The development of effective health interventions in low-income countries is often hindered by the complex interplay between poverty and place of residence. A study conducted in 2010 aimed to disentangle the effects of poverty and place of residence for strategic planning in health policy. The study used secondary analyses of Demographic and Health Survey (DHS) data sets from 16 countries to examine inequalities in key population and reproductive health indicators.
The study found that poverty is highly correlated with place of residence, with urban households tending to concentrate among the highest-wealth groups and rural households among the poor. This correlation makes it challenging to determine whether findings reflect inequalities by wealth or geography. To address this issue, the study developed separate urban and rural wealth indices to examine inequalities in key indicators, including family planning, antenatal care, and location of last birth.
The analyses demonstrated that disaggregating relative wealth by place of residence may reveal patterns obscured by national trends. The study found that wealth and residence differentials are probably inevitable at some point in program evolution, and that differentials in the early stages of program scale-up may be a “good” sign, indicating that groups likely to be innovators or early adopters are engaging in the desired behavior change or achieving the desired health outcomes.
However, persistent wealth and/or residential differentials, especially as privileged groups achieve moderate to high levels of the desired behavior change or health outcomes, should be a matter of program concern. Policymakers and program planners may find it useful to establish a priori minimum thresholds below which a “general population” approach is preferable to targeting. If no residence quintile achieves the minimum threshold for modern contraceptive use, the national family planning program should promote small-family norms, stress the health benefits of birth spacing, and increase access to family planning to all segments of the population regardless of any wealth gradient from the poorest to wealthiest quintile.
The study also highlighted the importance of comparing the urban poorest and rural wealthiest populations. If the poorest of the urban population show comparable or better outcomes than the wealthiest of the rural population, geographic targeting to rural areas should be a program priority, whether or not pro-poor strategies are also considered. Improved access to services in rural areas might also help reduce migration into urban slums. Additionally, the study suggested comparing family planning use with maternal health coverage, as health system strengthening stresses the integration of services. If family planning lags behind antenatal care, programs should look for barriers to family planning among MCH service providers and/or opportunities to promote post-partum family planning.