Wealth-based Inequalities Research Articles

Trend and projection of skilled birth attendants and institutional delivery coverage for adolescents in 54 low- and middle-income countries, 2000\u20132030

BackgroundLimitations to accessing delivery care services increase the risks of adverse outcomes during pregnancy and delivery for all pregnant women, particularly among adolescents in LMICs. In order to inform adolescent-specific delivery care initiatives and coverage, we conducted a comprehensive analysis of trends, projections and inequalities in coverage of delivery care services among adolescents at national, urban-rural and socio-economic levels in LMICs.MethodsUsing 224 nationally representative cross-sectional survey data between 2000 and 2019, we estimated the coverage of institutional delivery (INSD) and skilled birth attendants (SBA). Bayesian hierarchical regression models were used to estimate trends, projections and determinants of INSD and SBA.ResultsCoverage of delivery care services among adolescents increased substantially at the national level, as well as in both urban and rural areas in most countries between 2000 and 2018. Of the 54 LMICs, 24 countries reached 80% coverage of both INSD and SBA in 2018, and predictions for 40 countries are set to exceed 80% by 2030. The trends in coverage of INSD and SBA of adult mothers mostly align with those for adolescent mothers. Our findings show that urban-rural and wealth-based inequalities to delivery care remain persistent by 2030. In 2018, urban settings across 54 countries had higher rates of coverage exceeding 80% compared to rural for both INSD (45 urban, 16 rural) and SBA (50 urban, 19 rural). Several factors such as household head age ≥ 46 years, household head being female, access to mass media, lower parity, higher education, higher ANC visits and higher socio-economic status could increase the coverage of INSD and SBA among adolescents and adult women.ConclusionsMore than three-quarters of the LMICs are predicted to achieve 80% coverage of INSD and SBA among adolescent mothers in 2030, although with sustained inequalities.

Inequalities in full vaccination coverage based on maternal education and wealth quintiles among children aged 12–23 months: further analysis of national cross-sectional surveys of six South Asian countries

ObjectiveThis study was conducted to compare full vaccination coverage and its inequalities (by maternal education and household wealth quintile).DesignThis further analysis was based on the data from national-level cross-sectional Demographic...

Super polluters and carbon emissions: Spotlighting how higher-income and wealthier households disproportionately despoil our atmospheric commons

This study examines income- and wealth-based disproportionalities in carbon emissions from energy consumption in the residential sector of the United States. An ongoing debate in the field is whether or not inequality drives environmental degradation, especially carbon emissions. This study speaks to this important debate, focusing on the micro (household) level. While numerous studies address this question, they have done so largely at the macro- (cross-national) or meso- (subnational states and provinces) level. Based on probability-weighted ordinary least squares regression analysis of nationally representative data pertaining to United States households, I find substantial positive relationship between income and wealth inequality and carbon emissions from residential energy consumption. The data show huge disproportionalities in carbon emissions from energy consumption among the households analyzed, suggesting inequality does not bode well for environmental protection. What this finding also implies is that measures implemented to reduce income- and wealth-based inequalities may double as climate change mitigation policies.

1087Ethnic inequalities in reproductive health in Latin America

Abstract Background African descendants continue to be affected by discrimination in the Americas. We assessed ethnic inequalities in sexual/reproductive health (SRH) in Latin American countries. Methods Using data from national surveys we analyzed SRH in nine countries. Absolute differences in coverage for Afro women and the country-specific reference group (usually full or mixed European ancestry) were estimated for contraception with modern methods (CPmo), family planning needs satisfied with modern methods (FPSmo), 4+ antenatal care visits (ANC4), and antenatal care start in the first trimester (ANC1st). The slope index of inequality (SII) was used to assess wealth-based inequalities. Results Afrodescendants represented from 2.4% of the sample (Costa Rica) to 56.4% (Brazil) and SRH coverage was lower for Afros compared to the reference. Average difference was of 4 percent points (pp) for CPmo and 6pp for FPSmo, and respectively 7pp and 11pp in the poorest group. The lower average difference (0.64) was found for ANC4, however Colombia had a gap of 7pp. For ANC1st, ethnic differences were >5pp in Brazil, Colombia, Ecuador and Suriname. Suriname had systematically lower coverage among Afros. In Honduras Afros presented similar/higher coverage than the reference. Positive SII revealed coverage concentrated in the richest group for all indicators, however the wealth-based inequalities were much greater among Afros, especially for ANC1st (mean SII = 23pp). Conclusion Lower coverage for Afro women is pervasive and worse for the poorest ones. Key messages Such evidence can help overcome ethnic long-term disadvantage in the Americas.

