Equitable Healthcare Access

Health inequities occur when health services are not accessible or utilized by certain groups of people, based on their gender, socio-economic status, ethnicity, geographic residence, or other characteristics. Because of this lack of access, disadvantaged populations are at much higher risk of adverse health outcomes. For example, a majority of native Mayan women in Guatemala do not receive the recommended antenatal or post-partum care, contributing to a maternal mortality rate more than double the national average. In order to improve equity and ultimately reduce maternal, newborn, and child mortality, disadvantaged or high risk groups must be targeted for services and interventions. TRAction carried out mixed-methods case studies to explore interventions aimed at improving access to facility delivery among vulnerable populations. The results from these studies will inform local policy and decision-making in order to increase health care access among poor and marginalized women.

Key Results

These studies were conducted within the context of local interventions aimed at improving access to skilled delivery care and reducing maternal and neonatal mortality. All studies revealed important barriers and facilitators to care that influence the ability of women to deliver at facilities. Common barriers included distance to the facility, disrespect and abuse by health staff, lack of autonomy among women, and the gender of the health provider. Integration of traditional birth attendants within the health system emerged as a common facilitator that increased uptake of skilled delivery services. Some highlights from the TRAction studies include the following:

In Guatemalan partner communities where culturally appropriate birthing centers were established, 70% of births took place at a health facility compared to only 30% of births in non-partner communities.
A health facility improvement program in a remote area of Indonesia resulted in a statistically significant increase in facility delivery, from 34% to 51% of births.
In Indonesia, an Evidence-Based Planning and Budgeting program for maternal and child health increased the amount of the budget allocated for all MNCH programs in all districts where the program was implemented.

Our Partners

Ifakara Health Institute
AMREF Kenya
University Gadjah Mada
Curamericas Global
Nusa Tenggara Timur Provincial Health Office

Events

Brown Bag Presentation on Maternal Health in Indonesia (March 29, 2022)
Canadian Conference on Global Health (November 5-7, 2015)
Writing Workshop (January 5-9, 2015)

Publications Featuring TRAction Research

Casas Maternas in the Rural Highlands of Guatemala: A Mixed-Methods Case Study of the Introduction and Utilization of Birthing Facilities by an Indigenous Population

Collaborative Efforts

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A New Model of Care

A casa materna built in a rural community of Guatemala.

A New Model of Care to Improve Equity

The aim of this case study is to identify factors that influence the use of “Casa Maternas” for delivery. TRAction and its research partners aim to answer the following questions:

What are the factors influencing the use or non-use of Casa Maternas for delivery?
Does availability of Casa Maternas increase equitable access to health services?
What can be done to increase use of Casa Maternas for delivery?

Implemented by Curamericas Guatemala

Location: San Sebastián Coatán, Huehuetenango, Guatemala

Timeline: October, 2013 to June, 2015

Integration of Health Services

A health worker explains family planning methods to village mothers at an ICDDR,B satellite clinic in Matlab, Bangladesh. © 1990 Ansem Ansari, Courtesy of Photoshare

Effect of targeted interventions and services on access and use of family planning

TRAction is funding research examining the effectiveness of targeted interventions and services with emphasis on improving access to family planning and outcomes among high-risk populations in Bangladesh.

Implemented by International Centre for Diarrheal Disease Research (icddr,b)

Study Location: Sylhet and Brahmanbaria districts, Bangladesh

Community Approaches in Nomadic Populations

Photo of Kenyan community health workers, Photoshare

Community Based Approaches to Improve Equity in Nomadic Populations

The aim of this case study is to identify factors that influence the use of available facilities for delivery. TRAction and its research partners hope to answer the following questions:

Why do some women deliver at home and others in a facility?
What can be done to increase utilization of facilities for delivery?
What are the equity characteristics of women who deliver at home versus a facility?

Implemented by African Medical Research Foundation (AMREF) Kenya

Location: Magadi District, Kajiado County, Kenya

Timeline: December, 2013 to June, 2015

Evidence-based Planning and Budgeting

Endang, a 43-year-old midwife from Demak City Government, provides family planning education at a neighborhood health center in Pojok Village, Jragung Subdistrict of Demak City, Central Java, Indonesia.© 2014 Aji Styawan, Courtesy of Photoshare

Evidence-based Planning and Budgeting to Improve Equity

The aim of this study is to determine the impact of Evidence Based Planning and Budgeting on equitable health service delivery. Research questions include:

To what extent did the EBP approach influence equitable MNCH budget allocation at the district level?
What factors influence equitable MNCH budget allocation in three districts that have applied the EBP approach?

Implemented by the University of Gadjah Mada

Location: Papua, Indonesia

Timeline: December 2013 to June 2015

Facility Improvement and Promotion

Photo of Indonesian health center, Photoshare

Facility Improvement and Promotion to Improve Equity

The aim of this case study is to identify factors that influence the use of available facilities for delivery, within the context of the Revolusi KIA program. Research questions include:

Why do some women deliver in a facility and others at home?
What are the equity characteristics of women who deliver in facilities and at home?

Implemented by Nusa Tenggara Timur (NTT) Provincial Health Office

Location: Manggarai Barat district, East Nusa Tenggara Timur (NTT) province, Indonesia

Timeline: January, 2014 to June, 2015

Health Insurance Cards

A woman’s young infant sits patiently with her as she waits to be served during a family planning outreach event at a rural health facility in northern Tanzania.© 2014 Sala Lewis, Verve Photography, Courtesy of Photoshare

Health Insurance Cards to Improve Equity

This case study aims to investigate the processes and equity outcomes of both individual and geographic targeting of insurance cards. Research questions include:

What were the perceptions of each targeting approach, and why was individual targeting abandoned in favor of geographic targeting?
How does the insurance scheme impact equity and coverage?
What are the factors influencing the use of insurance cards for delivery?

Implemented by Ifakara Health Institute

Location: Rungwe District, Mbeya Region, Tanzania

Timeline:October, 2013 to June, 2015

Improving 24/7 delivery and EmONC services

This study has major implications in making EmONC services available in hard-to-reach areas, and for accelerating progress in achieving MDG 4&5 by 2015 and beyond. Ministry of Health stakeholders will be directly informed of potential strategies to mitigate the problem of HRH shortage from the results of this study, contributing to the overall strengthening of health systems in Bangladesh.