Examining horizontal inequity and social determinants of inequality in facility delivery services in three South Asian countries

Background: The utilization of maternal health care services has increased in many developing countries, but persistent wealth-related inequalities in use of maternal services remained an important public health issue. The paper examined the horizontal inequities and identified the key social determinants that can potentially explain such wealth-related inequalities in use of facility delivery services. Methods: The countries studied are Bangladesh, Pakistan and Nepal. We used horizontal inequity index to measure the horizontal inequity and decomposition of concentration index method to assess the contribution of different social determinants towards the wealth-related inequality. We have used household and women data from demographic and health surveys of Bangladesh (BDHS 2014), Pakistan (PDHS 2012-13) and Nepal (NDHS 2010-11). Results: All three countries showed pro-rich inequality in use of facility delivery services (Observed Concentration Index: Bangladesh = 0.235; Pakistan = 0.141; Nepal = 0.263). The study showed if the utilization were solely based on need factors there would have been little disparity between the rich and the poor (Need expected Concentration Index: Bangladesh = 0.004; Pakistan = 0.004; Nepal = 0.008). The use of facility delivery remained pro-rich in all three countries after taking the need factors into account (Horizontal inequity Index: Bangladesh = 0.231; Pakistan = 0.137; Nepal = 0.254). The decomposition analysis revealed that facility delivery is driven mostly by the social determinants of health rather than the individual health risk. Household socioeconomic condition, parental education, place of residence and parity emerged as the most important factors. Conclusions: Our study reiterates the importance of addressing social determinants of health in tackling wealth-related inequalities in use of facility delivery services. Health policy makers should acknowledge the importance of social determinants in determining individual health-seeking behaviour and accordingly set their strategies to improve access to facility delivery.