Trends and Inequalities in Maternal and Newborn Health Services for Unplanned Settlements of Lusaka City, Zambia.

Living conditions and other factors in urban unplanned settlements present unique challenges for improving maternal and newborn health (MNH), yet MNH inequalities associated with such challenges are not well understood. This study examined trends and inequalities in coverage of MNH services in the last 20 years in unplanned and planned settlements of Lusaka City, Zambia. Geospatial information was used to map Lusaka's settlements and health facilities. Zambia Demographic Health Surveys (ZDHS 2001, 2007, 2013/2014, and 2018) were used to compare antenatal care (ANC), institutional delivery, and Cesarean section (C-section) coverage, and neonatal mortality rates between the poorer 60% and richer 40% households. Health Management Information System (HMIS) data from 2018 to 2021 were used to compute service volumes and coverage rates for ANC1 and ANC4, and institutional delivery and C-sections by facility level and type in planned and unplanned settlements. Although the correlation is not exact, our data analysis showed close alignment; and thus, we opted to use the 60% poorer and 40% richer groups as a proxy for households in unplanned versus planned settlements. Unplanned settlements were serviced by primary centers or first-level hospitals. ZDHS findings show that by 2018, at least one ANC visit and institutional delivery became nearly universal throughout Lusaka, but early and four or more ANC visits, C-sections, and neonatal mortality rates remained worse among poorer than richer women in ZDHS. In HMIS, ANC and institutional delivery volumes were highest in public facilities, especially in unplanned settlements. The volume of C-sections was much greater within facilities in planned than unplanned settlements. Our study exposed persistent gaps in timing and use of ANC and emergency obstetric care between unplanned and planned communities. Closing such gaps requires strengthening outreach early and consistently in pregnancy and increasing emergency obstetric care capacities and referrals to improve access to important MNH services for women and newborns in Lusaka's unplanned settlements.

Going deeper with health equity measurement: how much more can surveys reveal about inequalities in health intervention coverage and mortality in Zambia?

BACKGROUND: Although Zambia has achieved notable improvements in reproductive, maternal, newborn and child health (RMNCH), continued efforts to address gaps are essential to reach the Sustainable Development Goals by 2030. Research to better uncover who is being most left behind with poor health outcomes is crucial. This study aimed to understand how much more demographic health surveys can reveal about Zambia's progress in reducing inequalities in under-five mortality rates and RMNCH intervention coverage. METHODS: Using four nationally-representative Zambia Demographic Health Surveys (2001/2, 2007, 2013/14, 2018), we estimated under-five mortality rates (U5MR) and RMNCH composite coverage indices (CCI) comparing wealth quintiles, urban-rural residence and provinces. We further used multi-tier measures including wealth deciles and double disaggregation between wealth and region (urban residence, then provinces). These were summarised using slope indices of inequality, weighted mean differences from overall mean, Theil and concentration indices. RESULTS: Inequalities in RMNCH coverage and under-five mortality narrowed between wealth groups, residence and provinces over time, but in different ways. Comparing measures of inequalities over time, disaggregation with multiple socio-economic and geographic stratifiers was often valuable and provided additional insights compared to conventional measures. Wealth quintiles were sufficient in revealing mortality inequalities compared to deciles, but comparing CCI by deciles provided more nuance by showing that the poorest 10% were left behind by 2018. Examining wealth in only urban areas helped reveal closing gaps in under-five mortality and CCI between the poorest and richest quintiles. Though challenged by lower precision, wealth gaps appeared to close in every province for both mortality and CCI. Still, inequalities remained higher in provinces with worse outcomes. CONCLUSIONS: Multi-tier equity measures provided similarly plausible and precise estimates as conventional measures for most comparisons, except mortality among some wealth deciles, and wealth tertiles by province. This suggests that related research could readily use these multi-tier measures to gain deeper insights on inequality patterns for both health coverage and impact indicators, given sufficient samples. Future household survey analyses using fit-for-purpose equity measures are needed to uncover intersecting inequalities and target efforts towards effective coverage that will leave no woman or child behind in Zambia and beyond.

