| 1、BackgroundEquity of health means every member of society has the opportunity to achieve a good health state.to achieve this goal, a fine health care system is necessary to ensure the basic right of the citizens not be affected by their economic states or other external factors. Equity was recommended as a key indicator to evaluate the healthcare system by WOH in2000, since then the equity of health and health care service became a hot topic for researchers in all counties. Studies on maternal and child healthcare showed that the inequity of utilization of maternal healthcare service (MHS) which was caused by different economic level is one of the main factors of health inequity, reflected on the huge gaps on Maternal Mortality Ration (MMR) between low-income, middle-income and high-income countries. Limited studies in maternal healthcare (MH) in china also showed that inequity of maternal health and MHS exists between urban and rural area, and different regions; the gaps in utilization of MHS and maternal health between migrants and local residents in urban area has also became a big challenge of MHS system.The two main factors of inequity of healthcare in china are economic factors and healthcare system. Development of society caused a wide gap on healthcare service utilization between rich and poor, the healthcare market cannot ensure the equity of utilization while the government did not play the key role in correcting the market failure. The origin of regulation is to achieve equity and other social goals. As recommended by WHO, regulation is an important tool in improving equity and government should take the responsibility in healthcare regulation. To find the way of improving MH equity, it is necessary to study on regulation. Chinese government had initiated a serious measure to improve the inequity of MHS utilization, the great improvement of hospital utilization on institutional delivery is a good example, which reflected the key role of regulation in improving equity. Currently, studies on MH equity are limited, and there is no study focused on regulation and its impact on MH equity. This study intended to narrow these gaps to some extent, and serve for facilitating the development of regulation, as well as promoting the equity of maternal health care.II Study goalTo analyze how an effective regulation play its role in improving health equity through a case study on Emergency Obstetric Care (EmOC) in a central district in Shanghai, and to explore how the key aspects of regulation affect its effect. Based on the EmOC regulation, to further analyses the equity of MHS utilization between local and migrant pregnant women in this district and find the gaps on regulations related to basic maternal healthcare, and to provide evidence-based recommendations for the further development of regulations and maternal healthcare equity.Ⅲ Study contents and methodologies1. Using the secondary data in China Health Statistical Yearbook to evaluate the equity of maternal health from2000to2009and the equity of MHS utilization and MHS resource allocation from2005-2009, and analysis the reasons on the improvement of institutional delivery equity.2. The effect of EmOC regulation on health equity between local and migrant pregnant women was analyzed by qualitative research methods.22respondents divided by4types were selected and semi-structured in-depth interview were conducted. Combined with the literature analysis method, the context, process, actors and mechanisms of regulation were evaluated based on the regulation conceptual framework.3. Using secondary data in the maternal health annual statistic report of this district to analyze the equity of MHS utilization between migrants and local residents. To analyze the factors that affect the utilization, a cross-sectional study was conducted. Totally436women from all13community health centers were investigated. Combined with the semi structured in-depth interview, the current gaps of regulation related to the basic MHS were analyzed and recommendations were proposed based on the principle of good governance and regulation. IV Main findings1.The national MMR kept on decreasing from2000to2009, and the most obvious trend of decline is MMR in the western region. From2003to2009, MMR in eastern and central region decreased by44%and53%, and MMR in western region decreased by62%. Ration Different (RD), Ratio Rate (RR) and Concentration Index (Cl) were calculated to evaluate the equity of maternal health. From2000to2009, the RD between eastern and central regions was10-20/100000, in contrast, the RD between eastern and western regions decreased obviously from65.43/100000to27.80/100000. The equity of maternal health was not improved from2000to2009if evaluated by Cl:all the values of Cl is negative, the Cl was-0.2～-0.3and compared with the Cl in2000, the absolute value of Cl in2009changed a little.2. The value of Cl for the utilization of prenatal check up, institutional delivery, postpartum interview and systematic management were positive, which means inequity existed in different regions. In the four types of services, the absolute value of Cl for systematic management was the highest, which means utilization of this service was the most inequitable. The absolute value of Cl for prenatal check-up was the lowest. From2005to2009, except for institutional delivery, the Cl of the other three kinds of service changed a little. However, the Cl of institutional delivery utilization decreased rapidly from0.0593to0.0177, which means a great improvement of equity in the utilization of institutional delivery, this is also a reflection of the effectiveness of regulations targeted on improving