Equity In Service Provision Research Articles

Consistency, completeness and external validity of ethnicity recording in NHS primary care records: a cohort study in 25 million patients’ records at source using OpenSAFELY

BackgroundEthnicity is known to be an important correlate of health outcomes, particularly during the COVID-19 pandemic, where some ethnic groups were shown to be at higher risk of infection and adverse outcomes. The recording of patients’ ethnic groups in primary care can support research and efforts to achieve equity in service provision and outcomes; however, the coding of ethnicity is known to present complex challenges. We therefore set out to describe ethnicity coding in detail with a view to supporting the use of this data in a wide range of settings, as part of wider efforts to robustly describe and define methods of using administrative data.MethodsWe describe the completeness and consistency of primary care ethnicity recording in the OpenSAFELY-TPP database, containing linked primary care and hospital records in > 25 million patients in England. We also compared the ethnic breakdown in OpenSAFELY-TPP with that of the 2021 UK census.Results78.2% of patients registered in OpenSAFELY-TPP on 1 January 2022 had their ethnicity recorded in primary care records, rising to 92.5% when supplemented with hospital data. The completeness of ethnicity recording was higher for women than for men. The rate of primary care ethnicity recording ranged from 77% in the South East of England to 82.2% in the West Midlands. Ethnicity recording rates were higher in patients with chronic or other serious health conditions. For each of the five broad ethnicity groups, primary care recorded ethnicity was within 2.9 percentage points of the population rate as recorded in the 2021 Census for England as a whole. For patients with multiple ethnicity records, 98.7% of the latest recorded ethnicities matched the most frequently coded ethnicity. Patients whose latest recorded ethnicity was categorised as Other were most likely to have a discordant ethnicity recording (32.2%).ConclusionsPrimary care ethnicity data in OpenSAFELY is present for over three quarters of all patients, and combined with data from other sources can achieve a high level of completeness. The overall distribution of ethnicities across all English OpenSAFELY-TPP practices was similar to the 2021 Census, with some regional variation. This report identifies the best available codelist for use in OpenSAFELY and similar electronic health record data.

Practicing During the COVID-19 Pandemic: Experiences of Canadian Hospital-Based Occupational Therapists.

Background. The COVID-19 pandemic disrupted hospital operations worldwide, including services delivered by occupational therapists (OTs). Purpose. This study aimed to understand the experiences of OTs at one Canadian, tertiary care hospital during the 2021-2022 period of the pandemic. Method. We used a qualitative descriptive approach to describe the experiences of OTs during the pandemic. Findings. While there were similarities in the 10 participating OTs' experiences, salient differences were largely linked to the method of service delivery. Inpatient OTs benefitted from the support of colleagues and developed coping strategies in response to high levels of workplace stress and anxiety and a perceived lack of support from many levels of society. Clinically, they spent more time on discharge planning with fewer resources. OTs providing virtual/hybrid services experienced unique challenges related to adapting their practice to a virtual platform, including challenges assessing patients. They described benefits associated with virtual/hybrid service delivery and brought up concerns around equity of service provision. Conclusion. OTs in this hospital setting faced challenges in providing patient care and supporting their own wellness during the pandemic. Future research could explore the role of leadership in supporting occupational therapy practice during public health emergencies.

Evaluating provision of psychological assessment and support in palliative care: A national survey of hospices in England

