMNCAH+N interventions seems high in North and South Kivu, often higher than the national level. Health facility data show a small negative association of insecurity and preventive service coverage within provinces. However, health outcomes are poorer in conflict-affected territories than in stable ones. The main challenges to service provisions identified by study respondents are the availability and retention of skilled personnel, the lack of basic materials and equipment as well as the insufficient financial resources to ensure health workers' regular payment, medicaments' availability and facilities' running costs. Insecurity exacerbates pre-existing challenges, but do not seem to represent the main barrier to service provision in North and South Kivu. CONCLUSIONS Provision of preventive schedulable RMNCAH+N services has continued during intermittent conflict in North and South Kivu. The prolonged effort by non-governmental organizations and UN agencies to respond to humanitarian needs was likely key in maintaining intervention coverage despite conflict. Health actors and communities appear to have adapted to changing levels and nature of insecurity and developed strategies to ensure preventive services are provided and accessed. However, emergency non-schedulable RMNCAH+N interventions do not appear to be readily accessible. Achieving the Sustainable Development Goals will require increased access to life-saving interventions, especially for newborn and pregnant women.
Collapse
Affiliation(s)
- Chiara Altare
- Centre for Humanitarian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Espoir Bwenge Malembaka
- Ecole Régionale de Santé Publique, ERSP, Faculty of Medicine, Université catholique de Bukavu, Bukavu, Democratic Republic of Congo
| | - Maphie Tosha
- Foundation RamaLevina, Bukavu, Democratic Republic of Congo
| | - Christopher Hook
- Centre for Humanitarian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Hamady Ba
- United Nations Children’s Fund, Bukavu, Democratic Republic of Congo
| | | | - Thea Scognamiglio
- Centre for Humanitarian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Hannah Tappis
- Centre for Humanitarian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | | | - Ghislain Bisimwa Balaluka
- Ecole Régionale de Santé Publique, ERSP, Faculty of Medicine, Université catholique de Bukavu, Bukavu, Democratic Republic of Congo
| | - Ties Boerma
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB Canada
| | - Paul Spiegel
- Centre for Humanitarian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| |
Collapse
|
29
|
Wehrmeister FC, Barros AJD, Hosseinpoor AR, Boerma T, Victora CG. Measuring universal health coverage in reproductive, maternal, newborn and child health: An update of the composite coverage index. PLoS One 2020; 15:e0232350. [PMID: 32348356 PMCID: PMC7190152 DOI: 10.1371/journal.pone.0232350] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 04/14/2020] [Indexed: 11/18/2022] Open
Abstract
Background Monitoring universal health coverage in reproductive, maternal and child health requires appropriate indicators for assessing coverage and equity. In 2008, the composite coverage index (CCI)–a weighted average of eight indicators reflecting family planning, antenatal and delivery care, immunizations and management of childhood illnesses–was proposed. In 2017, the CCI formula was revised to update the family planning and diarrhea management indicators. We explored the implications of adding new indicators to the CCI. Methods We analysed nationally representative surveys to investigate how addition of early breastfeeding initiation (EIBF), tetanus toxoid during pregnancy and post-natal care for babies affected CCI levels and the magnitude of wealth-related inequalities. We used Pearson’s correlation coefficient to compare different formulations, and the slope index of inequalities [SII] and concentration index [CIX] to assess absolute and relative inequalities, respectively. Results 47 national surveys since 2010 had data on the eight variables needed for the original and revised formulations, and on EIBF, tetanus vaccine and postnatal care, related to newborn care. The original CCI showed the highest average value (65.5%), which fell to 56.9% when all 11 indicators were included. Correlation coefficients between pairs of all formulations ranged from 0.93 to 0.99. When analysed separately, 10 indicators showed higher coverage with increasing wealth; the exception was EIBF (SII = -2.1; CIX = -0.5). Inequalities decreased when other indicators were added, especially EIBF–the SII fell from 24.8 pp. to 19.2 pp.; CIX from 7.6 to 6.1. The number of countries with data from two or more surveys since 2010 was 30 for the original and revised formulations and 15 when all the 11 indicators were included. Conclusions Given the growing importance of newborn mortality, it would be desirable to include relevant coverage indicators in the CCI, but this would lead a reduction in data availability, and an underestimation of coverage inequalities. We propose that the 2017 version of the revised CCI should continue to be used.
Collapse
Affiliation(s)
- Fernando C. Wehrmeister
- International Center for Equity in Health, Post-Graduate Programme in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
- * E-mail:
| | - Aluisio J. D. Barros
- International Center for Equity in Health, Post-Graduate Programme in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
| | - Ahmad Reza Hosseinpoor
- Division of Data, Analytics and Delivery, World Health Organization, Geneva, Switzerland
| | - Ties Boerma
- Center for Global Public Health, University of Manitoba, Winnipeg, Canada
| | - Cesar G. Victora
- International Center for Equity in Health, Post-Graduate Programme in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
| |
Collapse
|
30
|
Barros AJD, Wehrmeister FC, Ferreira LZ, Vidaletti LP, Hosseinpoor AR, Victora CG. Are the poorest poor being left behind? Estimating global inequalities in reproductive, maternal, newborn and child health. BMJ Glob Health 2020; 5:e002229. [PMID: 32133180 PMCID: PMC7042578 DOI: 10.1136/bmjgh-2019-002229] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 12/17/2019] [Accepted: 12/18/2019] [Indexed: 11/21/2022] Open
Abstract
Introduction Wealth-related inequalities in reproductive, maternal, neonatal and child health have been widely studied by dividing the population into quintiles. We present a comprehensive analysis of wealth inequalities for the composite coverage index (CCI) using national health surveys carried out since 2010, using wealth deciles and absolute income estimates as stratification variables, and show how these new approaches expand on traditional equity analyses. Methods 83 low-income and middle-income countries were studied. The CCI is a combined measure of coverage with eight key reproductive, maternal, newborn and child health interventions. It was disaggregated by wealth deciles for visual inspection of inequalities, and the slope index of inequality (SII) was estimated. The correlation between coverage in the extreme deciles and SII was assessed. Finally, we used multilevel models to examine how the CCI varies according to the estimated absolute income for each wealth quintile in the surveys. Results The analyses of coverage by wealth deciles and by absolute income show that inequality is mostly driven by coverage among the poor, which is much more variable than coverage among the rich across countries. Regardless of national coverage, in 61 of the countries, the wealthiest decile achieved 70% or higher CCI coverage. Well-performing countries were particularly effective in achieving high coverage among the poor. In contrast, underperforming countries failed to reach the poorest, despite reaching the better-off. Conclusion There are huge inequalities between the richest and the poorest women and children in most countries. These inequalities are strongly driven by low coverage among the poorest given the wealthiest groups achieve high coverage irrespective of where they live, overcoming any barriers that are an impediment to others. Countries that ‘punched above their weight’ in coverage, given their level of absolute wealth, were those that best managed to reach their poorest women and children.
