Delivery Channels and the Magnitude of Socioeconomic Inequalities in Coverage of RMNCH Interventions: Analysis of 36 Cross-Sectional Surveys in Low- 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 and middle-income countries (LMICs). Methods: Recent national surveys from 36 LMICs provided information on a set of 18 RMNCH interventions; 21 countries also had information on two malaria interventions. We classified interventions into four delivery channels: health facility-based, community-based, environmental and “culturally driven”. Within each country, wealth quintiles were derived from information on household asset indices. Absolute and relative inequalities were assessed using the slope index of inequality (SII) and the concentration index (CIX). Findings: All interventions tended to present pro-rich patterns, except for two breastfeeding indicators from the culturally driven group, which showed higher coverage among the poor. Environmental interventions were the most unequal, particularly use of clean fuels with median levels of SII and CIX of 48.8 and 67.0, respectively. Interventions primarily delivered in health facilities, namely institutional childbirth (median SII=46.7 and CIX=11.4) and antenatal care (median SII=26.7 and CIX=10.0), also tended to show marked pro-rich patterns. In comparison, primarily community-based interventions were more equitably distributed – such as oral rehydration therapy (SII 9.4, CIX 3.4) and polio immunization (SII 12.1, CIX 3.1). Interpretation: Community-based interventions tend to be more equitable than those delivered in fixed facilities or those that require changes in the home environment. Policymakers need to learn from community delivery channels to promote more equitable access to all RMNCH interventions. Funding Statement: The Bill & Melinda Gates Foundation Organization (grant numbers OPP1148933 and OPP1199234 to the Countdown to 2030 Initiative); Wellcome Trust (grant number 101815/Z/13/Z); and Associacao Brasileira de Saude Coletiva (ABRASCO). Declaration of Interests: We declare no competing interests.