BackgroundThe fifth Millennium Development Goal (MDG5) aims at improving maternal health. Globally, the maternal mortality ratio (MMR) declined from 400 to 260 per 100000 live births between 1990 and 2008. During the same period, MMR in sub-Saharan Africa decreased from 870 to 640. The decreased in MMR has been attributed to increase in the proportion of deliveries attended by skilled health personnel. Global improvements maternal health and health service provision indicators mask inequalities both between and within countries. In Namibia, there are significant inequities in births attended by skilled providers that favour those that are economically better off. The objective of this study was to identify the drivers of wealth-related inequalities in child delivery by skilled health providers.MethodsNamibia Demographic and Health Survey data of 2006-07 are analysed for the causes of inequities in skilled birth attendance using a decomposable health concentration index and the framework of the Commission on Social Determinants of Health.ResultsAbout 80.3% of the deliveries were attended by skilled health providers. Skilled birth attendance in the richest quintile is about 70% more than that of the poorest quintile. The rate of skilled attendance among educated women is almost twice that of women with no education. Furthermore, women in urban areas access the services of trained birth attendant 30% more than those in rural areas. Use of skilled birth attendants is over 90% in Erongo, Hardap, Karas and Khomas Regions, while the lowest (about 60-70%) is seen in Kavango, Kunene and Ohangwena. The concentration curve and concentration index show statistically significant wealth-related inequalities in delivery by skilled providers that are to the advantage of women from economically better off households (C = 0.0979; P < 0.001).Delivery by skilled health provider by various maternal and household characteristics was 21 percentage points higher in urban than rural areas; 39 percentage points higher among those in richest wealth quintile than the poorest; 47 percentage points higher among mothers with higher level of education than those with no education; 5 percentage points higher among female headed households than those headed by men; 20 percentage points higher among people with health insurance cover than those without; and 31 percentage points higher in Karas region than Kavango region.ConclusionInequalities in wealth and education of the mother are seen to be the main drivers of inequities in the percentage of births attended by skilled health personnel. This clearly implies that addressing inequalities in access to child delivery services should not be confined to the health system and that a concerted multi-sectoral action is needed in line with the principles of the Primary health Care.

BackgroundInequities in the utilization of maternal health services impede progress towards the MDG 5 target of reducing the maternal mortality ratio by three quarters, between 1990 and 2015. In Namibia, despite increasing investments in the health sector, the maternal mortality ratio has increased from 271 per 100,000 live births in the period 1991-2000 to 449 per 100,000 live births in 1998-2007. Monitoring equity in the use of maternal health services is important to target scarce resources to those with more need and expedite the progress towards the MDG 5 target. The objective of this study is to measure socio-economic inequalities in access to maternal health services and propose recommendations relevant for policy and planning.MethodsData from the Namibia Demographic and Health Survey 2006-07 are analyzed for inequities in the utilization of maternal health. In measuring the inequities, rate-ratios, concentration curves and concentration indices are used.ResultsRegions with relatively high human development index have the highest rates of delivery by skilled health service providers. The rate of caesarean section in women with post secondary education is about seven times that of women with no education. Women in urban areas are delivered by skilled providers 30% more than their rural counterparts. The rich use the public health facilities 30% more than the poor for child delivery.ConclusionMost of the indicators such as delivery by trained health providers, delivery by caesarean section and postnatal care show inequities favoring the most educated, urban areas, regions with high human development indices and the wealthy. In the presence of inequities, it is difficult to achieve a significant reduction in the maternal mortality ratio needed to realize the MDG 5 targets so long as a large segment of society has inadequate access to essential maternal health services and other basic social services. Addressing inequities in access to maternal health services should not only be seen as a health systems issue. The social determinants of health have to be tackled through multi-sectoral approaches in line with the principles of Primary Health Care and the recommendations of the Commission on Social Determinants of Health.

This paper explores the policy-making process in the 1990s in two countries, South Africa and Zambia, in relation to health care financing reforms. While much of the analysis of health reform programmes has looked at design issues, assuming that a technically sound design is the primary requirement of effective policy change, this paper explores the political and bureaucratic realities shaping the pattern of policy change and its impacts. Through a case study approach, it provides a picture of the policy environment and processes in the two countries, specifically considering the extent to which technical analysts and technical knowledge were able to shape policy change. The two countries' experiences indicate the strong influence of political factors and actors over which health care financing policies were implemented, and which not, as well as over the details of policy design. Moments of political transition in both countries provided political leaders, specifically Ministers of Health, with windows of opportunity in which to introduce new policies. However, these transitions, and the changes in administrative structures introduced with them, also created environments that constrained the processes of reform design and implementation and limited the equity and sustainability gains achieved by the policies. Technical analysts, working either inside or outside government, had varying and often limited influence. In part, this reflected the limits of their own capacity as well as weaknesses in the way they were used in policy development. In addition, the analysts were constrained by the fact that their preferred policies often received only weak political support. Focusing almost exclusively on designing policy reforms, these analysts gave little attention to generating adequate support for the policy options they proposed. Finally, the country experiences showed that front-line health workers, middle level managers and the public had important influences over policy implementation and its impacts. The limited attention given to communicating policy changes to, or consulting with, these actors only heightened the potential for reforms to result in unanticipated and unwanted impacts. The strength of the paper lies in its 'thick description' of the policy process in each country, an empirical case study approach to policy that is under-represented in the literature. While such an approach allows only a cautious drawing of general conclusions, it suggests a number of ways in which to strengthen the implementation of financing policies in each country.

Equity is an important policy objective in the health care field. The importance of equity in health care provision can be argued from various points of view. As a result governments in all countries attempt to provide health care systems that enable equal access for everyone. Zambia is no exception. In the health care reforms the objective of the national health strategy is to provide Zambians with equity of access to health care. We focus on access defined as the costs (both monetary and time) an individual incurs when visiting a health care facility. Using a survey of 900 households, this article explores equality of access to health care among Zambians. Four areas are compared: urban high cost, urban low cost, townships and rural areas. The results of the analysis indicate that there are inequalities among residential areas, especially between rural and urban areas. In particular these differences exist because of differing distances to the nearest health facility. Large distances make it very costly for rural dwellers to seek medical care, especially during the high season for farming. The analysis suggests that obtaining equality of access to health care poses a challenge for the Zambian Government.

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