Equity in Maternal & Child Health in Thailand

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Research

Bull World Health Organ2010;88:420427 | doi:10.2471/BLT.09.068791

Introduction

Globally, hal a million women die each year during pregnancyand delivery, and 10 million children aged under ve yearsdie, mainly due to limited access to basic but efective healthinterventions.1 Achieving the United Nations Millennium De-velopment Goal or maternal and child health (MCH) requiresstrong health systems.2 Te strength o a countrys health systemis reected in the distribution o health outcomes.3

Universal social protection and equity rom birth are parto a new agenda or global health equity.4 Ensuring that keyhealth interventions are widely and equitably available is criticalor improved child survival.5 For example, many studies haveound that women who are better of economically have greateraccess to a skilled birth attendant.6,7 In Tailand, universal healthcoverage was achieved in 2002, and the health system is seen asequitable.8 Te scheme is nanced through taxation in such away that those on higher incomes pay more than those on lowerincomes.9 Ambulatory and hospital care are available to the poorthrough a geographically widespread network o district-levelgovernment health acilities.10 Few households become impov-erished through health care costs because the health service is

comprehensive and ree o charge at the point o service.11 Tisprogressive nancing model, in addition to the equitable use ohealth services and public spending on health, have made Tai-land one o the best perormers in the AsiaPacic region.1215Equity in the Tai health systems has been attributed to theextension o health acilities and human resources over the pastthree decades16 and to the policy transition rom piecemealtargeting to an approach that ocuses on universality.17

Among 30 low- and middle-income countries, Tailand hasbeen one o the most efective countries in reducing mortality inchildren under ve.18 For example, the mortality rate ell rom 58

per 1000 live births in 1980 to 30 in 1990 and to 23 in 2000.19Te improvement in child survival has been accompanied by aremarkably small disparity between rich and poor.20

Tis study o MCH equity in Tailand is the rst to makeuse o a nationally representative household survey. Te study as-sesses equity in health service use and or all key MCH outcomes.For example, it includes child malnourishment because it is anunderlying cause o death associated with inectious diseases,and diarrhoea and pneumonia because they are the diseases most

oen associated with child deaths.21

Methods

Data sources

Data were obtained rom the Multiple Indicator Cluster Survey,which was conducted by the National Statistical Oce o Tai-land rom December 2005 to February 2006. Te survey usedstructured, ace-to-ace interviews with women o reproductiveage (1549 years) in all provinces, and anthropometric measure-ment o children less than 5 years o age. An original sample o43 440 nationally representative households was selected using a

two-stage, stratied sampling technique. In this sample, 40 511(or 93.3%) responded to the survey.

Indicators

Nine groups o MCH indicators were used as measures o healthoutcomes and coverage o health care interventions. Te mater-nal health indicator was teenage pregnancy; this was applied tothe 12 million women in Tailand aged 1549 years who hadgiven birth beore the survey started. Te coverage o maternalhealth indicators were amily planning, prenatal care and deliveryby a skilled health worker, and delivery in a health acility. Te

Une traduction en ranais de ce rsum fgure la fn de larticle. Al fnal del artculo se acilita una traduccin al espaol. .

Objective To assess equity in health outcomes and interventions for maternal and child health (MCH) services in Thailand.Methods Women of reproductive age in 40 000 nationally representative households responded to the Multiple Indicator Cluster Surveyin 20052006. We used a concentration index (CI) to assess distribution of nine MCH indicator groups across the household wealthindex. For each indicator we also compared the richest and poorest quintiles or deciles, urban and rural domiciles, and mothers orcaregivers with or without secondary school education.Findings Child underweight (CI: 0.2192; P< 0.01) and stunting (CI: 0.1767; P< 0.01) were least equitably distributed, beingdisproportionately concentrated among the poor; these were followed by teenage pregnancy (CI: 0.1073; P< 0.01), and childpneumonia (CI: 0.0896; P< 0.05) and diarrhoea (CI: 0.0531; P< 0.1). Distribution of the MCH interventions was fairly equitable, butricher women were more likely to receive prenatal care and delivery by a skilled health worker or in a health facility. The most equitablydistributed interventions were child immunization and family planning. All undesirable health outcomes were more prevalent amongrural residents, although the urbanrural gap in MCH services was small. Where mothers or caregivers had no formal education, alloutcome indicators were worse than in the group with the highest level of education.Conclusion Equity of coverage in key MCH services is high throughout Thailand. Inequitable health outcomes are largely due tosocioeconomic factors, especially differences in the educational level of mothers or caregivers.