1097Inequalities in full vaccination coverage by maternal education and wealth quintiles in South Asian countries

Abstract Background Estimated one in four children is not fully immunized in South Asia. This study aimed to compare full vaccination coverage in the region and its inequalities by maternal education and household wealth quintile. Methods We used data from the most recent Demographic and Health Survey (DHS) from Nepal, India, Pakistan, Bangladesh, Afghanistan, and the Maldives. Children aged 12-23 months were included. We defined full vaccination as receiving at least six antigen: Bacille Calmette Guerin, Diptheria, Pertussis, Tetanus, Polio, and Measles. We measured absolute inequalities using the slope index of inequality (SII), and relative inequalities using the relative index of inequality (RII) both for maternal education and household wealth quintiles. Results The full vaccination coverage ranged from 46% in Afghanistan to 84% in Bangladesh. Pakistan had the largest inequalities in coverage by maternal education (SII: -50.0, RII: 0.4) and household wealth quintile (SII: -47.1, RII: 0.5). The SII by wealth quintiles was smaller (-8.4) in Nepal compared to Bangladesh, India, Pakistan, and Afghanistan, but it was larger (-30.5) by maternal education compared to Bangladesh and India, although smaller than Pakistan and Afghanistan. The RII followed a similar trend. Conclusions All South Asian countries studied had full vaccination coverage under 85%. Both absolute and relative inequalities were larger by maternal education compared to wealth quintile in four of the six countries. Key messages Larger inequalities by maternal education compared to wealth-based inequalities in most South Asian countries indicate the critical role of maternal education to improve child health outcomes.

Less debt, more schooling? Evidence from cross-country micro data

Soaring levels of public debt in low-income countries are fuelling concerns about their ability to achieve the Sustainable Development Goals, such as free access to primary education. In the late 1990s and 2000s, international financial institutions introduced a series of debt relief initiatives aimed to restore debt sustainability among highly indebted countries. This study examines the impact of these initiatives on primary school attendance. We exploit the temporal variation in the implementation of these policies, in combination with individual-level data from 177 Demographic and Health Surveys covering more than 1.5 million school-age children from 44 low-income countries to implement difference-in-differences and spatial difference-in-discontinuity estimators. Results suggest that debt relief initiatives, by freeing up additional public resources, have significantly contributed to increasing primary school attendance in heavily indebted countries. Impact heterogeneity analysis also shows that debt relief has been effective at reducing wealth-based, intergenerational, religious, ethnic and spatial inequalities in education. Our results provide robust evidence to assert that debt relief, in combination with other financing sources, can contribute to improving educational outcomes in highly indebted poor countries.

A multivariate perspective on lithic technological organization at Housepit 54, Bridge River Site (EeRl4), British Columbia

The management of lithic raw materials is a significant concern to anthropological archaeologists interested in hunter-gatherer socio-economies. A wide range of studies have implicated quarry distance, work needs, occupational longevity, and consumer population to variation in tactics for reduction, use, and maintenance of chipped stone tools. Fewer studies have examined socio-political factors in the organization of stone tool technology. This study examines the interactive effects of population, occupational longevity, favored prey, and socio-political complexity on the tactics by which lithic raw materials were managed in a long-lived winter pithouse in North America’s interior Pacific Northwest. Results of bivariate and multivariate analyses implicate variability in toolstone economies as related to different classes of lithic items. Lithic cores and flake tools were more extensively reduced in contexts of productive subsistence economies, high populations, long winter occupations, and material wealth-based inequality. Bifaces were produced and maintained in relation to needs associated with intensity of deer hunting. The creation and maintenance of slate tools was affected at least in part by the intensity of salmon fishing. Combined, these data suggest that the organization of lithic tool technology responded to multiple factors across the lifespan of the house.

