Kenya Medical Research Institute, Wellcome Trust Research Programme, Nairobi, Kenya.
Int J Equity Health. 2012 Dec 13;11:75. doi: 10.1186/1475-9276-11-75.
Equitable access to health care is a key health systems goal, and is a particular concern in low-income countries. In Kenya, public facilities are an important resource for the poor, but little is known on the equity of service provision. This paper assesses whether poorer areas have poorer health services by investigating associations between public facility characteristics and the poverty level of the area in which the facility is located.
Data on facility characteristics were collected from a nationally representative sample of public health centers and dispensaries across all 8 provinces in Kenya. A two-stage cluster randomized sampling process was used to select facilities. Univariate associations between facility characteristics and socioeconomic status (SES) of the area in which the facility was located were assessed using chi-squared tests, equity ratios and concentration indices. Indirectly standardized concentration indices were used to assess the influence of SES on facility inputs and service availability while controlling for facility type, province, and remoteness.
For most indicators, we found no indication of variation by SES. The clear exceptions were electricity and laboratory services which showed evidence of pro-rich inequalities, with equity ratios of 3.16 and 3.43, concentration indices of 0.09 (p<0.01) and 0.05 (p=0.01), and indirectly standardized concentration ratios of 0.07 (p<0.01) and 0.05 (p=0.01). There were also some indications of pro-rich inequalities for availability of drugs and qualified staff. The lack of evidence of inequality for other indicators does not imply that availability of inputs and services was invariably high; for example, while availability was close to 90% for water supply and family planning services, under half of facilities offered delivery services or outreach.
The paper shows how local area poverty data can be combined with national health facility surveys, providing a tool for policy makers to assess the equity of input and service availability. There was little evidence of inequalities for most inputs and services, with the clear exceptions of electricity and laboratory services. However, efforts are required to improve the availability of key inputs and services across public facilities in all areas, regardless of SES.
公平获得医疗保健是卫生系统的一个关键目标，在低收入国家尤其受到关注。在肯尼亚，公共设施是穷人的重要资源，但对于服务提供的公平性知之甚少。本文通过调查设施所在地的贫困地区的公共设施特征与服务提供的贫困程度之间的关系，评估较贫困地区的医疗服务质量是否较差。
从肯尼亚全国 8 个省所有的公共卫生中心和诊所的全国代表性样本中收集了设施特征数据。采用两阶段聚类随机抽样过程选择设施。使用卡方检验、公平比和集中指数评估设施特征与设施所在地区的社会经济地位（SES）之间的单变量关联。使用间接标准化集中指数评估 SES 对设施投入和服务提供的影响，同时控制设施类型、省份和偏远程度。
对于大多数指标，我们没有发现 SES 存在差异的迹象。明显的例外是电力和实验室服务，它们显示出有利于富人的不平等，公平比为 3.16 和 3.43，集中指数为 0.09（p<0.01）和 0.05（p=0.01），间接标准化集中比为 0.07（p<0.01）和 0.05（p=0.01）。药物和合格人员的供应也存在一些有利于富人的不平等迹象。对于其他指标，没有不平等的证据并不意味着投入和服务的供应始终很高；例如，虽然供水和计划生育服务的供应接近 90%，但只有不到一半的设施提供分娩服务或外展服务。
本文展示了如何将当地贫困地区的数据与国家卫生设施调查相结合，为决策者提供了一种评估投入和服务提供公平性的工具。对于大多数投入和服务，几乎没有不平等的证据，电力和实验室服务除外。然而，需要努力改善所有地区公共设施的关键投入和服务的供应，无论 SES 如何。
