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

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Ababa University


Jemal Aliy (MD)

A thesis Submitted to the School of Graduate Studies of Addis Ababa University in Partial fulfillment of the requirements for the Degree of Masters of Public Health in the Department of Community Health.


Damen Haile Mariam (MD, MPH, PhD)

July 2005


First I would like to thank my advisor Dr Damen Haile Mariam who had provided me his intensive guidance, material supply and technical assistance.

A number of organizations and agencies have been so cooperative in the process of undertaking this study. Hence it is my pleasure to extend heartily appreciation to Addis Ababa University Medical Faculty for financial assistance of this study, all staffs of Community Health Department, Butajira Rural Health Program staffs, Meskan Woreda Health Office, Mareko Woreda Health Office, Butajira Health Center, Butajira Hospital, all health staffs at study site, data collectors and all study participants.
I would also like to thank the National HIV/AIDS Resource Center, and Disease Prevention and Control Department of the Federal Ministry of Health.

Table of contents

Abstract 1

I. Introduction 3

II. Literature Review and Statement of the Problem 5

2.1. Literature Review 5

2.2. Statement of the Problem 11

III. Objectives 12

General Objective: 12

Specific objectives: 12

IV. Methodology 13

4.1. Study Area and Period 13

4.2. Study design 14

4.3. Study population and Sampling 14

4.3.1. Study population 14

4.3.2. Sample size calculation 15

4.3.3. Identification and Selection of case and controls, and Sampling procedures 16

4.3.4. Operational definitions 16

4.3.5. Investigator's Field work experience 17

4.4. Data collection procedures (Instrument, personnel, data quality control) 18

4.5. Pre-testing 19

4.6. Data collection 19

4.7. Data Analysis procedures 20

4.8. Hypothesis to be tested 20

4.9. Ethical Considerations 22

V. Results 23

5.1. Socio-demographic characteristics 23

5.2. Household socio-economic characteristics 25

5.3. Socio-demographic and socio-economic determinants of health service utilization 27

5.4. Type and access to nearest HFs and family decision making pattern 30

5.5. Access, information and decision pattern as determinants of health service utilization 31

5.6. Results of multinomial logistic regression 32

5.7. Public health service knowledge 33

5.8. Geographic locality and health service utilization 34

VI. Discussion and Conclusions 38

6.1. Discussion 38

6.2. Strengths and Limitations of the Study 46

6.2.1. Strengths 46

6.2.2. Limitations 46

6.3. Conclusions 47

6.4. Recommendations 49

References 51

Annexes 54

Annex 1: Questionnaire for household survey 54

Annex 2: Data collection format for health facility Record review 58

List of Tables

Table 1. Socio demographic characteristics of the study population, Meskan and Mareko District, Ethiopia 2004. 24

Table 2. Economic status of the study population, Meskan and Mareko District, Ethiopia 2004. 26

Table 3. Association of Socio-demographic and socio-economic factors with utilization of health services, Meskan and Mareko Districts, Ethiopia, 2004. 29

Table 4. Type and distance of health facility, Source of information and Pattern of family decision making, Meskan and Mareko District, Ethiopia 2004. 30

Table 5. Access, information source and decision making pattern as determinant for utilization of Public health programs, Meskan and Mareko District, Ethiopia 2004. 31

Table 6. Multinomial logistic regression of socio-demographic, economic and health service factors, Meskan and Mareko District, Ethiopia 2004. 32

Table 7. Factors in utilization of Public health programs, Meskan and Mareko District, Ethiopia 2004. 34

Table 8. Distributions of maternal health and EPI service users by place of residence and distance from health facility, Meskan and Mareko District, Ethiopia 2004. 35

Table 9. Distribution of mothers' ANC status, birth outcome, and children's EPI status by place of residence and distance from health facility, Meskan and Mareko District, Ethiopia 2004. 37


Background: Though Primary health care programs were planned to be delivered free of charge to achieve a universal access for all segments of population, still majority of the population in developing countries are not equally benefiting from these services as that of other better-off groups.
Objective: To assess equity in the provision and utilization of primary maternal and child health care services across population of different demographic, socioeconomic, geographic characteristics; and to assess the determinants in the equitable distribution of primary health care services in Meskan and Mareko Woreda, southern Ethiopia.
Methods: The study comprised of two methods; reviewing of one-year (1996 EC.) charts of all health facilities in the woredas, and a case control study in sample of 192 cases and 192 controls, conducted in Butajira Rural Health Program site of Meskan and Mareko District, in Gurage Zone.
Analysis was done using SPSS/PC package. Associations between variables were assessed using Crude and Adjusted OR and significance of association was tested using Chi square test and multiple logistic regressions.
Results: Among all socio-demographic and socio-economic factors only place of residence being an urban (X2=9.96, p<0.01), average annual income level of more than 1000 birr (X2=6.67, p<0.05), mothers having some education (X2=8.57, p<0.05), and walking distance from a health facility <1hour (X2=4.96, p<0.05), were significantly associated with being a cases.

Health facility record review reveals that the urban residents and peasant associations located within a walking distance of less than an hour from health facilities accounts for significant proportion of all FP, ANC, delivery and EPI service users.

Living in urban area was significantly associated with using ANC service (X2=40.1, p<0.001), and children's to be fully immunized for EPI (X2=238.7, p<0.001). Furthermore, living within a distance of 6km from health institutions was significantly associated giving birth to live baby (X2=12.83, p<0.001).
Conclusion: This study revealed that different demographic, socioeconomic, geographic factors were barriers to the utilization public health programs. Positive discrimination to provide outreach for people to use services in low utilization areas, providing information, Education, and Communication (IEC) on the utilization of maternal and child health services and improving the status of the poor through intensification of the current effort of poverty reduction activities are recommended.

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