Horizontal inequity of infant healthcare service utilization in Ethiopia using performance monitoring for action data

Abstract

Despite Ethiopia’s progress in reducing infant morbidity and mortality, significant socioeconomic inequity in essential infant health service utilization hinders equitable Universal Health Coverage and Sustainable Development Goal targets. This study aimed to quantify horizontal inequity in infant healthcare service utilization in Ethiopia using performance monitoring for action data. This secondary analysis used data from Performance Monitoring for Action Ethiopia (October 2021 to November 2023). The source population comprised infants aged 12 months born to mothers aged 15–49 years. A total of 1801 births were followed from birth to twelve months using two-stage stratified cluster sampling. Utilization was defined across nutrition and supplementation, vaccination, and treatment domains. A comprehensive set of inequity metrics (absolute difference, relative ratio, Slope Index, Concentration Index) was used. Horizontal inequity was measured using indirect standardization, subtracting need-predicted from actual utilization. The equity analysis was performed at the end of the one-year follow-up period. Preventive coverage was highest for exclusive breastfeeding (71.2%) and BCG vaccination (77.4%), but lowest for minimum dietary diversity (21.5%). Significant pro-rich inequity was observed across most services. Complete immunization coverage was nearly five times higher among the richest compared to the poorest (62.2% vs. 12.7), followed by minimum dietary diversity (3.5-fold;7.2% vs. 10.6%). Curative coverage was suboptimal for febrile illness (29.4%) and acute respiratory infection symptoms (33.6%), with marked pro-rich inequities (Concentration index = 20% and 15%, SII = 32.5 and 25.4%, respectively). The largest absolute gap (50.97%) and highest SII (67.3%) occurred for the pentavalent vaccine. Non-socioeconomic factors (infant sex and illness) explained only 1.3%–3.90% of preventive services inequity. Horizontal inequity contributed over 95% to all services and exceeded 100% for curative care, indicating that need is concentrated among the poor, but care is concentrated among the rich. Infant healthcare utilization in Ethiopia was driven by horizontal inequity rather than health need differences, reflecting systemic unfairness. All routine immunizations, minimum dietary diversity, and treatment for febrile and respiratory illnesses favored socioeconomically advantaged households. Policies must prioritize pro-poor resource allocation for immunization, dietary diversity, and febrile or ARI treatment.