Equity in maternal and child health in ThailandSupon Limwattananon,a Viroj Tangcharoensathienb & Phusit Prakongsaib

a Khon Kaen University, Thanon Mitraparp, Amphoe Muang, Khon Kaen, 40002, Thailand.b International Health Policy Program, Ministry of Public Health, Nonthaburi, Thailand.Correspondence to Supon Limwattananon (e-mail: [email protected]).(Submitted: 16 June 2009 Revised version received: 12 October 2009 Accepted: 15 October 2009 Published online: 8 December 2009)


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Bull World Health Organ2010;88:420427 | doi:10.2471/BLT.09.068791 421

Supon Limwattananon et al. Equity in maternal and child health in ThailandResearch

amily planning indicator targeted theapproximately 13 million women mar-ried to or living with their male partnersand not pregnant; and the prenatal anddelivery indicators targeted the 2 millionmothers who had given birth during the

previous two years.Child health indicators were lowbirth weight, moderate-to-severe childmalnourishment and childhood illnesses.Low birth weight, dened as a weighto < 2.5 kg at birth, was assessed or thechildren o mothers who had given birthin the previous two years (i.e. 2 millionmothers). Malnourishment in childrenwas indicated by underweight, stunting(chronic malnutrition) and wasting (acutemalnutrition), based on United StatesNational Center or Health Statistics and

World Health Organization standards.Child illnesses were diarrhoea and sus-pected pneumonia, both very common.Child malnourishment and illnesses werecounted directly or those less than 5 yearso age (estimated at 5 million).

Coverage o child health indicatorswere treatment or child illness (diarrhoeaand suspected pneumonia) and childimmunization. For the latter, the targetpopulation was chi ldren aged 1223months (estimated at 1 million) whohad received the ollowing beore they

reached the age o 1 year: one dose obacille CalmetteGurin (BCG) vaccineand o vaccine against measles, mumpsand rubella (MMR); three doses o oralpolio vaccin e (OPV ) and o vaccineagainst diphtheria, pertussis (whoopingcough) and tetanus (DP); and one doseo hepatitis B vaccine.

Equity stratifers and measureso assess wealth, we used the presence (orabsence) o selected assets and durables ina sample household, because asset own-

ership tends to uctuate less than indi-vidual income or expenditure. Te assetswe considered in houses were permanentoors, roos or walls; ush or pour-ushtoilets; transportation, including bicycles,motorcycles, cars or trucks; and electricalequipment, including radios, televisions,line or mobile telephones, rerigeratorsand computers. Households with theseassets were considered richer than thosewithout. We used principal componentanalysis o all household samples to gener-ate a wealth index or each household, and

we used this as an equity stratier.Using a standard method, we sum-

marized the distribution o each MCH

indicator over a gradient o the wealthindex by a concentration index (CI) anda concentration curve (CC).22 Te CI,which ranges rom 1.0 to +1.0, capturesthe extent to which health outcomes andservice use are concentrated among di-

erent population groups (in this case,the richest and the poorest). A CI o zeromeans an equal distribution o a particu-lar indicator throughout the economicgradients. A negative CI indicates a con-centration among those who are poorer(i.e. the CC lies above the equality lineo 45 degrees), and a positive CI reects aconcentration among those who are richer(i.e. the CC lies below the equality line).