How Zambia reduced inequalities in under-five mortality rates over the last two decades: a mixed-methods study.

BACKGROUND: Zambia experienced a major decline in under-five mortality rates (U5MR), with one of the fastest declines in socio-economic disparities in sub-Saharan Africa in the last two decades. We aimed to understand the extent to which, and how, Zambia has reduced socio-economic inequalities in U5MR since 2000. METHODS: Using nationally-representative data from Zambia Demographic Health Surveys (2001/2, 2007, 2013/14 and 2018), we examined trends and levels of inequalities in under-five mortality, intervention coverage, household water and sanitation, and fertility. This analysis was integrated with an in-depth review of key policy and program documents relevant to improving child survival in Zambia between 1990 and 2020. RESULTS: The under-five mortality rate (U5MR) declined from 168 to 64 deaths per 1000 live births between 2001/2 and 2018 ZDHS rounds, particularly in the post-neonatal period. There were major reductions in U5MR inequalities between wealth, education and urban-rural residence groups. Yet reduced gaps between wealth groups in estimated absolute income or education levels did not simultaneously occur. Inequalities reduced markedly for coverage of reproductive, maternal, newborn and child health (RMNCH), malaria and human immunodeficiency virus interventions, but less so for water or sanitation and fertility levels. Several policy and health systems drivers were identified for reducing RMNCH inequalities: policy commitment to equity in RMNCH; financing with a focus on disadvantaged groups; multisectoral partnerships and horizontal programming; expansion of infrastructure and human resources for health; and involvement of community stakeholders and service providers. CONCLUSION: Zambia's major progress in reducing inequalities in child survival between the poorest and richest people appeared to be notably driven by government policies and programs that centrally valued equity, despite ongoing gaps in absolute income and education levels. Future work should focus on sustaining these gains, while targeting families that have been left behind to achieve the sustainable development goal targets.

Investing in the health workforce: fiscal space analysis of 20 countries in East and Southern Africa, 2021-2026.

BACKGROUND AND OBJECTIVES: The health workforce (HWF) is at the core of ensuring an efficient, effective and functional health system, but it faces chronic underinvestment. This paper presents a fiscal space analysis of 20 countries in East and Southern Africa to generate sustained evidence-based advocacy for significant and smarter investment in the HWF. METHODS: We adapted an established empirical framework for fiscal space analysis and applied it to the HWF. Country-specific data were curated and triangulated from publicly available datasets and government reports to model the fiscal space for the HWF for each country. Based on the current knowledge, three scenarios (business as-usual, optimistic and very optimistic) were modelled and compared. FINDINGS: A business-as-usual scenario shows that the cumulative fiscal space across the 20 countries is US$12.179 billion, which would likely increase by 28% to US$15.612 billion by 2026 but varies across countries-the highest proportional increases expected in Seychelles (117%) and Mozambique (69%) but lowest in Zambia (15%). Under optimistic assumptions, allocating an additional 1.5% of gross domestic product (GDP) to health even without further prioritising the proportional allocation to the wage bill could boost the cumulative fiscal space for HWF by US$4.639 billion. In a very optimistic scenario of a 1.5% increase in health expenditure as a proportion of GDP and further prioritisation of HWF within the health expenditure, the cumulative fiscal space for HWF could improve by some 105%-ranging from 24% in Zambia to 330% in Lesotho. CONCLUSION: Small increments in government health expenditure and increased prioritisation of HWF in funding in tandem with the 57% global average could potentially increase the fiscal space for HWF by at least 32% in 11 countries. Unless the HWF is sufficiently prioritised within the health expenditures, only increasing the overall health expenditure to even recommended levels would still portend severe underinvestment in HWF amid unabating shortages to deliver health services. Thus, HWF strategies and investment plans should include fiscal space analysis to deepen advocacy for sustainable investment in the HWF.