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Background: In Mozambique, despite significant socio-economic and health system challenges, there has been progress in reproductive and child health in recent years. However, there is still a lack of comprehensive studies that thoroughly unravel the socio-economic determinants of health and health inequalities in the country.

The overall aim of this thesis was to understand the socio-economic and geographic inequalities in reproductive and child health with the intention of informing and optimizing the implementation of targeted health programmes in Mozambique.

Methods: This thesis is based on three sub-studies that used data obtained from population-based health surveys. In sub-study I, prevalence ratios (PRs) with 95% confidence intervals (95% CI) were calculated by log binomial regression to assess the relationship of socio-economic, demographic, and geographic characteristics with three outcomes of interest: insecticide-treated bed nets (ITNs), child immunization coverage and modern contraceptive use. Sub-study II used the concentration index (Cindex) and decomposition analysis to assess the socio-economic and regional contributions to the wealth inequality in health preventive care. Sub-study III estimated absolute risk differences and the slope index of inequality (SII) as the measures of association between the socio-economic variables and the outcomes (ITN use, fever treatment and Fansidar prophylaxis) for the 2015 and 2018 surveys, as well as for the differences between the two time points.

Results: The proportion of mothers with at least one child aged under five years that did not use an ITN was 51.01%, while 46.25% of women had children aged one to four years who were not fully immunized and 74.28% of women did not use modern contraceptives. Non-educated mothers and residents of the southern region were more likely to report not using an ITN (PR = 1.36; 95% CI: 1.17–1.59), while those in the lowest wealth quintile had a higher chance of having children who were not fully immunized (PR = 1.34; 95% CI: 1.04–1.71). Similarly, non-educated mothers (PR = 1.17; 95% CI: 1.10–1.25), non-working women (PR = 1.09; 95% CI: 1.04–1.16) and those in the poorest wealth quintile (PR = 1.13; 95% CI: 1.04–1.24) were more likely to not use modern contraception (sub-study I). Sub-study II found a Cindex of -0.081 for non-ITN, -0.189 for a lack of vaccination coverage and -0.284 for non-contraceptive use, showing a worse health outcome among the poorest population. The study revealed that 88.41% of the wealth gap for ITNs was explained by socio-economic factors, with education and wealth playing the largest roles. With regard to the lack of full vaccination, socio-economic factors (47.74%), particularly the wealth quintile (35.79%), emerged as the predominant contributor to the inequality. Similarly, socio-economic factors (39.39%) were also the main explanatory factors for the lack of contraceptive use, but to a lesser degree than for the other two outcomes (sub-study II). Access to health preventive activities increased in all of the three studied outcomes between 2015 and 2018. Significant reductions in ITN inequality were observed for all socio-economic variables, but no decrease of inequalities in fever treatment and Fansidar prophylaxis was found over time (sub-study III).

Conclusion: This thesis revealed that bed net use and immunization coverage among children, and modern contraceptive use among women, were notably low. There was inequality, concentrated among the poor, in reproductive and child preventive measures. The greater part of this inequality could be attributed to low wealth and education, as well as to residence in rural areas. Reductions in socio-economic inequalities between 2015 and 2018 were observed for ITN use but not for fever treatment or malaria prophylaxis. Based on these findings, achieving universal health coverage in Mozambique will require an equitable resource distribution among rural regions, increased community education on health preventative measures and health service expansion to socio-economically disadvantaged households.