Measuring socioeconomic and health financing inequality in maternal mortality in Colombia: a mixed methods approach

Juan Carlos Rivillas,Raúl Devia-Rodriguez,Marie-Gloriose Ingabire

doi:10.1186/s12939-020-01219-y

Juan Carlos Rivillas, Raúl Devia-Rodriguez + Show 1 more

Open Access

https://doi.org/10.1186/s12939-020-01219-y

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Abstract

BackgroundUnderstanding health financing reforms and means is key to evaluate how maternal health has improved. Problems related to health financing policies are contributing to inadequate quality of care and inequitable use of healthcare by pregnant women, resulting in poor maternal health outcomes. The purpose of the study was to measure socioeconomic and health financing related inequality in maternal mortality in Colombia as well as identifying potential epicenters of this inequality.MethodsThe data used was obtained from National Information of Social Protection (Sispro), the Department of Planning and National Statistics Department. Maternal mortality ratios were calculated by health insurance scheme and disaggregated by health spending per capita quintiles to allow for closer examination of inequality. The Slope Index of Inequality and Concentration Index were estimated to express absolute and relative inequality. We conducted interviews with key informants involved in the implementation of health financing and maternal health policies.ResultsThe main finding shows inequality in maternal mortality across regions and in particular in the subsidized health insurance. The contributory health insurance scheme is closing gaps over time, but inequality in the subsidized scheme is significantly widening, which impacts the severity of overall measurements of inequality. 20% of territories with the lowest health spending per capita have reached 35% of maternal mortality, and it such rates are worsening. This means that there is a marginal exclusion in which most of maternal deaths still occur in the regions with lowest resources.ConclusionsBeyond the key issues in health financing, issues of quality of care must be addressed. The country must define its own approach to financing for maternal health coverage given its unique situation and starting point. Potential policy implications that emerged are: i) afro-Colombian, indigenous, poorer and migrant women must be put at the center of the maternal health care services; ii) better skills, Reproductive, Maternal, Newborn and Child Health RMNCH training and health worker retention strategies and training in rural, insular and remote geographical areas; ii) a better understanding of provider payment mechanisms and the incentives that influence provider behaviors; and iv) inequality prompt calls for a targeted approach, whereby care is directed toward the most disadvantaged regions.

Highlights

Understanding health financing reforms and means is key to evaluate how maternal health has improved
To explore the association between changes in maternal mortality ratios with changes in health spending per capita; secondly, to assess the patterns of inequalities in maternal mortality driven by health spending per capita; and to understand the implementation gaps in health financing reforms which impact maternal health policy implementation
Quantitative findings Maternal mortality and health financing Maternal Mortality Ratios have dropped by a quarter in a 10 a year-period (2005–2014), which means a progress in the reduction of maternal deaths of 23.51 percentage points

Summary

Introduction

Understanding health financing reforms and means is key to evaluate how maternal health has improved. As part of the SDGs, health is captured explicitly under the SDG-3 aimed at “Ensuring healthy lives and promoting well-being for all at all ages”. This goal includes reducing the global maternal mortality ratio to less than 70 per 100,000 live births to achieve universal health coverage by 2030. Multi-country studies [1, 2] show that universal health coverage is a critical component of sustainable development, and a key element in reducing social inequity and poverty, in particular in health financing reforms and policies. The definition of Universal Health Coverage (UHC) embodies three specific policy goals: i) equity in the use of health services; ii) quality of care; and iii) universal financial protection. Countries must pay attention to each of the three health financing functions: i) raising funds in an equitable way, ii) pooling to spread risk protection for all and iii) effective mechanisms to purchase health services

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