文章基本信息

标题：Equity of Skilled Birth Attendant Utilization in Developing Countries: Financing and Policy Determinants
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作者：Margaret E. Kruk ; Marta R. Prescott ; Sandro Galea 等
期刊名称：American journal of public health
印刷版ISSN：0090-0036
出版年度：2008
卷号：98
期号：1
页码：142-147
DOI：10.2105/AJPH.2006.104265
语种：English
出版社：American Public Health Association
摘要：Objectives. Developing countries with higher health care spending have greater overall utilization of maternal health services than do countries with lower spending. However, the rich tend to disproportionately use these services. We assessed whether redistributive government policies in the context of higher levels of health spending were associated with more-equitable use of skilled birth attendants (doctors, nurses, or midwives) between rich and poor. Methods. We used data from Demographic and Health Surveys of 45 developing countries and disaggregated by wealth quintile. Multivariable regression analyses were used to assess the joint effect of higher health care expenditures, the wealth distribution of women’s fifth-grade education (a proxy for redistributive policy environment within the central government) and the overall proportion of women with fifth-grade education (a proxy for female literacy and an indicator of governments’ commitment to girls’ education). Results. We found that utilization of skilled birth attendants was more equitable when higher health expenditures were accompanied by redistributive education policies. Conclusions. Higher health care expenditures should be accompanied by redistributive policies to reduce the gap in utilization of skilled birth attendants between poorer and richer women in developing countries. Millennium Development Goal 5, 1 of 8 global development goals agreed to by 190 world leaders in 2000, calls for a 75% reduction in maternal mortality between 1990 and 2015. 1 ^, 2 Maternal mortality is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy from any cause related to the pregnancy. 3 The lifetime risk of dying in pregnancy or shortly after delivery stands at 1 in 30000 in Sweden and 1 in 16 in sub-Saharan Africa—perhaps the largest differential between rich and poor countries of any health statistic. 4 Reduction of maternal mortality by 75% in the highest-burden regions such as sub-Saharan Africa will require a rapid and massive scale up of health systems including the provision of universal skilled birth attendance (by a doctor, nurse, or midwife), referral for complications, and widespread availability of emergency obstetric care, such as Caesarian section. 5 There is growing focus on the skilled birth attendant, particularly the trained midwife, as the cornerstone of renewed global efforts to reduce maternal mortality. 6 However, access to skilled birth attendants is limited, particularly in countries with the highest maternal mortality. Only 32% of births in sub-Saharan Africa and 35% in South and Southeast Asia—the regions with the highest maternal mortality—are attended by a doctor, nurse, or midwife; this is in stark contrast to universal or near universal use of skilled birth attendants in the developed world. 6 Average utilization of skilled attendants was slightly less than 50% in a sample of 40 developing countries that reported standardized data, with much lower levels in rural areas. 6 Although utilization of health services is a function of both patient demand and supply, in situations in which health budgets are very low, poor availability of services is a major constraint to utilization. The World Health Organization (WHO) Commission on Macroeconomics and Health determined that providing access to a basic package of essential services costs approximately $35 per capita per year. 7 In 2003, only 12 of 46 countries in the WHO Africa region spent this amount or more. 8 Higher absolute levels of health spending increase overall utilization of health services. 9 ^– 12 In previous work that used data from 40 developing countries, we have shown that countries with both higher total health spending and higher proportions of government spending on health have greater overall utilization of maternal health services including skilled birth attendants and Caesarian section. 13 The international community is increasingly interested in effective ways to strengthen health systems and improve availability and utilization of health services through greater official development assistance for health. After decades of declining official development assistance, with the impetus of the Millennium Development Goals, 16 of 25 donor countries have pledged to increase their official development assistance to the international target of 0.7% of gross domestic product by 2015. 14 Donor countries have also set up an international policy dialogue on funding and policies required to achieve the health Millennium Development Goals, including Goal 5. 15 Although additional health care spending may help to reduce average maternal mortality ratios in developing countries, thereby decreasing the inequity between rich and poor countries, there is increasing concern that this spending may increase inequities between rich and poor groups within the country. For example, observers in developed and developing countries cite the “inverse care law,” which states that the availability of medical care is often not determined by medical need but by other considerations including socioeconomic status. 16 This results in a situation in which the poor who tend to have poorer health outcomes—for example, mortality of children under age 5 in the poorest 20% versus the richest 20% of children was nearly twice as high across 56 countries 17 —have the least access to health services. 18 ^– 22 This is likely a result of health system factors such as insufficient government health budgets, the relative unaffordability of out-of-pocket payments for health care for the poor, and urban and tertiary care bias in health budget allocations by Ministries of Health, as well as factors outside the health system including poor education, transport links, and the status of women. 23 ^– 26 The mounting evidence of inequities in health care has led to discussions in the health policy community and among policymakers in developing countries about the need to adopt a pro-poor approach that explicitly targets the most vulnerable groups in health resource allocations. 16 Although evidence suggests that the rich within countries capture more of the benefits of health spending than do the poor, this is not inevitable. Equity in utilization of services between the rich and poor varies among countries at similar levels of health spending but with different policies on redistribution of health care resources. For example, in a sample of 21 industrialized countries, the 2 without a policy of universal coverage (United States and Mexico) had the greatest pro-rich inequities in physician visits when adjusted for health need. 27 Pro-poor policies including conditional cash transfers to the poor to encourage the use of health services can also reduce historic inequities in health outcomes such as child mortality, as has been demonstrated in several Latin American countries. 28 One approach to assessing a country’s commitment to redistribution is to examine the equity of utilization of essential services in sectors traditionally considered to be the responsibilities of governments, such as health and education. For the purposes of this paper, redistributive policies are defined as those that achieve equal or higher utilization of services for poorer compared with richer groups. More-equitable distribution in fifth grade completion, for example, may indicate commitment to redistribution within the education ministry and possibly within the government as a whole. A redistributive central government policy framework may in turn influence whether health dollars reach the poor. We investigated the extent to which redistributive education policies modify the impact of higher health spending on the utilization of skilled birth attendants among the poorest compared with the least poor women in 45 developing countries. The concentration index of fifth grade completion, which measures the degree of inequality in education as a function of wealth, was used as a proxy for the degree of redistribution in education policy.