Presented by Mai Do at the International Conference on Family Planning in November 2013.

1. Explaining Inequity in
the Use of Family Planning and
Institutional Delivery Services
Mai Do, Rieza Soelaeman, and David Hotchkiss
Tulane University School of Public Health
Department of Global Health Systems and Development

2. Introduction
 Wealth-related inequities in FP/RH service use remain
a substantial problem
 Disparities in maternal health care are greater than
those in many other types of health interventions
prioritized by governments
 Increased emphasis on improving service delivery for
the poor
 Community-level service provision
 Demand-side approaches: vouchers, health insurance

3. Hypothesis
 HI can lower wealth-related inequities in service
utilization by
 Removing financial barriers
 Increasing women’s access to health systems
 Indirectly improving QOC through training and
certifications
 Improve access to services among those intending to
use, and increase opportunities to seek services through
increased contacts and trust with health systems

4. Study purposes
1. To assess the degree of wealth-related inequities in the use of FP
and institutional delivery services in selected low- and middle-income
countries, and
2. To explain such socio-economic inequities by decomposing inequity
by the contributions made by various components, including health
insurance coverage, and other individual- and household-level
factors
..in four countries that have experienced an expansion of health
insurance coverage in recent years – Ghana, Rwanda, Columbia, and
the Philippines

5. Summary of Health Insurance programs
National HI
program
Types of HI FP
benefits
Delivery
benefits
Colombia Health care reform in
1993. A national health
insurance fund, Solidarity
and Guarantees Fund
(SGF), was created.
Two regimes:
‐ Contributory regime: members contribute
according to their ability to pay, includes
all formal sector employees and
independent workers able to pay
‐ Subsidized regime: targets the poor by
subsidizing their premiums
FP services
(consultation and
contraceptives) are
covered
All inpatient and
outpatient obstetric care
is covered
Philippines PhilHealth, government-
owned and operated, was
created in 1995:
‐ Extending benefits
to cover outpatient
services
‐ Extending coverage
to the poor and
informal sector
workers
PhilHealth membership is segregated into four
categories:
‐ Employed program: membership is
compulsory for all government and private
sector employees
‐ Indigent program: initiated by local
governments to target the poor
‐ Individual payment program: for those who
are not eligible for the above two programs
‐ Nonpaying program: targets those who
have reached retirement and have paid at
least 120 monthly premium contributions to
PhilHealth.
Covers only
surgical methods.
Maternity packages,
launched in 2003, covers
inpatient hospital care,
including normal
spontaneous delivery.

6. Data and Methods
 Recent DHS in four countries: Colombia (2010), Ghana
(2008), the Philippines (2008), and Rwanda (2005)
 Having available a nationally representative survey of women of
reproductive age conducted within the last five years, and
 A national health insurance program that includes FP and maternal
health care services in the benefits package
 Main independent variable: household wealth
 CIs calculated to estimate inequalities
 Adjusted for need for FP
 Decomposition of CIs using multivariate probit (O’Donnell et al.,
2008)

7. 0
10
20
30
40
50
60
70
80
90
100
Ghana (2008) Rwanda (2005) Colombia (2010) Philippines (2008)
Percentageofwomenwithhealth
insurancecoverage
Country
Fig 1. Percentage of women in the family planning analysis with
health insurance coverage by wealth quintile
Poorest
Poor
Middle
Richer
Richest
Total

8. Table 1. Prevalence and concentration index of modern
contraceptive use among women in union
Has Health Insurance Coverage
Household
wealth
Colombia (2010) Philippines (2008)
Total No Yes Total No Yes
(n=26,281) (n=2,551) (n=23,730) (n=8,418) (n=4,570) (n=3,848)
Poorest 67.9 55.94 69.6 25.75 23.96 32.28
Poor 72.84 67.28 73.54 35.18 32.96 39.53
Middle 73.04 66.93 73.76 35.93 34.39 38.09
Richer 75.01 73.6 75.15 38.27 37.65 38.72
Richest 74.84 74.11 74.88 32.99 33.84 32.68
Total 72.71 66.14 73.41 33.68 31.52 36.25
CIs (s.e.)
Actual 0.02 (0.003) 0.06 (0.01) 0.02 (0.003) 0.05 (0.009) 0.09 (0.013) -0.02 (0.012)
Need predicted -0.02 (0.001) -0.01 (0.004) -0.02 (0.001) -0.02 (0.002) 0 (0.003) -0.04 (0.003)
Need standardized 0.04 (0.003) 0.07 (0.009) 0.03 (0.003) 0.07 (0.009) 0.09 (0.013) 0.02 (0.012)