Objective: Psychological distress is common in palliative care patients. The 2004 National Institute of Healthcare and Excellence (NICE) guidance for supportive and palliative care for adults with cancer, which remains contemporary, recognised that access to psychological support was inconsistent and often inadequate. Their 4-tier model requires multidisciplinary psychological assessment at key points. Implicit is the need for improved training and support for staff and equity in service provision. This survey was designed to determine the levels of self-reported competence amongst healthcare staff in the psychological assessment and screening of patients in adult hospices in England and their awareness of the NICE guidelines. Methods: A short anonymised online questionnaire was sent to 164 hospices to determine perceptions of healthcare professionals (HCPs) on their own competence in screening and assessment of distress, provision of therapies and levels of training and supervision. Results: Responses were received from 140 HCPs in approximately thirty-eight hospices. Key findings included self-reported needs for training and supervision. Over a quarter of nurses (28.8%) and AHPs (27.8%) had no level 2 training, and only half of nurses, AHPs and physicians were aware of the NICE guidelines. Access to level 3 specialist psychological services was lacking and some HCPs felt unable to screen and assess patients for referral to specialist services. Conclusions: Consistent, standardised training in assessment of psychological needs is required to ensuring delivery of high-quality care for psychological needs. Areas for future development identified include essential communication skills and high-quality supervision for those delivering psychotherapeutic interventions.

InterRAI Pediatric Home Care (PEDS-HC) Assessment Tool: Evaluating Ontario Healthcare Workers' Experience.

High quality pediatric homecare requires comprehensive assessment of the needs, supports, and health care challenges of children with special healthcare needs and their families. There is no standardized homecare assessment system to evaluate children’s clinical needs in the home (support services, equipment, etc.) in Ontario, Canada, which contributes to inequitable homecare service allocation. In 2017, the interRAI Pediatric Home Care assessment tool (PEDS-HC) was implemented on a pilot basis in several regions of Ontario. This qualitative descriptive study explores the experiences of homecare coordinators using the PEDS-HC, seeking to understand the utility and feasibility of this tool through focus group discussion. Four major themes were identified including: the benefits of the tool; areas for modification; challenges to use; and Clinical Assessment Protocols to develop. These themes can guide modifications to the tool to improve utility and improve pediatric home care services. The PEDS-HC is an effective tool to assess children needing homecare in a standardized and comprehensive manner. Use of the tool can improve the quality of homecare services by ensuring equity in service provision and facilitate early identification of clinical issues to prevent unexpected health deteriorations.

Young men and young women in secure care: gender differences in the placement of those with mental health needs

BackgroundThe system of secure care for young people in England and Wales comprises youth justice, welfare and mental health facilities. Empirical studies have failed to investigate the system as a whole. The National Adolescent Study in 2016 was the first to provide comprehensive system wide information. This paper, derived from that data set, addresses equity of service provision for young men and women in secure care who have mental health problems.MethodsThe detained census population of English young people in 2016 was 1322 and detailed data were available on 93% of this population, including 983 young men and 290 young women. The descriptive census data were interrogated to identify associations between gender, other sociodemographic and clinical variables, using Chi-square and Fisher’s exact tests.ResultsNumerically more young men in secure care than young women in secure care warrant a psychiatric diagnosis but young women had a 9 fold increase in the odds of having a diagnosis compared with the young men. The pattern of mental health diagnoses differed significantly by gender as did the legislative framework under which females and males were placed. This different pattern of secure care placement continued to differ by gender when the nature of the mental health diagnosis was taken into account.ConclusionsNo definitive explanation is evident for the significantly different placement patterns of young men and young women with the same mental health diagnoses, but the anticipated consequences for some, young men and some young women are important. Proper explanation demands an examination of process variables outwith the remit of this study. The lack of routine scrutiny and transparent processes across secure settings could be responsible for the development of these differential placement practices; these practices seem at odds with the duty placed on public services by the Equality Act.

Evaluating demand responsive transit services using a density-based trip rate metric

Demand responsive transit (DRT) is attracting increased attention as a means to provide public transit to low-density populations. This research aims to provide a suite of evaluation metrics with low data requirement and widespread availability, so that operators, funders, regulators, and practitioners can better evaluate the performance of DRT services. Trip numbers can be divided by a number of available variables (period, trip length, population, and density) to create a number of derived metrics. By applying these variables across three different DRT service areas in Logan City, Australia, where other key factors are held constant, one can see how different formulations lead to very different readings of DRT system performance. The results confirm the dilemma of cost efficiency versus equity in service provision in low-density environments. This paper also highlights current data limitations and calls for better data collection to facilitate the development of new evaluation methods for DRT services and a new composite metric that can be used for inter-service comparison.

