Elsevier

The Lancet

Volume 380, Issue 9848, 29 September–5 October 2012, Pages 1149-1156
The Lancet

Articles
How changes in coverage affect equity in maternal and child health interventions in 35 Countdown to 2015 countries: an analysis of national surveys

https://doi.org/10.1016/S0140-6736(12)61427-5Get rights and content

Summary

Background

Achievement of global health goals will require assessment of progress not only nationally but also for population subgroups. We aimed to assess how the magnitude of socioeconomic inequalities in health changes in relation to different rates of national progress in coverage of interventions for the health of mothers and children.

Methods

We assessed coverage in low-income and middle-income countries for which two Demographic Health Surveys or Multiple Indicator Cluster Surveys were available. We calculated changes in overall coverage of skilled birth attendants, measles vaccination, and a composite coverage index, and examined coverage of a newly introduced intervention, use of insecticide-treated bednets by children. We stratified coverage data according to asset-based wealth quintiles, and calculated relative and absolute indices of inequality. We adjusted correlation analyses for time between surveys and baseline coverage levels.

Findings

We included 35 countries with surveys done an average of 9·1 years apart. Pro-rich inequalities were very prevalent. We noted increased coverage of skilled birth attendants, measles vaccination, and the composite index in most countries from the first to the second survey, while inequalities were reduced. Rapid changes in overall coverage were associated with improved equity. These findings were not due to a capping effect associated with limited scope for improvement in rich households. For use of insecticide-treated bednets, coverage was high for the richest households, but countries making rapid progress did almost as well in reaching the poorest groups. National increases in coverage were primarily driven by how rapidly coverage increased in the poorest quintiles.

Interpretation

Equity should be accounted for when planning the scaling up of interventions and assessing national progress.

Funding

Bill & Melinda Gates Foundation; World Bank; Governments of Australia, Brazil, Canada, Norway, Sweden, and UK.

Introduction

In order to achieve the Millennium Development Goals by 2015, low-income and middle-income countries have been scaling up coverage of interventions that are effective against maternal and child deaths. Success has been variable. Although some countries have shown rapid improvements, other countries present modest if any advances.1 At the same time that countries are striving for progress nationally, subnational socioeconomic inequalities are gaining visibility. The present focus on overall progress in coverage and health status might contribute to increasing inequalities2, 3 and reviews of the Millennium Development Goal framework and monitoring consistently criticise the lack of attention to inequalities.4 Newly introduced interventions will also potentially reach mothers and children in high-income groups before they are adopted by the rest of the population because rich families tend to be better informed about the advantages of new technologies and have greater access in geographical and economic terms than do poor families. This factor might contribute to increasing inequalities in child health, at least in the short term.5

Despite such concerns, we are unaware of any systematic attempt to document what happens to socioeconomic inequalities as coverage of maternal and child health interventions changes. However, the increased availability of repeated national surveys in low-income and middle-income countries has made such analyses possible.

The Countdown to 2015 collaboration monitors 75 countries that account for more than 95% of all global deaths of mothers and children. We investigated the relation between coverage change and socioeconomic inequalities in Countdown countries that had undertaken at least two national surveys since 1990.

Section snippets

Data sources and procedures

We listed all Demographic Health Surveys and Multiple Indicator Cluster Surveys undertaken in Countdown countries since 1990 that included data for household assets. We identified countries that had done two or more surveys at least 5 years apart. We compared two surveys from each country. If a country had done three or more surveys, we prioritised surveys of the same type or the earliest and most recent surveys if surveys were all of the same type. We based all analyses on publicly available

Results

We identified 35 countries that had undertaken two or more surveys 5–13 years apart. 23 (66%) of these countries were in sub-Saharan Africa, eight (23%) were in Asia, three (9%) were in Latin America and the Caribbean, and one (3%) was in North Africa. The full list of countries, surveys, and main variables used is shown in the appendix (pp 1–2). Data for family planning needs satisfied (FPS) were not available for five countries in the first survey and one in the second survey, and therefore

Discussion

Inequalities in the health of mothers and children in low-income and middle-income countries were infrequent from the global medical literature before 2000 (panel).2, 12, 13 The assumption was that all mothers and children in low-income and middle-income countries were equally poor, and that there was no need to account for subnational inequalities when strategies were designed for scaling up of health interventions. Practical difficulties in the stratification of health status by socioeconomic

References (22)

  • JT Boerma et al.

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

    Lancet

    (2008)
  • Cited by (190)

    View all citing articles on Scopus
    View full text