Collapse
Affiliation(s)
| | - Fernando C Wehrmeister
- International Center for Equity in Health, Universidade Federal de Pelotas, Pelotas, Brazil
| | | | | | - Ahmad Reza Hosseinpoor
- Post-Graduate Programme in Epidemiology, Universidade Federal de Pelotas, Pelotas, Brazil
| | | |
Collapse
|
31
|
Requejo J, Diaz T, Park L, Chou D, Choudhury A, Guthold R, Jackson D, Moller AB, Monet JP, Moran AC, Say L, Strong KL, Banerjee A. Assessing coverage of interventions for reproductive, maternal, newborn, child, and adolescent health and nutrition. BMJ 2020; 368:l6915. [PMID: 31983681 PMCID: PMC7461908 DOI: 10.1136/bmj.l6915] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Progress has been made in priority interventions, but we need new measurement systems that include the whole life course and give better assessment of equity of coverage, argue Jennifer Requejo and colleagues
Collapse
Affiliation(s)
| | | | - Lois Park
- Johns Hopkins University, Baltimore, USA
- University of Southern California, Los Angeles, USA
| | - Doris Chou
- World Health Organization, Geneva, Switzerland
| | | | | | - Debra Jackson
- Unicef, New York, USA
- University of Western Cape, Cape Town, South Africa
| | | | | | | | - Lale Say
- World Health Organization, Geneva, Switzerland
| | | | - Anshu Banerjee
- World Health Organization, Geneva, Switzerland
- United Nations H6+ Technical Group, New York, USA
| |
Collapse
|
32
|
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.
Collapse
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
| | | |
Collapse
|
33
|
Baye K, Laillou A, Chitweke S. Socio-Economic Inequalities in Child Stunting Reduction in Sub-Saharan Africa. Nutrients 2020; 12:nu12010253. [PMID: 31963768 PMCID: PMC7019538 DOI: 10.3390/nu12010253] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 01/10/2020] [Accepted: 01/14/2020] [Indexed: 11/16/2022] Open
Abstract
Stunting in children less than five years of age is widespread in Sub-Saharan Africa. We aimed to: (i) evaluate how the prevalence of stunting has changed by socio-economic status and rural/urban residence, and (ii) assess inequalities in children's diet quality and access to maternal and child health care. We used data from nationally representative demographic and health- and multiple indicator cluster-surveys (DHS and MICS) to disaggregate the stunting prevalence by wealth quintile and rural/urban residence. The composite coverage index (CCI) reflecting weighed coverage of eight preventive and curative Reproductive, Maternal, Neonatal, and Child Health (RMNCH) interventions was used as a proxy for access to health care, and Minimum Dietary Diversity Score (MDDS) was used as a proxy for child diet quality. Stunting significantly decreased over the past decade, and reductions were faster for the most disadvantaged groups (rural and poorest wealth quintile), but in only 50% of the countries studied. Progress in reducing stunting has not been accompanied by improved equity as inequalities in MDDS (p < 0.01) and CCI (p < 0.001) persist by wealth quintile and rural-urban residence. Aligning food- and health-systems' interventions is needed to accelerate stunting reduction more equitably.
Collapse
Affiliation(s)
- Kaleab Baye
- Center for Food Science and Nutrition, Addis Ababa University, PO Box: 1176, Addis Ababa, Ethiopia
- Correspondence:
| | - Arnaud Laillou
- United Nations Children’s Fund (UNICEF), Addis Ababa, Ethiopia; (A.L.); (S.C.)
| | - Stanley Chitweke
- United Nations Children’s Fund (UNICEF), Addis Ababa, Ethiopia; (A.L.); (S.C.)
| |
Collapse
|
34
|
Panda BK, Kumar G, Awasthi A. District level inequality in reproductive, maternal, neonatal and child health coverage in India. BMC Public Health 2020; 20:58. [PMID: 31937270 PMCID: PMC6961337 DOI: 10.1186/s12889-020-8151-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 12/31/2019] [Indexed: 01/12/2023] Open
Abstract
Background As India already missed maternal and child health related millennium development goals, the maternal and child health outcomes are a matter of concern to achieve sustainable development goals (SDGs). This study is focused to assess the gap in coverage and inequality of various reproductive, maternal, neonatal and child health (RMNCH) indicators in 640 districts of India, using data from most recent round of National Family Health Survey. Methods A composite index named Coverage Gap Index (CGI) was calculated, as the weighted average of eight preventive maternal and child care interventions at different administrative levels. Bivariate and spatial analysis were used to understand the geographical diversity and spatial clustering in districts of India. A socio-economic development index (SDI) was also derived and used to assess the interlinkages between CGI and development. The ratio method was used to assess the socio-economic inequality in CGI and its component at the national level. Results The average national CGI was 26.23% with the lowest in Kerala (10.48%) and highest in Nagaland (55.07%). Almost half of the Indian districts had CGI above the national average and mainly concentrated in high focus states and north-eastern part. From the geospatial analysis of CGI, 122 districts formed hotspots and 164 districts were in cold spot. The poorest households had 2.5 times higher CGI in comparison to the richest households and rural households have 1.5 times higher CGI as compared to urban households. Conclusion Evidence from the study suggests that many districts in India are lagging in terms of CGI and prioritize to achieve the desired level of maternal and child health outcomes. Efforts are needed to reduce the CGI among the poorest and rural resident which may curtail the inequality.
