A rapid systematic review and evidence synthesis of effective coverage measures and cascades for childbirth, newborn and child health in low- and middle-income countries

Effective coverage for maternal health: operationalising effective coverage cascades for antenatal care and nutrition interventions for pregnant women in seven low- and middle-income countries

Background

Efforts to improve maternal health have focused on measuring health and nutrition service coverage. Despite improvements in service coverage, maternal mortality rates remain high. This suggests that coverage indicators alone do not fully capture the quality of care and may overestimate the health benefits of a service. Effective coverage (EC) cascades have been proposed as an approach to capture service quality within population-based coverage measures, but the proposed maternal health EC cascades have not been operationalised. This study aims to operationalise the effective coverage cascades for antenatal care (ANC) and maternal nutrition services using existing data from low- and middle-income countries (LMICs).

Methods

We used household surveys and health facility assessments from seven LMICs to estimate EC cascades for ANC and maternal nutrition services provided during ANC visits. We developed theoretical coverage cascades, defined health facility readiness and provision/experience of care scores and linked the facility-based scores to household survey data based on geographic domain and facility type. We then estimated the coverage cascade steps for each service by country.

Results

Service contact coverage for at least one ANC visit (ANC1) was high, ranging from 80% in Bangladesh to 99% in Sierra Leone. However, there was a substantial drop in coverage from service contact to readiness-adjusted coverage, and a further drop to quality-adjusted coverage for all countries. For ANC1, from service contact to quality-adjusted coverage, there was an average net decline of 52 percentage points. For ANC1 maternal nutrition services, there was an average net decline of 48 percentage points from service contact to quality-adjusted coverage. This pattern persisted across cascades. Further exploration revealed that gaps in service readiness including lack of provider training, and gaps in provision/experience of care such as limited nutrition counselling were core contributors to the drops in coverage observed.

Conclusions

The cascade approach provided useful summary measures that identified major barriers to EC. However, detailed measures underlying the steps of the cascade are likely needed to support evidence-based decision-making with more actionable information. This analysis highlights the importance of understanding bottlenecks in achieving health outcomes and the inter-connectedness of service access and service quality to improve health in LMICs.

Developing a framework for monitoring the stages towards achieving effective coverage and equity for maternal, newborn, child health and nutrition interventions

Reaching the Sustainable Development Goal 2030 global mortality and morbidity targets will require increased access to essential health services. Scaling high-impact health interventions within the public sector is complex; delineation of the pathway to scale for each intervention within each distinct geography is important for prioritising actions to advance interventions towards effective coverage. Following a review of 38 theoretical frameworks describing pathways for scaling health system interventions, we developed, tested and refined a new schema-the Stages of Achieving Effective Coverage and Equity Framework-for use to describe the status of policy adoption, implementation and coverage of key maternal, newborn, child health and nutrition (MNCHN) interventions. We propose a framework with six domains (global, national, systems, implementation, availability and coverage) covering 26 critical milestones with identified corresponding, intervention-specific indicators. Our framework was validated by the alignment of over 83 000 data points sourced from document review, interviews and global or country surveys. Visualisations are presented to highlight how the framework is operationalised to assess scale-up progress. We outline our process of conceptualising and developing a new framework and articulate its use case for action-oriented monitoring of progress towards effective coverage through applied examples in key geographies. Our framework offers an easy-to-follow implementation pathway and a set of common policy and implementation indicators to monitor scale-up towards effective coverage that uses existing secondary data sources where available. Achieving prioritised maternal, newborn and child health targets requires scalable implementation strategies for lifesaving interventions, alongside monitoring progress towards achieving scale.

Utilization of insecticide-treated bed nets and associated factors among households in Pawie District, Benshangul Gumuz, Northwest Ethiopia

INTRODUCTION

Insecticide-treated bed nets are often used as a physical barrier to prevent infection of malaria. In Sub-Saharan Africa, one of the most important ways of reducing the malaria burden is the utilization of insecticide-treated bed nets. However, there is no sufficient information on the utilization of insecticide-treated bed nets and their associated factors in Ethiopia.

OBJECTIVES

This study aimed to assess the utilization of insecticide-treated bed nets and associated factors among households in Pawie District, Benshangul Gumuz, North West Ethiopia.

METHODS

A community-based cross-sectional study was conducted in the Pawie district to identify factors influencing the use of insecticide-treated nets (ITNs). Diverse household groups were engaged, and data were collected using a structured questionnaire and observational checklists by trained interviewers. The data were entered into Epi-Data version 3.1 and analyzed using SPSS version 23. Advanced statistical methods, including binary and multi-variable logistic regression, were employed to examine the factors associated with ITN utilization.