Fair accessibility – Operationalizing the distributional effects of policy interventions

A fair distribution of public transport benefits is a commonly stated goal of agencies and operators of public transport. However, it is less complicated and costly to provide accessibility in some parts of cities and their surroundings than in other parts. Densely populated areas, and areas situated closer to the city center therefore often have higher public transport accessibility than remote or sparsely populated areas. Neglecting these realities results with an unrealistic assessment of equity in service provision and hampers their consideration when setting policy goals. In this study, we propose a framework for investigating equity in the distribution of accessibility, where the suggested goal is to provide residents with equal accessibility for equally dense and central areas. For the Stockholm County, we show that accessibility may seem to be distributed horizontally inequitable and vertically regressive. However, once controlling for how dense and close to the city center residents live, while still being horizontally inequitable the distribution of accessibility in Stockholm County is found progressive, i.e., benefiting those with lower incomes. We demonstrate the proposed method for the case of skip-stop train operations and find that it shifts our constructed accessibility measure toward a more horizontally inequitable and vertically progressive state. We conclude that our proposed method can be a potent way for public transport agencies to measure and concretize equity goals and evaluate policy changes.

Standards for Equity in Healthcare Provision and Utlisaton: Pilot Test in Sixteen Countries

Background: Health systems are faced with different needs, conditions and expectations concerning health and healthcare delivery. The most vulnerable groups risk receiving poorer care due to barriers and inequities in health service provision and utilisation. However health care organisations are often not sufciently equipped to effectively recognise and respond to the diverse needs of the population served. To this end, the Task Force Migration, Equity and Diversity (TF MED) developed a set of standards that allow health care organisations to evaluate equity in service provision and implement improvements. A test was conducted in 52 pilot organisations from sixteen countries to assess compliance with the standards, as well as to explore challenges and opportunities for the effective uptake of equity measures. Methods: Purposeful sampling was utilised to identify participants for the pilot test by national coordinators of the TF MED (The TF MED was previously named Task Force on Migrant Friendly and Culturally Competent Health Care. The new name came into effect in 2016.). Organisations were general and specialised hospitals and other health care providers. Each pilot organisation defned appropriate structure and process to conduct assessment of service performance against the standards. A cross-sectional survey was used for data collection, participants were asked to fll in an online questionnaire with data collected though the self-assessment process. Data were analysed quantitatively as well as qualitatively. Results: The fndings of the pilot test show that compliance with the standards was low in three main areas: policy, participation and promoting equity outside the organisation. In particular, pilot institutions revealed difculties in engaging management and leaders on equity issues; in promoting the participation of users at risk of discrimination; in developing forms of collaboration with relevant stakeholders in the community. On a more positive side, the pilot test results show that in general organisations do have policies in place to improve access to healthcare, as well as policies to ensure that individual and family needs are taken into account throughout the care process; however their effectiveness and impact are rarely evaluated. Conclusion: The implementation of the standards for equity contributes to a self-reflective process, involving health professionals and managers, in which gaps and potential improvements are identifed. Many of the pilot organisations utilised the standards as part of a process of increasing their awareness of equity issues and changing the reorganizational culture.