utilization of this service in western region.3. The inequity of maternal health was reflected on migrants and local pregnant women. In the recent decade, most of the maternal deaths in Shanghai were migrant women, therefore, reconstruct the EmOC network in Shanghai and improve the consultation and rescue of critically ill pregnant women (CIPW) is one of the solutions to reduce MMR especially MMR of migrants. Since2007, a serious of regulations were issued by Shanghai bureau of health (BOH), and the regulation issued in April2008was the key one, which played an important role in improving the equitable access to EmOC service in Shanghai. The qualitative study showed that this regulation greatly improved the quality of EmOC, with the great increase of successful rescue rate of CIPW, the MMR of migrants decreased obviously and inequity of maternal health between migrants and local women improved.4. The enabling factors of the regulation effect are as follows:the international and national context for safe motherhood; the evidence-based process of regulation design and the interpretation of regulation at district and hospital levels. The application of different regulation mechanisms especially Accountability mechanism, which play the key role in supervising related actors; the actors involved in regulation process were mainly heath administrators and providers, which means the regulation can be well administrated and implemented at each level.Themain barriers of regulation effect and its sustainability are the financial sectors, which are the key actors of regulation, were not involved in the whole process of regulation, and the incentive mechanism did not play a better role in regulation.5.The study on EmOC regulation also showed that it is not enough to reduce the MMR of migrants only relaying on regulating EmOC service, another key point of regulation should be the basic MHS especially prenatal care. Currently, the main regulation focus on basic MHS is the regulation issued in2010by shanghais BOH, which is another output of EmOC regulation. this regulation is specifically focused on improving the utilization of establishing maternal card and systematic management.6. The utilization of establishing maternal card, and systematic management were inequity obviously and gradually expanded from2004to2009in this central district. However, this trend reversed since2010in which year the2010regulation was implemented in this district, the Cl of establishing maternal card kept on increasing from0.1308in2004to0.1746in2009, then decreased to0.1034in2010, in2011, the value is0.0594. The Cl of systematic management kept on increasing from2004to2009, then decreased since2010, the value is0.1434in2004and0.1804in2009, in2011, the value is only0.0652. The improvement of inequity of these two services reflected the effect of2010regulation.7.436cases included238local women and168migrants were involved in the cross sectional study conducted in this central district. The education level, occupation, average income per person in family and the coverage of health insurance as well as reproductive insurance were significantly different between these two groups of women (P<0.05). The utilization of establishing maternal card, prenatal check-up (more than8times), and the postpartum interview were lower in migrants then in local women with a significant differences. For the establishing maternal care, the RD is29.4%, RR is1.44and Cl is0.0816. for the prenatal check-up(more than8times), the RD is26.3%, RR is1.34and Cl is0.0798. The utilization of other MHS such as prenatal screening, school for pregnant women. The main factors that affect the utilization of MHS are the place where the woman is registered, the education and the reproductive insurance, the local pregnant women and women with reproductive insurance are more likely to establish maternal card and do prenatal check-up no less than8times.8. The qualitative analysis on the2010regulation showed that the regulation played an important role in improving the utilization of establishing maternal card and systematic management. However, the sustainability of this regulation was affected by some factors, especially the key actors and their role.V Recommendation for further improving equity of maternal health1. To further improve the equity of MHS, the prenatal care should be the next focus point, and a possible way is improve the utilization of service by project then normalizing the service by regulations.2. Context is important to the regulation effect. The new healthcare reform focused on the equalization of public health services is an enabling factor for improving equity of maternal health and MHS, actors of the2010regulation should take the opportunity3. More actors should be involved in the2010regulation to ensure the sustainability of regulation.(1) Financial sectors should be involved in the process of regulation especially the stage of regulation formulation.(2) Civil society should play a greater role in the management of migrant pregnant women to ensure the sustainability of regulation.4. Requirements on other MHS such as school of pregnant women should be involved into the content of2010regulation to further improve the equity of service utilization.5. The process of regulation formulation should be procedural and normalize. To make sure the good effect of regulation, interpretation is necessary and need at each district.6. Mechanisms such as incentive, sanction and performance assessment should be used synthetically, especially the economic incentive mechanism, which can ensure the active participation of implementers. |
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