Monitoring the decomposition of wealth-related inequality in the use of regular antenatal care in Egypt (1995\u20132014)

BackgroundBetween 1995 and 2014 Egypt successfully increased the use of regular antenatal care (URAC) among women from 30.4 to 82.9%. The same period saw a decrease in the wealth-based inequality in URAC. This paper investigates the changes in the main determinants contributing to the wealth-based inequality in URAC for the 2 years of 1995 and 2014, and the determinants that underlined the declines in this inequality.MethodsThe secondary analysis was based on data from the 1995 and 2014 rounds of the Egypt Demographic and Health Survey. Logistic regression was implemented to model URAC for the 2 years and inequality was measured using the concentration index. Decomposition of the concentration index and Blinder -Oaxaca decomposition were implemented to assess the contribution of the URAC determinants to its inequality and the changes between 1995 and 2014.ResultsDecomposition of inequalities in URAC in 1995 and 2014 showed that social determinants were the main contributors to these inequalities. More than 90% of the inequalities were explained by the living in rural Upper Egypt, women and their husbands secondary and higher education, the household standard of living, and birth order. These same determinants were responsible for more than 76% of the decline in the inequality in URAC between 1995 and 2014. Wide spread of poverty in rural Upper Egypt was found to contribute significantly to the inequality in URAC. Women and their husbands who have secondary or higher education maintained their high odds of URAC.ConclusionSince poverty in rural Upper Egypt, and inequality in education and parity are crucial social determinants of URAC inequality and its change overtime, new policies and interventions need to focus not only on the health system but on social initiatives with an equity lens to tackle the structural causes underlying these factors and their inequalities.

3+ parity in Egypt: a multilevel decomposition of wealth-based inequality

BackgroundWealth disparities in levels of fertility are well documented in Egypt. Data from the Egypt Demographic and Health Survey (2014) showed that 61% of births to mothers from the poorest wealth quintile were of the third order or higher compared to 33% among mothers from the richest wealth quintile. The current paper investigates the main individual and socio-contextual level determinants of having more than two living children among women aged 30 and older, and decomposes its wealth-based inequality.MethodsThe secondary analysis was based on the 2014 Egypt Demographic and Health Survey. Multilevel linear regression was used to model the number of additional living children a woman has after her first two living children. A decomposition analysis of the wealth-based concentration index was applied using a multilevel model.ResultsIndividual level and area level attributes explained 83 and 17% of the variation in 3+ parity, respectively. Only areas not well served by the health system were significantly related to 3+ parity.Decomposition of the wealth-based concentration index revealed that 55.7 and 44.3% of the 3+ parity inequality were attributed to individual level attributes and area level attributes, respectively. At the individual level, early marriage accounted for 26% of the inequality in 3+ parity inequality. At the area level, living in areas not well served by the health system accounted for 22.3% of the 3+ parity wealth- based inequality, while highly gendered areas contributed 5.8% to this inequality. Areas’ random effects contributed 7.1% to the 3+ parity inequality, assist in identifying specific areas that require targeted policies.ConclusionMultilevel decomposition allowed the contributions of both the individual and area level attributes to be quantified. The decomposition highlighted the need for more tailored policies that target different social groups and different areas. Decomposition analysis also pinpointed specific areas that require additional targeted policies. This targeted approach can be used to support the efficient use of limited resources within any society.