Ethnic inequality within the elderly population in utilizing healthcare services

The accessibility of minority ethnic groups to healthcare services is challenging in many societies, most especially among the elderly population. Elderly individuals from minority groups have been found to have lower levels of utilizing healthcare services, including preventive care, intensive hospital care, advanced technological procedures and rehabilitation. Universal health coverage is incapable of addressing all of healthcare’s access inequities and there is a need to assess the overall outcomes, including mortality rates over time, functionality of discharged patients, quality of life and/or unplanned readmissions that may indicate low quality hospital discharge processes. There is a need to investigate the impact of perceived trust/distrust in the healthcare system of elderly patients from minority ethnicities on their willingness to consume medical services.To ensure equity in service provision, there is a need to examine whether medical providers, even unconsciously, prioritize vital services, such as rehabilitation services to populations that share similar social backgrounds. An essential measure is enhancement of health literacy at all levels, from the individual to policy-makers and strategic adoption of health literacy programs that encompass all ethnicities, considering their respective needs, norms and expectations.Ethnic equality in accessing medical services is crucial in view of the numerous migrants and asylum-seekers who look for refuge in varied societies globally. Such populations are perceived as faring worse in healthcare quality of care, and this highlights the need to adapt the healthcare systems to the varied health behaviors, contextual factors, language barriers, lower health literacy levels and limited access to timely care. Improving equity and access to medical care is dependent on enhanced health literacy; policies that consider diverse needs of majority and minority groups; and advanced research. Concurrent implementation of these measures will be well aligned with the global strive to promote the Sustainable Development Goals (SDGs).

Service provision in Scotland for people with an intellectual disability and dementia: adherence to good practice guidelines

Background: Good practice guidelines aim to promote equity in service provision and quality in order to improve the outcomes, experiences and quality of life of service users.Specific Aims: to evaluate the extent to which the practices of NHS services for people with an intellectual disability and dementia in Scotland were consistent with a range of quality indicators that covered screening, assessment, and intervention. Method: Participants were staff from 10 intellectual disability services in Scotland who completed an online survey. They rated the extent to which their service met quality indicators adapted from the British Psychological Society, Division of Clinical Psychology & Royal College of Psychiatrists (2015) Good Practice Standards Self-Assessment Checklist. Findings: The areas that were most commonly ‘fully met’ related to assessment and diagnosis, those that were most commonly ‘not/only partially met’ related to areas such as flexible funding, service development and monitoring and location of out of area placements. Discussion: The results suggest there is some disparity in the extent to which the participating services have practices which are consistent with all of the quality indicators. The limitations and implications for nurses are discussed.

Regional Outcome Evaluation Program (P.Re.Val.E.): Reduction of inequality in access to effective health care in the Lazio region of Italy (2012-2015).

BackgroundInequalities in health among groups of various socio-economic status (as measured by education, occupation, and income) constitute one of the main challenges for public health. Since 2006, the Lazio Regional Outcome Evaluation Program (P.Re.Val.E.), presents a set of indicators of hospital performance based on quality standards driven by strong clinical recommendations, and measures the variation in the access to effective health care for different population groups and providers in the Lazio Region. One of the aims of the program was to compare population subgroups in order to promote equity in service provision. Since June 2013, a new management strategy has been put in place that assigned specific goals based on performance assessment to the chief executive officers of the hospitals.AimTo evaluate whether, in recent years, there has been a reduction in the differential access to effective health care, among individuals with different educational levels.MethodsWe enrolled all patients discharged from both public and private hospitals of the Lazio region between 2012 and 2015, living in Lazio region. We analysed the proportion of patients with ST-elevation myocardial infarction (STEMI) treated with percutaneous coronary intervention within 90 minutes (primary PCI), the proportion of patients with hip fracture (HF) who underwent surgery within 2 days, and the proportion of women with primary C-section. We applied multivariate logistic regression models to assess the effect of educational level on health outcomes, adjusting for demographic characteristics and comorbidities that could affect the outcomes. For each year of the study period, we compared adjusted proportions of outcomes for the highest and the lowest level of education by using percentage differences.ResultsIn the Lazio region, 44.6% of STEMI patients (N = 3,299) were treated with primary PCI, 54.4% of patients with hip fractures (N = 6,602) underwent surgery within 2 days, and 27.7% of women without a previous C-section (N = 34,718) delivered via C-section, in 2015. The corresponding proportions in 2012 were 27.8%, 31.3% and 31.5%, respectively. By comparing the adjusted proportions in patients with the highest education level (a university degree or higher) to those with the lowest level education level (None/Primary school), a decrease in the percentage difference was observed during the study period. In STEMI and delivery cohorts, the improvement of outcomes involved the least and the most educated patients, respectively, and the difference between the two educational levels was close to zero in 2015, whereas for hip patients, the improvement was more evident among the less educated patients.ConclusionsIn the Lazio region, we observed a reduction in the differential access to effective heath care by educational level, in different clinical areas. Different factors might explain these results. On top of the public disclosure of outcome data, the management strategy applied in mid-2013 might have driven the overall improvement of the health system for the considered conditions, helping to achieve a fairer access to health.

