Assessment of equity in provision and utilization of maternal and child health programs in butajira, southern ethiopia

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I. Introduction

Equity in health implies that ideally everyone should have a fair opportunity to attain his or her full health potential and, that no one should be disadvantaged from achieving this potential, if it can be avoided. Equity in public health is that the primary determinant in the use of services should be the need for them. Other factors such as income, race, location of residence and so forth should not play an important role in selecting who receives care and who does not. Equity in access to and use of health services is commonly an important goal for policymakers in most countries (1,2).
Equity cannot simply be identified with equality of treatment in general, because of differences in need; but if need for a services is uniformly distributed across all groups of society, the rate of utilization of the services should be equal. If the rates of utilization of certain services by different social groups are found to be different, it is an indication that further study is needed to ascertain why the utilization rates are different. But, where use of services is restricted by social or economic disadvantage, there is a case for aiming for equal utilization rates for equal need. For instance, in relation to immunization and other preventive services, positive discrimination may be justified in providing outreach and other imaginative schemes to make it easier for people to use services in low uptake areas.
Understanding the hampering impact of poverty on the ability and willingness to pay of the poor, most governments planned to provide basic preventive Maternal and child health services, such as vaccination for children and antenatal care and postnatal care among all pregnant women, free of charge.
However, various studies have shown the distribution of poverty, race, rural residence, urbanization and homelessness, family stability, migration, education, information and skills for prevention and access to health care as having effect on distribution of morbidity and mortality (3-5).
Even when Primary Health Care services are provided for free or at subsidized price, various demographic, socio-economic and geographic factors affect utilization by target communities. Low income is associated with lower levels of education, and low education is associated with exposure. Mothers having at least some schooling were more likely to have their children vaccinated, to take them to health facility for treatment, to receive maternal preventive services and to have less chance of under-five child death. Rural residents have lower access to health facilities and other promotional activities that are urban based as well as to education as well as have increased distance from health facility with increase in transportation cost and lost production time.
Public health services are often thought to cater primarily to the poor while the rich go to private sector but the government health service expenditure tends to provide greater benefit to the rich than the poor and health services provided free at point of contact have benefited richer over poorer groups which may be because of the significant amount of indirect and intangible service cost, though the direct service cost is free, that can hinder the lower income group from using the service.
The health policy of Ethiopia emphasizes universal access for all segments of population, but the health service is characterized by low coverage of 64% (6, 7). A study in rural Ethiopia showed those in urban area, those with higher asset score, and males were significantly more likely to visit higher-level health facilities (8).
Generating data on equity in the distribution of Primary Health Care programs and on the factors affecting this distribution is of vital operational importance. This is particularly true in developing countries such as Ethiopia, where emphasis on equitable distribution of basic health services is currently established as one of the major prerequisites of poverty reduction initiatives.

II. Literature Review and Statement of the Problem

2.1. Literature Review

The urban – rural gross inequities in the distribution of health facilities and benefits has resulted in a situation where the rural majority suffer poor health, but receive little health care, while the better urban minority receive the benefits of wide health related facilities and services in developing countries. This situation gave raise to the concept of primary health care approach with fundamental principle to narrow health equity gaps, focus on preventive health service, and aimed at universal coverage among which MCH was identified as one of the " essential components of PHC" (9, 10).

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The fundamental idea of equity is that of equal treatment for all section of the population with the intention to assure good health for all and equally good health to be pursued through preventive or curative treatment. Equity cannot simply be identified with equality in general, because of differences in need, but is equality of treatment for equal need (11).