Collapse
Affiliation(s)
- Basant Kumar Panda
- International Institute for Population Sciences, Mumbai, Maharashtra, India
| | - Gulshan Kumar
- International Institute for Population Sciences, Mumbai, Maharashtra, India.
| | - Ashish Awasthi
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, Gurugram, India
| |
Collapse
|
35
|
Boerma T, Tappis H, Saad-Haddad G, Das J, Melesse DY, DeJong J, Spiegel P, Black R, Victora C, Bhutta ZA, Barros AJD. Armed conflicts and national trends in reproductive, maternal, newborn and child health in sub-Saharan Africa: what can national health surveys tell us? BMJ Glob Health 2019; 4:e001300. [PMID: 31297253 PMCID: PMC6590971 DOI: 10.1136/bmjgh-2018-001300] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 01/28/2019] [Accepted: 02/25/2019] [Indexed: 01/22/2023] Open
Abstract
Armed conflicts are widespread in sub-Saharan Africa and considered to be an important factor in slowing down national progress in reproductive, maternal, newborn and child health (RMNCH). The measurement of the impact of conflicts on national levels and trends in RMNCH is difficult. National surveys conducted before and sometimes during and after conflicts are a major source of information on the national and local effects of conflicts on RMNCH. We examined data from national surveys in 13 countries in sub-Saharan Africa with major conflicts during 1990–2016 to assess the levels and trends in RMNCH intervention coverage, nutritional status and mortality in children under 5 years in comparison with subregional trends. The surveys provide substantive evidence of a negative association between levels and trends in national indicators of RMNCH service coverage, child growth and under-5 mortality with armed conflict, with some notable exceptions. National surveys are an important source of data to assess the longer term national consequences of conflicts for RMNCH in most countries, despite limitations due to sampling and timing of the surveys.
Collapse
Affiliation(s)
- Ties Boerma
- Center for Global Public Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Hannah Tappis
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ghada Saad-Haddad
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Jai Das
- Faculty of Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Dessalegn Y Melesse
- Community Health Science, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jocelyn DeJong
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Paul Spiegel
- International Health, Bloomberg School of Public Health, Johns Hopkins Unversity, Baltimore, Maryland, USA
| | - Robert Black
- International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Cesar Victora
- Epidemiology, Federal University of Pelotas, Pelotas, Brazil
| | | | - Aluisio J D Barros
- International Center for Equity in Health, Universidade Federal de Pelotas, Pelotas, Brazil
| |
Collapse
|
36
|
Aung T, Niyeha D, Shagihilu S, Mpembeni R, Kaganda J, Sheffel A, Heidkamp R. Optimizing data visualization for reproductive, maternal, newborn, child health, and nutrition (RMNCH&N) policymaking: data visualization preferences and interpretation capacity among decision-makers in Tanzania. Glob Health Res Policy 2019; 4:4. [PMID: 30783631 PMCID: PMC6376719 DOI: 10.1186/s41256-019-0095-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 01/28/2019] [Indexed: 11/11/2022] Open
Abstract
Background Reproductive, maternal, newborn, child health, and nutrition (RMNCH&N) data is an indispensable tool for program and policy decisions in low- and middle-income countries. However, being equipped with evidence doesn’t necessarily translate to program and policy changes. This study aimed to characterize data visualization interpretation capacity and preferences among RMNCH&N Tanzanian program implementers and policymakers (“decision-makers”) to design more effective approaches towards promoting evidence-based RMNCH&N decisions in Tanzania. Methods We conducted 25 semi-structured interviews in Kiswahili with junior, mid-level, and senior RMNCH&N decision-makers working in Tanzanian government institutions. We used snowball sampling to recruit participants with different rank and roles in RMNCH&N decision-making. Using semi-structured interviews, we probed participants on their statistical skills and data use, and asked participants to identify key messages and rank prepared RMNCH&N visualizations. We used a grounded theory approach to organize themes and identify findings. Results The findings suggest that data literacy and statistical skills among RMNCH&N decision-makers in Tanzania varies. Most participants demonstrated awareness of many critical factors that should influence a visualization choice—audience, key message, simplicity—but assessments of data interpretation and preferences suggest that there may be weak knowledge of basic statistics. A majority of decision-makers have not had any statistical training since attending university. There appeared to be some discomfort with interpreting and using visualizations that are not bar charts, pie charts, and maps. Conclusions Decision-makers must be able to understand and interpret RMNCH&N data they receive to be empowered to act. Addressing inadequate data literacy and presentation skills among decision-makers is vital to bridging gaps between evidence and policymaking. It would be beneficial to host basic data literacy and visualization training for RMNCH&N decision-makers at all levels in Tanzania, and to expand skills on developing key messages from visualizations. Electronic supplementary material The online version of this article (10.1186/s41256-019-0095-1) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Tricia Aung
- 1Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Debora Niyeha
- 1Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | | | - Rose Mpembeni
- 3School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Ashley Sheffel
- 1Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Rebecca Heidkamp
- 1Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| |
Collapse
|
37
|
Shibanuma A, Yeji F, Okawa S, Mahama E, Kikuchi K, Narh C, Enuameh Y, Nanishi K, Oduro A, Owusu-Agyei S, Gyapong M, Asare GQ, Yasuoka J, Ansah EK, Hodgson A, Jimba M. The coverage of continuum of care in maternal, newborn and child health: a cross-sectional study of woman-child pairs in Ghana. BMJ Glob Health 2018; 3:e000786. [PMID: 30233827 PMCID: PMC6135430 DOI: 10.1136/bmjgh-2018-000786] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 05/18/2018] [Accepted: 06/09/2018] [Indexed: 12/20/2022] Open
Abstract
Introduction The continuum of care has recently received attention in maternal, newborn and child health. It can be an effective policy framework to ensure that every woman and child receives timely and appropriate services throughout the continuum. However, a commonly used measurement does not evaluate if a pair of woman and child complies with the continuum of care. This study assessed the continuum of care based on two measurements: continuous visits to health facilities (measurement 1) and receiving key components of services (measurement 2). It also explored individual-level and area-level factors associated with the continuum of care achievement and then investigated how the continuum of care differed across areas. Methods In this cross-sectional study in Ghana in 2013, the continuum of care achievement and other characteristics of 1401 pairs of randomly selected women and children were collected. Multilevel logistic regression was used to estimate the factors associated with the continuum of care and its divergence across 22 areas. Results Throughout the pregnancy, delivery and post-delivery stages, 7.9% of women and children achieved the continuum of care through continuous visits to health facilities (measurement 1). Meanwhile, 10.3% achieved the continuum of care by receiving all key components of maternal, newborn and child health services (measurement 2). Only 1.8% of them achieved it under both measurements. Women and children from wealthier households were more likely to achieve the continuum of care under both measurements. Women’s education and complications were associated with higher continuum of care services-based achievement. Variance of a random intercept was larger in the continuum of care services-based model than the visit-based model. Conclusions Most women and children failed to achieve the continuum of care in maternal, newborn and child health. Those who consistently visited health facilities did not necessarily receive key components of services.
