Elsevier

The Lancet

Volume 371, Issue 9620, 12–18 April 2008, Pages 1259-1267
The Lancet

Articles
Mind the gap: equity and trends in coverage of maternal, newborn, and child health services in 54 Countdown countries

https://doi.org/10.1016/S0140-6736(08)60560-7Get rights and content

Summary

Background

Increasing the coverage of key maternal, newborn, and child health interventions is essential if Millennium Development Goals (MDG) 4 and 5 are to be reached. We have assessed equity and trends in coverage rates of a key set of interventions through a summary index, to provide overall insight into past performance and progress perspectives.

Methods

Data from household surveys from 54 countries in the Countdown to 2015 for Maternal, Newborn and Child Survival initiative during 1990–2006 were used to compute an aggregate coverage index based on four intervention areas: family planning, maternal and newborn care, immunisation, and treatment of sick children. The four areas were given equal weight in the computation of the index. Standard measures were applied to assess current levels and trends in the coverage gap measure by wealth quintile.

Findings

The overall size of the coverage gap ranged from less than 20% in Tajikistan and Peru to over 70% in Ethiopia and Chad, with a mean of 43% for the most recent surveys in the 54 countries. Large intracountry differences were noted, with a country mean coverage gap of 54% for the poorest quintiles of the population and 29% for the wealthiest. Differences between the poorest and the wealthiest were largest for the maternal and newborn health intervention area and smallest for immunisation. In 40 countries with more than one survey, the coverage gap had decreased by an average of 0.9 percentage points per year since the early 1990s. Declines greater than 2 percentage points per year were seen in only three countries after 1995: Cambodia, Mozambique, and Nepal. Country inequity patterns were remarkably persistant over time, with only gradual changes from top inequity (disproportionately smaller gap for the wealthiest) in countries with coverage gaps exceeding 40%, to linear patterns and bottom inequity (disproportionately greater gap for the poorest) in surveys with gaps below 40%.

Interpretation

Despite most Countdown countries having made gradual progress since 1990, coverage gaps for key interventions remain wide and, in most such countries, the pace of decline needs to be more than doubled to reach levels of coverage of these and other interventions needed in the context of MDG 4 and 5. In general, in-country patterns of inequality are consistant and change only gradually if at all, which has implications for the targeting of interventions.

Funding

None.

Introduction

Coverage, defined as the percentage of people receiving a specific intervention in those who need it,1 is an important output of health services and should be an essential part of any strategy to monitor progress in programme implementation. Coverage includes two interactive components—service provision and service use—indicating the need for effective public health actions to address both supply and demand. The ability to reach and maintain high rates of coverage for priority interventions among the general and disadvantaged populations in a country is an indication of the strength of the health system.2

The Countdown to 2015 for Maternal, Newborn and Child Survival3 initiative consists of individuals and institutions who share the aim of stimulating country action by tracking coverage for interventions that are essential for the attainment of major health Millennium Development Goals (MDG). The Countdown strategy is to establish a process through which national and international policy makers, programme implementers, development and media partners, and researchers can work together to compile and disseminate the most recent information about individual countries' progress in achieving high, sustained, and equitable coverage—with health interventions effective in reducing mortality in women, newborn babies, and children under 5 years of age. Country-specific data are presented for the 68 countries that represent an estimated 97% of yearly maternal and child deaths worldwide.4 Coverage levels are presented in the Countdown report in a two-page country profile that combines estimates and trends for coverage with other information needed to interpret them.3 This profile includes country-specific data for nutrition and mortality, the uptake of relevant policies, the status of selected measures of health system strength, and equity.

Previous work has shown the usefulness of an index that summarises coverage across a range of interventions.5 Victora and colleagues5 used data from Demographic and Health Surveys (DHS) to construct a so-called co-coverage score including eight public health interventions with proven benefit in reducing child mortality: vaccinations for BCG, diphtheria, pertussis, and tetanus (DPT), and measles; tetanus toxoid vaccination for the mother; vitamin A supplementation; antenatal care; skilled birth attendance; and safe water supply. The resulting score was used as an outcome measure to describe within-country inequalities in coverage by socioeconomic status, and served as the indicator of equity in the 2005 cycle of Countdown.2 The co-coverage score was calculated for each child within the survey sample, and was therefore limited to the subset of interventions that all children and their mothers should receive—ie, the measure was limited to preventive interventions. A similar measure was recently used to describe inequities in coverage of four neonatal survival interventions in eight countries.6

A wider range of interventions was used to develop a composite measure of health system coverage to compare health system performance between states in Mexico.7 This measure was based on 14 interventions for child and adult health for which state-level estimates of coverage were available. This method allowed the inclusion of curative as well as preventive interventions.

Here we extend these earlier efforts by developing and applying an aggregate coverage gap measure based on a broad set of interventions in maternal, newborn, and child health programme areas. The immediate objective was to develop a summary measure of coverage that could be used to assess and report on equity in the 2008 Countdown cycle, with special attention to time trends.

Section snippets

Data

Estimates for intervention coverage were obtained from large-scale nationally-representative surveys implemented under the Demographic and Health Surveys (DHS) programme8 or UNICEF's Multiple Indicator Cluster Surveys (MICS) programme9 between 1990 and 2006. Coverage data were obtained in these surveys through standardised interviews with women aged 15–49 years. We included all low-income and lower middle-income countries identified as priority countries in the 2008 Countdown cycle.4 Data from

Results

Table 2 shows the mean coverage gap by wealth quintile for the summary measure and each of the four intervention areas with respective indicators for 54 countries, on the basis of the most recent survey data (median year of survey 2004). The mean overall gap was 43%, ranging from around 54% for the poorest to almost 29% for the wealthiest quintiles. The mean size of the gap was largest for the treatment interventions, followed by family planning and maternal and newborn care, and was smallest

Discussion

We have shown that the coverage gap index can serve as a reliable and meaningful summary measure to describe and monitor trends and equity in coverage of key interventions for maternal, newborn, and child health. The basic approach identifies a set of intervention areas, each containing one or more coverage indicators that have distinct delivery strategies within the health system.

One application of the coverage gap index is to document long-term trends. The summary measure of the four

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