There is no single measure to gauge equity in the distribution of health care system. It might be carried out by distribution of health resources, health expenditures, morbidity and mortality, or need for basic preventive care services. The distribution of need for basic preventive services such as vaccination for EPI among all under five children, ANC follow up among all pregnant women can be judged to have inequity as these services are equally needed by all children and mothers (11).
Health status is unequally distributed across the countries of African region, and within countries across race, class, gender and geographical area. Low income, black and rural communities have been documented to have consistently higher rates of Tuberculosis, malnutrition, mortality, water related diseases and other morbidity and mortality indicators in the region (4, 12-16).
Health differentials exist between male and female, urban and rural, between social groups with different levels of education, between races and between poor and non-poor (17, 18). A study in south western Ethiopia has found that about 63% of ANC attendants were urban mothers; and 59% of children immunized for BCG, 65% of children immunized for DPT3, and 84% of children immunized for measles were urban residents (19). Another study in northwest Ethiopia has reported that women who reside in rural areas were less likely to use safe delivery service than their urban counterparts (OR=0.03, 95%CI: 0.02, 0.05) (20). One study in Peru showed that there were a large inequity in vaccination for EPI across urban and rural children with urban rural differential of 2:1 for BCG and Measles and nearly 4:1 for polio and DPT with similar pattern in mountainous and jungle areas, which indicated the low coverage and poor protection received by rural children (21).
Women living in urban areas are generally twice as likely as those living in rural areas to report four or more antenatal care visits. Overall, some 86% of women in urban areas report at least one antenatal visit and 61% report four or more visits. By contrast, the figures for women in rural areas are only 65% and 39%, respectively. Women reporting no antenatal care are most likely to be living in rural areas. Among all the developing countries with data, one third of women in rural areas report no antenatal care (22).
Low income is associated with lower levels of education, and low education is associated with exposure. Mothers having at least some schooling were more likely to have their children vaccinated, to take them to health facility for treatment, to receive maternal preventive services and to have less chance of under-five child death. Children of those women who had been to school were less likely to die of these preventable infectious conditions. This could be because schooled women were more likely to have used preventive services for themselves and for their children (23). Educated women are more likely to receive antenatal care and the likelihood of their using antenatal care is associated with their level of education. Educated women are also more likely to report four or more visits. In most countries, the greatest proportionate difference occurs between women with no education and those with primary education (22).
The 2000 Demographic Health Survey (DHS) in Ethiopia has shown that among non-schooled mothers coverage for ANC, PNC and EPI for children to be 21%, 7% and 10.2% while in those with primary education it was 45%, 17% and 24.8% respectively (24). There is also evidence that women with secondary education were 20-40% more likely to take their children to health facility for treatment than were women with no education. For both fever and cough, about 60% women with secondary education took their children to health facilities compared with 45% of mothers with no education (25). Similarly under-five mortality was 2.3 times higher among children born to women without education compared with women with secondary and higher education and 1.9 times higher among children whose fathers worked in agriculture compared with children whose fathers had professional, technical or clerical occupation (22).
In India, 30% of mothers of children who had not been vaccinated did not know the importance of immunization for the health of their child, and a further 33% did not know where to go to have their child vaccinated (26). In Uganda Immunization coverage were 80% for BCG, 69% for DPT, and 63% for measles in those with some schooling; while these were 69% for BCG, 51% for DPT, and 52% for measles in those without schooling. ANC and FP coverage were 98.7% and 12.7%, for schooled but 89% and 5% for non-schooled (23).
Health knowledge is another factor in the utilization of health service as well as health status of the population. A study from Guinea-Bissau has identified household income and health knowledge as key determinants of child morbidity and mortality with a low prevalence of malnutrition in those with better health knowledge. The study also reported the fact that health knowledge appears to have a separate and positive effect, not necessarily associated with higher income (27).
Poverty is fundamentally a condition in which individuals lack the capacities required to satisfy their needs, fulfill their aspirations and participate fully in society. Poverty, lack of political empowerment and education are factors in the exclusion of people from health care (12). The World Bank has produced an analysis of antenatal care use based on wealth quintiles, in which households are categorized by their wealth into five groups each representing 20% of the total population. An analysis of these data shows that use of antenatal care is heavily influenced in the expected direction by wealth in all regions. Women living in households that fall within the poorest population quintile use antenatal services much less frequently than do those in the richest 20%. The data also show that whereas some degree of wealth differential exists everywhere, the gap between the richest 20% and the poorest 20% for use of antenatal care varies enormously. Particularly steep gradients are observed in Bangladesh, Chad, Egypt, India, Mali, Morocco and Pakistan (22).
Analysis of Demographic and Health surveys (DHS) of southern Africa countries has indicated that as much as twofold differentials between the poorest and richest quintiles in relation to malnutrition and fertility, and 50% higher levels of mortality in children. At the same time, access to health services was lower in these groups (28).
Children born to poor families are more exposed to risks for disease, have low resistance, and are the least likely to receive preventive interventions(29). There is differential health service use of the sick by socioeconomic and geographic variables. This was evidenced in ten of eleven Sub Sahara Africa countries where on average, 41% of children from high class were treated and 27% went untreated compared with 30% treated and 35% untreated in the lowest class (23). A study from Tanzania shown even within poor rural areas—use of appropriate health care varies with wealth. In a poor rural area of Tanzania, the poorest children were 27% less likely to seek care from an appropriate provider than the least poor, and children from the poorest families were not as -likely as their better-off peers to have received anti-malarials for fever or antibiotics for pneumonia (30).
Public health services are often thought to cater primarily to the poor while the rich go to private sector. And it reported that higher percentage of the poor than the rich actually use the government health facilities though the difference is modest. A study has shown 53% of the poor compared with 40% of the rich to use public facility while 40% of the poor compared with 59% of the rich to use the private facilities (31).
According to the benefit incidence approach, the government health service expenditure tends to provide greater benefit to the rich than the poor. In Sub Saharan Africa the richest 20% of the population received well over twice as much financial benefit as the poorest 20% from overall government financial expenditure and primary care expenditure. World Bank analysis of southern Africa countries found for example that health services provided free at point of contact have benefited richer over poorer groups (32, 28).
Distance from health facility is also an important factor in the utilization of health services. According to a study in Kenya, the most significant predictors of choosing home delivery (an informal delivery setting) are the distance from the household to the nearest maternity bed (33). Another study in Nepal has also reported distance of more than one hour to the maternity hospital (OR = 7.9) as being statistically significantly associated with an increased risk of home delivery (34).
Policy measures that increase access of services to the poor can narrow the gap between poor and rich. Studies from Brazil showed ANC attendance for women in the lowest income group were 74% in 1982, which was increased to 84% in 1993 while it was 98% among females from wealthy families in both years (35).

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