Situational Analysis of Equity in Access to Quality Health Care for Women and Children in Vietnam Presentation by Sarah Bales and Jim Knowles Ha Long Bay, 8 April 2008
Organization of the Presentation Purpose Methodology Main findings Data gaps Interventions to reduce inequality in MCH Conclusions
Purpose Assess the extent of existing inequalities in key MNCH outcomes Assess changes over time in the inequalities, where possible Identify underlying factors most closely associated with key MNCH outcomes Assess the contributions of these factors to the observed inequalities
Purpose (continued) Focus is on inequalities, rather than national averages Focus is on income inequalities rather than inequalities with respect to other factors (e.g., gender, region, ethnicity) Why is it important to focus on inequalities? θ To sustain continued improvement in national averages θ To achieve an equitable distribution of the benefits of economic development
Methodology Conceptual Framework Measurement of inequality Sources of inequality Analysis of provincial-level data
Conceptual framework Observed underlying factors Age Sex Education Income Ethnicity Religion Location Unobserved factors Region level Province level District level Commune level Village level Household Health services Physical proximity Quality Affordability Intermediate outcomes Family planning Antenatal care Obstetric delivery care Neonatal care Postnatal care Immunization Malaria prevention Nutritional supplements Infant feeding practices Utilization of safe water and sanitation Curative care High-level outcomes Mortality Morbidity Nutritional status Fertility
Measurement of inequality Population-weighted quintiles Concentration curve Concentration index (CI) Living standards measures (LSM) The methodology is described in great detail in: O Donnell, O, et al. (2008) Analyzing Health Equity Using Household Survey Data: A Guide to Techniques and Their Implementation, Washington, D.C.: World Bank
Population-weighted quintiles Proportion of children under 5 with moderately low weight for age Percent 45 40 35 30 25 20 15 10 5 0 Poorest Near poor Middle Near rich Richest 1992/93 2006 Source: 1992/93 Vietnam Living Standards Survey; 2006 VHLSS
Concentration curve Inequality in the components of a complete antenatal care exam, 2006 Cum. share of women receiving antenatal services 0.2.4.6.8 1 Source: 2006 MICS III 0.2.4.6.8 1 cumul. share of mothers (poorest first) weighed blood test ultrasound HIVadvice line of equality
Concentration index Definition: Twice the area between the concentration curve and the line of equality (the 45 line). The larger the absolute value, the greater the inequality Convention is to assign negative values to areas above the line of equality and positive values to areas below Inequalities may favor or disfavor the poor and favor or disfavor the rich
Living standards measures Direct measures Reported household income per capita Reported household consumption per capita Reported household wealth per capita Average ranking of direct measures Indirect measures Predicted household income per capita Predicted household consumption per capita Predicted household wealth per capita Wealth index
Living standards measures Proportions of obstetric deliveries in a hospital by quintile (using alternative LSMs to define quintiles), 1992/93 Percent 100 90 80 70 60 50 40 30 20 10 0 Direct income Source: 1992/93 Vietnam Living Standards Survey Direct consumption Direct wealth Average ranking Indirect income Indirect consumption Indirect wealth Wealth index Poor Near poor Average Next riches Richest
Analysis of sources of inequality Regression analysis Decomposition of the concentration index (i.e., decomposition of the observed inequality) Contribution to inequality depends on elasticity and the concentration index for explanatory variables
Decomposition of inequalities for full antenatal care Variable Elasticities Concentration indices Contribution Mother s age (years) 0.999 0.014 0.014 Mother s schooling 0.449 0.132 0.059 Highest education of adults in household 0.208 0.077 0.016 Head of household is Vietnamese or Chinese ethnicity -0.267 0.137-0.037 Wealth index 1.352 0.301 0.407 Commune fixed effects (combined) 2.713-12.622 0.049 Residual -0.012 Total 0.497
Decomposition of inequality Decomposition of concentration index for antenatal care and full package of antenatal care, 2006 0.50 Any antenatal care (0.059)Full antenatal (0.497) Contribution 0.40 0.30 0.20 0.10 Offsetting factor 0.00-0.10 Age of mother (years) Mother's schooling Highest Ethnic schoolingvietnamese or Chinese Wealth index Commune "Residual" fixed effects Source: 2006 MICS III
Analysis of provincial data Outcome data available from surveys and Health Statistics Yearbook by province Living standard measure is mean household income per capita Concentration curves, indices and decompositions Complements analysis at the household level
Main findings
High level outcomes Child mortality Maternal mortality Morbidity Nutritional status Fertility
Intermediate outcomes Family planning Antenatal care Obstetric delivery care Immunization Malaria prevention Nutritional supplements Infant feeding practices Curative care
Important achievements in improving basic health indicators 2001 2006 MMR (per 100 000 live births) IMR (per 1000 live births) U5MR (per 1000 live births) Child malnutrition rate (%) TFR (births per woman) 95 31 42 31.9 2.25 75 16 26 23.4 2.1
