Explaining Inequity in the Use of Institutional Delivery Services in Selected Countries

Abstract

Wealth-related disparities in the use of reproductive health services remain a substantial problem in many low- and middle-income countries. Very few studies have attempted to explain such inequalities through decomposition of the contributions made by various individual- and household-level factors. This study aims to: (1) assess the degree of wealth-related inequality and inequity in the use of institutional delivery services in selected low- and middle-income countries, and (2) to explain wealth-related inequity through decomposition by the contributions made by various components, including health insurance coverage. Data come from Demographic and Health Surveys in three countries: Ghana, Rwanda, and the Philippines. Concentration indices are used to calculate inequality and horizontal inequity in service utilization. Multivariate methods are used to decompose inequity. Findings indicate a moderate to high degree of inequity in institutional delivery service use in all study countries. The study provides some evidence of the contribution of health insurance to increased wealth-related inequity in the use of institutional delivery services, although having health insurance was also associated with increased utilization of services. Results suggest that increased health insurance coverage does not automatically translate to lower wealth-related inequity in service utilization. Inequities in service utilization exist if there are still inequities in the health insurance status. The study advocates for expanding health insurance coverage, particularly among the poor to reduce inequity in insurance coverage and increase service utilization.

The Impact of Healthcare Insurance on the Utilisation of Facility-Based Delivery for Childbirth in the Philippines

“…The analysis relies on a set of observable socioeconomic and demographic variables derived primarily from the results of previous studies in the literature as well as data availability [4, 14, 22–25]. To capture socioeconomic status several variables were utilised.…”

“…An earlier study of DHS data found that PhilHealth coverage increased the odds of receiving at least four prenatal visits, but was not significantly associated with the odds of institutional delivery [13]. More recently, a study of the 2008 DHS in various countries, including the Philippines, found that insurance coverage was significantly associated with FBD, although household wealth, education, parity and urban residence all demonstrated a stronger influence [14]. At the same time, a recent review of qualitative studies in low and middle income countries found that while health insurance may improve women’s rate of FBD, insurance coverage does not necessarily alleviate the negative impact of physical barriers where they exist [15].…”

Inequalities in reproductive health care use in five West-African countries: A decomposition analysis of the wealth-based gaps

“…This applies to the use of reproductive health care services as well. While several studies have shown that better-off women have easier access to reproductive health care [5,[7][8][9], other studies have demonstrated that socio-demographic factors such as marital status, education, occupation, residence typology, attitude of health workers, and distance to health facility also contribute to the inequality in the use reproductive health care among women [9][10][11][12][13][14][15][16]. In addition, it is unclear to what extent these determinants explain the use of reproductive health care and contribute to the differences between the groups [6,17].…”

Unmet reproductive health care needs among rural Ghanaian women

“…Our finding that increasing age and parity are associated with less or least adequate care is well established in several studies (Do et al, 2014;Kodzi et al, 2012;Kruk, Rockers, Mbaruku, Paczkowski, & Galea, 2010;Ononokpono, Odimegwu, Imasiku, & Adedini, 2013;Smith, Tawiah, & Badasu, 2012) as these women are likely to assume confidence in themselves for their own maternity needs. This could be evident in environments where cost and access factors (distance/transport) may create a condition of "despair" and lower seeking behavior for them.…”

“…The lack of health insurance contributing to least adequate care could have resulted in a decline in facility visits since direct out-ofpockets payments would create financial obstacles to seek care. This association is supported by evidence that women with public health insurance are likely to improve utilization of health care services (Baker, Sudano, Albert, Borawski, & Dor, 2001;De Allegri et al, 2011;Do, Soelaeman, & Hotchkiss, 2014;Okafor, Obi, & Ugwu, 2010;Zere, Kirigia, Duale, & Akazili, 2012).…”