Collapse
Affiliation(s)
- Akira Shibanuma
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Francis Yeji
- Navrongo Health Research Centre, Navrongo, Ghana
| | - Sumiyo Okawa
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | | | - Kimiyo Kikuchi
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Clement Narh
- Dodowa Health Research Centre, Dodowa, Ghana.,School of Public Health, University of Health and Allied Sciences, Ho, Ghana
| | | | - Keiko Nanishi
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | | | | | | | | | - Junko Yasuoka
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Research and Education Center for Prevention of Global Infectious Diseases of Animals, Tokyo University of Agriculture and Technology, Fuchu, Japan
| | - Evelyn Korkor Ansah
- Research and Development Division, Ghana Health Service, Accra, Ghana.,Institute for Health Research, University of Health and Allied Sciences, Ho, Ghana
| | - Abraham Hodgson
- Research and Development Division, Ghana Health Service, Accra, Ghana
| | - Masamine Jimba
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | | |
Collapse
|
38
|
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.
Collapse
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
| |
Collapse
|
39
|
Fitzpatrick C, Bangert M, Mbabazi PS, Mikhailov A, Zouré H, Polo Rebollo M, Robalo Correia E Silva M, Biswas G. Monitoring equity in universal health coverage with essential services for neglected tropical diseases: an analysis of data reported for five diseases in 123 countries over 9 years. LANCET GLOBAL HEALTH 2018; 6:e980-e988. [PMID: 30054258 DOI: 10.1016/s2214-109x(18)30307-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 05/23/2018] [Accepted: 06/15/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND A service coverage index has recently been proposed to monitor progress towards universal health coverage (UHC), and baseline results for 2015 are available. However, evidence on equity in that progress is scarce. The service coverage index did not consider services for neglected tropical diseases (NTDs), a group of preventable diseases defined by WHO member states on the basis of the disproportionate burden they place on their poorest, remotest, and otherwise most marginalised communities. Because of the much-needed equity lens that it could provide, NTD service coverage should not be neglected in efforts to monitor UHC progress. METHODS We developed an index focused on coverage of services for NTDs, comparable in methods to the UHC service coverage index. On the basis of data availability, we focused on preventive chemotherapy, which was recently included in the highest-priority package of essential UHC interventions. We used data reported to WHO since 2008 for the five NTDs amenable to preventive chemotherapy (lymphatic filariasis, onchocerciasis, schistosomiasis, soil-transmitted helminthiases, and trachoma) to develop an NTD service coverage index based on the geometric mean of coverage rates for individual NTD services with regularly reported data. We then compared this NTD service coverage index with the UHC service coverage index. A high UHC index value and a low NTD index value suggest that a country might not be adequately prioritising interventions for the poor. We measured Spearman rank-order correlation (ρ) of the NTD service coverage index with income inequality, as measured by the Gini coefficient (range of 0-1), where values of the Gini coefficient close to 1 indicate higher income inequality, and a negative correlation was evidence of socioeconomic barriers to health service coverage for people who are least well off. FINDINGS At least 123 countries can monitor NTD service coverage by use of a simple index. The median national NTD index was 32 in 2016, an increase from 3 in 2012, and from 0 in 2008. In 2015, the NTD index was lower than the UHC index in 81 of the 113 countries for which both NTD and UHC indices are available, by up to 80 points. The NTD index was negatively but weakly correlated with income inequality; this correlation was strongest in the African Region (ρ=-0·46 in 2008, ρ=-0·32 in 2015), suggesting that high-income inequality, although associated with low coverage of services targeting the poor, does not preclude the extension of that coverage. INTERPRETATION The NTD index can be used to measure equity in progress towards UHC. A broader NTD index including services for other NTDs could be developed at regional and country levels. Comparing the NTD and UHC service coverage indices reveals that some countries that are performing well by the measure of the UHC service coverage index still have work to do in prioritising services for their poorest and otherwise most marginalised communities. Our results offer hope that socioeconomic barriers to health service coverage can be overcome. FUNDING None.
