Measuring health inequality among children in developing countries: does the choice of the indicator of economic status matter?

Background Currently, poor-rich inequalities in health in developing countries receive a lot of attention from both researchers and policy makers. Since measuring economic status in developing countries is often problematic, different indicators of wealth are used in different studies. Until now, there is a lack of evidence on the extent to which the use of different measures of economic status affects the observed magnitude of health inequalities. Methods This paper provides this empirical evidence for 10 developing countries, using the Demographic and Health Surveys data-set. We compared the World Bank asset index to three alternative wealth indices, all based on household assets. Under-5 mortality and measles immunisation coverage were the health outcomes studied. Poor-rich inequalities in under-5 mortality and measles immunisation coverage were measured using the Relative Index of Inequality. Results Comparing the World Bank index to the alternative indices, we found that (1) the relative position of households in the national wealth hierarchy varied to an important extent with the asset index used, (2) observed poor-rich inequalities in under-5 mortality and immunisation coverage often changed, in some cases to an important extent, and that (3) the size and direction of this change varied per country, index, and health indicator. Conclusion Researchers and policy makers should be aware that the choice of the measure of economic status influences the observed magnitude of health inequalities, and that differences in health inequalities between countries or time periods, may be an artefact of different wealth measures used

The training and development needs of midwives in Indonesia: paper 2 of 3

BACKGROUND: There is a shortfall in midwives in Indonesia (an estimated 26 per 100 000 people), which means that the quality of antenatal, perinatal and postnatal care varies widely. One consequence of this is the high rate of maternal and perinatal mortality, which has prompted a number of health initiatives. The current study was part of a review of the existing complex system of midwifery training and the development of a coherent programme of continuing professional development, tighter accreditation regulations and clearer professional roles. Its aims were to identify the occupational profiles and development needs of the participating midwives, and to establish whether any differences existed between grades, geographical location and hospital/community midwives. METHODS: A psychometrically valid training-needs instrument was administered to 332 midwives from three provinces, covering both hospital and community staff and a range of midwifery grades. The instrument had the capacity to identify occupational roles and education/training needs of the respondents. RESULTS: The occupational roles of the midwives varied significantly by province, indicating regional service delivery distinctions, but very little difference in the roles of hospital and community midwives. The most educated midwives attributed more importance to 35 out of the 40 tasks, suggesting an implicit role distinction in terms of level of activity. All midwives reported significant training needs for all 40 tasks. The most-educated midwives recorded training needs for 24 tasks, while the less-educated had training requirements for all tasks, which suggests that new training programmes are effective. Few differences in training needs were revealed between hospital and community midwives CONCLUSION: The results from this survey suggest important regional differences in how the midwife's role is discharged and underline the importance of this sort of research, in order to ensure the suitability of basic and postbasic educational provision. The study also highlights the need for further development and training of midwives in a wide range of tasks. These results provide a systematic and reliable overview of current midwifery roles and development needs and could serve to inform future training

Addressing Inequity to Achieve the Maternal and Child Health Millennium Development Goals: Looking Beyond Averages.

Inequity in access to and use of child and maternal health interventions is impeding progress towards the maternal and child health Millennium Development Goals. This study explores the potential health gains and equity impact if a set of priority interventions for mothers and under fives were scaled up to reach national universal coverage targets for MDGs in Tanzania. We used the Lives Saved Tool (LiST) to estimate potential reductions in maternal and child mortality and the number of lives saved across wealth quintiles and between rural and urban settings. High impact maternal and child health interventions were modelled for a five-year scale up, by linking intervention coverage, effectiveness and cause of mortality using data from Tanzania. Concentration curves were drawn and the concentration index estimated to measure the equity impact of the scale up. In the poorest population quintiles in Tanzania, the lives of more than twice as many mothers and under-fives were likely to be saved, compared to the richest quintile. Scaling up coverage to equal levels across quintiles would reduce inequality in maternal and child mortality from a pro rich concentration index of -0.11 (maternal) and -0.12 (children) to a more equitable concentration index of -0,03 and -0.03 respectively. In rural areas, there would likely be an eight times greater reduction in maternal deaths than in urban areas and a five times greater reduction in child deaths than in urban areas. Scaling up priority maternal and child health interventions to equal levels would potentially save far more lives in the poorest populations, and would accelerate equitable progress towards maternal and child health MDGs

