Dynamics of care and sector use between birth, contraception and sick child services

Governments in low- and middle-income countries increasingly recognize their role as stewards of mixed health systems comprising both public and private actors, but policy often lacks a nuanced understanding of how individuals switch between these two sectors for their healthcare needs, especially for family planning (FP) and maternal, newborn and child health (MNCH). In this cross-sectional study, we used data collected by The Demographic and Health Surveys Program between 2014-2021 from eight countries (Afghanistan, India, Indonesia, Kenya, Malawi, Nigeria, Pakistan, and Uganda) to describe service and sector use among women with a recent birth, a need for FP, and a child under five years old experiencing an illness (N = 53,014). We applied multivariable logistic regressions in each country to test the associations first between sector for birth and missed opportunities for contraceptives or sick child care, and next, between sector use dynamics between birth and contraceptive use (sector fidelity, sector switching, or nonuse of services) and nonuse of sick child care. Sector at facility for birth and sector switching between services was common, but neither were generally associated with missed opportunities for care for sick children. However, private sector use at birth predicted nonuse of contraceptives in four countries, though the directionality varied. Consistently, women who did not access care at birth and contraception had significantly greater odds of missing care for sick children. Notably, in Malawi, the adjusted odds ratio of missed sick child care among those with nonuse of care for birth or contraceptives was 2.5 times that of those with sector fidelity (95% Confidence Interval: 1.43-4.22). These findings underscore the need for health system stewards to closely consider both the public and private sectors in health governance. Greater cross-sectoral cooperation and continuity of care is paramount to improving health outcomes.