Socioeconomic inequalities in effective service coverage for reproductive, maternal, newborn, and child health: a comparative analysis of 39 low-income and middle-income countries

Abstract

Background: Reducing socioeconomic inequalities in access to good quality health care is key for countries to achieve Universal Health Coverage. This study aims to assess socioeconomic inequalities in effective coverage of reproductive, maternal, newborn and child health (RMNCH) in low-and middle-income countries (LMICs). Methods: Using the most recent national health surveys from 39 LMICs (between 2014 and 2018), we calculated coverage indicators using effective coverage care cascade that consists of service contact, crude coverage, quality-adjusted coverage, and user-adherence-adjusted coverage. We quantified wealth-related and education-related inequality using the relative index of inequality, slope index of inequality, and concentration index. Findings: The quality-adjusted coverage of RMNCH services in 39 countries was substantially lower than service contact, in particular for postnatal care (64 percentage points [pp], p-value<0¢0001), family planning (48¢7 pp, p<0¢0001), and antenatal care (43¢6 pp, p<0¢0001) outcomes. Upper-middle-income countries had higher effective coverage levels compared with low-and lower-middle-income countries in family planning, antenatal care, delivery care, and postnatal care. Socioeconomic inequalities tend to be wider when using effective coverage measurement compared with crude and service contact measurements. Our findings show that upper-middle-income countries had a lower magnitude of inequality compared with low-and lower-middle-income countries. Interpretation: Reliance on the average contact coverage tends to underestimate the levels of socioeconomic inequalities for RMNCH service use in LMICs. Hence, the effective coverage measurement using a care cascade approach should be applied. While RMNCH coverages vary considerably across countries, equitable improvement in quality of care is particularly needed for lower-middle-income and low-income countries.

High coverage but low quality of maternal and newborn health services in the coverage cascade: who is benefitted and left behind in accessing better quality health services in Nepal?

“…We applied the health service coverage cascade adapting from Marsh and colleagues to quantify the use of services at the different conditional stages [ 16 , 20 ] (Fig. 4 ).…”

“…Similarly, other stages of on coverage cascade include quality-adjusted coverage (who comes into contact with a service that is ready and that receives the service according to quality-of-care standards); user adherence-adjusted coverage (refers to who receives the service according to quality-of-care standards and that adheres to provider instructions); and outcome-adjusted coverage (refers to who receives the service according to quality-of-care standards, adheres to provider instructions, and has the expected health outcome) [16]. The quality-adjusted coverage of health services incorporates the population in need of health services, the proportion of health service contact, and the composite coverage of intervention/procedures of health services [2,16,[20][21][22]. In addition, it also includes the frequency and adequacy of services provided by skilled health workers and service uptake (of essential interventions) at health facilities [3,15,23], the delivery procedure, and uptake of technical interventions, including respectful care [24,25], providing a proxy measure of the quality of health services and health system performance [26,27].…”

Desigualdades en la cobertura y en la calidad de la atención prenatal en Perú, 2009-2019

“…Los países de ingresos medianos (PIM) tienen el desafío de mejorar la salud de las mujeres con escasos recursos económicos o carencias sociales, debido a limitaciones de acceso a los servicios de salud materna y atención de calidad insuficiente, con niveles elevados de mortalidad ( 1 , 2 ). De la misma manera, 99% de la mortalidad materna ocurre en los países en vías de desarrollo, donde se mantiene como problema de salud pública frente a muertes prevenibles por complicaciones durante la gestación ( 1 ).…”

“…En 2020, 88,4% de las embarazadas peruanas recibió al menos seis CPN, como lo establece el Ministerio de Salud (MINSA) ( 10 , 11 ). No obstante, aún existen disparidades en la calidad de la atención brindada a las embarazadas; esto constituye un obstáculo para continuar mejorando los resultados de salud y alcanzar así las metas de reducción de la mortalidad materna y neonatal del tercer objetivo de desarrollo sostenible (ODS 3.1 y ODS 3.2), para garantizar una vida sana y promover el bienestar de todos a todas las edades ( 1 , 2 ). El monitoreo de las desigualdades en salud debería ser una prioridad que asegure que ninguno quede detrás ( 12 , 13 ).…”

“…Con respecto al monitoreo, ya se ha señalado que para el análisis de las desigualdades en la prestación de los servicios de salud no es posible focalizarse en temas de acceso y dejar de lado su calidad ( 1 , 2 ). De hecho, son conocidas las menores probabilidades de determinados grupos poblacionales para acceder a los servicios de atención prenatal de calidad, lo que deja en evidencia las desigualdades a favor de los más acomodados económicamente ( 14 - 16 ).…”