Collapse
Affiliation(s)
| | | | | | | | - Honorat Zouré
- World Health Organization, Regional Office for Africa, Brazzaville, Republic of the Congo
| | - Maria Polo Rebollo
- World Health Organization, Regional Office for Africa, Brazzaville, Republic of the Congo
| | | | | |
Collapse
|
40
|
Mothupi MC, Knight L, Tabana H. Measurement approaches in continuum of care for maternal health: a critical interpretive synthesis of evidence from LMICs and its implications for the South African context. BMC Health Serv Res 2018; 18:539. [PMID: 29996924 PMCID: PMC6042348 DOI: 10.1186/s12913-018-3278-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 06/05/2018] [Indexed: 01/09/2023] Open
Abstract
Background Global strategies recommend a continuum of care for maternal health to improve outcomes and access to care in low and middle income countries (LMICs). South Africa has already set priority interventions along the continuum of care for maternal health, and mandated their implementation at the district health level. However, the approach for monitoring access to this continuum of care has not yet been defined. This review assessed measurement approaches in continuum of care for maternal health among LMICs and their implications for the South African context. Methods We conducted a critical interpretive synthesis of quantitative and qualitative research sourced from Academic Search Complete (EBSCO), MEDLINE (Pubmed), Cambridge Journals Online, Credo Reference and Science Direct. We selected 20 out of 118 articles into the analysis, following a rigorous quality appraisal and relevance assessment. The outcomes of the synthesis were new constructs for the measurement of continuum of care for maternal health, derived from the existing knowledge gaps. Results We learned that coverage was the main approach for measuring and monitoring the continuum of care for maternal health in LMICs. The measure of effective coverage was also used to integrate quality into coverage of care. Like coverage, there was no uniform definition of effective coverage, and we observed gaps in the measurement of multiple dimensions of quality. From the evidence, we derived a new construct called adequacy that incorporated timeliness of care, coverage, and the complex nature of quality. We described the implications of adequacy to the measurement of the continuum of care for maternal health in South Africa. Conclusions Critical interpretive synthesis allowed new understandings of measurement of the continuum of care for maternal health in South Africa. The new construct of adequacy can be the basis of a new measure of access to the continuum of care for maternal health. Although adequacy conceptualizes a more holistic approach, more research is needed to derive its indicators and metrics using South African data sources. Electronic supplementary material The online version of this article (10.1186/s12913-018-3278-4) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
| | - Lucia Knight
- University of the Western Cape, Robert Sobukwe Road, Bellville, 7535, South Africa
| | - Hanani Tabana
- University of the Western Cape, Robert Sobukwe Road, Bellville, 7535, South Africa
| |
Collapse
|
41
|
Garchitorena A, Miller AC, Cordier LF, Rabeza VR, Randriamanambintsoa M, Razanadrakato HTR, Hall L, Gikic D, Haruna J, McCarty M, Randrianambinina A, Thomson DR, Atwood S, Rich ML, Murray MB, Ratsirarson J, Ouenzar MA, Bonds MH. Early changes in intervention coverage and mortality rates following the implementation of an integrated health system intervention in Madagascar. BMJ Glob Health 2018; 3:e000762. [PMID: 29915670 PMCID: PMC6001915 DOI: 10.1136/bmjgh-2018-000762] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 04/24/2018] [Accepted: 04/27/2018] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION The Sustainable Development Goals framed an unprecedented commitment to achieve global convergence in child and maternal mortality rates through 2030. To meet those targets, essential health services must be scaled via integration with strengthened health systems. This is especially urgent in Madagascar, the country with the lowest level of financing for health in the world. Here, we present an interim evaluation of the first 2 years of a district-level health system strengthening (HSS) initiative in rural Madagascar, using estimates of intervention coverage and mortality rates from a district-wide longitudinal cohort. METHODS We carried out a district representative household survey at baseline of the HSS intervention in over 1500 households in Ifanadiana district. The first follow-up was after the first 2 years of the initiative. For each survey, we estimated maternal, newborn and child health (MNCH) coverage, healthcare inequalities and child mortality rates both in the initial intervention catchment area and in the rest of the district. We evaluated changes between the two areas through difference-in-differences analyses. We estimated annual changes in health centre per capita utilisation from 2013 to 2016. RESULTS The intervention was associated with 19.1% and 36.4% decreases in under-five and neonatal mortality, respectively, although these were not statistically significant. The composite coverage index (a summary measure of MNCH coverage) increased by 30.1%, with a notable 63% increase in deliveries in health facilities. Improvements in coverage were substantially larger in the HSS catchment area and led to an overall reduction in healthcare inequalities. Health centre utilisation rates in the catchment tripled for most types of care during the study period. CONCLUSION At the earliest stages of an HSS intervention, the rapid improvements observed for Ifanadiana add to preliminary evidence supporting the untapped and poorly understood potential of integrated HSS interventions on population health.
Collapse
Affiliation(s)
- Andres Garchitorena
- UMR 224 MIVEGEC, Institut de Recherche pour le Developpement, Montpellier, France
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
- PIVOT, Ranomafana, Madagascar
| | - Ann C Miller
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Victor R Rabeza
- Direction de la Démographie et des Statistiques Sociales, Institut National de la Statistique, Antananarivo, Madagascar
| | - Marius Randriamanambintsoa
- Direction de la Démographie et des Statistiques Sociales, Institut National de la Statistique, Antananarivo, Madagascar
| | - Hery-Tiana R Razanadrakato
- Direction de la Démographie et des Statistiques Sociales, Institut National de la Statistique, Antananarivo, Madagascar
| | | | | | | | | | | | - Dana R Thomson
- Social Statistics Department, University of Southampton, Southampton, UK
| | - Sidney Atwood
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael L Rich
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Megan B Murray
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Josea Ratsirarson
- Ministère de la Sante Publique de Madagascar, Antananarivo, Madagascar
| | | | - Matthew H Bonds
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
- PIVOT, Ranomafana, Madagascar
| |
Collapse
|
42
|
Countdown to 2030: tracking progress towards universal coverage for reproductive, maternal, newborn, and child health. Lancet 2018; 391:1538-1548. [PMID: 29395268 DOI: 10.1016/s0140-6736(18)30104-1] [Citation(s) in RCA: 270] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 12/11/2017] [Accepted: 12/14/2017] [Indexed: 01/04/2023]
Abstract
Building upon the successes of Countdown to 2015, Countdown to 2030 aims to support the monitoring and measurement of women's, children's, and adolescents' health in the 81 countries that account for 95% of maternal and 90% of all child deaths worldwide. To achieve the Sustainable Development Goals by 2030, the rate of decline in prevalence of maternal and child mortality, stillbirths, and stunting among children younger than 5 years of age needs to accelerate considerably compared with progress since 2000. Such accelerations are only possible with a rapid scale-up of effective interventions to all population groups within countries (particularly in countries with the highest mortality and in those affected by conflict), supported by improvements in underlying socioeconomic conditions, including women's empowerment. Three main conclusions emerge from our analysis of intervention coverage, equity, and drivers of reproductive, maternal, newborn, and child health (RMNCH) in the 81 Countdown countries. First, even though strong progress was made in the coverage of many essential RMNCH interventions during the past decade, many countries are still a long way from universal coverage for most essential interventions. Furthermore, a growing body of evidence suggests that available services in many countries are of poor quality, limiting the potential effect on RMNCH outcomes. Second, within-country inequalities in intervention coverage are reducing in most countries (and are now almost non-existent in a few countries), but the pace is too slow. Third, health-sector (eg, weak country health systems) and non-health-sector drivers (eg, conflict settings) are major impediments to delivering high-quality services to all populations. Although more data for RMNCH interventions are available now, major data gaps still preclude the use of evidence to drive decision making and accountability. Countdown to 2030 is investing in improvements in measurement in several areas, such as quality of care and effective coverage, nutrition programmes, adolescent health, early childhood development, and evidence for conflict settings, and is prioritising its regional networks to enhance local analytic capacity and evidence for RMNCH.