Sustaining an Equitable Heath System: Need for Evidence Informed Decision Making

Provision of universal health coverage has drawn attention across the globe. Attaining equity in service provision while sustaining the health system has become the major challenge. As limited resources become a barrier to achieve both at the same time, short term measures dominate policy cycles based on options and interests of individuals and groups than hard evidence. Taking Sri Lankan health system as an example this paper discusses the importance of evidence based decisions to achieve both equity and sustainability of services in low resource settings.

The effectiveness of implementation in Indigenous Australian healthcare: an overview of literature reviews.

BackgroundEffective implementation can maximise the beneficial impacts of health services. It is therefore important to review implementation in the context of Indigenous populations, who suffer some of the greatest disadvantage within developed countries. This paper analyses Aboriginal and Torres Strait Islander (hereafter Indigenous) Australian health implementation reviews to examine the research question: What is the effectiveness of implementation, as reported in the Indigenous Australian health implementation literature?MethodsEight databases were systematically searched to find reviews of Indigenous Australian health services and/or programs where implementation was the focus. Search terms included Aborigin* OR Indigen* OR Torres AND health AND service OR program* OR intervention AND implementation (or like terms) AND Australia AND review. Review findings were analysed through the lens of the PARiHS framework which theorises that successful implementation occurs through the interplay of evidence, context and facilitation. The review followed Cochrane methods but was not registered.ResultsSix reviews were found; these encompassed 107 studies that considered health service/program implementation. Included studies described many health services implemented across Australia as not underpinned by rigorous impact evaluation; nevertheless implementers tended to prefer evidence-based interventions. Effective implementation was supported by clearly defined management systems, employment of Indigenous health workers as leaders, community control, partnerships, tailoring for diverse places and settings; and active facilitation methods. Short-term funding meant most studies focused on implementation in one site through pilot initiatives. Only two mentioned cost effectiveness. Indigenous Australian studies incorporated two elements not included in the PARiHS reference guide: the value of community control and equity of service provision across sites.ConclusionsComparison of the Indigenous Australian review findings against the PARiHS reference guide elements suggested a fledgling but growing state of Indigenous implementation research, and considerable scope to improve the effectiveness of implementation. Further research is required to explore Indigenous people’s understandings of what is important in healthcare implementation; particularly in relation to the value of community control and equity issues.

Interagency collaboration in children and young people's mental health: a systematic review of outcomes, facilitating factors and inhibiting factors.

In the UK and internationally, there have been increasing calls for interagency collaboration across mental health services for children and young people. However, it is not clear whether such practices do, indeed, have a positive impact and, if so, what factors facilitate and inhibit collaboration across agencies. Electronic searches were carried out on seven key computerized bibliographic databases. For inclusion in the review, studies needed to report on close working by two or more services that provided mental health support for children and/or young people and that had some systematic collection of qualitative and/or quantitative data. Outcomes were analysed narratively, and facilitating and inhibiting factors were examined using thematic analysis. A final sample of 33 studies was identified from 4136 initial records. Outcomes were mixed, with some findings indicating that interagency collaboration was associated with greater service use and equity of service provision, but other suggesting negative outcomes on service use and quality. However, interagency collaboration was perceived as helpful and important by both service users and professionals, and collaborative initiatives were evaluated positively. The factors most commonly identified as facilitating interagency collaboration were good interagency communication, joint trainings, good understandings across agencies, mutual valuing across agencies, senior management support, protocols on interagency collaboration and a named link person. The most commonly perceived barriers to interagency collaboration were inadequate resourcing, poor interagency communication, lack of valuing across agencies, differing perspectives, poor understandings across agencies and confidentiality issues. The results are consistent with findings from previous reviews of interagency collaboration across adult and child services: there were some indications of benefit; and facilitating and inhibiting factors involved working relationships and multi-agency processes, resources and management. The identification of these factors has implications for practitioners, service managers, trainers, commissioners and researchers.

