Poor Quality of Care for All Women? Equity in Quality of Reproductive Health Services in Ethiopia

Background: The Ethiopian health system faces persistent geographic and socioeconomic inequities in healthcare utilization, health outputs and outcomes, despite continued efforts to expand health service coverage across the country. While the previously mentioned inequities are fairly well documented, there is little evidence in the literature describing the status of equity in the quality of healthcare. This paper aims to understand the disparities in quality of reproductive health services (antenatal care and family planning) among the poor and non-poor communities. Methods: We used the 2016 Ethiopia Demographic and Health Survey (DHS) data to compute a Multidimensional Poverty Index (MPI), and the 2014 Service Provision Assessment (SPA) data to assess quality of antenatal care (ANC) and family planning (FP) services - defined as the level of adherence to World Health Organization (WHO) clinical and service guidelines - in private and public facilities. We merged the two datasets using geographical coordinates, and aggregated service users into facility catchment area clusters using a 2-kilometer radius for urban and 10-kilometer radius for rural facilities. We computed ANC and FP quality and MPI indices for each facility and assigned this to these catchment areas. Using the international cut-off point for deprivation (MPI=33.3%) to categorize poor and non-poor catchment areas, we evaluated whether the quality of ANC and FP services varies by socioeconomic status of catchment areas. Findings: The majority of catchment areas (75.7%) were found to be deprived using MPI cut-off point of 33.3%. While the overall quality of ANC and FP services are low (33% and 34% respectively), we found little variation in the distribution of the quality of these services between poor and non-poor areas, urban and rural settings, or regionally. More specifically, the relatively more deprived catchment areas received 33.1% of the standard ANC and 32.9% of FP clinical actions, while these figures were 33.2% and 36.4% respectively for less-deprived areas. Interpretation There is little disparity in the quality of ANC and FP services provided in less- or more-deprived catchment areas of public or private facilities; hence, the short-term focus of the health system needs to be to continue on improving the overall quality of services rather than to focus primarily on its distribution. Funding Statement: Bill & Melinda Gates Foundation Declaration of Interests: We have no conflict of interest.