Acknowledgements: with contributions from Dr Adesoji Ologun and Jennifer Armitage

Can a composite index for socioeconomic deprivation enhance equitable access to reproductive and maternal health? 

In a previous article, we examined the complexities of estimating the costs associated with reaching high-impact clients (HICs) in a donor-funded, multi-country programme implemented in East and Central Africa as well as Southeast Asia. A primary obstacle was the lack of clear differentiation between the costs of reaching HICs and those of non-HICs, stemming from inadequate data on the general population and HIC profiles in the target countries. The need for equity-driven solutions remains evident as we continue to explore the intersection of socioeconomic factors and access to essential healthcare services. Disparities in healthcare access, particularly in reproductive and maternal health, are closely linked to broader socioeconomic inequalities. This article examines the role of socioeconomic status in shaping healthcare access and assesses the utility of a composite socioeconomic deprivation index as a metric for equitable access to healthcare.

Socioeconomic deprivation and healthcare access

A recent study by Leonardo Z. Ferreira et al., published in the Bulletin of the World Health Organization on December 8, 2023, provides an in-depth analysis of socioeconomic deprivation and its impact on reproductive and maternal health interventions across 73 low- and middle-income countries. The study introduces a composite index of socioeconomic deprivation, which integrates two key dimensions: education and material living standards. The index comprises eight indicators, including years of schooling, school attendance, type of cooking fuel, sanitation facilities, drinking water accessibility, electricity, housing materials, and asset ownership. Unlike traditional wealth indices, which reflect relative economic positioning within a country, this new index provides an absolute measure of deprivation with fixed cut-offs, allowing for cross-country comparisons and long-term tracking of progress.

The study highlights persistent disparities in access to reproductive and maternal healthcare among socioeconomically deprived populations. Findings indicate that 41% of populations in low-income countries experience deprivation, compared to 11% in lower-middle-income countries and less than 1% in upper-middle-income countries. Skilled birth attendance exhibited the largest inequalities, with coverage being substantially lower among the most deprived populations. Antenatal care (at least four visits) and demand for modern family planning methods also showed significant gaps, favoring wealthier groups. These patterns align with the inverse equity hypothesis, where wealthier populations initially benefit from increased healthcare coverage before more deprived groups begin to catch up. Notable disparities exist by country, with Nigeria and Haiti showing the most pronounced inequities, while Malawi and Iraq have implemented effective policies that have reduced these disparities.

Policy implications and equity-driven interventions

The findings underscore the need for targeted, equity-focused policies addressing geographic accessibility, women’s education, and healthcare infrastructure in underserved areas. Malawi’s policy restricting traditional birth attendants has significantly improved skilled birth attendance, demonstrating a successful model that could be replicated elsewhere. Investments in health infrastructure and targeted interventions in countries like Iraq have helped close gaps in antenatal care coverage. The study emphasizes the need for refining and continuously applying the composite deprivation index to guide policy formulation and resource allocation to reduce disparities.

Applications of the socioeconomic deprivation index

The socioeconomic deprivation index can be applied in multiple ways to enhance health equity and policy effectiveness. By integrating this index into decision-making, governments, donors, and humanitarian organizations can better target their interventions and allocate resources efficiently.

1. Targeted health programme planning and implementation: The index can help identify socioeconomically disadvantaged populations, facilitating precise targeting of healthcare interventions. Some reproductive health programmes*, such as those in Nigeria, already utilize deprivation data to concentrate on rural communities with low skilled birth attendance rates. However, incorporating this specific index could further improve the precision of programme targeting and enhance maternal healthcare service delivery.
2. Monitoring, evaluation, and policy formulation: By establishing consistent baseline and endline measures, the index can help track progress in reducing disparities and provide stronger evidence for policy decisions. Although many countries currently track antenatal care and reproductive health disparities using various socioeconomic indicators**, employing this refined index could improve the assessment of whether policies are effectively closing gaps in healthcare access for marginalized populations.
3. Equitable resource allocation and humanitarian aid: This index could facilitate data-driven allocation of funding and resources, ensuring that investments focus on high-need populations. Organizations like MSF (Médecins Sans Frontières) and WHO already emphasize resource distribution based on deprivation-related metrics. However, integrating this composite index into humanitarian planning could further enhance the distribution of aid in disaster-prone regions, ensuring that marginalized populations receive timely healthcare interventions.
4. Enhancing social protection and health equity interventions: Many governments have already implemented conditional cash transfer (CCT) programmes that tie financial support to maternal healthcare visits. However, these programmes typically use broader socioeconomic indicators like income level or household assets rather than a comprehensive deprivation index. Incorporating the socioeconomic deprivation index could improve beneficiary selection, ensuring that the most socioeconomically deprived individuals benefit from financial aid and other social protection schemes.
5. Customization of health education and outreach programmes: Countries like Pakistan and Bangladesh have already implemented community-led antenatal care awareness campaigns aimed at marginalized populations. These programmes rely on general demographic and socioeconomic data but often lack precise insights into multidimensional deprivation. The socioeconomic deprivation index could enhance these programmes by offering a more detailed understanding of cultural and contextual barriers to healthcare, thus enabling even more tailored messaging and intervention strategies.

Conclusion

Despite some limitations, the socioeconomic deprivation index presents a valuable tool for monitoring health inequalities and guiding interventions to achieve universal health coverage. Its application can enhance the effectiveness of equity-focused policies and ensure that healthcare resources are distributed in a manner that prioritizes those most in need. However, certain limitations must be considered:

1. Data limitations: Household surveys, the primary data source for calculating the index, may not fully capture some of the most vulnerable populations, such as internally displaced persons, those in conflict zones, or individuals affected by disasters.
2. Cross-country comparability: Variations in survey timing and methodology across countries may affect the comparability of results.
3. Limited scope of determinants: The index, while providing a valuable measure of deprivation, does not account for other structural determinants of health, such as gender disparities, cultural barriers, and governance challenges that impact access to maternal and reproductive healthcare.

Addressing these limitations through enhanced data collection methods, improved survey representativeness, and integration with broader social determinants of health frameworks can strengthen its utility. The insights derived from this index are instrumental in informing policy decisions, addressing disparities, and ultimately achieving the broader goals of health equity and sustainable development.

* We saw this when we supported programmes such as FCDO’s Lafiya programme where decisions were made to concentrate interventions in the northern part of Nigeria (see Lafiya’s business case).

**See national DHS surveys, e.g. Nigeria’s DHS survey disaggregate by wealth quintile and rural vs. urban 

This article is based on the study “A Composite Index for Socioeconomic Deprivation and Coverage of Reproductive and Maternal Health Interventions” by Leonardo Z. Ferreira et al., published in the Bulletin of the World Health Organization on December 8, 2023. The full article can be accessed here.