Metastatic Colorectal Cancer Treatment and Survival: the Experience of Major Public Hospitals in South Australia Over Three Decades.

Registry data from four major public hospitals indicate trends over three decades from 1980 to 2010 in treatment and survival from colorectal cancer with distant metastases at diagnosis (TNM stage IV). Kaplan-Meier product-limit estimates and Cox proportional hazards models for investigating disease-specific survival and multiple logistic regression analyses for indicating first-round treatment trends. Two-year survivals increased from 10% for 1980-84 to 35% for 2005-10 diagnoses. Corresponding increases in five-year survivals were from 3% to 16%. Time-to-event risk of colorectal cancer death approximately halved (hazards ratio: 0.48 (0.40, 0.59) after adjusting for demographic factors, tumour differentiation, and primary sub-site. Survivals were not found to differ by place of residence, suggesting reasonable equity in service provision. About 74% of cases were treated surgically and this proportion increased over time. Proportions having systemic therapy and/or radiotherapy increased from 12% in 1980-84 to 61% for 2005-10. Radiotherapy was more common for rectal than colonic cases (39% vs 7% in 2005-10). Of the cases diagnosed in 2005-10 when less than 70 years of age, the percentage having radiotherapy and/or systemic therapy was 79% for colorectal, 74% for colon and 86% for rectum (and RS)) cancers. Corresponding proportions having: systemic therapies were 75%, 71% and 81% respectively; radiotherapy were 24%, 10% and 46% respectively; and surgery were 75%, 78% and 71% respectively. Based on survey data on uptake of offered therapies, it is likely that of these younger cases, 85% would have been offered systemic treatment and among rectum (and RS) cases, about 63% would have been offered radiotherapy. Pronounced increases in survivals from metastatic colorectal cancer have occurred, in keeping with improved systemic therapies and surgical interventions. Use of radiotherapy and/or systemic therapy has increased markedly and patterns of change accord with clinical guideline recommendations.

Market-Type Mechanisms and Public Service Equity: A Review of Experiences in European Public Services

In seeking to benefit from the competitive pressures exerted through marketization, governments have hoped to gain improvements in public service efficiency. Yet, concerns remain about the effects of marketization on how equitably public services are provided. We consider evidence about the relationship between the introduction of market-type mechanisms in the European public sector and the efficiency and equity of service provision. Our analysis reveals that although market-type mechanisms sometimes result in worse service equity, there is only weak evidence of a trade-off between efficiency and equity.

The relationship between young people׳s transit use and their perceptions of equity concepts in transit service provision

This study investigates the effect of price and travel mode fairness and spatial equity in transit provision on the perceived transit service quality, willingness to pay, and habitual frequency of use. Based on the theory of planned behavior, we developed a web-based questionnaire for revealed preferences data collection. The survey was administered among young people in Copenhagen and Lisbon to explore the transit perceptions and use under different economic and transit provision conditions. The survey yielded 499 questionnaires, analyzed by means of structural equation models. Results show that higher perceived fairness relates positively to higher perceived quality of transit service and higher perceived ease of paying for transit use. Higher perceived spatial equity in service provision is associated with higher perceived service quality. Higher perceived service quality relates to higher perceived ease of payment, which links to higher frequency of transit use.