Important achievements in improving access to health care 1992/93 2006 Contraceptive prevalence among married women (%) % of pregnant women receiving antenatal care % of women receiving professional assistance at delivery % of women delivering at health facility 66.1 59.5 73.6 54.7 75.6 91.2 87.7 84.4 % of children under 5 completely vaccinated (according to mother s reporting) 39.1 61.7
Important variation in degree of inequality The degree of inequality in both high-level outcomes and intermediate outcomes varies greatly. As a reference point for this comparison, the Gini-coefficients (basically the concentration indices for living standards variables) using the 2006 MICSIII are: Wealth index (0.297) Estimated consumption (0.394)
Variation in inequality for high-level outcomes 0.00 Concentration index -0.10-0.20-0.30-0.40-0.50-0.60 Incidence of respiratory infection Fertility Diarrhea Stunting Underweight % of children whose mother has died
Variation in inequality for selected intermediate outcomes (1) Concentration index 0.60 0.50 0.40 0.30 0.20 0.10 Any antenatal care Weighed Blood pressure measured Ultrasound Urine test Blood test HIV advice Full antenatal 0.00
Variation in inequality for selected intermediate outcomes (2) 0.60 Concentration index 0.50 0.40 0.30 0.20 0.10 Full dose of all vaccines BCG Polio DPT Measles Full dose in first year of life 0.00
Changes in inequality over time There has been significant improvement in reducing inequalities in some intermediate outcomes, but little improvement in reducing inequalities in several higherlevel outcomes
Reduced inequality over time Use of contraception Any antenatal care Professional assistance at delivery Facility or hospital delivery
Almost complete reduction in inequality for use of contraception 100% % of married women using contraception 80% 60% 40% 1992/93 2006 20% 0% Poorest Near poor Middle Near rich Richest
Important reduction in inequality for use of any antenatal care 0.2.4.6.8 1 0.2.4.6.8 1 cumul. share of pregnancies (poorest first) 1992/93 2006 line of equality
Important improvements in middle quintiles for obstretic care 100% 80% % of deliveries with professionally assistance 60% 40% 20% 1992/93 2006 0% Poorest Near poor Middle Near rich Richest
Less improvement in inequality for high-level outcomes Child malnutrition Child mortality Incidence of diarrhea Fertility
Increased inequality in stunting 0.2.4.6.8 1 cumul. share of stunted children 1992/93 2006 Low inequality 0.2.4.6.8 1 Higher inequality 0.2.4.6.8 1 cumul. share of children (poorest first) consumption wealth index line of equality 0.2.4.6.8 1 cumul. share of children under 5 wealth index direct consumption line of equality
No reduction in inequality in child mortality Deaths per 1000 children ever born 90 80 70 60 50 40 30 20 10 0 Poorest Near poor Child mortality Middle Near rich Richest 1992/93 2006 Gap in 1992/93 Gap in 2006
Slow reductions in poorer groups 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0.0 Number of children ever born Slower Poorest Near poor Middle Near rich Faster Richest 1992/93 2006
Factors examined for their contribution to inequalities Income Education of mother, of adults in household Ethnicity Mother s and father s nutritional status Location (communal fixed effects) Sex Religion
Main factors affecting inequality The main factors contributing to the observed inequalities in maternal and child health outcomes are: Inequalities in household income Inequalities related to location (i.e., to the commune of residence). Other important factors for some outcomes include: Inequalities in education Inequalities in ethnicity
Factors contributing to inequalities in child malnutrition, 2006 Contribution to inequality 0.04 0.02 0.00-0.02-0.04-0.06-0.08-0.10-0.12-0.14-0.16 Child's age Sex Mother's schooling Mean adult schooling Ethnic Vietnamese or Chinese Wealth index Commune fixed effects Height for age (-0.181) Weight for age (-0.167)
Factors contributing to inequalities in incidence of diarrhea, 2006 Contribution to inequality 0.10 0.05 0.00-0.05-0.10-0.15-0.20 Child's age Child's sex Mother's schooling Mean adult schooling Ethnic Vietnamese or Chinese Commune fixed effects Wealth index Concentration index (-0.136)
Factors contributing to inequalities in obstetric care, 2006 Contribution to inequality 0.14 0.12 0.10 0.08 0.06 0.04 0.02 0.00 Woman's age Woman's schooling Highest adult schooling Ethnic Vietnamese or Chinese Wealth index Commune fixed effects Professionally assisted delivery (0.096) Facility-based delivery (0.116) Hospital delivery (0.218)
Factors contributing to inequalities in child immunization, 2006 Contribution to inequality 0.20 0.15 0.10 0.05 0.00-0.05-0.10 Days -0.15survived -0.20-0.25-0.30 Sex Mother's schooling Highest adult schooling Wealth index Ethnic Vietnamese or Chinese Commune fixed effects Complete vaccination in first year (0.235) No vaccinations (-0.535)
Contribution of education to inequality Women s/mother s schooling is not as closely related to many of the outcomes analyzed as is the schooling of other adult household members
Parental nutrition Nutritional status of father and mother are significantly associated with child s nutritional status (only available in the 1992/93 VLSS).
