Did Equity of Reproductive and Maternal Health Service Coverage Increase during the MDG Era? An Analysis of Trends and Determinants across 74 Low- and Middle-Income Countries

IntroductionDespite widespread gains toward the 5th Millennium Development Goal (MDG), pro-rich inequalities in reproductive health (RH) and maternal health (MH) are pervasive throughout the world. As countries enter the post-MDG era and strive toward UHC, it will be important to monitor the extent to which countries are achieving equity of RH and MH service coverage. This study explores how equity of service coverage differs across countries, and explores what policy factors are associated with a country’s progress, or lack thereof, toward more equitable RH and MH service coverage.MethodsWe used RH and MH service coverage data from Demographic and Health Surveys (DHS) for 74 countries to examine trends in equity between countries and over time from 1990 to 2014. We examined trends in both relative and absolute equity, and measured relative equity using a concentration index of coverage data grouped by wealth quintile. Through multivariate analysis we examined the relative importance of policy factors, such as political commitment to health, governance, and the level of prepayment, in determining countries’ progress toward greater equity in RH and MH service coverage.ResultsRelative equity for the coverage of RH and MH services has continually increased across all countries over the past quarter century; however, inequities in coverage persist, in some countries more than others. Multivariate analysis shows that higher education and greater political commitment (measured as the share of government spending allocated to health) were significantly associated with higher equity of service coverage. Neither country income, i.e., GDP per capita, nor better governance were significantly associated with equity.ConclusionEquity in RH and MH service coverage has improved but varies considerably across countries and over time. Even among the subset of countries that are close to achieving the MDGs, progress made on equity varies considerably across countries. Enduring disparities in access and outcomes underpin mounting support for targeted reforms within the broader context of universal health coverage (UHC).

引言
尽管全球在推进第五个千年发展目标（Millennium Development Goal, MDG）方面取得了广泛进展，但生殖健康（Reproductive Health, RH）与孕产妇健康（Maternal Health, MH）领域的亲富型不平等现象仍在全球范围内普遍存在。随着各国迈入后千年发展目标时代，并致力于实现全民健康覆盖（Universal Health Coverage, UHC），监测各国在生殖健康和孕产妇健康服务覆盖公平性方面的达成程度，将成为一项重要工作。本研究旨在探讨不同国家间服务覆盖公平性的差异，并解析哪些政策因素与各国在提升生殖健康和孕产妇健康服务覆盖公平性方面取得进展（或未取得进展）存在关联。

研究方法
本研究使用来自74个国家的人口与健康调查（Demographic and Health Surveys, DHS）所获取的生殖健康与孕产妇健康服务覆盖数据，考察1990年至2014年间各国之间以及随时间推移的公平性趋势。研究同时分析了相对公平与绝对公平的变化趋势，并采用按财富五分位组划分的覆盖数据集中指数来衡量相对公平性。通过多变量分析，本研究考察了各类政策因素在决定各国提升生殖健康和孕产妇健康服务覆盖公平性进展中的相对重要性，这些政策因素包括卫生领域的政治承诺、治理水平以及预付筹资水平。

结果
在过去25年间，所有国家的生殖健康与孕产妇健康服务覆盖相对公平性均持续提升；但覆盖公平性的不平等现象依然存在，且不同国家的不平等程度存在差异。多变量分析结果显示，更高的教育水平以及更强的卫生领域政治承诺（以政府卫生支出占比衡量）与更高的服务覆盖公平性显著相关。而国家收入水平（即人均国内生产总值）与更完善的治理水平均与公平性无显著关联。

结论
生殖健康与孕产妇健康服务覆盖公平性虽有所改善，但在不同国家以及不同时期均存在显著差异。即便在接近达成千年发展目标的国家子集当中，公平性方面的进展也存在显著的国别差异。服务获取与健康结局方面持续存在的不平等，推动了在全民健康覆盖整体框架下开展针对性改革的呼声日益高涨。