Policy analytics need more than a spreadsheet: a case study in funding formulae

This article presents two case studies, concerning the allocation of £Billions by a mechanism communicated via spreadsheet models. It argues that technical analytic skills as well as policy development skills are a vital component of governance. In the UK, Central Government uses funding formulae to distribute money to local service providers. One commonly stated goal of such formulae is equity of service provision. However, given the complexity of public services, together with variations in need, delivery style and the exercise of stakeholder judgement as to which needs should be met and how, such formulae frequently obscure the process by which equity has been taken into account. One policy ‘solution’ to managing such tensions is to seek ‘transparency’. With respect to funding formulae, this commonly involves publishing the underlying data and formulae in spreadsheets. This paper extends the argument that such ‘transparency’ requires an audience that understands the policy assumptions (and related conceptualisations), data sources, methodological approaches and interpretation of results. It demonstrates how the search for policy ‘transparency’ is also met by the technical quality assurance goals that the operational research community would recognise as best practice in the development both of software generally and spreadsheet models specifically. Illustrative examples of complex formulae acting to subvert equity are drawn from the English Fire and Rescue Service and Police Service allocation formulae. In the former, an increase in the amount of deprivation, as measured by one of six indicators, has the perverse effect of decreasing the financial allocation. In the latter, metropolitan areas such as London are found to gain most from the inclusion of variables measuring sparsity. The conclusion from these scenarios is that the steps needed to for technical quality assurance and policy transparency are mutually reinforcing goals, with policy analysts urged to make greater use of technical analytic skills in software development.

“From your own thinking you can't help us”: Intercultural collaboration to address inequities in services for Indigenous Australians in response to the World Report on Disability

Inequity in service provision for Indigenous Australians with communication disability is an issue requiring urgent attention. In the lead article, note that, even in the relatively affluent Minority World, including Australia, equity in service provision for people with communication disability has not been achieved. In remote communities in the Northern Territory (NT) almost all residents speak a language other than English as their primary language. However, there are no speech-language pathologists (SLPs) in the NT who speak an Indigenous language or who share their cultural background. Specific data on the prevalence of communication disability in this population are unavailable due to a range of factors. The disability data that are available, for example, demonstrating the high level of conductive hearing loss, indicates that the risk of communication disability in this population is particularly high. Change is urgently needed to address current inequities in both availability of, and access to, culturally responsive services for Indigenous people with communication disability. Such change must engage Indigenous people in a collaborative process that recognizes their expertise in identifying both their needs and the most effective form of response to these needs.

Analyzing the equity of public primary care provision in Kenya: variation in facility characteristics by local poverty level

IntroductionEquitable access to health care is a key health systems goal, and is a particular concern in low-income countries. In Kenya, public facilities are an important resource for the poor, but little is known on the equity of service provision. This paper assesses whether poorer areas have poorer health services by investigating associations between public facility characteristics and the poverty level of the area in which the facility is located.MethodsData on facility characteristics were collected from a nationally representative sample of public health centers and dispensaries across all 8 provinces in Kenya. A two-stage cluster randomized sampling process was used to select facilities. Univariate associations between facility characteristics and socioeconomic status (SES) of the area in which the facility was located were assessed using chi-squared tests, equity ratios and concentration indices. Indirectly standardized concentration indices were used to assess the influence of SES on facility inputs and service availability while controlling for facility type, province, and remoteness.ResultsFor most indicators, we found no indication of variation by SES. The clear exceptions were electricity and laboratory services which showed evidence of pro-rich inequalities, with equity ratios of 3.16 and 3.43, concentration indices of 0.09 (p<0.01) and 0.05 (p=0.01), and indirectly standardized concentration ratios of 0.07 (p<0.01) and 0.05 (p=0.01). There were also some indications of pro-rich inequalities for availability of drugs and qualified staff. The lack of evidence of inequality for other indicators does not imply that availability of inputs and services was invariably high; for example, while availability was close to 90% for water supply and family planning services, under half of facilities offered delivery services or outreach.ConclusionsThe paper shows how local area poverty data can be combined with national health facility surveys, providing a tool for policy makers to assess the equity of input and service availability. There was little evidence of inequalities for most inputs and services, with the clear exceptions of electricity and laboratory services. However, efforts are required to improve the availability of key inputs and services across public facilities in all areas, regardless of SES.