Access vs Utilization and Inequality vs Inequity

“Access” refers to an individual’s ability to receive healthcare [38], while “utilization” presumes that access exists and receipt of service or recommendations from a healthcare plan [38]. Access determines people’s potential to use the health service which is directly connected to their utilization power [39]. Then again, people do not utilize the healthcare due to access problem in healthcare [40]. As a result, “utilization” of health care is frequently used as an operational proxy for “access” to health care in developing countries and this review includes both terms for identifying papers [41].

Inequality refers to observable inequalities in health between subsets of a population, while inequity is a normative term that refers to the avoidable and/or unfair differences in health among demographic segments. This review includes both terms, as observed inequalities often reflect inequities in healthcare access [25].

Dimensions of “access to healthcare”

There is no universal definition of access [42]. Penchansky and Thomas (1981) demonstrated five dimensions of health care access: accessibility, affordability, accommodation, availability, and acceptability [43]. Accessibility refers to geographic accessibility, availability assesses whether the provider has the necessary resources, affordability refers to the cost of the service, accommodation involves meeting client preferences and acceptability reflects relationship between clients’ expectation and provider characteristics [43]. This review focuses on four dimensions—availability, geographic accessibility, affordability, and acceptability— as adapted by different literature, to examine inequalities in maternal healthcare access [40].

Eligibility criteria

Primarily socioeconomic factors and maternal healthcare indicators were selected for inclusion criteria. Socioeconomic factors were economy (economic position or income of the mother, father, or family), education (maternal and paternal), wealth (individual or household status) and occupation (maternal and paternal). Maternal healthcare indicators were ANC, PNC, SBA, ID and EmOC. Studies that explored access dimensions (geographic accessibility. affordability, availability, and acceptability) were also included. Studies conducted in South-Asian countries between 2000 and 2024 that were published in English, were considered for inclusion. This time frame was selected as most all the development goals were set from 2000 and condition of maternal healthcare after taking such initiative is important. Quantitative studies were mainly the cross-sectional analytical ones, were included to comprehend the magnitude of the problem; while qualitative and mixed method studies were added to understand users’ and service providers’ views on the potential reasons for inequality. Other types of studies including scoping, systematic or narrative reviews were avoided to keep the findings simple and straightforward. Studies on abortion, contraception, and cesarean sections were excluded due to their complex sociocultural contexts, which fall outside the focus of this review on socioeconomic factors in MHC access [44,45]. Similarly, studies on indigenous, tribal, and migratory populations were not included, as their healthcare inequalities are often influenced more by geographic and cultural factors than purely socioeconomic ones [46–48].

Search strategy

The database MEDLINE was searched for five different key terms, such as socioeconomic factors (economy, education, occupation, wealth), maternal healthcare (ANC, SBA, PNC, EmOC), inequality (inequity, inequality, disparity, barrier), access dimensions (accessibility, affordability, availability, acceptability) and country (South-Asian region). MeSH terms, synonyms for the main concepts were used as keywords and subject headings in the selected databases. The detailed search code for MEDLINE is included in the S1 File. Google scholar was searched manually with key terms such as, “socioeconomic inequality”, “maternal healthcare”, “access”, “utilization”, “South-Asian countries”. First 10 pages of googles scholar was taken into account since after that relevant results were not found.

Data extraction process

Database search from MEDLINE was extracted 15^th March 2024 and from google scholar on 30^th March 2024. All studies were initially exported in Rayyan software. After merging duplicates were removed. Initial elimination was done based on title only. After primary screening was done, abstracts were checked for inclusion criteria. Further in-depth screening was then done to identify articles meeting eligibility criteria by reviewing the methodology sections for each publication. Two reviewers searched independently and the eligible studies were cross checked by both. Following this screening process, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart (S3 File) was adapted to assort resulted articles into identified papers, screened publications, and included and excluded articles with specific reasons [49]. The principal outcome was any socioeconomic inequalities that are faced in access to maternal healthcare in this region. Data regarding socioeconomic inequalities such as “Education”, “Occupation”, “Wealth”, “Women autonomy” were sought regarding maternal healthcare. Any disagreement during the study selection and data extraction process were resolved through discussion.