We compa red the pre valen ce ohealth outcomes and the coverage othe MCH interventions between the

richest and the poorest subgroups usinga risk ratio (RR). All households wereranked according to their wealth indices,which were divided equally into quintile(5) and decile (10) subgroups. Onlythe top (richest) and bottom (poorest)quintiles and deciles were selected orthe RR calculation, to demonstrate anydisparity between rich and poor. We alsoused ratio analysis to compare urban withrural domiciles, and mothers or caregiverseducated beyond secondary school levelwith those lacking ormal education.

Based on the results o the analyses,we estimated gures or the population oTailand using the individual householdmembers sampling weights provided bythe National Statistical Oce.

Resultsable 1 summarizes the denition andnumber o the samples surveyed or eachindicator, and the eligible estimated pop-ulation in each case. able 2 summarizesequity measures or all MCH indicators

in terms o CI and RR between the richestand poorest quintiles and deciles.

Economic inequity in healthoutcomesEconomic inequity in MCH was ap-parent in teenage pregnancy, low birthweight, child malnourishment and childillness (Fig. 1). Tese undesirable healthoutcomes were concentrated in the poorersubgroups (as shown by the negativeCIs in able 2). Concentration amongthe poor was greatest and was statistical

signicant or child underweight andstunting. Te CI o child wasting wasnegative, but this had no statistical signi-

cance. eenage pregnancy ranked third inmagnitude o concentration among thepoor. Suspected pneumonia and diar-rhoea in children less than 5 years o agewere also more concentrated among thepoor (able 2).

In comparing MCH outcomesbetween the top and bottom wealthquintiles, RRs were consistent with thecomputed CI. eenage pregnancy, childunderweight, and reported diarrhoeaand suspected pneumonia were moreconcentrated in the poorer than in thericher households. Te RR between thetop and bottom quintiles ranged rom0.24 or child underweight to 0.79 orchild wasting (able 2).

Economic disparity in low birthweight was less clear. Te positive CI re-

ected its concentration among relativelyrich households, but without statisticalsignicance. Also, the corresponding CCin Fig. 1 shows that the concentrationoccurred mainly in the third and ourthwealthiest quintiles, which were not par-ticularly rich in absolute terms.

Economic inequity in servicecoverageTe key interventions or MCH weremore uniormly distributed across eco-nomic strata than were the health out-

comes (able 2).For the maternal care interven-

tions, prenatal and delivery care eitherby a skilled health worker or in a healthacility showed a statistically signicantconcentration among the rich. However,the magnitude o the CI was modest andthe RR between the richest and the poor-est groups was close to one, indicating anegligible gap between rich and poor.

Coverage with oral rehydration salts/oral rehydration therapy or diarrhoeawas greatest in the richest quintile and

decile. In contrast, coverage with appro-priate health-care providers or suspectedpneumonia was greatest in the poorestquintile and decile.

able 2 shows that, or childhoodimmunization coverage, the CI o theve vaccine types ranged rom 0.0104to 0.0002, and that the CI or amilyplanning (at 0.0005) was not statisti-cally diferent rom zero. Tus, there wasalmost equitable service coverage orthese indicators. Results on RR or theseindicators were mixed (able 2); all were

less than one or comparison between therst and h quintiles, and two o thesix were less than one between the rst


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Supon Limwattananon et al.Equity in maternal and child health in ThailandResearch

and h deciles, with the remaining ourslightly positive.

Geographic disparity o MCHHealth outcome prevalences were asollows: teenage pregnancy among allmothers, 37.3%; low birth weight, 8.3%;and child stunting, 11.9% ( able 3).Service coverage was more equitable; or

example, on average, more than 97% orespondents had prenatal care deliveredeither by skilled health workers or in

health acilities, and more than 90% ochildren had received all vaccinationsexcept the one against hepatitis B virus.

able 3 also summarizes the urbanrural and educational disparity in MCH,as reected by the RR. Except or lowbirth weight, all undesirable MCH in-dicators were more concentrated in ruralthan in urban areas. Te most prooundhealth gap was child underweight, whichwas 48% more prevalent in rural than inurban areas. Child wasting and reported

diarrhoea had the narrowest urbanruraldisparity. In contrast, low birth weightwas more prevalent in urban than in ruralareas by 15%.

