Comprehensive review of the evidence regarding the effectiveness of community–based primary health care in improving maternal, neonatal and child health: 5. equity effects for neonates and children

Abstract

BackgroundThe degree to which investments in health programs improve the health of the most disadvantaged segments of the population—where utilization of health services and health status is often the worst—is a growing concern throughout the world. Therefore, questions about the degree to which community–based primary health care (CBPHC) can or actually does improve utilization of health services and the health status of the most disadvantaged children in a population is an important one.MethodsUsing a database containing information about the assessment of 548 interventions, projects or programs (referred to collectively as projects) that used CBPHC to improve child health, we extracted evidence related to equity from a sub–set of 42 projects, identified through a multi–step process, that included an equity analysis. We organized our findings conceptually around a logical framework matrix.ResultsOur analysis indicates that these CBPHC projects, all of which implemented child health interventions, achieved equitable effects. The vast majority (87%) of the 82 equity measurements carried out and reported for these 42 projects demonstrated “pro–equitable” or “equitable” effects, meaning that the project’s equity indicator(s) improved to the same degree or more in the disadvantaged segments of the project population as in the more advantaged segments. Most (78%) of the all the measured equity effects were “pro–equitable,” meaning that the equity criterion improved more in the most disadvantaged segment of the project population than in the other segments of the population.ConclusionsBased on the observation that CBPHC projects commonly provide services that are readily accessible to the entire project population and that even often reach down to all households, such projects are inherently likely to be more equitable than projects that strengthen services only at facilities, where utilization diminishes greatly with one’s distance away. The decentralization of services and attention to and tracking of metrics across all phases of project implementation with attention to the underserved, as can be done in CBPHC projects, are important for reducing inequities in countries with a high burden of child mortality. Strengthening CBPHC is a necessary strategy for reducing inequities in child health and for achieving universal coverage of essential services for children.

Effects of community health worker interventions on socioeconomic inequities in maternal and newborn health in low-income and middle-income countries: a mixed-methods systematic review

“…While previous reviews found that there were effects of home visits or women’s group interventions on mortality overall, they did not detect subgroup differences, and we found that only a few studies on participatory women’s groups linked improved equity in coverage to equity in behaviours or mortality 25 28. This could relate to an inadequacy of conventional methodologies, or an implicit theoretical assumption that equity is achieved once everyone has access, by giving equal freedom of choice to enact healthy behaviours, but not also prioritising equitable realisation of health outcomes 12 49 54. Future studies should focus on CHW interventions’ equity effects across the continuum of care, particularly including mortality 55…”

“…Finally, while there is a working assumption that CHWs can redress widespread gaps in formal care in low-resource settings, this review underlines that linkages with the formal health care system are crucial not only in achieving effectiveness but also equity in maternal and newborn health outcomes 12. Past studies of community interventions’ overall effectiveness for maternal and newborn health have found that both home-based care practices and care seeking have generally been improved,49 56 while our review showed that the latter was not achieved as equitably as the former.…”

“…Many interventions relied heavily on demand generation as the main strategy, with a focus on mobilising people to use services. The challenges that some home visiting as well as community-based group interventions experienced for heightening care seeking equitably, particularly in more remote regions, calls into question the ability of CHWs to overcome supply-side health system barriers playing out across the ‘time’ dimension (prenatal to postnatal period) of the continuum of care, as well as the ‘space dimension’ between community-family care and facility-based clinical services 9 12. These contextual challenges underscore the urgent need to support CHWs’ efforts by addressing, rather than compensating for, gaps in formal health services’ accessibility, availability, quality and affordability 12 48.…”

“…The challenges that some home visiting as well as community-based group interventions experienced for heightening care seeking equitably, particularly in more remote regions, calls into question the ability of CHWs to overcome supply-side health system barriers playing out across the ‘time’ dimension (prenatal to postnatal period) of the continuum of care, as well as the ‘space dimension’ between community-family care and facility-based clinical services 9 12. These contextual challenges underscore the urgent need to support CHWs’ efforts by addressing, rather than compensating for, gaps in formal health services’ accessibility, availability, quality and affordability 12 48. More multilevel analyses to consider how equity effects on maternal and newborn health outcomes are influenced by health system issues in different locales, like the degree that adequate provision of supplies, health personnel and delivery points are available or accessible, will likewise be needed.…”

“…They did not describe effects on equity in maternal and neonatal behavioural or mortality outcomes 11. Another review looked at the effects of community-based primary health care programmes on maternal, newborn and child health 12. It found that these programmes improved coverage of CHW home visits and essential newborn care equitably among poorer and less poor households 12…”