Study assessment

There were three different study types (cross sectional, qualitative, mixed method) included in the review. There are numerous validated quality assessment tools to assess cross sectional and qualitative studies but none for mixed method study. Only Mixed Method Appraisal tool (MMAT) allowed to assess all three types of study. Thus, to keep the consistency in the study assessment criteria Mixed Method Appraisal tool (MMAT) was used. MMAT is a reliable assessment tool for mixed method studies in healthcare research, particularly for systematic reviews [50]. For each study design it has two basic screening question in general and five specific questions for appraisal. Papers were sorted into “Good” (100%), “Moderate” (80%) and “Poor” (≤60%) categories for better understanding. The assessment tool was only used for the appraisal of the studies. Thus, all the papers were included for result synthesis, regardless of their assessment score. Quality appraisals were conducted by two reviewers independently. A detailed result provided in the S2 File.

Data synthesis

The quantitative results were described by socioeconomic factors. Table 3 has information with details on the study, sample size, indicator of MHC, significant result and MMAT score. To synthesize qualitative results, thematic analysis was used to uncover the underlying reasons for lack of MHC access. There are different versions of thematic analysis, and it has a broader degree of theoretical flexibility, that makes it easy to analyze [51]. Small summary of each finding is also added to provide an overall view in the supplementary material.

Characteristics of the included studies

Of the 55 articles, 43 (78.18%) were cross sectional analytical, 10 (18.18%) were qualitative and 2 (3.64%) were mixed-method studies. Studies from five countries of South-Asia was found to be eligible to include in the review. Additionally, three cross-sectional papers that presented findings across multiple countries were included. Instead of counting papers for each country, the following table counts papers once for consistency. However, the results are displayed individually for each country in the result table. Among the 43 quantitative studies, 35 studies reported economy [37,52–85], 33 studies reported education [52,54,56,58–61,63–71,73–75,77–90], 14 studies reported occupation [52,54,60,61,64,66,70,71,73,74,77,82,87,91] and 11 studies reported about women autonomy [52,64,66,71,73,74,77,83,88,92,93]. Among the 10 qualitative papers, 10 studies reported economy [94–103], while 4 studies focused on education [95–97,100] and 4 studies examined women autonomy [94,95,100,103]. Both of the mixed method studies reported economy [104,105]. One study described three South-Asian countries (Nepal, Bangladesh and Pakistan) and is counted once in the Table 1 to keep consistency for study number [73]. Additionally, two studies [82,83] examined Bangladesh and Pakistan; these studies are counted as two instead of four in order to maintain consistency for study number in Table 1.

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Table 1. Number of total studies and study types included in the review by country.

https://doi.org/10.1371/journal.pone.0326130.t001

The Majority of the quantitative studies conducted secondary analysis using demographic and health survey data, resulting in large sample size. For understanding the impact of socioeconomic position, most of the studies measured and used wealth index/quintile and rich-poor ratio/gap. Very few compared with household income as demographic health surveys do not collect data on this to measure socio-economic position. Most qualitative studies were regional exploration of inequalities, especially in rural counterparts of the country.

Summary of the findings

Household wealth status and position in wealth quintile was strongly associated accessing MHC services in India, Nepal, Bangladesh, Pakistan, and Afghanistan. A significant rich-poor gap ratio was also evident in the service utilization. Education had a positive impact on accessing MHC, however, many studies demonstrated this impact was more significant after secondary or higher education. Health literacy played a crucial role in accessing different care components. Due to lack of awareness of the service and complications of pregnancy, women did not utilize MHC, resulting in some very unhealthy and dangerous medium of delivery practice. Only a few studies found women’s employment status significant for MHC utilization, whereas husband’s occupation was more influential factor. Women autonomy played a vital role in access part in these countries of South-Asia, especially decision-making autonomy on healthcare. In many cases, women were restricted by the decision of husband, elderly, or mother-in-law for utilizing MHC.

The findings of the qualitative studies were categorized into three key themes related to socioeconomic factors that acted as barriers to MHC access. They were organized under the theme of “Economy” if the study described financial constraint, poverty etc.; “Education” if the study highlighted on health literacy, lack of awareness of complication, lack of awareness of service etc.; “Women’s autonomy” if the study talked about lack of decision-making power on healthcare utilization for not accessing MHC.

Quantitative findings

Quantitative findings are explained briefly in Table 2 while detailed results are available in the S4 File.