Te urbanrural gap or MCHservice coverage was small. Women liv-ing in urban areas were up to 4% morelikely than those in rural areas to receiveprenatal and delivery care rom a skilledhealth worker, and delivery in a healthacility. Although overall coverage at thenational level o these recommended ma-

Table 1. Defnition and number o surveyed samples and estimated population or each indicator o maternal and child health,Thailand, 20052006

MCH indicator Defnitiona Eligible populationbNo. o samples

(no. o estimated populationc)

I. Maternal health

Outcome indicator

1. Teenage pregnancy First pregnancy at age under 20 years Women aged 1549 years, havinggiven birth

24 018 (11 950 095)

Coverage indicator

2. Family planning Use of modern contraceptive methods includingsterilization, pill, injection, implantation, IUD andcondom

Women 1549 years, married toor living with male partner and notknown to be pregnant

26 119 (13 079 990)

3. Prenatal care Pregnancy cared for by physicians, nurses,midwives or auxiliary midwives

Women 1549 years, giving birthduring the previous 2 years

3 365 (1 848 734)

4. Delivery care 4.1 Delivery by physicians, nurses, midwives orauxiliary midwives4.2 Delivery in subdistrict health centres; district,provincial and teaching hospitals; and private health

facilities

II. Child health

Outcome indicator

5. Low birth weight Babies born with weight below 2.5 kg Women 1549 years, giving birthduring the previous 2 years

3 365 (1 848 734)

6. Child moderate-to-severemalnourishment

6.1 Weight below 2 SD of the mean for thesame age (underweight)6.2 Height below 2 SD of the mean for thesame age (stunting)6.3 Weight below 2 SD of the mean for thesame height (wasting)

Children 059 months successfullymeasured for weight and height

8 993 (4 632 238)

7. Child il lness 7.1 Mothers or caregivers reporting diarrhoea inthe last 2 weeks

7.2 Mothers or caregivers reporting cough withdifculty in breathing and tightness in the chest(suspected pneumonia) in the last 2 weeks

Children 059 months 9 409 (4 837 701)

Coverage indicator

8. Treatment for childillness

8.1 Receiving ORS/ORT 8.1 Children 059 months withdiarrhoea

767 (419 756)

8.2 Receiving advice/treatment from public andprivate health providers

8.2 Children 059 months withsuspected pneumonia

379 (219 )

9. Child immunization Receiving one dose of BCG vaccine and MMRvaccine, and three doses of OPV, DPT vaccine andHBV vaccine in their rst year of life

Children 1223 months 1 932 (974 880)

BCG, bacille CalmetteGurin; DPT, diphtheria, pertussis (whooping cough) and tetanus; HBV, hepatitis B virus; IUD, intrauterine device; MCH, maternal and childhealth; MMR, measles, mumps and rubella; OPV, oral polio vaccine; ORS/ORT, oral rehydration salts/oral rehydration therapy; SD, standard deviation.a The numerator for calculating the prevalence or coverage for MCH indicator.b The denominator for calculating the prevalence or coverage for MCH indicator.c For the whole country, based on individual household members weights of the surveyed samples.


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ternal care indicators was high (> 95%),the lowest coverage was in the southernregion o Tailand, especially in thethree southernmost provinces, where the

population is mainly Muslim (data notshown). Coverage o amily planning bymodern methods in the southern regionwas only 60%, lower than the nationalaverage o 73%. In contrast, coverage oamily planning and all types o childimmunization was greater in rural areas(able 3). Notably, immunization cover-age in Bangkok was lower than in all otherregions (data not shown).

