Rivillas Juan Carlos, Devia Rodriguez Raul, Song Gloria, Martel Andréanne
Initiative of Research in Health Services and Systems, School of Public Health, University of Valle, Cali, Colombia.
Faculty of Medicine, University of Valle, Cali, Colombia.
PLoS One. 2018 Jan 18;13(1):e0188654. doi: 10.1371/journal.pone.0188654. eCollection 2018.
This paper assesses inequalities in access to reproductive and maternal health services among females affected by forced displacement and sexual and gender-based violence in conflict settings in Colombia. This was accomplished through the following approaches: first, we assessed the gaps and gradients in three selected reproductive and maternal health care services. Second, we analyzed the patterns of inequalities in reproductive and maternal health care services and changes over time. And finally, we identified challenges and strategies for reaching girls and women who are the hardest to reach in conflict settings, in order to accelerate progress towards universal health coverage and to contribute to meeting the Sustainable Development Goals of good health and well-being and gender equality by 2030.
Three types of data were required: data about health outcomes (relating to rates of females affected by conflict), information about reproductive and maternal health care services to provide a social dimension to unmask inequalities (unmet needs in family planning, antenatal care and skilled births attendance); and data on the female population. Data sources used include the National Information System for Social Protection, the National Registry of Victims, the National Administrative Department of Statistics, and Demographic Health Survey at three specific time points: 2005, 2010 and 2015. We estimated the slope index of inequality to express absolute inequality (gaps) and the concentration index to expresses relative inequality (gradients), and to understand whether inequality was eliminated over time.
Our findings show that even though absolute health care service-related inequalities dropped over time, relative inequalities worsened or remain unchanged. All summary measures still indicated the existence of inequalities as well as common patterns. Our findings suggest that there is a pattern of marginal exclusion and incremental patterns of inequality in the reproductive and maternal health care service provided to female affected by armed conflict.
Overall, the effects of conflict continue to threaten reproductive and maternal health in Colombia, impeding progress towards the realization of universal health care (UHC) and reinforcing already-existing inequities. Key messages and steps forward include the need to understand the two distinct patterns of inequalities identified in this study in order to prompt improved general policy responses. Addressing unmet needs in reproductive and maternal health requires supporting gender equality and prioritizing the girls and women in regions with the highest rates of victims of armed conflict, with the objective of leaving no girl or woman behind. This analysis represents the first attempt to analyze coverage-related inequality in reproductive and maternal health care services for female affected by armed conflict in Colombia. As the World Health Organization and global health systems leaders call for more inclusive engagement, this approach may serve as the key to shaping people-centred health systems. In this particular case, health care facilities must be located in close proximity to girls and women in conflict and post-conflict settings in order to deliver essential reproductive and maternal health care services. Finally, reducing inequalities in opportunities would not only promote equity, but also drive sustainable development.
本文评估了哥伦比亚冲突地区受强迫流离失所及性暴力和性别暴力影响的女性在获得生殖健康和孕产妇健康服务方面的不平等情况。这是通过以下方法实现的：首先，我们评估了三项选定的生殖健康和孕产妇保健服务方面的差距和梯度。其次，我们分析了生殖健康和孕产妇保健服务方面的不平等模式及其随时间的变化。最后，我们确定了在冲突地区接触最难接触到的女童和妇女的挑战和策略，以加速实现全民健康覆盖的进程，并为在2030年前实现健康与福祉及性别平等的可持续发展目标做出贡献。
需要三类数据：关于健康结果的数据（与受冲突影响的女性比例有关）、关于生殖健康和孕产妇保健服务的信息，以便从社会层面揭示不平等现象（计划生育、产前护理和熟练接生方面未满足的需求）；以及女性人口数据。所使用的数据源包括社会保护国家信息系统、受害者国家登记处、国家统计行政部门以及2005年、2010年和2015年这三个特定时间点的人口与健康调查。我们估计了不平等斜率指数以表示绝对不平等（差距），并估计了集中指数以表示相对不平等（梯度），并了解不平等是否随时间消除。
我们的研究结果表明，尽管与医疗保健服务相关的绝对不平等随时间下降，但相对不平等却加剧或保持不变。所有汇总指标仍表明存在不平等现象以及常见模式。我们的研究结果表明，在为受武装冲突影响的女性提供的生殖健康和孕产妇保健服务中，存在边际排斥模式和不平等加剧模式。
总体而言，冲突影响继续威胁着哥伦比亚的生殖健康和孕产妇健康，阻碍实现全民医疗覆盖的进程，并加剧了现有的不平等。关键信息和前进步骤包括需要了解本研究中确定的两种不同的不平等模式，以便促使改进总体政策应对措施。解决生殖健康和孕产妇健康方面未满足的需求需要支持性别平等，并优先关注武装冲突受害者比例最高地区的女童和妇女，目标是不让任何女童或妇女掉队。本分析是首次尝试分析哥伦比亚受武装冲突影响的女性在生殖健康和孕产妇保健服务方面与覆盖范围相关的不平等情况。随着世界卫生组织和全球卫生系统领导人呼吁更具包容性的参与，这种方法可能是塑造以人为本卫生系统的关键。在这种特殊情况下，医疗保健设施必须位于冲突地区和冲突后地区女童和妇女附近，以便提供基本的生殖健康和孕产妇保健服务。最后，减少机会不平等不仅将促进公平，还将推动可持续发展。