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Table 2. Quantitative findings summary.

https://doi.org/10.1371/journal.pone.0326130.t002

Economy

Economic disparity was highly pronounced in India, both nationally and regionally. Economic position—measured through wealth quintile, wealth index, household income, or rich-poor ratio—was positively associated with receiving adequate ANC [54–57,80,85] and PNC [37]. However, some exceptions were also seen, i.e., inequality was less for iron and folic acid supplement [55,56]. Only a few studies have (n = 2) have assessed the economic inequality in state level. Gap of utilization for ANC 4 + was higher in central, eastern states [55]; for ANC and SD in Uttaranchal, Uttar Pradesh, Bihar, Jharkhand, and Madhya Pradesh [53].

Similar to India, inequality in utilizing ANC, SBA, PNC, and ID was explored and found significantly associated with socioeconomic position in Bangladesh [62,64–68,73,74,76,77,82–84], Pakistan [69,70,73,75,78,82,83], Nepal [58,59,61,73,81,86] and Afghanistan [71,79,106]. In contrast to that, household monthly expenditure was not an independent factor for utilization of ANC and PNC among rural pregnant woman where as women’s association with microfinance program was insignificant in uptake of delivery care in Bangladesh [64,90]. Unlike other countries, a mixed method study reported travel cost to EmONC facility was unaffordable for both public and private hospitals in Pakistan [104].

Education

Effect of maternal and paternal education was found significant in accessing MHC services especially ANC and ID in most of the South-Asian countries. Maternal education positively affected the utilization of ANC [52,54,56,80,85] in India; ANC [58,61,93], PNC [60], SBA and ID [58,59,73,81,86,87] in Nepal; ID [63,64,66,68,84], SBA [65,66,77], Place of delivery [73], ANC [66,67,77,84], PNC [83] in Bangladesh; and ANC and SBA [71,79,88] in Afghanistan. Likewise, in Bangladesh, higher levels of maternal education were linked to better utilization of MHC services [74,84]. Almost all four components of MHC (ANC, SBA, ID and PNC) were positively associated with higher maternal education level, awareness and knowledge of available MCH services in Pakistan [73,75]. Furthermore, inequity was largest in at least four ANC by skilled providers by the education of the women and their husbands in Pakistan, across various maternal healthcare services [82]. Notable association of MHC services utilization apparently after secondary education of mother was reported in the South-Asian countries [52,59,63,69,85]. Similar to the findings of maternal education, inequality persists based on the literacy rate and education level of husbands in access to the MHC services, i.e., ANC in India [54]; ID and PNC in Nepal [60,86]; ANC in Afghanistan [79,89] and ANC, SBA, ID and PNC in Bangladesh [64,66–68,73,77] etc. Besides, maternal education was significant for ANC utilization in all provinces of Pakistan except in Baluchistan and Khyber Pakhtunkhwa [70].

Occupation

Women’s employment status was found to be a significant factor in accessing MHC services, particularly in India, where it was notably significant in Uttar Pradesh [52,54]. In Nepal, women’s occupation, other than agriculture had higher odds of using SBA [87] and PNC [91] and husbands doing formal sector job/working abroad or professional/ manual occupation were more likely to attend PNC [60,91] and less likely to prefer home delivery [73]. In contrast to them, SBA and place of delivery had positive association with occupation in Bangladesh [73,74,77]. However, employment-related inequalities varied by country. In Bangladesh, employment inequality was most pronounced for ID, whereas in Pakistan, it was highest for accessing at least four ANC visits by a qualified provider [82]. Additionally, compared to women who are not employed, working mothers had greater likelihood of receiving appropriate ANC contact in Bangladesh [64,66]For Pakistan, husband’s occupation was significant factor in uptake of ANC; only in Sindh province [70]. On the other hand, women’s employment status was not associated with accessing ID in Pakistan [69,73]. However, ANC and SBA utilization was positively associated with women’s working status in Afghanistan [71].