Collapse
|
43
|
Silva ICMD, Restrepo-Mendez MC, Costa JC, Ewerling F, Hellwig F, Ferreira LZ, Ruas LPV, Joseph G, Barros AJD. Measurement of social inequalities in health: concepts and methodological approaches in the Brazilian context. EPIDEMIOLOGIA E SERVIÇOS DE SAÚDE 2018; 27:e000100017. [PMID: 29513856 PMCID: PMC7705122 DOI: 10.5123/s1679-49742018000100017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
This study aims to describe methodological approaches to measure and monitor health inequalities and to illustrate their applicability. The measures most frequently used in the literature were reviewed. Data on coverage and quality of pre-natal care in Brazil, from the Demographic and Maternal and Child Health Survey (PNDS-2006) and the National Health Survey (PNS-2013) were used to illustrate their applicability. Absolute and relative measures of inequalities were presented, highlighting their complementary character. Despite the progress achieved in the national indicators of pre-natal care, important inequalities were still identified between population subgroups, with no change in the magnitude of the differences throughout the studied period. Brazil has important social inequalities, whose consequences still lead to health inequalities. Their description and monitoring are highly relevant to support polices focused on those vulnerable population groups who have been left behind.
Collapse
Affiliation(s)
- Inácio Crochemore Mohnsam da Silva
- Universidade Federal de Pelotas, Programa de Pós-graduação em Epidemiologia, Centro Internacional de Equidade em Saúde, Pelotas, RS, Brasil
| | - Maria Clara Restrepo-Mendez
- Universidade Federal de Pelotas, Programa de Pós-graduação em Epidemiologia, Centro Internacional de Equidade em Saúde, Pelotas, RS, Brasil
| | - Janaína Calu Costa
- Universidade Federal de Pelotas, Programa de Pós-graduação em Epidemiologia, Centro Internacional de Equidade em Saúde, Pelotas, RS, Brasil
| | - Fernanda Ewerling
- Universidade Federal de Pelotas, Programa de Pós-graduação em Epidemiologia, Centro Internacional de Equidade em Saúde, Pelotas, RS, Brasil
| | - Franciele Hellwig
- Universidade Federal de Pelotas, Programa de Pós-graduação em Epidemiologia, Centro Internacional de Equidade em Saúde, Pelotas, RS, Brasil
| | - Leonardo Zanini Ferreira
- Universidade Federal de Pelotas, Programa de Pós-graduação em Epidemiologia, Centro Internacional de Equidade em Saúde, Pelotas, RS, Brasil
| | - Luis Paulo Vidaletti Ruas
- Universidade Federal de Pelotas, Programa de Pós-graduação em Epidemiologia, Centro Internacional de Equidade em Saúde, Pelotas, RS, Brasil
| | - Gary Joseph
- Universidade Federal de Pelotas, Programa de Pós-graduação em Epidemiologia, Centro Internacional de Equidade em Saúde, Pelotas, RS, Brasil
| | - Aluísio J D Barros
- Universidade Federal de Pelotas, Programa de Pós-graduação em Epidemiologia, Centro Internacional de Equidade em Saúde, Pelotas, RS, Brasil
| |
Collapse
|
44
|
Hogan DR, Stevens GA, Hosseinpoor AR, Boerma T. Monitoring universal health coverage within the Sustainable Development Goals: development and baseline data for an index of essential health services. LANCET GLOBAL HEALTH 2017; 6:e152-e168. [PMID: 29248365 DOI: 10.1016/s2214-109x(17)30472-2] [Citation(s) in RCA: 201] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 11/20/2017] [Accepted: 11/27/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Achieving universal health coverage, including quality essential service coverage and financial protection for all, is target 3.8 of the Sustainable Development Goals (SDG). As a result, an index of essential health service coverage indicators was selected by the UN as SDG indicator 3.8.1. We have developed an index for measuring SDG 3.8.1, describe methods for compiling the index, and report baseline results for 2015. METHODS 16 tracer indicators were selected for the index, which included four from within each of the categories of reproductive, maternal, newborn, and child health; infectious disease; non-communicable diseases; and service capacity and access. Indicator data for 183 countries were taken from UN agency estimates or databases, supplemented with submissions from national focal points during a WHO country consultation. The index was computed using geometric means, and a subset of tracer indicators were used to summarise inequalities. FINDINGS On average, countries had primary data since 2010 for 72% of the final set of indicators. The median national value for the service coverage index was 65 out of 100 (range 22-86). The index was highly correlated with other summary measures of health, and after controlling for gross national income and mean years of adult education, was associated with 21 additional years of life expectancy over the observed range of country values. Across 52 countries with sufficient data, coverage was 1% to 66% lower among the poorest quintile as compared with the national population. Sensitivity analyses suggested ranks implied by the index are fairly stable across alternative calculation methods. INTERPRETATION Service coverage within universal health coverage can be measured with an index of tracer indicators. Our universal health coverage service coverage index is simple to compute by use of available country data and can be refined to incorporate relevant indicators as they become available through SDG monitoring. FUNDING Ministry of Health, Japan, and the Rockefeller Foundation.
