Explaining Inequity in the Use of Family Planning and Institutional Delivery Services

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Presented by Mai Do at the International Conference on Family Planning in November 2013.

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Explaining Inequity in the Use of Family Planning and Institutional Delivery Services

  1. 1. Explaining Inequity in the Use of Family Planning and Institutional Delivery Services Mai Do, Rieza Soelaeman, and David Hotchkiss Tulane University School of Public Health Department of Global Health Systems and Development
  2. 2. Introduction  Wealth-related inequities in FP/RH service use remain a substantial problem  Disparities in maternal health care are greater than those in many other types of health interventions prioritized by governments  Increased emphasis on improving service delivery for the poor  Community-level service provision  Demand-side approaches: vouchers, health insurance
  3. 3. Hypothesis  HI can lower wealth-related inequities in service utilization by  Removing financial barriers  Increasing women’s access to health systems  Indirectly improving QOC through training and certifications  Improve access to services among those intending to use, and increase opportunities to seek services through increased contacts and trust with health systems
  4. 4. Study purposes 1. To assess the degree of wealth-related inequities in the use of FP and institutional delivery services in selected low- and middle-income countries, and 2. To explain such socio-economic inequities by decomposing inequity by the contributions made by various components, including health insurance coverage, and other individual- and household-level factors ..in four countries that have experienced an expansion of health insurance coverage in recent years – Ghana, Rwanda, Columbia, and the Philippines
  5. 5. Summary of Health Insurance programs National HI program Types of HI FP benefits Delivery benefits Colombia Health care reform in 1993. A national health insurance fund, Solidarity and Guarantees Fund (SGF), was created. Two regimes: ‐ Contributory regime: members contribute according to their ability to pay, includes all formal sector employees and independent workers able to pay ‐ Subsidized regime: targets the poor by subsidizing their premiums FP services (consultation and contraceptives) are covered All inpatient and outpatient obstetric care is covered Philippines PhilHealth, government- owned and operated, was created in 1995: ‐ Extending benefits to cover outpatient services ‐ Extending coverage to the poor and informal sector workers PhilHealth membership is segregated into four categories: ‐ Employed program: membership is compulsory for all government and private sector employees ‐ Indigent program: initiated by local governments to target the poor ‐ Individual payment program: for those who are not eligible for the above two programs ‐ Nonpaying program: targets those who have reached retirement and have paid at least 120 monthly premium contributions to PhilHealth. Covers only surgical methods. Maternity packages, launched in 2003, covers inpatient hospital care, including normal spontaneous delivery.
  6. 6. Data and Methods  Recent DHS in four countries: Colombia (2010), Ghana (2008), the Philippines (2008), and Rwanda (2005)  Having available a nationally representative survey of women of reproductive age conducted within the last five years, and  A national health insurance program that includes FP and maternal health care services in the benefits package  Main independent variable: household wealth  CIs calculated to estimate inequalities  Adjusted for need for FP  Decomposition of CIs using multivariate probit (O’Donnell et al., 2008)
  7. 7. 0 10 20 30 40 50 60 70 80 90 100 Ghana (2008) Rwanda (2005) Colombia (2010) Philippines (2008) Percentageofwomenwithhealth insurancecoverage Country Fig 1. Percentage of women in the family planning analysis with health insurance coverage by wealth quintile Poorest Poor Middle Richer Richest Total