Issues in the construction of wealth indices for the measurement of socio-economic position in low-income countries

BACKGROUND: Epidemiological studies often require measures of socio-economic position (SEP). The application of principal components analysis (PCA) to data on asset-ownership is one popular approach to household SEP measurement. Proponents suggest that the approach provides a rational method for weighting asset data in a single indicator, captures the most important aspect of SEP for health studies, and is based on data that are readily available and/or simple to collect. However, the use of PCA on asset data may not be the best approach to SEP measurement. There remains concern that this approach can obscure the meaning of the final index and is statistically inappropriate for use with discrete data. In addition, the choice of assets to include and the level of agreement between wealth indices and more conventional measures of SEP such as consumption expenditure remain unclear. We discuss these issues, illustrating our examples with data from the Malawi Integrated Household Survey 2004-5. METHODS: Wealth indices were constructed using the assets on which data are collected within Demographic and Health Surveys. Indices were constructed using five weighting methods: PCA, PCA using dichotomised versions of categorical variables, equal weights, weights equal to the inverse of the proportion of households owning the item, and Multiple Correspondence Analysis. Agreement between indices was assessed. Indices were compared with per capita consumption expenditure, and the difference in agreement assessed when different methods were used to adjust consumption expenditure for household size and composition. RESULTS: All indices demonstrated similarly modest agreement with consumption expenditure. The indices constructed using dichotomised data showed strong agreement with each other, as did the indices constructed using categorical data. Agreement was lower between indices using data coded in different ways. The level of agreement between wealth indices and consumption expenditure did not differ when different consumption equivalence scales were applied. CONCLUSION: This study questions the appropriateness of wealth indices as proxies for consumption expenditure. The choice of data included had a greater influence on the wealth index than the method used to weight the data. Despite the limitations of PCA, alternative methods also all had disadvantages

Equity in community health insurance schemes: evidence and lessons from Armenia

Introduction Community health insurance (CHI) schemes are growing in importance in low-income settings, where health systems based on user fees have resulted in significant barriers to care for the poorest members of communities. They increase revenue, access and financial protection, but concerns have been expressed about the equity of such schemes and their ability to reach the poorest. Few programmes routinely evaluate equity impacts, even though this is usually a key objective. This lack of evidence is related to the difficulties in collecting reliable data on utilization and socio-economic status. This paper describes the findings of an evaluation of the equity of Oxfam's CHI schemes in rural Armenia

Maternal deaths in Pakistan : intersection of gender, class and social exclusion.

Background: A key aim of countries with high maternal mortality rates is to increase availability of competent maternal health care during pregnancy and childbirth. Yet, despite significant investment, countries with the highest burdens have not reduced their rates to the expected levels. We argue, taking Pakistan as a case study, that improving physical availability of services is necessary but not sufficient for reducing maternal mortality because gender inequities interact with caste and poverty to socially exclude certain groups of women from health services that are otherwise physically available. Methods: Using a critical ethnographic approach, two case studies of women who died during childbirth were pieced together from information gathered during the first six months of fieldwork in a village in Northern Punjab, Pakistan. Findings: Shida did not receive the necessary medical care because her heavily indebted family could not afford it. Zainab, a victim of domestic violence, did not receive any medical care because her martial family could not afford it, nor did they think she deserved it. Both women belonged to lower caste households, which are materially poor households and socially constructed as inferior. Conclusions: The stories of Shida and Zainab illustrate how a rigidly structured caste hierarchy, the gendered devaluing of females, and the reinforced lack of control that many impoverished women experience conspire to keep women from lifesaving health services that are physically available and should be at their disposal

Economic Status, Education and Empowerment: Implications for Maternal Health Service Utilization in Developing Countries

