Person:

Sharma, Jigyasa

Background: Quality of healthcare is an important determinant of future progress in global health. However, the distributional aspects of quality of care have received inadequate attention. We assessed whether high quality maternal care is equitably distributed by (1) mapping the quality of maternal care in facilities located in poorer versus wealthier areas of Kenya; and (2) comparing the quality of maternal care available to Kenyans in and not in poverty. Methods: We assessed three measures of maternal care quality: facility infrastructure and clinical quality of antenatal care and delivery care, using indicators from the 2010 Kenya Service Provision Assessment (SPA), a standardized facility survey with direct observation of maternal care provision. We calculated poverty of the area served by antenatal or delivery care facilities using the Multidimensional Poverty Index. We used regression analyses and non-parametric tests to assess differences in maternal care quality in facilities located in more and less impoverished areas. We estimated effective coverage with a minimum standard of care for the full population and those in poverty. Results: A total of 564 facilities offering at least one maternal care service were included in this analysis. Quality of maternal care was low, particularly clinical quality of antenatal and delivery care, which averaged 0.52 and 0.58 out of 1 respectively, compared to 0.68 for structural inputs to care. Maternal healthcare quality varied by poverty level: at the facility level, all quality metrics were lowest for the most impoverished areas and increased significantly with greater wealth. Population access to a minimum standard (≥0.75 of 1.00) of quality maternal care was both low and inequitable: only 17% of all women and 8% of impoverished women had access to minimally adequate delivery care. Conclusion: The quality of maternal care is low in Kenya, and care available to the impoverished is significantly worse than that for the better off. To achieve the national targets of maternal and neonatal mortality reduction, policy initiatives need to tackle low quality of care, starting with high-poverty areas.

Objectives: To assess input and process capacity for basic delivery and newborn (intrapartum care hereafter) care in the Indian public health system and to describe differences in facility capacity between rural and urban areas and across states. Design: Cross-sectional study. Setting: Data from the nationally representative 2012–2014 District Level Household and Facility Survey, which includes a census of community health centres (CHC) and sample of primary health centres (PHC) across 30 states and union territories in India. Participants: 8536 PHCs and 4810 CHCs. Outcome measures We developed a summative index of 33 structural and process capacity items matching the Indian Public Health Standards for PHCs as a metric of minimum facility capacity for intrapartum care. We assessed differences in performance on this index across facility type and location. Results: About 30% of PHCs and 5% of CHCs reported not offering any intrapartum care. Among those offering services, volumes were low: median monthly delivery volume was 8 (IQR=13) in PHCs and 41 (IQR=73) in CHCs. Both PHCs and CHCs failed to meet the national standards for basic intrapartum care capacity. Mean facility capacity was low in PHCs in both urban (0.64) and rural (0.63) areas, while in CHCs, capacity was slightly higher in urban areas (0.77vs0.74). Gaps were most striking in availability of skilled human resources and emergency obstetric services. Poor capacity facilities were more concentrated in the more impoverished states, with 37% of districts from these states receiving scores in the lowest third of the facility capacity index (<0.70), compared with 21% of districts otherwise. Conclusions: Basic intrapartum care capacity in Indian public primary care facilities is weak in both rural and urban areas, especially lacking in the poorest states with worst health outcomes. Improving maternal and newborn health outcomes will require focused attention to quality measurement, accountability mechanisms and quality improvement. Policies to address deficits in skilled providers and emergency service availability are urgently required.