Women’s autonomy

Beyond economic position, education and occupation, women’s autonomy in making decisions on household expenses and utilizing MHC also contributed to inequalities in access to MHC in the South-Asian countries. Regional variation in women’s autonomy and inequality to access in MHC services were observed in India and Nepal. In India, women’s financial autonomy was associated with “delivery by a trained person” (South), “postnatal checkup” (South), “institutional delivery” (North, east, south) [92]. However, Pallikadavath (2016) found significant association with the odds of ‘high autonomy’ of women in receiving ANC in Uttar Pradesh and Madhya Pradesh [52]. In Nepal, ANC and SBA access increased with high autonomy in large household purchases and decisions regarding money earned by their husbands [93]. Similar like Nepal, women autonomy was related with ANC and SBA uptake in Bangladesh. However, the type of autonomy was different. Significant association was reported for women’s autonomy on healthcare decision making with ANC [66,77] and SBA [77]. Furthermore, inequality exists regarding women’s autonomy in Bangladesh and Pakistan, favoring those who were able to make decisions about obtaining PNC checks for women either on their own or in jointly with their husbands [83]. On the other hand, no observable association between ID and women’s decision-making autonomy on spending money was reported [64]. However, Rahman and his colleagues hadn‘t found any significant association of decision making autonomy in three South-Asian countries [73]. Conversely, in Afghanistan, women’s decision-making autonomy on spending husband’s earnings was associated with ANC 4+ and SBA utilization [71].

Qualitative findings

As mentioned in the literature, several indirect factors stem from socioeconomic factors. For example, health literacy, lack of awareness of complication or service was not directly socioeconomic factors as such. However, they are the result of illiteracy or lack of education. Three themes emerged from the qualitative findings that is acting as a barrier for accessing MHC in these five countries. The summary of the findings is described in Table 3.

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Table 3. Qualitative findings summary.

https://doi.org/10.1371/journal.pone.0326130.t003

Economy

Across all five countries, financial constraints or poverty were consistently reported as barriers to accessing various components of MHC. Financial barrier was impeding the utilization of MHC in different regions of India [94,95]. That includes transportation cost for routine care because it required hiring private vehicle which was unaffordable [94]. Biased and rude behavior towards rural poor mother was also impeding the utilization of delivery service [95]. In Nepal [96,97] and Afghanistan [103,105] mothers did not access MHC services due to financial costs and constrains. Participants in Bangladesh reported unofficial or hidden costs resulting from corruption was a huge barrier in accessing MHC. This unofficial cost includes tipping the cleaning staff, taking the mother to the operation room or for admission to the clinic [98,99]. Qualitative findings from Pakistan showed financial limitations in utilizing MHC was due to under-the-table payments, limited access to emergency transportation, physical inaccessibility of hospitals, treatment, medicine, and consultation cost (private facility) [100–102,104]. Similar like India, hospital stuffs discriminated based on socioeconomic position of the patients in consultation, treatment and even in emergency conditions [104].

Education

Several issues stemming from a lack of education—such as poor health literacy, lack of awareness about available services, and unawareness of pregnancy complications—hindered access to MHC. The result was of similar pattern in four countries except Afghanistan did not have any qualitative findings in this regard. Verbal abuse and biased behavior against illiterate women also a reason for not utilizing MHC services in India [95]. Similarly, in Nepal and Pakistan, illiteracy or lack of awareness were perceived as significant barriers to accessing MHC [96,97,100,102].

Women’s autonomy

Overall, in South-Asian context women’s decision-making autonomy on health was very less as family structures were mostly patriarchal. Four countries of this region, India [94,95], Pakistan [100], and Afghanistan [103] reported that decisions regarding delivery, ANC and other MHC services were taken by elderly, mother-in-law, or husband, therefore, restricting women from utilizing the service.

Discussion

To the best of the authors’ knowledge, this is the first systematic review to examine socioeconomic inequalities in accessing maternal healthcare (MHC) in the South Asian region. Almost all quantitative findings could be generalized nationally as most of the studies used demographic health survey data and sample size was big. In contrast, while qualitative findings were drawn from studies conducted in specific rural areas, they provide in-depth insights into the lived experiences of women facing barriers to MHC. These qualitative studies, despite smaller sample sizes, offer rich contextual understanding that complements the broader patterns identified in the quantitative analyses.

No relatable studies were found in Maldives, and Sri Lanka. This can be explained by previously mentioned literature. These two countries along with Bhutan have highest coverage for ANC, SBA and ID compared to other five countries [107–109]. Another possible reason behind this is the out-of-pocket-expenditure is not very high in Maldives resulting in insignificant socioeconomic inequalities in MHC access [110]. Besides, both countries had a higher decline in MMR from 1990 to 2015 [111]. Individually, Maldives has achieved remarkable improvement in maternal health in recent years. The MMR decrease from 1990 to 2015 was 9.2 in Maldives whereas the annual decrease globally was only 2.3 [112].

