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Abstract:
Utilisation of key reproductive, maternal and
child health services has improved in Mali.
However, the pace of improvement varies
across services, and there is also a large
disparity in service utilisation across
regions. Service utilisation at the
population level is determined by various
factors such as demand for a service and,
among those with demand for the service,
ability to access quality care. To understand
the determinants of service utilisation and
trends in utilisation, it is crucial to study
service utilisation in the context of access
to quality care by using data from both the
population and health facilities.
In 2018, Mali conducted a Demographic Health
Survey (DHS) and a Service Availability and
Readiness Assessment (SARA). This provided a
relatively rare opportunity to study both the
service environment and service utilization
in the country. The 2018 Mali SARA collected
data from a representative sample of
facilities in the country, which provided
information on the availability of
facilities, availability of services among
the sampled facilities, and service readiness
among the facilities that provide specific
services. The two elements of access to care
that can be studied with data from SARA
include geographic accessibility (by using a
crude proxy indicator) and service quality.
This study aims to increase our understanding
of the service environment and its
association with service utilisation at the
regional level for eight services, using data
from the 2018 SARA and the 2018 DHS. The
services include family planning, antenatal
care (ANC), delivery care, childhood
vaccination, child health services, malaria
diagnosis and treatment, intermittent
preventive treatment in pregnancy for malaria
(IPTp), and counselling and testing for human
immunodeficiency virus (HIV). For each of the
select services, the specific aims are to (1)
assess service readiness, by domain and
average across domains; (2) examine service
availability, both unadjusted and adjusted;
and (3) explore associations between service
utilization and various measures of service
availability. In addition, we provide a
region-specific summary of the service
environment and utilization that will
facilitate use of the study findings at the
regional and national levels.
For each of the eight services, we
constructed a service readiness score for the
four domains of service readiness (staff and
guidelines, equipment, diagnostics, and
medicine and commodities). In addition, for
each service, we created a summary service
readiness score that averaged the four domain
scores. Operational capacity among facilities
that offer specific services varies greatly
across services, although this generally
ranges between 60 and 90 of the maximum score
of 100. Across the eight service areas,
readiness is lower in the staffing and
guidelines and the diagnostics domains than
in the equipment and medicines and
commodities domains. Overall, childhood
vaccination readiness is relatively high and
consistent across the four domains. Among the
regions, Bamako has relatively low service
readiness across all service areas. In Kayes,
Sikasso, and Mopti, the readiness score is
higher than or close to the national average
across the eight service areas.
We also calculated service availability
(percent of facilities that offer specific
services), which is relatively high for all
services except HIV counselling and testing.
We then calculated the service availability
adjusted for service readiness (percent of
facilities that offer a specific service with
operational capacity to provide the service).
The average adjusted availability is lower
than the unadjusted availability by 22
percentage points across all regions and
services areas. To address the large
variation in facility density across regions,
we further adjusted the availability by using
the relative facility density score against
the World Health Organization (WHO) benchmark
(ranging from 0.45 in Mopti and Segou and 0.8
in Bamako). After the final adjustment, the
ranking of regions changed substantially
because regions with low availability and/or
readiness scores have relatively higher
facility density (such as Bamako) and vice
versa. For each region, we produced detailed
information on utilization, service
readiness, and service availability, along
with relative comparisons against the
national average and regional ranges.
Finally, we assessed the relationships
between service utilization and the three
service availability measures.
Although it is difficult to draw statistical
inferences based on a small number of
regions, we found no statistically
significant linear correlation between
utilisation and service availability in any
service area. When we examine associations
between utilization and service availability
adjusted for readiness and facility density,
statistically significant linear correlation
was observed in two areas: a negative
association with malaria IPTp (correlation
coefficient: -0.74, p-value: 0.03) and a
positive association with HIV counselling and
testing (correlation coefficient: 0.72, p-
value: 0.04).
It is important to note that any significant
correlation based on observational data does
not indicate causality. A negative
association can reflect targeted
interventions that can improve the service
environment in regions with low utilization.
The overall lack of associations with most
services suggests the importance of other
elements of access in service utilization,
which are not addressed in our study. These
include information, sociocultural
acceptability, and affordability. We
attempted to control for geographic
accessibility, another important element for
access, by adjusting service readiness with
the relative density score across regions.
However, since the geographic distribution of
facilities differs from the geographic
distribution of population in many regions,
the aggregate regional-level facility density
may not have been an effective measure for
adjusting geographic access.
In summary, we assessed the service
environment at the regional level with
various quality and availability measures for
eight select services in Mali. Although most
services are commonly offered at facilities,
readiness to provide specific services varies
greatly across regions and services. Further,
relatively low facility density indicates
lower accessibility at the population level.
When assessing the relationship between
utilization and various service availability
measures, we found significant associations
in only a few services. We speculate that
other elements of access to care contribute
to differences in service utilization at the
regional level. However, it is important to
note that lack of association between the
service environment and utilization at the
population level does not imply that service
quality is unimportant. Receiving high-
quality service is a patient right,
regardless of its impact at the population
level.
Availability, Readiness, and Utilization of Services in Mali (PDF, 6076K)