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> 4. Inequalities
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How should we address inequality?
What are the most important approaches that DFID/UK should consider to tackle inequalities in reproductive, maternal and newborn health outcomes?
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Our thanks for all the comments submitted. All of the ideas and suggestions put forward will feed into our new policy, helping to shape the direction of our work.
Once the final policy document is released you will be able to find it at www.dfid.gov.uk
All of the mechanisms mentioned to address inequalities in access to and use of care are important to address the central issue of inequality and health. For maternal health, transport and other access issues related to emergency obstetric care are critical. However, the larger issues of inequality in the social and economic determinants of health are also very important factors in MCH outcomes. Addressing poverty and illiteracy have to be seen as essential elements of any strategy to improving health — documenting the effects of improvements in these areas could be a pioneering area for DFID projects. Direct cash transfers are an important potential approach but there need to be many others.
Effectively tackling inequalities in reproductive, maternal and newborn health requires multiple approaches and entry points. Investing in creating a more supportive legal and policy environment is essential and should include emphasis on eliminating institutional barriers to equality and on enforcing non-discrimination and other basic human rights in access to health care. Also necessary are health-system and community-based approaches. In the case of reducing unsafe abortion, theses should include:
1) better data collection and monitoring of services, so that women’s need for care is fully understood and services are planned and managed appropriately,
2) values clarification for service providers to sensitize them to women’s needs and reduce negative provider attitudes toward women seeking abortion care, which are barriers to women’s access to needed care in many settings, and
3) efforts to make information and care related to preventing and safely managing unwanted pregnancy available to women in their communities.
Mechanisms that remove financial barriers faced by the poorest and offer choice where relevant (such as vouchers and services that are free at the point of use to pregnant women and children) can have a significant positive impact. However, they may have a negative impact as well; eg by increasing the number of caesarean sections that are undertaken without good obstetric indications.
The first step would be to plan appropriate responses based on a gender analysis that acknowledges and recognizes the dual role of women as carers and food producers. It is important to analyse the power relations and the use and distribution of resources that affect them. DFID actions should strive to lessen the work burden placed on women.
Tackling inequalities will require a national approach: i.e. policies and identification and therefore targeting of the correct beneficiaries. Positive discrimination for female education for example, ensuring that there is as much investment in the rural infrastructure and health services. Barriers to health care services have to be removed alongside creating demand for health care in the target groups.
Unless services are geared toward fully grown women as well as young people, inequalities will not decrease. In addition, we must provide better and more transparent data to track results if results benefit the poorest. And overall, we must apply a rights-based approach to sexual and reproductive health.
Providing interest free long term payable credit, cash transfer/vouchers could make the household members free from fear of borrowing high interest credit from money lenders or selling the sources of income (such as: milking cow, van etc) and encourage them to take their female members to the health facilities in their labour. It has been noted that financial assistance from Manoshi ( a project of BRAC) reduced the delay in obtaining obstetric care. In addition to, innovation of low cost transports or exploring the ways of transporting women to the health centres are some of the ways to reduce inequality in access to health services.