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    • National coverage trends were accelerated because of

    2019-05-13

    National coverage trends were accelerated because of the contribution of trends in the two poorest quintiles. In middle-income countries, for example, the estimated increase in national trends was around 25% faster as a result of the contribution of poor populations. Increases in coverage in rural areas were consistently faster than those in urban areas, because rural areas tend to have more poor people. Progress in rural areas had an important role in acceleration of national-level progress. These patterns were noted in most countries (appendix pp 18–20), although variability among countries was substantial. Our analyses have several limitations. Data for trends in coverage were not available for all countries. Our analyses covered 26 of 31 low-income countries, 27 of 52 lower-middle-income countries, and 11 of 56 upper-middle-income countries, and global results should be interpreted with this order BAY 87-2243 limitation in mind. But our analyses of 64 countries is the largest set published so far. Our analyses covered most countries in sub-Saharan Africa and south Asia, but less than 20% of all countries in the East Asia and Pacific region and in the North Africa and Middle East region (as defined by UNICEF). Another limitation is that the CCI includes only eight interventions of the dozens that are promoted globally. However, the interventions included were those for which trend information is available for the past 20 years. Newly introduced interventions, such as postnatal care, could not be included. Reassuringly, the CCI correlates very highly in cross-sectional analyses with more complex summary coverage indicators that include many more interventions. The high correlations for nearly all eight interventions in our study shows that CCI is not being driven by only a few components. Although two different types of survey were used (DHS and MICS), datasets were revised to ensure that indicators were uniformly compliant with international definitions. The CCI is restricted to coverage indicators that were standardised in the 1990s and for which definitions remained stable with time. The only change was for care seeking for pneumonia: in 2005, the denominator was changed to exclude children with difficulty breathing due to a blocked nose. For surveys in which both the old and new definitions could be calculated, care seeking is about 5 percent points higher with the new definition. This change, however, does not affect comparisons per wealth quintile or residence, because all groups were equally affected. Finally, asset indices have limitations but remain the method of choice for assessment of socioeconomic position from survey data in low-income and middle-income countries. The calculation of the indices takes into account the differences between assets in urban and rural areas. During the era of the Millennium Development Goals, coverage with key reproductive, maternal, newborn, and child health interventions has increased slowly but steadily at global level. A detailed discussion of which factors drive coverage increases among poor populations is beyond the scope of our analyses. Country-level case studies suggest that improvements in equity result from a combination of changes in social determinants of health, pro-poor approaches in programmes in the health and other sectors, and specific targeting of health services to the geographical areas most in need. At a global level, studies of inequalities in health are much more common than ever before, and availability of information about asset indices through national surveys has resulted in many analyses and publications, which have prompted action at many different fronts, as exemplified by the UNICEF equity-focus approach, the Every Woman Every Child Global Strategy, and the efforts led by the US Agency for International Development to incorporate equity considerations into programming. Our results are directly relevant to the achievement of several of the Sustainable Development Goals. Goal 17.18 demands analyses of progress that are disaggregated according to wealth and place of residence. Goal 3.8 promotes universal health coverage, for which our composite coverage index is a proxy. High and equitable coverage with the indicators described in epistasis Article will contribute to progress towards goals 3.1 on maternal mortality, 3.2 on newborn and child survival, and 3.7 on sexual and reproductive health. Because of reduced infectious disease morbidity, higher intervention coverage will also contribute to the achievement of goal 2.2 on child undernutrition.