Going deeper with health equity measurement: how much more can surveys reveal about inequalities in health intervention coverage and mortality in Zambia?

Although Zambia has achieved notable improvements in reproductive, maternal, newborn and child health (RMNCH), continued efforts to address gaps are essential to reach the Sustainable Development Goals by 2030. Research to better uncover who is being most left behind with poor health outcomes is crucial. This study aimed to understand how much more demographic health surveys can reveal about Zambia's progress in reducing inequalities in under-five mortality rates and RMNCH intervention coverage. Using four nationally-representative Zambia Demographic Health Surveys (2001/2, 2007, 2013/14, 2018), we estimated under-five mortality rates (U5MR) and RMNCH composite coverage indices (CCI) comparing wealth quintiles, urban-rural residence and provinces. We further used multi-tier measures including wealth deciles and double disaggregation between wealth and region (urban residence, then provinces). These were summarised using slope indices of inequality, weighted mean differences from overall mean, Theil and concentration indices. Inequalities in RMNCH coverage and under-five mortality narrowed between wealth groups, residence and provinces over time, but in different ways. Comparing measures of inequalities over time, disaggregation with multiple socio-economic and geographic stratifiers was often valuable and provided additional insights compared to conventional measures. Wealth quintiles were sufficient in revealing mortality inequalities compared to deciles, but comparing CCI by deciles provided more nuance by showing that the poorest 10% were left behind by 2018. Examining wealth in only urban areas helped reveal closing gaps in under-five mortality and CCI between the poorest and richest quintiles. Though challenged by lower precision, wealth gaps appeared to close in every province for both mortality and CCI. Still, inequalities remained higher in provinces with worse outcomes. Multi-tier equity measures provided similarly plausible and precise estimates as conventional measures for most comparisons, except mortality among some wealth deciles, and wealth tertiles by province. This suggests that related research could readily use these multi-tier measures to gain deeper insights on inequality patterns for both health coverage and impact indicators, given sufficient samples. Future household survey analyses using fit-for-purpose equity measures are needed to uncover intersecting inequalities and target efforts towards effective coverage that will leave no woman or child behind in Zambia and beyond.

Blanchard AK ，Jacobs C ，Musukuma M ，Chooye O ，Sikapande B ，Michelo C ，Boerma T ，Wehrmeister FC ... -  《International Journal for Equity in Health》

How Zambia reduced inequalities in under-five mortality rates over the last two decades: a mixed-methods study.

Zambia experienced a major decline in under-five mortality rates (U5MR), with one of the fastest declines in socio-economic disparities in sub-Saharan Africa in the last two decades. We aimed to understand the extent to which, and how, Zambia has reduced socio-economic inequalities in U5MR since 2000. Using nationally-representative data from Zambia Demographic Health Surveys (2001/2, 2007, 2013/14 and 2018), we examined trends and levels of inequalities in under-five mortality, intervention coverage, household water and sanitation, and fertility. This analysis was integrated with an in-depth review of key policy and program documents relevant to improving child survival in Zambia between 1990 and 2020. The under-five mortality rate (U5MR) declined from 168 to 64 deaths per 1000 live births between 2001/2 and 2018 ZDHS rounds, particularly in the post-neonatal period. There were major reductions in U5MR inequalities between wealth, education and urban-rural residence groups. Yet reduced gaps between wealth groups in estimated absolute income or education levels did not simultaneously occur. Inequalities reduced markedly for coverage of reproductive, maternal, newborn and child health (RMNCH), malaria and human immunodeficiency virus interventions, but less so for water or sanitation and fertility levels. Several policy and health systems drivers were identified for reducing RMNCH inequalities: policy commitment to equity in RMNCH; financing with a focus on disadvantaged groups; multisectoral partnerships and horizontal programming; expansion of infrastructure and human resources for health; and involvement of community stakeholders and service providers. Zambia's major progress in reducing inequalities in child survival between the poorest and richest people appeared to be notably driven by government policies and programs that centrally valued equity, despite ongoing gaps in absolute income and education levels. Future work should focus on sustaining these gains, while targeting families that have been left behind to achieve the sustainable development goal targets.