Collapse
Affiliation(s)
| | | | | | - Ties Boerma
- Department of Community and Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| |
Collapse
|
45
|
Carvajal–Aguirre L, Amouzou A, Mehra V, Ziqi M, Zaka N, Newby H. Gap between contact and content in maternal and newborn care: An analysis of data from 20 countries in sub-Saharan Africa. J Glob Health 2017; 7:020501. [PMID: 29423178 PMCID: PMC5804037 DOI: 10.7189/jogh.07.020501] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Over the last decade, coverage of maternal and newborn health indicators used for global monitoring and reporting have increased substantially but reductions in maternal and neonatal mortality have remained slow. This has led to an increased recognition and concern that these standard globally agreed upon measures of antenatal care (ANC), skilled birth attendance (SBA) and postnatal care (PNC) only capture the level of contacts with the health system and provide little indication of actual content of services received by mothers and their newborns. Over this period, large household surveys have captured measures of maternal and newborn care mainly through questions assessing contacts during the antenatal, delivery and postnatal periods along with some measures of content of care. This study aims to describe the gap between contact and content -as a proxy for quality- of maternal and newborn health services by assessing level of co-coverage of ANC and PNC interventions. METHODS We used Demographic and Health Surveys (DHS) data from 20 countries between 2010 and 2015. We analysed the proportion of women with at least 1 and 4+ antenatal care visit, who received 8 interventions. We also assessed the percentage of newborns delivered with a skilled birth attendant who received 7 interventions. We ran random effect logistic regression to assess factors associated with receiving all interventions during the antenatal and postnatal period. RESULTS While on average 51% of women in the analysis received four ANC visits with at least one visit from a skilled health provider, only 5% of them received all 8 ANC interventions. Similarly, during the postnatal period though two-thirds (65%) of births were attended by a skilled birth attendant, only 3% of newborns received all 7 PNC interventions. The odds of receiving all ANC and PNC interventions were higher for women with higher education and higher wealth status. CONCLUSION The gap between coverage and content as a proxy of quality of antenatal and postnatal care is excessively large in all countries. In order to accelerate maternal and newborn survival and achieve Sustainable Development Goals, increased efforts are needed to improve both the coverage and quality of maternal and newborn health interventions.
Collapse
Affiliation(s)
| | - Agbessi Amouzou
- Institute for International Programs, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Vrinda Mehra
- Data and Analytics, Division of Data, Research and Policy, UNICEF, New York, New York, USA
| | - Meng Ziqi
- Data and Analytics, Division of Data, Research and Policy, UNICEF, New York, New York, USA
| | - Nabila Zaka
- UNICEF, Program Division, New York, New York, USA
| | | |
Collapse
|
46
|
Wehrmeister FC, da Silva ICM, Barros AJD, Victora CG. Is governance, gross domestic product, inequality, population size or country surface area associated with coverage and equity of health interventions? Ecological analyses of cross-sectional surveys from 80 countries. BMJ Glob Health 2017; 2:e000437. [PMID: 29225951 PMCID: PMC5717925 DOI: 10.1136/bmjgh-2017-000437] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 08/31/2017] [Accepted: 09/18/2017] [Indexed: 11/18/2022] Open
Abstract
Objective To assess associations between national characteristics, including governance indicators, with a proxy for universal health coverage in reproductive, maternal, newborn and child health (RMNCH). Design Ecological analysis based on data from national standardised cross-sectional surveys. Setting Low-income and middle-income countries with a Demographic and Health Survey or a Multiple Indicator Cluster Survey since 2005. Participants 1 246 710 mothers and 2 129 212 children from 80 national surveys. Exposures of interest Gross domestic product (GDP), country surface area, population, Gini index and six governance indicators (control of corruption, political stability and absence of violence, government effectiveness, regulatory quality, rule of law, and voice and accountability). Main outcomes Levels and inequality in the composite coverage index (CCI), a weighted average of eight RMNCH interventions. Relative and absolute inequalities were measured through the concentration index (CIX) and slope index of inequality (SII) for CCI, respectively. Results The average values of CCI (70.5% (SD=13.3)), CIX (5.3 (SD=5.1)) and mean slope index (19.8 (SD=14.7)) were calculated. In the unadjusted analysis, all governance variables and GDP were positively associated with the CCI and negatively with inequalities. Country surface showed inverse associations with both inequality indices. After adjustment, among the governance indicators, only political stability and absence of violence was directly related to CCI (β=6.3; 95% CI 3.6 to 9.1; p<0.001) and inversely associated with relative (CIX; β=−1.4; 95% CI −2.4 to −0.4; p=0.007) and absolute (SII; β=−5.3; 95% CI –8.9 to −1.7; p=0.005) inequalities. The strongest associations with governance indicators were found in the poorest wealth quintile. Similar patterns were observed for GDP. Country surface area was inversely related to inequalities on CCI. Conclusions Levels and equity in RMNCH interventions are positively associated with political stability and absence of violence, and with GDP, and inversely associated with country surface area.