, and maternal health service utilization in developing countries. are significantly associated with utilization of maternal health services. The odds of having a skilled attendant at delivery for women in the poorest wealth quintile are 94% lower than that for women in the highest wealth quintile and almost 5 times higher for women with complete primary education relative to those less educated. The likelihood of using modern contraception and attending four or more antenatal care visits are 2.01 and 2.89 times, respectively, higher for women with complete primary education than for those less educated. Women with the highest empowerment score are between 1.31 and 1.82 times more likely than those with a null empowerment score to use modern contraception, attend four or more antenatal care visits and have a skilled attendant at birth.Efforts to expand maternal health service utilization can be accelerated by parallel investments in programs aimed at poverty eradication (MDG 1), universal primary education (MDG 2), and women's empowerment (MDG 3)

Providing free maternal health care: ten lessons from an evaluation of the national delivery exemption policy in Ghana

Background: There is a growing movement, globally and in the Africa region, to reduce financial barriers to health care generally, but with particular emphasis on high priority services and vulnerable groups. Objective: This article reports on the experience of implementing a national policy to exempt women from paying for delivery care in public, mission and private health facilities in Ghana. Design: Using data from a complex evaluation which was carried out in 2005-2006, lessons are drawn which can inform other countries starting or planning to implement similar service-based exemption policies. Results: On the positive side, the experience of Ghana suggests that delivery exemptions can be effective and cost-effective, and that despite being universal in application, they can benefit the poor. However, certain ‘negative’ lessons are also drawn from the Ghana case study, particularly on the need for adequate funding, and for strong institutional ownership. It is also important to monitor the financial transfers which reach households, to ensure that providers are passing on benefits in full, while being adequately reimbursed themselves for their loss of revenue. Careful consideration should also be given to staff motivation and the role of different providers, as well as quality of care constraints, when designing the exemptions policy. All of this should be supported by a proactive approach to monitoring and evaluation. Conclusion: The recent movement towards making delivery care free to all women is a bold and timely action which is supported by evidence from within and beyond Ghana. However, the potential for this to translate into reduced mortality for mothers and babies fundamentally depends on the effectiveness of its implementation

Quality or equality? The Norwegian experience with medical monopolies

BACKGROUND: In order to maintain both quality and efficiency of health services in a small country with a scattered population, Norway established a monopoly system for 38 highly specialized medical services. The geographical distributions of these services, which are provided by one or two university hospitals only, were analysed. METHODS: The counties of residence for 2 711 patients admitted for the first time in 2001 to these 31 monopolies and 7 duopolies were identified. RESULTS: The general tendency observed was that with increasing distance from residential home to monopoly hospitals there was a declining coverage of these health services. The same pattern was found even with regard to explicit diagnoses or treatments such as organ transplantations (except renal transplantations). Duopolies seemed to yield a more even geographical distribution of the services. CONCLUSION: Monopolies may serve as a useful means for maintaining quality in highly specialized medical services, but seem to have an inherent tendency to do this at the expense of geographical equality

Does health intervention improve socioeconomic inequalities of neonatal, infant and child mortality? Evidence from Matlab, Bangladesh

<p>Abstract</p> <p>Background</p> <p>Although there are wide variations in mortality between developed and developing countries, socioeconomic inequalities in health exist in both the societies. The study examined socioeconomic inequalities of neonatal, infant and child mortality using data from the Matlab Health and Demographic Surveillance System of the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B).</p> <p>Methods</p> <p>Four birth cohorts (1983–85, 1988–90, 1993–95, 1998–00) were followed for five years for death and out-migration in two adjacent areas (ICDDR,B-service and government-service) with similar socioeconomic but differ health services. Based on asset quintiles, inequality was measured through both poor-rich ratio and concentration index.</p> <p>Results</p> <p>The study found that the socioeconomic inequalities of neonatal, infant and under-five mortality increased over time in both the ICDDR,B-service and government-service areas but it declined substantially for 1–4 years in the ICDDR,B- service area.</p> <p>Conclusion</p> <p>The study concluded that usual health intervention programs (non-targeted) do not reduce poor-rich gap, rather the gap increases initially but might decrease in long run if the program is very intensive.</p