Inequalities in reproductive health care use in five West-African countries: A decomposition analysis of the wealth-based gaps

BackgroundFamily planning and maternal care services have become increasingly available in West Africa but the level of non-use remains high. This unfavorable outcome may be partly due to the unaffordability of reproductive health care services.MethodsUsing the Demographic Health Survey data from Burkina Faso, Niger, Nigeria, Ghana, and Senegal, we perform a decomposition analysis to quantify the contribution of socio-demographic characteristics to disparities in exposure to mass media information on family planning, use of modern contraceptives, adequate antenatal care visits, facility-based childbirth and C-section between low-wealth and high-wealth women.ResultsOur study shows that differences in maternal characteristics between the wealth groups explain at least 40% of the gap in exposure to mass media family planning information, 30% in modern contraceptive use, 24% of adequate antenatal care visits, 47% of the difference in facility-based childbirths, and 62% in C-section. Lack of information on pregnancy complications, living in rural residence, religion, lack of autonomy in health facility seeking decision, need to pay, and distance explains the disparity in reproductive health care use across all countries. In countries with complete fee exemption policies for specific groups in the population, Ghana, Niger, and Senegal, the inequality gaps between wealth groups in having an adequate number of antenatal care visits and facility-based childbirth are smaller than in countries with partial or no exemption policies. But this is not the case for C-section.ConclusionsThere is evidence that current policies addressing the cost of maternal care services may increase the wealth-based inequality in maternal care use if socio-demographic differences are not addressed. Public health interventions are needed to target socio-demographic disparities and health facility seeking problems that disadvantage women in poor households.

Time trends in demand for family planning satisfied: analysis of 73 countries using national health surveys over a 24-year period.

BackgroundUniversal access to family planning is key to extend its health and economic benefits worldwide. Our aim was to track progress in demand for family planning satisfied with modern methods (mDFPS) and its inequalities in low- and middle-income countries (LMICs).MethodsAnalyses were based on Demographic and Health Surveys and Multiple Indicator Cluster Surveys carried out between 1993 and 2017 in 73 LMICs, using data for married women aged 15-49 years. We estimated trends in mDFPS coverage by country and world region and evaluated trends in wealth-based inequalities. The analyses pooling all countries together were stratified by wealth quintiles, area of residence and woman’s age. mDFPS coverage in 2030 for each country was predicted using a linear model.ResultsOverall, mDFPS increased and poor-rich gaps narrowed. Eastern & Southern Africa showed an average increase of 1.5 percentage points (p.p.) a year, being the region with the fastest progress. West & Central Africa had an increase in mDFPS of 1 p.p. a year but current coverage is still below 40%. Generally, inequalities were reduced, except for West & Central Africa and Europe & Central Asia where almost no change was observed. The country with the fastest progress in mDFPS was Rwanda, with an increase of 5 p.p./y, while Timor Leste had the fastest reduction in absolute inequality, less 3.8 p.p./y. Inequalities by area of residence were reduced, but large gaps remain. A similar trend was observed for different age groups. If the current trend is not accelerated, 44 countries will not achieve universal coverage in mDFPS by 2030.ConclusionsGenerally, mDFPS is increasing and inequalities are decreasing. However, progress is slow in some regions, especially West & Central Africa, where low coverage is combined with high levels of inequalities. Efforts to increase family planning coverage must be prioritized in countries where progress is slow or inexistent.

Current Practices and Challenges of Medical Services on Health Care System of Mandalay General Hospital

In Myanmar, the main challenge to provide quality healthcare by Universal Health Care approach is documented as low health services coverage with substantial wealth-based inequality. To achieve the effective health care system, strong medical care system is essential. Understanding on challenges and needs in provision of medical services among patients and health care providers is critical to provide quality care with desirable outcomes. The aim of the study was to explore the patients’ and health care providers’ perceptions on the challenges in provision of medical services at the Mandalay General Hospital. This was a qualitative study conducted at the tertiary level hospital (Mandalay General Hospital). The data was collected by using focus group discussions and in-depth interviews with hospitalized patients or attendants, healthcare providers such as medical doctors, nurses, laboratory scientists and hospital administrators in March 2017. The qualitative data was analyzed using themes by themes matrix analysis. Most patients were satisfied with the care provided by the doctors because they believed that they received quality care. However, some patients complained about long waiting time for elective operation, congested conditions in the ward, burden for investigations outside the hospital for urgent needs and impolite manners of general workers. Healthcare providers reported that they had heavy workload due to limited human and financial resources in the hospital, poor compliances with hospital rules and regulation among patients and attendants, and inefficient referral practices from other health facilities. Other challenges experienced by healthcare providers were lack of ongoing training to improve knowledge and skills, limited health infrastructure and inadequate medicinal supplies. The findings highlighted the areas needed to be improved to provide quality health care at the tertiary level hospital. The challenges and problems encountered in this hospital can be improved by allocating adequate financial and human resources. The systematic referral system and hospital management guidelines are needed to reduce workload of health staff.

