Abstract
Current methods for measuring intervention coverage for reproductive, maternal, newborn, and child health and nutrition (RMNCH+N) do not adequately capture the quality of services delivered. Without information on the quality of care, it is difficult to assess whether services provided will result in expected health improvements. We propose a six-step coverage framework, starting from a target population to (1) service contact, (2) likelihood of services, (3) crude coverage, (4) quality-adjusted coverage, (5) user-adherence-adjusted coverage and (6) outcome-adjusted coverage. We support our framework with a comprehensive review of published literature on effective coverage for RMNCH+N interventions since 2000. We screened 8103 articles and selected 36 from which we summarised current methods for measuring effective coverage and computed the gaps between ‘crude’ coverage measures and quality-adjusted measures. Our review showed considerable variability in data sources, indicator definitions and analytical approaches for effective coverage measurement. Large gaps between crude coverage and quality-adjusted coverage levels were evident, ranging from an average of 10 to 38 percentage points across the RMNCH+N interventions assessed. We define effective coverage as the proportion of individuals experiencing health gains from a service among those who need the service, and distinguish this from other indicators along a coverage cascade that make quality adjustments. We propose a systematic approach for analysis along six steps in the cascade. Research to date shows substantial drops in effective delivery of care across these steps, but variation in methods limits comparability of the results. Advancement in coverage measurement will require standardisation of effective coverage terminology and improvements in data collection and methodological approaches.
Highlights
Monitoring intervention coverage, defined as the proportion of the population in need of a health intervention who receives it, is essential for tracking progress towards universal health coverage—an aim of Sustainable
►► Most reproductive, maternal, newborn, and child health and nutrition (RMNCH+N) intervention coverage indicators—the proportion of the population in need of an intervention that receives it—monitored for decades do not capture the quality of delivery of the interventions and provide only weak links with actual health benefits received by the population in need
We propose a framework for the measurement of effective coverage, apply it in our systematic review of the literature and provide examples of how the framework can be operationalised for reproductive, maternal, newborn, and child health and nutrition (RMNCH+N)
Summary
►► Most reproductive, maternal, newborn, and child health and nutrition (RMNCH+N) intervention coverage indicators—the proportion of the population in need of an intervention that receives it—monitored for decades do not capture the quality of delivery of the interventions and provide only weak links with actual health benefits received by the population in need. ►► Building on previous frameworks and our review of current practices, we propose an organising framework to harmonise terminologies and methodological approaches for the measurement of a coverage cascade, and a definition of effective coverage as ‘the proportion of individuals experiencing health gains from a service among those who need the service’. An increasing number of studies have quantified the alarming gaps between crude or contact coverage indicators and those that measure the receipt and benefits from high-quality services (effective coverage indicators).[1,2,3,4,5]. The only study that reported crude and quality-adjusted measures for postnatal care used recall-based information from household surveys to estimate quality-adjusted
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