Delivery channels and socioeconomic inequalities in coverage of reproductive, maternal, newborn, and child health interventions: analysis of 36 cross-sectional surveys in low-income and middle-income countries

Abstract

Background Global reports have described inequalities in coverage of reproductive, maternal, newborn, and child health (RMNCH) interventions, but little is known about how socioeconomic inequality in intervention coverage varies across multiple low-income and middle-income countries (LMICs). We aimed to assess the association between wealth-related inequalities in coverage of RMNCH interventions. MethodsIn this cross-sectional study, we identified publicly available Demographic Health Surveys and Multiple Indicator Cluster Surveys from LMICs containing information on household characteristics, reproductive health, women's and children's health, nutrition, and mortality. We identified the most recent survey from the period 2010-19 for 36 countries that contained data for our preselected set of 18 RMNCH interventions. 21 countries also had information on two common malaria interventions. We classified interventions into four groups according to their predominant delivery channels: health facility based, community based, environmental, and culturally driven (including breastfeeding practices). Within each country, we derived wealth quintiles from information on household asset indices. We studied two summary measures of within-country wealth-related inequality: absolute inequalities (akin to coverage differences among children from wealthy and poor households) using the slope index of inequality (SII), and relative inequalities (akin to the ratio of coverage levels for wealthy and poor children) using the concentration index (CIX). Propoor inequalities are present when intervention coverage decreased with increasing household wealth, and pro-rich inequalities are present when intervention coverage increased as household wealth increased. FindingsAcross the 36 LMICs included in our analyses, coverage of most interventions had pro-rich patterns in most countries, except for two breastfeeding indicators that mostly had higher coverage among poor women, children and households than wealthy women, children, and households. Environmental interventions were the most unequal, particularly use of clean fuels, which had median levels of SII of 48•8 (8•6-85•7) and CIX of 67•0 (45•0-85•8). Interventions primarily delivered in health facilities-namely institutional childbirth (median SII 46•7 [23•1-63•3] and CIX 11•4 [4•5-23•4]) and antenatal care (median SII 26•7 [17•0-47•2] and CIX 10•0 [4•2-17•1])-also usually had pro-rich patterns. By comparison, primarily community-based interventions, including those against malaria, were more equitably distributed-eg, oral rehydration therapy (median SII 9•4 [2•9-19•0] and CIX 3•4 [1•3-25•0]) and polio immunisation (SII 12•1 [2•3-25•0] and CIX 3•1 [0•5-7•1]). Differences across the four types of delivery channels in terms of both inequality indices were significant (SII p=0•0052; CIX p=0•0048). Interpretation Interventions that are often delivered at community level are usually more equitably distributed than those primarily delivered in fixed facilities or those that require changes in t...

Are the Poor Catching Up with the Rich in Utilising Reproductive, Maternal, New Born and Child Health Services: An Application of Delivery Channels Framework in Indian Context

“…Our findings by and large show trends are aligned with the global trends of coverage for RMNCH interventions in low- and middle-income countries (Leventhal et al, 2021). The median values of CIX and SII across the two rounds of NFHS-3 (2005–2006) and NFHS-4 (2015–2016) suggest that the coverage is becoming more equitable.…”

“…The present study has adopted the framework of four delivery channels as proposed by Leventhal et al (2021) in the Indian context. It utilises the SII (absolute) and CIX (relative) measures of inequalities to describe the magnitude of socioeconomic inequality in the coverage of 16 RMNCH indicators.…”

“…These indicators were included in the Countdown to 2015 initiative, which tracks the progress of RMNCH indicators across different countries worldwide because they are included in the majority of studies pertaining to RMNCH indicators (Barros et al, 2012;Bryce et al, 2003;Countdown 2008Equity Analysis Group, 2008Victora et al, 2003Victora et al, , 2016. Previous studies on delivery channels framework included only the community-based interventions; however, we have adopted the latest delivery channels framework which includes cultural and environmental interventions in addition to community and health facility-based ones (Leventhal et al, 2021).…”

“…Further evidence suggests that services delivered at community level are more equitably delivered among socioeconomic sections than those through health facilities was published by the Countdown to 2015 group (Barros et al, 2012; Countdown 2008 Equity Analysis Group, 2008). A recent Lancet study (2021) has expanded on the concept of delivery channels and included the environmental and cultural delivery channels (Leventhal et al, 2021). It has segregated a set of globally agreed upon RMNCH indicators based on the most usual channels through which they are delivered to the beneficiaries: these are environmental, health facility-based, community-based and culturally driven interventions.…”

“…However, to date, there is no such study in the Indian context. Therefore, the first objective of this study is to adopt Leventhal et al’s (2021) ‘delivery channels framework’ to understand inequality in RMNCH coverage in the Indian context.…”