Reducing childhood malnutrition in Bangladesh: the importance of addressing socio-economic inequalities.

To obtain projections of the prevalence of childhood malnutrition indicators up to 2030 and to analyse the changes of wealth-based inequality in malnutrition indicators and the degree of contribution of socio-economic determinants to the inequities in malnutrition indicators in Bangladesh. Additionally, to identify the risk factors of childhood malnutrition. Cross-sectional study. A Bayesian linear regression model was used to estimate trends and projections of malnutrition. For equity analysis, slope index, relative index and decomposition in concentration index were used. Multilevel logistic models were used to identify risk factors of malnutrition. Household surveys in Bangladesh from 1996 to 2014. Children under the age of 5 years. A decreasing trend was observed for all malnutrition indices. In 1990, predicted prevalence of stunting, wasting and underweight was 55·0, 15·9 and 61·8 %, respectively. By 2030, prevalence is projected to reduce to 28·8 % for stunting, 12·3 % for wasting and 17·4 % for underweight. Prevalence of stunting, wasting and underweight were 34·3, 6·9 and 32·8 percentage points lower in the richest households than the poorest households. Contribution of the wealth index to child malnutrition increased over time and the largest contribution of pro-poor inequity was explained by wealth index. Being an underweight mother, parents with a lower level of education and poorer households were the key risk factors for stunting and underweight. Our findings show an evidence-based need for targeted interventions to improve education and household income-generating activities among poor households to reduce inequalities and reduce the burden of child malnutrition in Bangladesh.

Trends and projections of universal health coverage indicators in Ghana, 1995-2030: A national and subnational study.

Ghana has made significant stride towards universal health coverage (UHC) by implementing the National Health Insurance Scheme (NHIS) in 2003. This paper investigates the progress of UHC indicators in Ghana from 1995 to 2015 and makes future predictions up to 2030 to assess the probability of achieving UHC targets. National representative surveys of Ghana were used to assess health service coverage and financial risk protection. The analyses estimated the coverage of 13 prevention and four treatment service indicators at the national level and across wealth quintiles. In addition, we calculated catastrophic health payments and impoverishment to assess financial hardship and used a Bayesian regression model to estimate trends and future projections as well as the probabilities of achieving UHC targets by 2030. Wealth-based inequalities and regional disparities were also assessed. At the national level, 14 out of the 17 health service indicators are projected to reach the target of 80% coverage by 2030. Across wealth quintiles, inequalities were observed amongst most indicators with richer groups obtaining more coverage than their poorer counterparts. Subnational analysis revealed while all regions will achieve the 80% coverage target with high probabilities for the prevention services, the same cannot be applied to the treatment services. In 2015, the proportion of households that suffered catastrophic health payments and impoverishment at a threshold of 25% non-food expenditure were 1.9% (95%CrI: 0.9–3.5) and 0.4% (95%CrI: 0.2–0.8), respectively. These are projected to reduce to 0.4% (95% CrI: 0.1–1.3) and 0.2% (0.0–0.5) respectively by 2030. Inequality measures and subnational assessment revealed that catastrophic expenditure experienced by wealth quintiles and regions are not equal. Significant improvements were seen in both health service coverage and financial risk protection over the years. However, inequalities across wealth quintiles and regions continue to be cause of concerns. Further efforts are needed to narrow these gaps.