9. Table 2. Decomposition of modern contraceptive use
inequity among women in union
Colombia (2010) Philippines (2008)
Variables E C.I. Contr. E C.I. Contr.
Need for family planning 0.540 -0.012 -0.007 *** 0.789 -0.016 -0.013 ***
Women’s education 0.063 0.152 0.010 ** 0.111 0.165 0.018 *
Parity 0.102 -0.122 -0.012 *** 0.125 -0.116 -0.014 ***
Women’s age -0.009 0.025 0.000 *** -0.521 0.015 -0.008 ***
Urban residence -0.034 0.275 -0.009 *** 0.012 0.294 0.003
Partner’s education -0.016 0.142 -0.002 -0.038 0.162 -0.006
Women’s is employed 0.020 0.088 0.002 *** 0.141 0.068 0.010 ***
Visited by a FP worker in the
last 12 months
-0.001 -0.234 0.000 0.012 -0.102 -0.001
Visited a health facility in the
last 12 months
0.034 0.039 0.001 -0.053 -0.031 0.002 *
Told of FP at health facility in
the last 12 months
-0.005 -0.015 0.000 0.048 -0.080 -0.004 ***
Has health insurance
coverage
0.030 0.012 0.000 *** 0.045 0.237 0.011 *
Controlled for wealth, religion, and exposure to FP messages on TV, radio and newspapers
* p<.05, ** p<.01, *** p<.001

10. 0
10
20
30
40
50
60
70
80
90
100
Ghana (2008) Rwanda (2005) Colombia (2010) Philippines (2008)
Percentageofwomenwithhealth
insurancecoverage
Country
Figure 2. Percentage of women in the institutional delivery
analysis with health insurance coverage by wealth quintile
Poorest
Poor
Middle
Richer
Richest
Total

11. Table 3. Prevalence and concentration index of institutional
delivery among women in union
Has Health Insurance Coverage
Household
wealth
Colombia (2010) Philippines (2008)
Total No Yes Total No Yes
(n=4,343) (n=456) (n=3,887) (n=2,261) (n=1,377) (n=883)
Poorest 85.33 77.74 86.61 12.39 10.8 19.33
Poor 97.53 95.31 97.85 31.49 25.34 45.87
Middle 99.21 100 99.12 51.97 49.9 55.49
Richer 99.62 96.84 99.96 72.04 61.31 79.77
Richest 98.84 97.38 98.94 89.76 77.3 94.72
Total 95.35 91.09 95.9 45.73 33.09 65.43
CI..
Actual (SE) 0.04 (0.003) 0.08 (0.012) 0.03 (0.003) 0.36 (0.012) 0.39 (0.02) 0.23 (0.014)

12. Table 4. Decomposition of institutional delivery
inequity among women in union
Colombia (2010) Philippines (2008)
Variables E c.i. Contr. E c.i. Contr.
Women’s education 0.050 0.161 0.008 ** 0.422 0.164 0.069 ***
Parity -0.019 -0.218 0.004 *** -0.200 -0.191 0.038 ***
Women’s age 0.079 0.016 0.001 *** 0.407 -0.003 -0.001 *
Urban residence 0.032 0.320 0.010 ** 0.115 0.289 0.033 ***
Partner’s education 0.005 0.146 0.001 0.384 0.165 0.063 ***
Women’s is employed -0.016 0.084 -0.001 ** -0.004 0.071 0.000
Has health insurance
coverage
0.018 0.018 0.000 ** 0.111 0.264 0.029 ***
Controlled for wealth and religion
* p<.05, ** p<.01, *** p<.001

13. Conclusions
 Moderate to high levels of inequities in service use
 Associations between HI coverage and service use
 Some evidence of contributions of HI to inequities in
institutional delivery services, and to a lesser extent, in
modern FP use
 Having HI may have increased overall access to services
 Impact on lowering out-of-pocket spending on services unclear
 Advocates for expanding HI coverage, particularly among
the poor in order to increase service utilization as well as
reduce wealth-related inequities in service use

14. Unanswered Questions
 What are the mechanisms for HI to affect service
use and inequities?
 Effects on financial barriers?
 Why are the poor not enrolled in HI, in spite of
subsidized schemes?

15. MEASURE Evaluation PRH is a MEASURE project funded by
the United States Agency for International Development
(USAID) through Cooperative Agreement GHA-A-00-08-00003-
00 and is implemented by the Carolina Population Center at
the University of North Carolina at Chapel Hill in partnership
with Futures Group International, Management Sciences for
Health, and Tulane University. Views expressed in this
presentation do not necessarily reflect the views of USAID or
the U.S. Government. MEASURE Evaluation PRH supports
improvements in monitoring and evaluation in population,
health and nutrition worldwide.