Jacobs C ，Musukuma M ，Sikapande B ，Chooye O ，Wehrmeister FC ，Boerma T ，Michelo C ，Blanchard AK ... -  《BMC HEALTH SERVICES RESEARCH》

Are the poorest poor being left behind? Estimating global inequalities in reproductive, maternal, newborn and child health.

Wealth-related inequalities in reproductive, maternal, neonatal and child health have been widely studied by dividing the population into quintiles. We present a comprehensive analysis of wealth inequalities for the composite coverage index (CCI) using national health surveys carried out since 2010, using wealth deciles and absolute income estimates as stratification variables, and show how these new approaches expand on traditional equity analyses. 83 low-income and middle-income countries were studied. The CCI is a combined measure of coverage with eight key reproductive, maternal, newborn and child health interventions. It was disaggregated by wealth deciles for visual inspection of inequalities, and the slope index of inequality (SII) was estimated. The correlation between coverage in the extreme deciles and SII was assessed. Finally, we used multilevel models to examine how the CCI varies according to the estimated absolute income for each wealth quintile in the surveys. The analyses of coverage by wealth deciles and by absolute income show that inequality is mostly driven by coverage among the poor, which is much more variable than coverage among the rich across countries. Regardless of national coverage, in 61 of the countries, the wealthiest decile achieved 70% or higher CCI coverage. Well-performing countries were particularly effective in achieving high coverage among the poor. In contrast, underperforming countries failed to reach the poorest, despite reaching the better-off. There are huge inequalities between the richest and the poorest women and children in most countries. These inequalities are strongly driven by low coverage among the poorest given the wealthiest groups achieve high coverage irrespective of where they live, overcoming any barriers that are an impediment to others. Countries that 'punched above their weight' in coverage, given their level of absolute wealth, were those that best managed to reach their poorest women and children.

Barros AJD ，Wehrmeister FC ，Ferreira LZ ，Vidaletti LP ，Hosseinpoor AR ，Victora CG ... -  《BMJ Global Health》

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.

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. In 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). Pro-poor 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. Across 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). 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 the home environment. Policy makers need to learn from community delivery channels to promote more equitable access to all RMNCH interventions. Bill & Melinda Gates Foundation and Wellcome Trust. For the French, Portuguese and Spanish translations of the abstract see Supplementary Materials section.

Leventhal DGP ，Crochemore-Silva I ，Vidaletti LP ，Armenta-Paulino N ，Barros AJD ，Victora CG ... -  《Lancet Global Health》

Wealth and education-related inequalities in the utilisation of reproductive, maternal, newborn, and child health interventions within scheduled tribes in India: an analysis of Odisha and Jharkhand.

The utilisation of Reproductive, Maternal, Newborn and Child Health (RMNCH) services remains lower among the Scheduled Tribes (ST) in India than among the rest of the country's population. The tribal population's poorest and least-educated households are further denied access to RMNCH care due to the intersection of their social status, wealth, and education levels. The study analyses the wealth- and education-related inequalities in the utilisation of RMNCH services within the ST population in Odisha and Jharkhand. We have constructed two summary measures, namely, the Co-coverage indicator and a modified Composite Coverage Index (CC), to determine wealth- and education-related inequalities in the utilisation of RMNCH indicators within the ST population in Odisha and Jharkhand. The absolute and relative inequalities with respect to wealth and education within the ST population are estimated by employing the Slope Index of Inequality (SII) and the Relative Index of Inequality (RII). The results of the study highlight that access to RMNCH services is easier for women who are better educated and belong to wealthier households. The SII and RII values in the co-coverage indicator and modified CCI exhibit an increase in wealth-related inequalities in Odisha between NFHS-4 (2015-16) and NFHS-5 (2019-21) whereas in Jharkhand, the wealth- and education-related absolute and relative inequalities present a reduction between 2016 and 2021. Among the indicators, utilisation of vaccination was high, while the uptake of Antenatal Care Centre Visits and Vitamin A supplementation should be improved. The study results underscore the urgent need of targeted policies and interventions to address the inequalities in accessing RMNCH services among ST communities. A multi-dimensional approach that considers the socioeconomic, cultural and geographical factors affecting healthcare should be adopted while formulating health policies to reduce inequalities in access to healthcare.

S R ，Neethi Mohan V ，Vaidyanathan G ，Dash U ，Muraleedharan VR ... -  《BMC PUBLIC HEALTH》