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Crossing the River: Inequities in Maternal Health Services in Cambodia

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Crossing the River: Inequities in Maternal Health Services in Cambodia UNIVERSITY OF SOUTHAMPTON FACULTY OF SOCIAL, HUMAN AND MATHEMATICAL SCIENCES Social Statistics & Demography CROSSING THE RIVER: INEQUITIES IN MATERNAL HEALTH SERVICES IN CAMBODIA by Kristine Nilsen Thesis for the degree of Doctor of Philosophy January 2017 Abstract FACULTY OF SOCIAL, HUMAN AND MATHEMATICAL SCIENCES Social Statistics and Demography Thesis for the degree of Doctor of Philosophy CROSSING THE RIVER: INEQUITIES IN MATERNAL HEALTH SERVICES IN CAMBODIA Kristine Nilsen With the focus on universal health coverage (UHC) and the inclusion of an equity target in the newly adopted Sustainable Development Goals, equity analysis is becoming prominent in the evaluation of health policies in low-income countries. Focusing on Cambodia, the overall aim of this thesis is to examine spatial and socio-economic equity patterns in maternal health services between 2000 and 2014, a period characterised by extensive health systems reforms. Inequities of maternal health services are examined on one UHC dimensions, population coverage in terms of use and quality of services. Using household surveys and the population census, inequities are measured using econometric analysis, logistic multilevel models and small area estimation. Results show that irrespective of residency, inequities in the use of services decrease over time as population coverage increases. However, use remains pro-rich in 2014. The pro-rich bias in urban areas is particularly strong when examining inequities of the quality of services received. In rural areas, inequities in quality by socio-economic status are low as most of the health services provided fail to meet the quality criteria applied. Moving beyond the urban/ rural dichotomy, large spatial inequities in the utilisation of services are for the first time observed at small areas, suggesting that health system characteristics and other socio-economic determinants manifest themselves geographically. Findings are discussed in the context of inverse equity hypothesis, health system reform and socio-economic development. The thesis concludes that there is partial support for the inverse equity hypothesis and that the hypothesis may have a spatial dimension that has previously not been captured. It also concludes that health system reforms targeting the supply-side of service provision probably had an effect on reducing inequities, but that socio-economic development including increased household wealth cannot be excluded as a major contributor to increased service uptake. Table of Contents Table of Contents Abstract .................................................................................................................. i Table of Contents .................................................................................................. i List of Tables ......................................................................................................... v List of Figures ..................................................................................................... vii Declaration of Authorship ................................................................................... xi Acknowledgements ............................................................................................ xiii Abbreviations ....................................................................................................... xv 1. Introduction .................................................................................................. 1 Maternal health, inequities and the health system ................................................. 1 Research aim and research questions ...................................................................... 6 Structure of the thesis ............................................................................................... 8 2. Literature Review ........................................................................................ 11 Inequalities and inequities .......................................................................................12 The social determinants of health .........................................................................13 Health System organisation, inequities and UHC ...............................................15 Maternal health services ..........................................................................................22 Measuring inequities in the provision of maternal health services ....................30 Inequities in use of maternal health care: empirical findings .............................35 Determining and measuring quality of care in maternal health services ..........40 2.7.1 Inequities in the quality of maternal health care: empirical findings ......... 46 The inverse equity hypothesis ................................................................................49 3. Cambodia and its health system ................................................................ 53 Geography ................................................................................................................53 History .......................................................................................................................54 Population and socio-economic development .....................................................56 The Cambodian health system and maternal health care ...................................59 i 3.4.1 The public health system and health system reforms ................................. 61 3.4.2 Health system organisation and infrastructure ............................................ 64 3.4.3 Maternal health service delivery ..................................................................... 65 3.4.4 Health financing ............................................................................................... 66 3.4.5 Health workforce ............................................................................................. 70 3.4.6 Health management information ................................................................... 72 4. Inequity Trends and Patterns in Maternal Health Service Use ................. 75 Methodology ............................................................................................................ 76 4.1.1 Indicators .......................................................................................................... 76 4.1.2 Measuring socio-economic status .................................................................. 77 4.1.3 Measuring inequalities ..................................................................................... 78 Data ........................................................................................................................... 84 Background .............................................................................................................. 87 4.3.1 Household and individual characteristics ..................................................... 87 Results ....................................................................................................................... 99 4.4.1 Trends by residency socio-economic status and health facility type ........ 99 4.4.2 Advanced measures of equity ...................................................................... 113 Discussion .............................................................................................................. 124 4.5.1 Placing findings in the context of previous research ................................ 129 4.5.2 The inverse equity hypothesis ...................................................................... 132 4.5.3 Supply and demand-side health system interventions .............................. 136 5. Inequities in Use and Quality of ANC ..................................................... 145 Methodology .......................................................................................................... 146 5.1.1 Outcome and predictor variables ................................................................ 148 5.1.2 Bivariate analysis and logistic single level regression models................... 152 5.1.3 Logistic multilevel regression models ......................................................... 154 5.1.4 Model selection .............................................................................................. 156 5.1.5 Data ................................................................................................................. 158 Results ..................................................................................................................... 158 5.2.1 Descriptive analysis ....................................................................................... 158 5.2.2 Model selection .............................................................................................. 164 5.2.3 ANC visits: logistic multilevel fixed and random effects ......................... 166 ii Table of Contents 5.2.4 ANC quality: logistic multilevel fixed and random effects ....................... 171 Discussion .............................................................................................................. 175 5.3.1 Components of ANC services as a measure of quality ............................. 175 5.3.2 Factors influencing use and quality of ANC services ............................... 178 6. The Spatial Distribution of Facility Births at Sub-national Levels ......... 183 Methodology.........................................................................................................
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