Educational disparity and MCHinequityFormal education o the mother or care-giver o children is a major determinanto MCH inequity ; those who were more

educated ared better on all outcomeindicators. Te diference was most strik-ing or teenage pregnancy. Uneducatedwomen (3% o the 12 million mothers)

were 90% more likely than those educatedbeyond secondary school (10% o the12 million mothers) to have their rstpregnancy beore the age o 20 years.

Children who were underweight,stunted or wasted were more likely (71%,61% and 48%, respectively) to havemothers or caregivers with no ormaleducation (4% o 5 million children) thanwith education beyond secondary school(12% o 5 million children). Educationalinequity among mothers o children

who were ill or had low birth weight wassmall, but these indicators were still moreprevalent in the subgroup with mothersor caregivers lacking education (able 3).

Women who were educated beyondsecondary school were 1028% morelikely than those without any ormaleducation to receive amily planning,

prenatal care and delivery by a skilledhealth worker or in a health acility. Terewas also a consistent increase in maternalcare coverage with higher educationalattainment, with a signicantly sharp di-erence (RR: 1.11.28; P< 0.01) notedbetween the uneducated and those whohad completed primary school (data notshown). Surprisingly, children born tomothers or cared or by someone who hadbeen educated beyond the secondary levelwere 59% less likely than those not in

this subgroup to receive all types o vacci-nation (except MMR vaccine) beore therst year o age. Te coverage or all vevaccines in the subgroup educated beyond

Table 2. Concentration index and ratio o richest to poorest quintile or decile or each indicator o maternal and child health,Thailand, 20052006

MCH indicator CI RR(quintile 5: quintile 1)a RR(decile 10: decile 1)b

I. Maternal health

Outcome indicator

1. Teenage pregnancy 0.1073*** 0.51*** 0.42***Coverage indicator

2. Family planning 0.0005 0.99*** 1.07***3. Prenatal care by skilled health worker 0.0078*** 1.05*** 1.08***4. Delivery care

By skilled health worker 0.0172*** 1.10*** 1.16***In health facility 0.0173*** 1.10*** 1.15***

II. Child healthOutcome indicator

5. Low birth weight 0.0367 0.92*** 0.91***6. Child malnourishment

Underweight 0.2192*** 0.24*** 0.28***Stunting 0.1767*** 0.34*** 0.21***Wasting 0.0655 0.79*** 0.88***

7. Child illnessDiarrhoea 0.0531* 0.65*** 0.53***Suspected pneumonia 0.0896** 0.60*** 0.60***

Coverage indicator

8. Child illness treatmentORS/ORT for diarrhoea 0.0220 1.22*** 1.30***Appropriate provider for pneumonia 0.0164 0.92*** 0.72***

9. Child immunizationBCG 0.0104 0.94*** 0.93***MMR 0.0041 0.91*** 0.89***OPV 0.0002 0.99*** 1.02***DPT 0.0002 0.99*** 1.02***HBV 0.0052 0.97*** 1.03***

* P< 0.1; ** P< 0.05; ***P< 0.01.BCG, bacille CalmetteGurin; CI, concentration index; DPT, diphtheria, pertussis (whooping cough) and tetanus; HBV, hepatitis B virus; MCH, maternal and childhealth; MMR, measles, mumps and rubella; OPV, oral polio vaccine; ORS/ORT, oral rehydration salts/oral rehydration therapy; RR, risk ratio.a Quintile 5 is the richest; quintile 1 is the poorest.b Decile 10 is the richest; decile 1 is the poorest.


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the secondary level was also lower than intwo other subgroups: those educated tothe primary and secondary levels (datanot shown).