Overall, socioeconomic factors contributing in access to MHC were economic position, education, occupation, and women autonomy. This finding was mostly consistent except occupation from another systematic review on inequalities in MHC utilization developing countries [17]. Majority of quantitative studies explored and reported inequality in ANC and SBA services. Previous studies demonstrated the similar result [110,113].

Most of the studies included in this review have found household wealth status/wealth index/wealth quintile was associated with MHC access. This finding is aligned with wide range of literature from low-income and developing countries [18,19,21,22,114–117]. The qualitative findings also support this result. They reported poverty as the barrier for not utilizing MHC. Another qualitative study conducted in rural areas of Zimbabwe also reported the same [118]. As a reason for not utilizing MHC, they mostly mentioned costs for transportation, medicine service and under the table payments. Few of them also reported that informal payments were taken from them forcefully, otherwise hospital staff refused to provide service. Previous studies indicated transportation, medicine cost as well as informal cost as a barrier for utilizing MHC in low- and middle-income setting [119,120]. Besides, for poor people, rather than accessing MHC it is feasible to buy food and cloths. This makes them to go for cheap services such as traditional birth attendants but not using ID or SBA [77]. Engagement to microfinance (MFI) program is another significant aspect to assess socioeconomic position of mother. According to a report of World Bank, 17% of the households in South-Asian region are facilitated by MFI program [121]. However, only one study from Bangladesh assessed this factor and found a negative association. Literature affirms the fact that coverage of MFI is low in this South-Asian region. In 2005, the total demand for microcredit was $15 billion, but only $2.3 billion was given to the poor [121]. However, the impact of MFI is somewhat inconclusive in South-Asia. Another important finding from qualitative studies was that mothers from low socioeconomic position were treated badly and prioritized less compared to rich people. Literature from low and low-middle countries are in line with this finding [122–124]. This can also be linked with the supply side inequality in access to MHC as stated before in the review.

Maternal education was an important socioeconomic factor contributing in inequality to MHC access. Findings from quantitative studies affirmed that and it is also aligned with literature [18,21,115–117,125]. On the other hand, most of the qualitative findings indicated lack of awareness about service and complication as the barrier for not using MHC. Besides, due to lack of health literacy MHC was not a felt need to them as they considered this as a natural event. Two systematic reviews on barriers in accessing MHC in low-income countries had similar findings [119,126]. Studies demonstrated formal education had the potential to impact the utilization of health-care facilities in a variety of ways [127]. Women with higher education have more access to written material, and they are more knowledgeable about healthcare services [128,129]. Also, an educated woman can better catch health messages delivered through newspapers, billboards, and other media, resulting in higher health education [130]. Then again, formal education challenges traditional beliefs about health and health-seeking and transforms women’s attitudes towards accessing MHC care [130,131]. One important finding from this review is that impact of maternal education on MHC utilization is significant only after secondary education. Even though this finding is similar with the findings from WHO report on state of inequality in developing countries, it does not explain the reason [25]. Possible reason can be that girls do not get reproductive health information in primary education in South-Asia. Also, teachers feel uncomfortable discussing this chapter as this is a taboo, especially in front of male students making it unavailable for young girls [132]. Then again, most of the curriculums include reproductive health knowledge from 9^th grade or from 11^th grade in some countries. To get all information on reproductive health formally, it takes at least 12 years of education in this region. On the other hand, a sizable portion of girls get married before age of 15, leaving them unaware about the necessary information and complications of pregnancy. The reproductive health education can improve knowledge and reduce reproductive health problems among adolescents in developing countries [127]. Previous studies also reported that educated male had better knowledge about the benefit and awareness of the service utilization [19,133,134]. Part of the reasons behind that is because of the patriarchal structure of the families in South-Asia, husbands decide where to spend money and if they are educated, they access MHC services if needed [135]. Moreover, educated husbands have a good communication with their spouses about availing maternal healthcare in developing countries [128,129].