Collapse
Affiliation(s)
- Fernando C Wehrmeister
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
| | | | - Aluisio J D Barros
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
| | - Cesar G Victora
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
| |
Collapse
|
47
|
Rahman MM, Karan A, Rahman MS, Parsons A, Abe SK, Bilano V, Awan R, Gilmour S, Shibuya K. Progress Toward Universal Health Coverage: A Comparative Analysis in 5 South Asian Countries. JAMA Intern Med 2017; 177:1297-1305. [PMID: 28759681 PMCID: PMC5710570 DOI: 10.1001/jamainternmed.2017.3133] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
IMPORTANCE Achieving universal health coverage is one of the key targets in the newly adopted Sustainable Development Goals of the United Nations. OBJECTIVE To investigate progress toward universal health coverage in 5 South Asian countries and assess inequalities in health services and financial risk protection indicators. DESIGN AND SETTINGS In a population-based study, nationally representative household (335 373 households) survey data from Afghanistan (2014 and 2015), Bangladesh (2010 and 2014), India (2012 and 2014), Nepal (2014 and 2015), and Pakistan (2014) were used to calculate relative indices of health coverage, financial risk protection, and inequality in coverage among wealth quintiles. The study was conducted from June 2012 to February 2016. MAIN OUTCOMES AND MEASURES Three dimensions of universal health coverage were assessed: access to basic services, financial risk protection, and equity. Composite and indicator-specific coverage rates, stratified by wealth quintiles, were then estimated. Slope and relative index of inequality were used to assess inequalities in service and financial indicators. RESULTS Access to basic care varied substantially across all South Asian countries, with mean rates of overall prevention coverage and treatment coverage of 53.0% (95% CI, 42.2%-63.6%) and 51.2% (95% CI, 45.2%-57.1%) in Afghanistan, 76.5% (95% CI, 61.0%-89.0%) and 44.8% (95% CI, 37.1%-52.5%) in Bangladesh, 74.2% (95% CI, 57.0%-88.1%) and 83.5% (95% CI, 54.4%-99.1%) in India, 76.8% (95% CI, 66.5%-85.7%) and 57.8% (95% CI, 50.1%-65.4%) in Nepal, and 69.8% (95% CI, 58.3%-80.2%) and 50.4% (95% CI, 37.1%-63.6%) in Pakistan. Financial risk protection was generally low, with 15.3% (95% CI, 14.7%-16.0%) of respondents in Afghanistan, 15.8% (95% CI, 14.9%-16.8%) in Bangladesh, 17.9% (95% CI, 17.7%-18.2%) in India, 11.8% (95% CI, 11.8%-11.9%) in Nepal, and 4.4% (95% CI, 4.0%-4.9%) in Pakistan reporting incurred catastrophic payments due to health care costs. Access to at least 4 antenatal care visits, institutional delivery, and presence of skilled attendant during delivery were at least 3 times higher among the wealthiest mothers in Afghanistan, Bangladesh, Nepal, and Pakistan compared with the rates among poor mothers. Access to institutional delivery was 60 to 65 percentage points higher among wealthy than poor mothers in Afghanistan, Bangladesh, Nepal, and Pakistan compared with 21 percentage points higher in India. Coverage was least equitable among the countries for adequate sanitation, institutional delivery, and the presence of skilled birth attendants. CONCLUSIONS AND RELEVANCE Health coverage and financial risk protection was low, and inequality in access to health care remains a serious issue for these South Asian countries. Greater progress is needed to improve treatment and preventive services and financial security.
Collapse
Affiliation(s)
- Md Mizanur Rahman
- Department of Global Health Policy, School of International Health, The University of Tokyo, Tokyo, Japan.,Department of Population Science and Human Resource Development, University of Rajshahi, Rajshahi, Bangladesh
| | - Anup Karan
- Indian Institute of Public Health Delhi, Public Health Foundation of India, Delhi, India
| | - Md Shafiur Rahman
- Department of Global Health Policy, School of International Health, The University of Tokyo, Tokyo, Japan
| | - Alexander Parsons
- Department of Global Health Policy, School of International Health, The University of Tokyo, Tokyo, Japan
| | - Sarah Krull Abe
- Department of Global Health Policy, School of International Health, The University of Tokyo, Tokyo, Japan
| | - Ver Bilano
- Department of Epidemiology and Biostatistics, Imperial College London, London, England
| | - Rabia Awan
- Pakistan Bureau of Statistics, Islamabad, Pakistan
| | - Stuart Gilmour
- Department of Global Health Policy, School of International Health, The University of Tokyo, Tokyo, Japan
| | - Kenji Shibuya
- Department of Global Health Policy, School of International Health, The University of Tokyo, Tokyo, Japan
| |
Collapse
|
48
|
Victora CG, Barros AJD, França GVA, da Silva ICM, Carvajal-Velez L, Amouzou A. The contribution of poor and rural populations to national trends in reproductive, maternal, newborn, and child health coverage: analyses of cross-sectional surveys from 64 countries. LANCET GLOBAL HEALTH 2017; 5:e402-e407. [PMID: 28238719 PMCID: PMC5565524 DOI: 10.1016/s2214-109x(17)30077-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 12/05/2016] [Accepted: 01/09/2017] [Indexed: 11/29/2022]
Abstract
Background Coverage levels for essential interventions aimed at reducing deaths of mothers and children are increasing steadily in most low-income and middle-income countries. We assessed how much poor and rural populations in these countries are benefiting from national-level progress. Methods We analysed trends in a composite coverage indicator (CCI) based on eight reproductive, maternal, newborn, and child health interventions in 209 national surveys in 64 countries, from Jan 1, 1994, to Dec 31, 2014. Trends by wealth quintile and urban or rural residence were fitted with multilevel modelling. We used an approach akin to the calculation of population attributable risk to quantify the contribution of poor and rural populations to national trends. Findings From 1994 to 2014, the CCI increased by 0·82 percent points a year across all countries; households in the two poorest quintiles had an increase of 0·99 percent points a year, which was faster than that for the three wealthiest quintiles (0·68 percent points). Gains among poor populations were faster in lower-middle-income and upper-middle-income countries than in low-income countries. Globally, national level increases in CCI were 17·5% faster than they would have been without the contribution of the two poorest quintiles. Coverage increased more rapidly annually in rural (0·93 percent points) than urban (0·52 percent points) areas. Interpretation National coverage gains were accelerated by important increases among poor and rural mothers and children. Despite progress, important inequalities persist, and need to be addressed to achieve the Sustainable Development Goals. Funding UNICEF, Wellcome Trust.
Collapse
Affiliation(s)
- Cesar G Victora
- International Center for Equity in Health, Post-Graduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil.
| | - Aluisio J D Barros
- International Center for Equity in Health, Post-Graduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
| | - Giovanny V A França
- International Center for Equity in Health, Post-Graduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
| | - Inácio C M da Silva
- International Center for Equity in Health, Post-Graduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
| | | | | |
Collapse
|