DiscussionA clear policy message emerges romthis study universal access to health

care is undamental to achieving the goalo health equity. In Tailand, child im-munization was distributed uniormlyover the economic gradient o mothersor caregivers. Surprisingly, immunizationcoverage in rural areas and in the childrenwhose mothers or caregivers had no or-mal education was slightly higher than inurban areas and in those educated beyondsecondary school. Tese ndings suggestthat better service coverage is providedin rural areas (mainly by district healthsystems) than in urban areas. In spite o

a positive CI, coverage o maternal careby skilled health workers in Tailand isnot as concentrated among the rich as it

is in other developing countries under theDemographic and Health Survey (DHS)programme (or prenatal care, Tailandhas a CI o 0.0078, compared to 0.1095or DHS; or delivery, Tailand has a CI o0.0172, compared to 0.2747 or DHS).23

Te relatively equitable distributiono MCH service coverage in Tailand between rich and poor, urban and rural can be explained by government commit-ment to investment in health inrastruc-ture and expansion o health insurancecoverage over the past three decades.24Te countrys well unctioning primaryhealth-care service is acilitated by the gov-ernments pro-rural policy o mandatorypublic service by all medical, pharmacist,dentist and nurse graduates at the districtlevel, as well as by other paramedics at sub-district levels.17 Te geographic coverageo district hospitals and subdistrict healthcentres has continued to expand over thepast three decades. District health systems,including hospitals and health centres,are at the oreront in providing a com-

prehensive range o curative, preventativeand health-promotion services, includingMCH.16.Tis in-country study supportsndings rom cross-country analyses thathave ound a negative correlation betweenthe overall level o MCH interventionsand the richpoor gap in such coverage,7and a strong positive association betweenhealth-worker density and child immuni-zation coverage.25

However, some disparity in childhealth outcomes is still noticeable be-tween rich and poor, and between urbanand rural areas in Tailand. For example,the countrys CIs or diarrhoea, mal-nourishment, underweight and stuntingare comparable to those o the DHS ordeveloping countries.23

Education is one o the most impor-tant social determinants o health ineq-uity. Tis study ound that education gapsor the indicators o teenage pregnancyand child malnourishment were muchlarger than those or the urbanrural di-erential. Prevalence o teenage pregnancy

Fig. 1. Concentration curves or teenage pregnancy, low birth weight, child malnourishment and child illness, Thailand, 20052006

0

Cumulativeproportiono

fcases

1

0 0.2 0.4 0.6 0.8 1

0.2

0.4

0.6

0.8

Cumulative population proportion

Equality line

Teenage pregnancy

0

Cumulativeproportiono

fcases

1

0 0.2 0.4 0.6 0.8 1

0.2

0.4

0.6

0.8


Equality line

Low birth weight

0

Cumulativeproportionofcases

1

0 0.2 0.4 0.6 0.8 1

0.2

0.4

0.6

0.8


Diarrhoea

Suspected pneumonia

Equality line

0

Cumulativeproportionofcases

1

0 0.2 0.4 0.6 0.8 1

0.2

0.4

0.6

0.8


Underweight

Wasting

Stunting

Equality line


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and child malnourishment decreased asthe ormal education level o the motheror caregiver increased (data not shown).In particular, the prevalence o teenage

pregnancy dropped sharply among thoseeducated beyond the secondary level. Itis clear rom this and other studies thatmaternal education is a vital part o poli-cies to improve MCH.

In the context o universal healthcoverage, access to MCH services is airlyequitable in Tailand. Te remaining chal-lenge is inequity in health outcomes, orwhich social determinants (e.g. poverty,maternal education and other structuralsocial inequities) are important, althoughthey are oen outside the mandate o the

health sector. Te overall prevalence ochild underweight, stunting and wast-ing in this study was 9%, 12% and 4%,

respectively. Wasting in children indicatesacute malnutrition and stunting indicateschronic malnutrition, which is generally aresult o chronic household poverty. Poli-

cies should address inequity rom birth;they should, or example, tackle issuessuch as low birth weight, teenage preg-nancy and child malnutrition, or whichthe Commission on Social Determinantso Health recommends multisectoralactions.4 Inequity at birth has long-termnegative implications; undernutrition, orinstance, is associated with a decrease inhuman capital (i.e. the skills and knowl-edge that enable people to work and thusproduce economic value).26

A limitation o this study is its cross-

sectional nature. ime trend inormationcould not be extracted rom the databecause the Multiple Indicator Cluster

Survey 2006 was the rst survey wave inTailand. A sample size o over 40 000representative households is adequatewhen compared to numbers used in typi-

cal surveys conducted in Tailand by theNational Statistical Oce. A strength othis study is the application o a wealthindex, which better reects a householdseconomic status than personal income andis easier and quicker to assess.