  8. 8. Table 1. Prevalence and concentration index of modern contraceptive use among women in union Has Health Insurance Coverage Household wealth Colombia (2010) Philippines (2008) Total No Yes Total No Yes (n=26,281) (n=2,551) (n=23,730) (n=8,418) (n=4,570) (n=3,848) Poorest 67.9 55.94 69.6 25.75 23.96 32.28 Poor 72.84 67.28 73.54 35.18 32.96 39.53 Middle 73.04 66.93 73.76 35.93 34.39 38.09 Richer 75.01 73.6 75.15 38.27 37.65 38.72 Richest 74.84 74.11 74.88 32.99 33.84 32.68 Total 72.71 66.14 73.41 33.68 31.52 36.25 CIs (s.e.) Actual 0.02 (0.003) 0.06 (0.01) 0.02 (0.003) 0.05 (0.009) 0.09 (0.013) -0.02 (0.012) Need predicted -0.02 (0.001) -0.01 (0.004) -0.02 (0.001) -0.02 (0.002) 0 (0.003) -0.04 (0.003) Need standardized 0.04 (0.003) 0.07 (0.009) 0.03 (0.003) 0.07 (0.009) 0.09 (0.013) 0.02 (0.012)
  9. 9. Table 2. Decomposition of modern contraceptive use inequity among women in union Colombia (2010) Philippines (2008) Variables E C.I. Contr. E C.I. Contr. Need for family planning 0.540 -0.012 -0.007 *** 0.789 -0.016 -0.013 *** Women’s education 0.063 0.152 0.010 ** 0.111 0.165 0.018 * Parity 0.102 -0.122 -0.012 *** 0.125 -0.116 -0.014 *** Women’s age -0.009 0.025 0.000 *** -0.521 0.015 -0.008 *** Urban residence -0.034 0.275 -0.009 *** 0.012 0.294 0.003 Partner’s education -0.016 0.142 -0.002 -0.038 0.162 -0.006 Women’s is employed 0.020 0.088 0.002 *** 0.141 0.068 0.010 *** Visited by a FP worker in the last 12 months -0.001 -0.234 0.000 0.012 -0.102 -0.001 Visited a health facility in the last 12 months 0.034 0.039 0.001 -0.053 -0.031 0.002 * Told of FP at health facility in the last 12 months -0.005 -0.015 0.000 0.048 -0.080 -0.004 *** Has health insurance coverage 0.030 0.012 0.000 *** 0.045 0.237 0.011 * Controlled for wealth, religion, and exposure to FP messages on TV, radio and newspapers * p<.05, ** p<.01, *** p<.001
  10. 10. 0 10 20 30 40 50 60 70 80 90 100 Ghana (2008) Rwanda (2005) Colombia (2010) Philippines (2008) Percentageofwomenwithhealth insurancecoverage Country Figure 2. Percentage of women in the institutional delivery analysis with health insurance coverage by wealth quintile Poorest Poor Middle Richer Richest Total
  11. 11. Table 3. Prevalence and concentration index of institutional delivery among women in union Has Health Insurance Coverage Household wealth Colombia (2010) Philippines (2008) Total No Yes Total No Yes (n=4,343) (n=456) (n=3,887) (n=2,261) (n=1,377) (n=883) Poorest 85.33 77.74 86.61 12.39 10.8 19.33 Poor 97.53 95.31 97.85 31.49 25.34 45.87 Middle 99.21 100 99.12 51.97 49.9 55.49 Richer 99.62 96.84 99.96 72.04 61.31 79.77 Richest 98.84 97.38 98.94 89.76 77.3 94.72 Total 95.35 91.09 95.9 45.73 33.09 65.43 CI.. Actual (SE) 0.04 (0.003) 0.08 (0.012) 0.03 (0.003) 0.36 (0.012) 0.39 (0.02) 0.23 (0.014)
  12. 12. Table 4. Decomposition of institutional delivery inequity among women in union Colombia (2010) Philippines (2008) Variables E c.i. Contr. E c.i. Contr. Women’s education 0.050 0.161 0.008 ** 0.422 0.164 0.069 *** Parity -0.019 -0.218 0.004 *** -0.200 -0.191 0.038 *** Women’s age 0.079 0.016 0.001 *** 0.407 -0.003 -0.001 * Urban residence 0.032 0.320 0.010 ** 0.115 0.289 0.033 *** Partner’s education 0.005 0.146 0.001 0.384 0.165 0.063 *** Women’s is employed -0.016 0.084 -0.001 ** -0.004 0.071 0.000 Has health insurance coverage 0.018 0.018 0.000 ** 0.111 0.264 0.029 *** Controlled for wealth and religion * p<.05, ** p<.01, *** p<.001
  13. 13. Conclusions  Moderate to high levels of inequities in service use  Associations between HI coverage and service use  Some evidence of contributions of HI to inequities in institutional delivery services, and to a lesser extent, in modern FP use  Having HI may have increased overall access to services  Impact on lowering out-of-pocket spending on services unclear  Advocates for expanding HI coverage, particularly among the poor in order to increase service utilization as well as reduce wealth-related inequities in service use
  14. 14. Unanswered Questions  What are the mechanisms for HI to affect service use and inequities?  Effects on financial barriers?  Why are the poor not enrolled in HI, in spite of subsidized schemes?
  15. 15. MEASURE Evaluation PRH is a MEASURE project funded by the United States Agency for International Development (USAID) through Cooperative Agreement GHA-A-00-08-00003- 00 and is implemented by the Carolina Population Center at the University of North Carolina at Chapel Hill in partnership with Futures Group International, Management Sciences for Health, and Tulane University. Views expressed in this presentation do not necessarily reflect the views of USAID or the U.S. Government. MEASURE Evaluation PRH supports improvements in monitoring and evaluation in population, health and nutrition worldwide.

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