Essays on health inequalities and utilization of health service in low- and middle- income countries

Thesis(Doctoral) --KDI School:Ph.D in Public Policy,2018ch.1 Objectives: The main objectives of this study were to identify key socioeconomic determinants of health inequality and evaluate the likely effectiveness of different types of interventions aimed at reducing socio-economic health inequalities available from the literature and highlight appropriate types of interventions to tackle health inequalities for future evidence-based policy. Methods: This study systematically reviews 73 articles on the determinants of health inequality and 26 studies on impact evaluation of interventions and policies to tackle health inequality. Key databases were searched including EBSCO, PubMed, JSTOR, Cochrane library of databases and DHS database. Results: Income and income inequality, education and place of living were associated with health outcomes of the population. Interventions targeting healthy behaviors and prevention were most effective at reducing health inequalities compared to other type of interventions. Interventions based on education and accesses to health care services were mostly successful in reducing health inequality. Interventions on poverty reduction and housing showed inconclusive mixed results, but were mainly unsuccessful. Conclusion: Programs based on healthy lifestyle and behaviors and access to health care, specifically improving distribution of health professionals in remote disadvantaged areas are effective to tackle health inequalities. ch.2 Objectives: This paper examines the effect of expansion of essential maternal and child health intervention coverage on reducing level and inequity in child mortality. Methods: Using 167 nationally representative Demographic and Health Surveys and Multiple Indicator Cluster Surveys of 54 low income and middle income countries during 1993 to 2014, we estimated a panel random effects model of health intervention coverage and the child mortality rate. A composite coverage index is constructed as a weighted average of eight maternal and child health intervention coverage. Inequalities in the child mortality and health intervention coverage were measured by the Concentration Index by household wealth quantiles. Results: The descriptive analysis shows substantial inequalities in intervention coverage and child mortality were present by household wealth and across countries. The result of panel data analysis showed that a one percent increase in composite coverage index results in 1.4 fewer deaths per 1000 live births and equity in child mortality improve by 0.17 point. On the other hand, inequality in coverage has a harmful effect on level and equity in child mortality. Results suggested that one point increase in inequality of intervention coverage increase under-five mortality per 1000 live births by three more deaths and increase inequality in child mortality rate by 0.5 percent, holding other factors constant. Conclusion: Results of this study suggest that persistent efforts must continue to be made to expand coverage of essential maternal and child health interventions for the poorest mothers and children as fast as possible, in order to save lives of children and reduce inequality in both health care and health outcome. ch.3 Objective: This study aimed to examine the effect of demand-side access barriers on the utilization of maternal health care services in Cameroon. Methods: Repeated cross-sectional data of 2004 and 2011 Demographic and Health Survey from Cameroon were employed. Information about the mothers of 71767 live-born children age under five years in the five years preceding the survey was included in this study. Multiple logistic regression models were used to examine the effects of demand-side barriers on the utilization of skilled antenatal care and delivery care. Results: The adjusted odds ratios of both utilization of antenatal care and delivery care were significantly lower if women reported that they have big financial, cultural and geographical problems accessing health care than who reported they have less difficulties. Mothers residing in the urban area, mothers with higher levels of education, and those in the highest wealth quintiles were most likely to receive professional antenatal care and delivery care. The important barriers to access antenatal care and delivery care in Cameroon was getting money to get medical treatment, distance, and transport to a health facility. Conclusion: Women who have barriers to seeking health care for themselves were least likely to receive professional antenatal care and delivery care. The result of this study implies that policies to reduce demand-side barriers, such as lowering or exempting user fees for essential maternal care especially for the poorest and most vulnerable mothers, bringing healthcare closer to the people, improving infrastructure and organization of transport networks will significantly increase utilization of effective maternal care in the country.Chapter 1: Socioeconomic determinants of health inequalities and its impact: Overview of the evidence Chapter 2: Child Health and Health Intervention Coverage in low- and middle- income countries: An Panel Analysis on Health Inequity Chapter 3: Effect of access barriers on service use in maternal health care: Evidence from CameroondoctoralpublishedKhorolsuren LKHAGVASUREN