ConclusionUniversal health coverage in Tailandhas resulted in a airly equitable distribu-tion o MCH services. Major challengesremain in connection with inequity in

health outcomes, particularly in the areaso teenage pregnancy and child malnour-ishment. Te gaps between rich and poor

Table 3. Prevalence, service coverage and risk ratio with respect to urbanrural areas and educational attainment, Thailand,20052006

MCH indicator Average prevalenceor coverage(%)

RR between urban andrural areas

RR between higher andno ormal education a

I. Maternal health

Outcome indicator

1. Teenage pregnancy 37.3 0.76*** 0.10***Coverage indicator

2. Family planning 72.6 0.92*** 1.10***3. Prenatal care by skilled health worker 97.8 1.0006** 1.10***4. Delivery care

By skilled health worker 97.3 1.03*** 1.23***In health facility 96.8 1.04*** 1.28***

II. Child health

Outcome indicator

5. Low birth weight 8.3 1.15*** 0.91***

6. Child malnourishmentUnderweight 9.3 0.52*** 0.29***Stunting 11.9 0.66*** 0.39***Wasting 4.1 0.92*** 0.52***

7. Child illnessDiarrhoea 8.7 0.90*** 0.62***Suspected pneumonia 4.6 0.62*** 0.93***

Coverage indicator

8. Child illness treatmentORS/ORT for diarrhoea 68.3 0.91*** 1.05***Appropriate provider for pneumonia 84.7 0.93*** 0.91***

9. Child immunization

BCG 98.0 0.94*** 0.92***MMR 91.4 0.90*** 1.00OPV 91.5 0.94*** 0.95***DPT 91.4 0.94*** 0.95***HBV 85.7 0.97*** 0.91***

** P< 0.05; *** P< 0.01.BCG, bacille CalmetteGurin; DPT, diptheria, pertussis (whooping cough) and tetanus; HBV, hepatitis B virus; MMR, measles, mumps and rubella; OPV, oral poliovaccine; ORS/ORT, oral rehydration salts/oral rehydration therapy; RR, risk ratio.a Higher education refers to schooling beyond the secondary level.


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.2006 2005

. 40000

.

.0.2192 : (

0.1767 : ( )0.01 P)0.01 P

0.1073 : (: ( )0.01 P

: ( )0.05 P 0.0896.)0.01 P 0.0531

.

.

..

.

.

Rsumquit en termes de sant maternelle et inantile en ThalandeObjectif valuer lquit en termes dvnements et dinterventionssanitaires faisant intervenir les services de sant maternelle et de lenfant(MCH) en Thalande.Mthodes Des femmes en ge de procrer appartenant 40 000mnages reprsentatifs au plan national ont rpondu une enquteen grappes indicateurs multiples sur la priode 20052006. Nousavons utilis lindice de concentration (IC) pour valuer la distribution deneuf groupes dindicateurs concernant les services MCH en fonction delindice de richesse des mnages. Pour chaque indicateur, nous avonsaussi effectu des comparaisons entre le quintile ou le dcile le plus

riche et le plus pauvre, entre origine urbaine et rurale et entre mres oupersonnes soccupant des enfants ayant reu ou nayant pas reu uneducation secondaire.RsultatsCtaient le dcit pondral (IC: 0,2192 ; p < 0,01) et le retardde croissance (IC: 0,1767 ; p < 0,01) qui prsentaient la distribution lamoins quitable, avec une concentration disproportionne chez les plusdmunis ; venaient ensuite les grossesses ladolescence (IC: 0,1073 ;p < 0,01), la pneumonie infanto-juvnile (IC: 0,0896 ; p < 0,05) et la