This review found paternal occupation significantly associated with MHC service utilization, but maternal occupation was not that much. However, few literatures suggest, paternal and maternal occupation has association with MHC utilization [114–116]. Review finding was otherwise might be because most women in low socioeconomic position was housewife or engaged in agriculture. Even if they were working, in most cases they did not have the autonomy on that. Furthermore, the significance of occupation was mostly evident in case of formal jobs or any job other than agriculture. Having agriculture as occupation was either not significant or negatively significant. The underlying reason can be formal job exposes them to outside world and they learn more about maternal health and service information. Literature also suggests, women who work in fields other than agriculture may be able to earn more money in cash, allowing them to make more independent decisions and access maternal services [87]. Conversely, most rural women who primarily work in agriculture do not receive cash to spend on their health [87].

Women autonomy was the least assessed form of socioeconomic inequality overall. Quantitative analysis demonstrated women autonomy especially in household decision making was an important factor in accessing MHC in South-Asia. Previous findings from low-income and developing countries are in line with this finding [92,115,116,136] On the other hand, qualitative findings indicated women’s less autonomy on healthcare decision making was a significant barrier in accessing MHC. Most of the times decisions were taken by husband or mother-in-law restricting them to access health facility services. Literature also suggested as due to the dominant patriarchal mindset and as the sole earning member of the family, husband, and husband’s female family member especially, mother-in-law’s decision was a determining factor in women’s ability to seek for institutional care [137,138]. In Bangladesh, 35.6% of women mentioned in-laws’ objections and 17% mentioned husbands’ objections to obtaining medical help during medical emergencies [137]. This is often the case in South-Asian household. For example, husbands and elder female in-laws in Pakistan frequently defined women’s treatment needs, such as which services were required, which health concerns required medical attention, and whether household money should be spent on health care [137]. One significant factor to consider in this study is that, women autonomy is a complicated term and indicators to calculate this vary widely based on context and country. Even after coming from a wealthy background, women can have little control over their healthcare decision-making. Mostly because mothers-in-law have preconceived view that their daughters-in-law should deliver without medical attention, just as they themselves had done in the past [97]. Husbands have the similar mindset comparing their wives with their mother [97]. In more religious settings, such as Afghanistan, women needed husband’s permission even to go out from home and they were not allowed to be alone in public [71,79]. For this reason, as most of the times male members were busy outside, women could not go for health checkups. This systematic review suggests even though women autonomy was the least studied factor, it is one of the most concerning socioeconomic factors for South-Asia. This region deals with the double burden of barrier – patriarchy and religion which is shaping the pathway of women autonomy.

Sri Lanka’s approach towards maternal health can be a good example for fighting inequality to MHC access for other countries in this region as it shares similar socio-demographic characteristics. Despite having low GDP compared to other countries of South-Asia, they have the highest decline in maternal mortality. Approximately 89% of adult women were literate in Sri Lanka compared with 43% of South-Asian average. This naturally increases access to MHC. On the other hand, its public health infrastructure is very strong focusing on access especially for vulnerable groups; a viable referral system with accessible transport option; quality improvements etc. Moreover, the most distinguished approach they have taken is professionalization of midwifery. Sri Lanka have provided specialized training to midwives to gain clinical competence, are licensed or authorized by government agencies, and are provided with support in the form of supplies and monitoring. Besides, they are also linked to an active referral system, so they know where women may get higher-level care in the event of an obstetric emergency. Furthermore, as midwives can be trained and supported at a cheap cost, and because their pay are significantly lower than those of medical doctors, effective utilization of this group of health professionals is one of the keys to saving mothers’ lives on a limited budget [139]. Similar approach is observed in Maldives, another example of highest declining country in maternal mortality. Primarily, Maldives has prioritized investments and policies aimed at maternal and child health. Since 1991, the number of nurses and midwives in the population has increased by a factor of twelve which is four times more than the average in South-Asia [140].

Conclusion

Systematic review indicates there are significant socioeconomic inequalities in every component of MHC in most of the South-Asian countries. However, to understand the causal relationship and actual magnitude of the problem, further studies are needed such as, meta-analysis or large control group interventions. Socioeconomic inequalities in access to maternal healthcare is a multidimensional issue. Especially, in South-Asian region, this problem has complex and divergent nature due to multicultural structure. Therefore, it is crucial to apprehend the extent of the problem to implement country and context specific approach. This study will create a baseline for future research in understanding in-depth about the inequality to MHC access.

Supporting information