Assessment of equity in provision and utilization of maternal and child health programs in butajira, southern ethiopia
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VI. Discussion and Conclusions6.1. DiscussionNowadays, equity in access to and use of health services is an important goal for policymakers in most countries. 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 as being inequity as these services are equally needed by all children and mothers (11). The health policy of Ethiopia emphasizes the importance of achieving a universal access to a basic package of quality primary health care, via a decentralized management system and extension of health service to the underserved rural population (6). To implement this, government has increased the number of health units and health personnel, and primary health care programs were made to be delivered free of charge to achieve access to 100% of the population. But information concerning basic health service provision and utilization inequality is scarce. This study therefore has tried to assess the degree and direction of basic health service provision inequality in benefiting the vulnerable groups of the society such as children and mothers and in a way that help policy making. The health service in Ethiopia is characterized by low coverage of 64%. The health facilities are more concentrated to urban area while 85% of populations are rural residents with poor access (7). From this study it has been shown that the government health care units in general and primary health care units in particular were the most accessible in 98% and 93% respectively. Additionally it was observed that the number of health facilities in general and that of primary health care units in particular had significantly increased over the recent years. But the lower health care units such as health posts/stations, which take the lion share in number, were not staffed with trained health professionals and hence not involved in provision of preventive MCH services. Only 3 (one hospital and two health centers) out of 26 health facilities available in the two districts were providing preventive MCH services during 1996 EC. These facilities provided FP services for a total of 2368 mothers, ANC services for a total of 4129 mothers, delivery services for a total of 750 mothers, and EPI services for a total of 2454 children. In the household survey of this study, there were significant differences between cases and controls with respect to place of residence, with mothers who used the service more likely to be an urban resident with the odds of being an urban resident to be 3.86 times higher for cases than controls (X2=18.71, p<0.001). Additionally, from health facility record review of the present study, it was observed that from all FP, ANC, delivery and EPI service users, 54%, 23%, 45% and 38%, and 58% all fully immunized children were from urban residents, with statistically significance association between being from urban resident and using ANC service (X2=40.1, p<0.001), giving birth to live baby (X2=6.46, p<0.05), and children to be fully immunized (X2=238.7, p<0.001). This may be explained by the fact that urban women tend to have better access to health facilities and other promotional activities that are urban based as well as to education. This is also reported by other studies. 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). Other 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 has similarly shown the presence of 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). Other study reported that 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). Mothers' and husbands' education were also found to be associated with health service utilization with mothers who used the service 2.81 times more likely to have some schooling and /or 1.99 times more likely to have husband with some schooling. Testing this association further with multinomial logistic regression, only mothers' having schooling is associated with service use (X2=8.57, p<0.05). This may be attributed to the fact that educated women have greater access to modern health care, have a better understanding of the benefit of using health services, are more willing to utilize health services. Several studies from other developing countries has reported similar finding. A study in Uganda reported that children of those women who had been to school were less likely to die of 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). According to the 2000 DHS in Ethiopia, receiving ANC from a health professional is highly associated with mother’s level of education: only 21% of uneducated women received ANC compared with 72% of mothers with at least secondary education. A mother’s education was also related with tetanus toxoid coverage. Uneducated women were two times less likely to have received any protection against tetanus than women with secondary and higher level education (24). Other studies also showed women with secondary education to be 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 facility compared with 45% of mothers with no education (25). Similarly under five mortality was 2.3 times high among children born to women without education compared with women with secondary and higher education and 1.9 times high 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 that immunization was important 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 it was 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). 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). Occupation of heads of households were associated with service use; with being non-farmer to be 2.89 times higher for cases than controls (X2=13.22, p<0.001), which can be explained by the fact that majority of urban peoples who have better access to health services and facilities are non-farmers while the reverse is true for rural peoples. However, this association was not seen with multinomial logistic regression. Household income was to be another determinant factor to use health care service. In the study it was found that households with the mothers who used the service were more likely to have average annual income level of more than 1000 birr than non- users, with the odds of having average annual income level of more than 1000 birr being 2.35 times higher for cases. However, nonusers were found more likely to own land and private house with odds of 2.82 and 2.92 respectively compared to users. This may be explained by the fact that most rural residents and farmers' posses own land and private house compared to urban residents and non-farmers but with less utilization. Adjusting socio economic factors with place of residence and testing using multinomial logistic regression, only average annual income level remained associated with service utilization (OR=2.02, 95% CI: 1.18, 3.43), while land and house showed no association indicating that these factors were confounded by place of residence. The association of income level with health service utilization 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. Low income is associated with higher exposure to health risks, lower levels of education, and low education is associated with exposure. Low income constrains use of appropriate medical care both directly-because user fees cannot be paid and indirectly because the other costs associated with using health services, such as transport costs are unaffordable. Poverty is fundamentally a condition in which individuals lack the capacities required to satisfy their needs, fulfill their aspirations and participate fully in society. The World Bank analyzed antenatal care use of 51 developing countries 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 by world bank indicated 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). 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). According to study in Tanzania 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 those who are slightly better off, 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. Study showed 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 Demographic and Health surveys (DHS) of southern Africa countries found, for example that health services provided free at point of contact have benefited richer over poorer groups (32, 28). Living distance from health facility were also associated with utilizing health services in that cases were more likely to be from a walking distance of less than an hour (X2=6.67, p<0.05). From health facility record review, there were significance associations between living within a distance of 6km and using ANC (X2=29.3, p<0.001), giving birth to live baby (X2=12.83, p<0.001), and children being fully immunized (X2=126.2, p<0.001). This can be due to the fact that with increasing distance from health facility, there is associated increase in transportation cost and lost production time, as well as possible lower exposure to health information. This finding is in line with other studies. Study from Kenya reported the most significant predictors of choosing home delivery (an informal delivery setting) are the distance from the household to the nearest maternity bed (33). Other study from Nepal reported a distance of more than one hour to the maternity hospital (OR = 7.9), were statistically significantly associated with an increased risk of home delivery (34). |