Trends and factors associated with child marriage in four Asian countries

Background:Child marriage, defined as marriage before the age of 18, is a human rights violation and is associated with numerous adverse health, social, and economic outcomes. As such, the phenomena of child marriage garners substantial programmatic and policy action. However, a better understanding of specifically how child marriage is or is not changing is needed.Methods:This study analyzes trends in the age structure of child marriage with cumulative incidence functions using data from Demographic and Health Surveys in four Asian countries. It further uses equiplots and chi-square tests of independence to identify specific patterns of and trends in inequalities of child marriage across three socio-economic factors: education, wealth, and residence.Results:We find significant decreases in child marriage in all four countries since the 1990s. The rate of change has been unevenly paced, with rapid increases in age at marriage followed by periods of little observable change. Child marriage generally falls first during the youngest ages, followed by decreases in marriage later in adolescence. Marriage remains an adolescent experience for the majority of women in Bangladesh and Nepal. Child marriage is most common in Bangladesh and least common in Indonesia, while India has experienced the largest declines in child marriage. There is no discernible trend toward non-marriage, but rather a trend toward delayed marriage only. We find widespread education-, wealth-, and residence-based inequalities, with child marriage concentrated among more disadvantaged groups. Inequalities based on education are wider than either those based on wealth or residence. Inequalities have mostly lessened over the previous decade, except in Nepal. A pattern of mass deprivation is observed with regard to education, while wealth-based inequalities follow a queuing pattern. Conclusions:These inequality patterns suggest delayed marriage be broadly promoted, alongside targeted interventions directed to the most disadvantaged groups.

THE EVOLUTION OF MATERIAL WEALTH-BASED INEQUALITY: THE RECORD OF HOUSEPIT 54, BRIDGE RIVER, BRITISH COLUMBIA

The evolution of material wealth-based inequality is an important topic in archaeological research. While a number of explanatory models have been proposed, rarely have they been adequately tested. A significant challenge to testing such models concerns our ability to define distinct, temporally short-term, residential occupations in the archaeological record. Sites often lack evidence for temporally persistent inequality, or, when present, the palimpsest nature of the deposits often make it difficult to define the processes of change on scales that are fine enough to evaluate nuanced model predictions. In this article, we use the detailed record of Housepit 54 from the Bridge River site, interior British Columbia, to evaluate several alternative hypotheses regarding the evolution of persistent material wealth-based inequality. Results of our analyses indicate that inequality appeared abruptly coincident with a decline in intra-house cooperation associated with population packing and the initiation of periodic subsistence stress. We conclude that persistent inequality in this context was a byproduct of altered social networks linked to a Malthusian transition and ceiling.

Trends in, and projections of, indicators of universal health coverage in Bangladesh, 1995-2030: a Bayesian analysis of population-based household data.

Many countries are implementing health system reforms to achieve universal health coverage (UHC) by 2030. To understand the progress towards UHC in Bangladesh, we estimated trends in indicators of the health service and of financial risk protection. We also estimated the probability of Bangladesh's achieving of UHC targets of 80% essential health-service coverage and 100% financial risk protection by 2030. We estimated the coverage of UHC indicators-13 prevention indicators and four treatment indicators-from 19 nationally representative population-based household surveys done in Bangladesh from Jan 1, 1991, to Dec 31, 2014. We used a Bayesian regression model to estimate the trend and to predict the coverage of UHC indicators along with the probabilities of achieving UHC targets of 80% coverage of health services and 100% coverage of financial risk protection from catastrophic and impoverishing health payments by 2030. We used the concentration index and relative index of inequality to assess wealth-based inequality in UHC indicators. If the current trends remain unchanged, we estimated that coverage of childhood vaccinations, improved water, oral rehydration treatment, satisfaction with family planning, and non-use of tobacco will achieve the 80% target by 2030. However, coverage of four antenatal care visits, facility-based delivery, skilled birth attendance, postnatal checkups, care seeking for pneumonia, exclusive breastfeeding, non-overweight, and adequate sanitation were not projected to achieve the target. Quintile-specific projections showed wide wealth-based inequality in access to antenatal care, postnatal care, delivery care, adequate sanitation, and care seeking for pneumonia, and this inequality was projected to continue for all indicators. The incidence of catastrophic health expenditure and impoverishment were projected to increase from 17% and 4%, respectively, in 2015, to 20% and 9%, respectively, by 2030. Inequality analysis suggested that wealthiest households would disproportionately face more financial catastrophe than the most disadvantaged households. Despite progress, Bangladesh will not achieve the 2030 UHC targets unless the country scales up interventions related to maternal and child health services, and reforms health financing systems to avoid high dependency on out-of-pocket payments. The introduction of a national health insurance system, increased public funding for health care, and expansion of community-based clinics in rural areas could help to move the country towards UHC. Japan Ministry of Health, Labour, and Welfare.

