Background Maternal health affects the lives of many women and children globally every year and it is one of the high priority programs of the Government of Nepal (GoN). Different evidence articulate that the equity gap in accessing and using maternal health services at national level is decreasing over 2001–2016. This study aimed to assess whether the equity gap in using maternal health services is also decreasing at subnational level over this period given the geography of Nepal has already been identified as one of the predictors of accessibility and utilization of maternal health services. Methods The study used wealth index scores for each household and calculated the concentration curves and indexes in their relative formulation, with no corrections. Concentration curve was used to identify whether socioeconomic inequality in maternity services exists and whether it was more pronounced at one point in time than another or in one province than another. The changes between 2001 and 2016 were also disaggregated across the provinces. Test of significance of changes in Concentration Index was performed by calculating pooled standard errors. We used R software for statistical analysis. Results The study observed a progressive and statistically significant decrease in concentration index for at least four antenatal care (ANC) visit and institutional delivery at national level over 2001–2016. The changes were not statistically significant for Cesarean Section delivery. Regarding inequality in four-ANC all provinces except Karnali showed significant decreases at least between 2011 and 2016. Similarly, all provinces, except Karnali, showed a statistically significant decrease in concentration index for institutional delivery between 2011 and 2016. Conclusion Despite appreciable progress at national level, the study found that the progress in reducing equity gap in use of maternal health services is not uniform across seven provinces. Tailored investment to address barriers in utilization of maternal health services across provinces is urgent to make further progress in achieving equitable distribution in use of maternal health services. There is an opportunity now that the country is federalized, and provincial governments can make a need-based improvement by addressing specific barriers.
ObjectivesWe analysed predictors of health insurance enrolment in Nepal, measured wealth-related inequality and decomposed inequality into its contributing factors.DesignCross-sectional study.SettingWe used nationally representative data based on Nepal Multiple Indicator Cluster Survey 2019. Out of 10 958 households included in this study, 6.95% households were enroled in at least one health insurance scheme.Primary outcomemeasures health insurance (of any type) enrolment.ResultsHouseholds were more likely to have health insurance membership when household head have higher secondary education or above compared with households without formal education (adjusted OR 1.87; 95% CI: 1.32 to 2.64)). Households with mass media exposure were nearly three times more likely to get enroled into the schemes compared with their counterparts (adjusted OR 2.96; 95% CI 2.03 to 4.31). Hindus had greater odds of being enroled (adjusted OR 1.82; 95% CI 1.20 to 2.77) compared with non-Hindus. Dalits were less likely to get enroled compared with Brahmin, Chhetri and Madhesi (adjusted OR 0.66; 95% CI 0.47 to 0.94). Households from province 2, Bagmati and Sudurpaschim were less likely to have membership compared with households from province 1. Households from Richer and Richest wealth quintiles were more than two times more likely to have health insurance membership compared with households from the poorest wealth quintile. A positive concentration index 0.25 (95% CI 0.21 to 0.30; p<0.001) indicated disproportionately higher health insurance enrolment among wealthy households.ConclusionsEducation of household head, exposure to mass media, religious and ethnic background, geographical location (province) and wealth status were key predictors of health insurance enrolment in Nepal. There was a significant wealth-related inequality in health insurance affiliation. The study recommends regular monitoring of inequality in health insurance enrolment across demographic and socioeconomic groups to ensure progress towards Universal Health Coverage.