diarrhe (IC: 0,0531 ; p < 0,1). La distribution des interventions desMCH tait plutt quitable, mais les femmes riches avaient une plusgrande probabilit de bncier de soins prnatals et dun accouchementassist par du personnel mdical quali ou dans un tablissement desoins. Les interventions les plus quitablement distribues taient lavaccination infantile et la planication familiale. Dans leur ensemble, lesvnements sanitaires indsirables prsentaient une plus forte prvalencechez les ruraux, mme si lcart rural-urbain tait faible dans le cas desservices MCH. Lorsque la mre ou la personne soccupant de lenfantnavait reu aucune ducation formelle, tous les indicateurs dvnements

taient moins bons que dans le groupe disposant dun plus haut niveaudducation.Conclusion En matire de couverture par les services MCH essentiels,un haut niveau dquit est atteint dans lensemble de la Thalande. Lesvnements sanitaires indsirables sont largement dus des facteurssocioconomiques et notamment aux diffrences dans le niveaudducation des mres ou des personnes soccupant des enfants.

Resumen

Equidad de la salud maternoinantil en TailandiaObjetivo Evaluar la equidad en materia de resultados e intervencionessanitarias de salud maternoinfantil (SMI) en Tailandia.Mtodos Mujeres en edad fecunda de 40 000 hogares representativosa nivel nacional respondieron a la Encuesta de Indicadores Mltiples por

Conglomerados de 2005-2006. Usamos un ndice de concentracin (IC)para evaluar la distribucin de nueve grupos de indicadores de la saludmaternoinfantil en un gradiente del ndice de riqueza de los hogares. Paracada indicador comparamos tambin los quintiles o deciles ms rico y

and between urban and rural areas reveal asimilar pattern. Maternal education is themain determinant o health inequity. Keypolicy leverage and multisectoral actionswill be required to close the gap.4

AcknowledgementsWe acknowledge a genuine partnershipbetween Tailands National Statistical

Oce and Ministry o Public Healthin past decades. A constructive engage-ment between the two constituencieshas produced a strong oundation orevidence-based policy decisions. Tisstudy was made possible by permission

rom the National Statistical Oce touse the 2006 Multiple Indicator ClusterSurvey data set.

Funding: Te United Nations ChildrensFund (UNICEF) provides technical andnancial support to the National Statis-tical Oce or the Multiple IndicatorCluster Survey. No unding support wasreceived or this study.

Competing interests: None declared.


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ms pobre, los hogares urbanos y rurales, y las madres o cuidadores cono sin educacin secundaria.Resultados La insuciencia ponderal (IC: 0,2192; P< 0,01) y el retrasodel crecimiento (IC: 0,1767; P< 0,01) infantiles fueron los problemasdistribuidos menos equitativamente, pues se concentraban de maneradesproporcionada entre los pobres; les siguieron el embarazo enla adolescencia (IC: 0,1073, P< 0,01), y la neumona (IC: 0,0896,P< 0,05) y la diarrea (IC: 0,0531, P< 0,1) infantiles. La distribucin delas intervenciones de salud maternoinfantil fue bastante equitativa, perolas mujeres ms ricas tenan ms probabilidades de recibir atencinprenatal y, en el momento del parto, atencin especializada o en un centrode salud. Las intervenciones distribuidas de forma ms equitativa fueron

la inmunizacin infantil y la planicacin familiar. Todos los resultadossanitarios desfavorables fueron ms frecuentes en las zonas rurales,si bien la brecha urbano-rural en los servicios de salud maternoinfantilera pequea. Entre las madres y los cuidadores sin estudios, todos losindicadores de resultados fueron peores que en el grupo con mayor nivelde educacin.Conclusin Se observa en toda Tailandia una alta equidad en materiade cobertura de los principales servicios de salud maternoinfantil. Losresultados sanitarios no equitativos se deben en gran medida a factoressocioeconmicos, en particular al diferente nivel educativo de las madresy los cuidadores.
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Equity in Maternal & Child Health in Thailand