WEALTH-BASED INEQUALITY IN CHILD IMMUNIZATION IN INDIA: A DECOMPOSITION APPROACH.

Despite years of health and medical advancement, children still suffer from infectious diseases that are vaccine preventable. India reacted in 1978 by launching the Expanded Programme on Immunization in an attempt to reduce the incidence of vaccine-preventable diseases (VPDs). Although the nation has made remarkable progress over the years, there is significant variation in immunization coverage across different socioeconomic strata. This study attempted to identify the determinants of wealth-based inequality in child immunization using a new, modified method. The present study was based on 11,001 eligible ever-married women aged 15-49 and their children aged 12-23 months. Data were from the third District Level Household and Facility Survey (DLHS-3) of India, 2007-08. Using an approximation of Erreyger's decomposition technique, the study identified unequal access to antenatal care as the main factor associated with inequality in immunization coverage in India.

Inequalities in financial risk protection in Bangladesh: an assessment of universal health coverage

BackgroundFinancial risk protection and equity are major components of universal health coverage (UHC), which is defined as ensuring access to health services for all citizens without any undue financial burden. We investigated progress towards UHC financial risk indicators and assessed variability of inequalities in financial risk protection indicators by wealth quintile. We further examined the determinants of different financial hardship indicators related to healthcare costs.MethodsA cross-sectional, three-stage probability survey was conducted in Bangladesh, which collected information from 1600 households from August to November 2011. Catastrophic health payments, impoverishment, and distress financing (borrowing or selling assets) were treated as financial hardship indicators in UHC. Poisson regression models were used to identify the determinants of catastrophic payment, impoverishment and distress financing separately. Slope, relative and concentration indices of inequalities were used to assess wealth-based inequalities in financial hardship indicators.ResultsThe study found that around 9% of households incurred catastrophic payments, 7% faced distress financing, and 6% experienced impoverishing health payments in Bangladesh. Slope index of inequality indicated that the incidence of catastrophic health payment and distress financing among the richest households were 12 and 9 percentage points lower than the poorest households respectively. Multivariable Poisson regression models revealed that all UHC financial hardship indicators were significantly higher among household that had members who received inpatient care or were in the poorest quintile. The presence of a member with chronic illness in a household increased the risk of impoverishment by nearly double.ConclusionThis study identified a greater inequality in UHC financial hardship indicators. Rich households in Bangladesh were facing disproportionately less financial hardship than the poor ones. Households can be protected from financial hardship associated with healthcare costs by implementing risk pooling mechanism, increasing GDP spending on health, and properly monitoring subsidized programs in public health facilities.

Inequalities in Human Well-Being in the Urban Ganges Brahmaputra Meghna Delta

The recently endorsed Sustainable Development Goals (SDGs) agenda unanimously agrees on the need to focus on inclusive development, the importance of eradicating extreme poverty and managing often complex human well-being impacts of rapid urban growth. Sustainable and inclusive urbanisation will accelerate progress towards the SDGs and contribute to eradicating extreme poverty. In tropical delta regions, such as the Ganges Brahmaputra Meghna delta region, urban growth and resulting intra-urban inequalities are accelerated by the impact of environmental and climate change. In this context, the present study uses the 2010 Household Income and Expenditure Survey to analyse the extent of wealth-based inequalities in human well-being in the urban delta region and the determinants of selected welfare measures. The results suggest that the extent of intra-urban inequalities is greatest in educational attainment and access to postnatal healthcare and relatively low in the occurrence of gastric disease. The paper concludes by providing policy recommendations to reduce increasing wealth inequalities in urban areas, thus contributing to sustainable development of the region.