A child s sex is not significantly related to any of the outcomes analyzed in 2006 80 70 60 50 40 30 20 10 0 Stunted Underweight Diarrhea Cough and fever Ill past 4 weeks Full immunization Full immunization first year Exclusive breastfeeding 6 months Vitamin A Percent Male Female
Analysis of commune fixed effects In some cases, commune effects explain a large proportion of the concentration index. Important commune level factors include: Mean education of adults in households in the commune (for most outcomes) Regions (Southeast and Mekong Delta better than average, Northwest, Central Highlands worse than average) Proportion ethnic Vietnamese or Chinese in commune Road goes to center of commune (family planning, antenatal care, obstetric care) Proportion Catholic in the commune (fertility, use of family planning)
Ethnicity Analysis of province-level data, commune fixed effects and household level data all indicate that ethnicity is an important factor in inequality for many outcomes (IMR, fertility, malaria morbidity, antenatal care, births attended by health worker, child immunizations).
Fertility and IMR, 2005 Contribution 0.04 0.02 0.00-0.02-0.04 Factors contributing to inequality in fertility in provincial analysis Schooling Ethnicity Population density Urbanization Residual -0.06-0.08 Income Infant mortality
Inequalities in government health spending, 2005 Pro-poor national program spending 0.2.4.6.8 1 Pro-rich curative care spending 0.2.4.6.8 1 cumul. share of population (poorest first) total health expenditure national program expenditure treatment & prevention expenditure other expenditure line of equality
Indicators of access to curative care disfavoring the middle income provinces, 2005 Pro-poor 0.2.4.6.8 1 Pro-rich 0.2.4.6.8 1 cumul. share of population (poorest first) medical doctors inpatient beds HI coverage line of equality
Data gaps There are still several important data gaps in the area of maternal-child health in Viet Nam that need to be addressed to support effective monitoring of inequalities in maternal and child health
Missing data Maternal nutritional status (to understand the intergenerational associations with child malnutrition) Complete birth history data is missing for recent years Information on number of antenatal exams
Need for revising survey instruments New or newly available interventions require constant revision of survey instruments. For example: Zinc supplements and use of zinc to treat diarrhea, Vitamin K injections at birth, Use of folic acid and/or iron during pregnancy, Use of deworming medicines, Post-natal exams, Delivery by C-section.
New data collection methodologies New developments and reductions in cost of data collection methods also require consideration: anemia testing, HIV testing (with consent), information about delivery complications, oral autopsy about child deaths, etc. (Good example is the Cambodian DHS)
Inadequacy of current HIS Difficulties in using HIS data for health equity analysis, either because of: Under-reporting of pregnancies/births Only partial coverage (Doesn t include private services). Missing indicators of quality aspects
Interventions to reduce inequality in Maternal and Child health (1) Extensive public health infrastructure in all localities throughout the country Numerous pilot projects (mainly NGO) to reduce mortality among newborns focused at the grassroots level Population and family planning program focusing efforts and budget in areas with remaining high fertility
Interventions to reduce inequality in Maternal and Child health (2) National health target programs focusing efforts and budget on disadvantaged areas Military-civilian medical cooperation for border areas, disaster areas School health programs Targeted health financing for the poor, for children under age 6
Conclusions (1) Most government health programs have been very effective in Viet Nam in improving average health status among mothers and children For most intermediate outcomes, they have been effective in reducing inequalities For higher-level outcomes reduction in inequality has been less successful
Conclusions (2) Income and commune-level factors explain much of the inequality Education and ethnicity also contribute importantly to inequality for some outcomes At the commune level, general educational level, region, ethnicity, road access and even religion explain some of the inequalities
Conclusions (3) Important data gaps inhibit monitoring of inequality in some aspects of maternal and child health Government and non-governmental interventions need to increasingly focus efforts and budget on disadvantaged areas or groups where outcomes are worse. There is a need for interventions on both demand and supply side.