Background Inequality in maternal healthcare use is a major concern for low-and middle-income countries (LMICs). Maternal health indicators at the national level have markedly improved in the last couple of decades in Nepal. However, the progress is not uniform across different population sub-groups. This study aims to identify the determinants of institutional delivery, measure wealth-related inequality, and examine the key components that explain the inequality. Methods Most recent nationally representative Multiple Indicator Cluster Survey (MICS) 2019 was used to extract data about married women (15-49 years) with a live birth within two years preceding the survey. Logistic regression models were employed to assess the association of independent variables with the institutional delivery. The concentration curve (CC) and concentration index (CIX) were used to analyze the inequality in institutional delivery. Wealth index scores were used as a socio-economic variable to rank households. Decomposition was performed to identify the determinants that explain socio-economic inequality. Results The socio-economic status of households to which women belong was a significant predictor of institutional delivery, along with age, parity, four or more ANC visits, education status of women, area of residence, sex of household head, religious belief, and province. The concentration curve was below the line of equality and the relative concentration index (CIX) was 0.097 (p < 0.001), meaning the institutional delivery was disproportionately higher among women from wealthy groups. The decomposition analysis showed the following variables as the most significant contributor to the inequality: wealth status of women (53.20%), education of women (17.02%), residence (8.64%) and ANC visit (6.84%). Conclusions To reduce the existing socio-economic inequality in institutional delivery, health policies and strategies should focus more on poorest and poor quintiles of the population. The strategies should also focus on raising the education level of women especially from the rural and relatively backward province (Province 2). Increasing antenatal care (ANC) coverage through outreach campaigns is likely to increase facility-based delivery and decrease inequality. Monitoring of healthcare indicators at different sub-population levels (for example wealth, residence, province) is key to ensure equitable improvement in health status and achieve universal health coverage (UHC).
Background Child undernutrition continues to be a major public health problem in many countries, including Nepal. The repercussions of undernutrition are not only limited to the affected children and families but also transcend to the national and global economy. Earlier studies from Nepal have predominantly used either ordinary least squares (OLS) regression or binary regression to analyse the socioeconomic and demographic correlates of the nutritional outcome. In this study, quantile regression was used to understand a complete and more precise estimate of the effects of the covariates on the child nutritional status. Methods This study was based on the most recent nationally representative Nepal Multiple Indicator Cluster Survey (MICS) 2019. Height-for-age z scores (HAZ) were used as an indicator for assessing the nutritional status of under-five children. Quantile regression was used to examine the heterogeneous association of covariates with conditional HAZ distribution across the different quantiles (0.10, 0.30, 0.50, 0.85). As a comparison, the effects of covariates at conditional mean of HAZ using OLS regression was also analysed. The graphs were plotted to visualize the changes in the coefficients for each regressor across the entire conditional HAZ distribution. Results Age of children, sex of children, province and wealth had a consistent and statistically significant association with HAZ in both OLS and quantile regression. Improved toilet facility was positively correlated with HAZ at the lower tails (tenth and thirtieth percentiles). Ethnicity (Janajati and Newer) was positively correlated with HAZ at the lower tail (thirtieth percentile) and mean (OLS regression). Maternal education was a significant predictor of improved height-for-age across conditional quantiles, except at the tenth percentile. Maternal age, number of under-five children in household, number of household members, and improved source of drinking water showed heterogeneous effects across different quantiles of conditional HAZ distribution. Conclusion Use of quantile regression approach showed that the effect of different factors differed across the conditional distribution of HAZ. Policymakers should consider the heterogeneous effect of different factors on HAZ so that the targeted intervention could be implemented to maximize the nutritional benefits to children.
Nepal is pursuing Social Health Insurance as a way of mobilizing revenues to achieve Universal Health Coverage. The Social Health Insurance governance encourages service providers to maintain quality and efficiency in services provision by practicing strategic purchasing. Social Health Security Programme is a social protection program which aspires to achieve the goals of Social Health Insurance. Social Health Security Development Committee needs to consider following experiences to function as a strategic purchaser. The Social Health Security Development Committee need to be an independent body instead of falling under Ministry of Health. Similarly, purchasing of health services needs to be made strategic, i.e., Social Health Security Development Committee should use its financial power to guide the provider behavior that will eventually contribute to achieving the goals of quality and efficiency in service provision. The other social health security funds should be merged with Social Health Security Development Committee and develop a single national fund. Finally, the state has to regulate and monitor the performance of the SHI agency.
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