RESULTS

From the total of 633 respondents, more than two third, 438 (69.2% with 95% CI: 65.2%, 72.5%) had utilized insecticide-treated bed nets during the early morning of the interview. Approximately 297 respondents (67.8%) successfully hung their insecticide-treated nets (ITNs) properly during the early morning of observation. In this study, 406 respondents (64.1%, 95% CI: 60.5, 68.1) showed a solid understanding of insecticide-treated nets (ITNs) utilization. Key predictors for the utilization of insecticide-treated bed nets (ITNs) included age (AOR = 1.86, 95% CI: 1.11, 3.13, p = 0.019), educational status (AOR = 0.45, 95% CI: 0.26, 0.77, p = 0.008), knowledge level (AOR = 2.64, 95% CI: 1.89, 3.81, p < 0.001), and family size (AOR = 1.89, 95% CI: 1.31, 2.74, p = 0.001). All of these variables were found to be statistically significant for the utilization of insecticide-treated bed net.

CONCLUSIONS

Utilization of the insecticide-treated bed nets (ITNs) remains low in the study area. To address this, it is crucial to raise public awareness and improve utilization of the insecticide-treated bed nets (ITNs) to decrease malaria transmission in the district. Ongoing health education initiatives, including demonstrations on the proper way to hang bed nets, will be essential in fostering better practices and improving community health outcomes.

Recommendations for Using Health Service Coverage Cascades to Measure Effective Coverage for Maternal, Newborn, Child, and Adolescent Health Services or Interventions

Using health service coverage cascades to measure effective coverage for maternal, newborn, child, and adolescent health services on a global scale is premature and requires further research and validation to reach consensus.

Quality adjusted coverage of family planning services in low- and middle-income countries: Analysis of 33 countries using Demographic and Health Survey data

Background

Monitoring service quality for family planning programmes in low- and middle-income countries (LMICs) has been challenging due to data availability. Self-reported service quality from Demographic and Health Surveys (DHS) can provide additional information on quality beyond simple service contact.

Methods

The DHS collects need, use and counselling for contraceptives. We used this data from 33 LMICs to develop quality-adjusted demand for modern family planning satisfied indicator (DFPSq). We compared it with the crude indicator (demand for family planning satisfied (DFPS)) and performed an equity analysis. Median, interquartile ranges (IQR) and the absolute and relative gap by country were used to describe the findings.

Results

The median DFPS was 49% (IQR = 41-57%) and the median DPFSq was 19% (IQR = 14-27%). We found similar relative differences in the gap stratified by SES indicating quality was universally low. One exception is that adolescents had a higher relative gap (70%, IQR = 57-79%) compared to adults (54%, IQR = 46-68%), indicating lower quality access.

Conclusions

Severe and pervasive quality gaps exist in family planning services across most LMICs. Our novel DFPSq indicator is one additional tool for monitoring access and quality of service that is critical to meet the family planning needs of women.

Association between antenatal care facility readiness and provision of care at the client level and facility level in five low- and middle-income countries

BACKGROUND

Despite growing interest in monitoring improvements in quality of care, data on service quality in low-income and middle-income countries (LMICs) is limited. While health systems researchers have hypothesized the relationship between facility readiness and provision of care, there have been few attempts to quantify this relationship in LMICs. This study assesses the association between facility readiness and provision of care for antenatal care at the client level and facility level.

METHODS

To assess the association between provision of care and various facility readiness indices for antenatal care, we used multilevel, multivariable random-effects linear regression models. We tested an inflection point on readiness scores by fitting linear spline models. To compare the coefficients between models, we used a bootstrapping approach and calculated the mean difference between all pairwise comparisons. Analyses were conducted at client and facility levels.

RESULTS

Our results showed a small, but significant association between facility readiness and provision of care across countries and most index constructions. The association was most evident in the client-level analyses that had a larger sample size and were adjusted for factors at the facility, health worker, and individual levels. In addition, spline models at a facility readiness score of 50 better fit the data, indicating a plausible threshold effect.

CONCLUSIONS

The results of this study suggest that facility readiness is not a proxy for provision of care, but that there is an important association between facility readiness and provision of care. Data on facility readiness is necessary for understanding the foundations of health systems particularly in countries with the lowest levels of service quality. However, a comprehensive view of quality of care should include both facility readiness and provision of care measures.

Effective Coverage in Health Systems: Evolution of a Concept

The manner in which high-impact, life-saving health interventions reach populations in need is a critical dimension of health system performance. Intervention coverage has been a standard metric for such performance. To better understand and address the decay of intervention effectiveness in real-world health systems, the more complex measure of "effective coverage" is required, which includes the health gain the health system could potentially deliver. We have carried out a narrative review to trace the origins, timeline, and evolution of the concept of effective coverage metrics to illuminate potential improvements in coherence, terminology, application, and visualizations, based on which a combination of approaches appears to have the most influence on policy and practice. We found that the World Health Organization first proposed the concept over 45 years ago. It became increasingly popular with the further development of theoretical underpinnings, and after the introduction of quantification and visualization tools. The approach has been applied in low- and middle-income countries, mainly for HIV/AIDS, TB, malaria, child health interventions, and more recently for non-communicable diseases, particularly diabetes and hypertension. Nevertheless, despite decades of application of effective coverage concepts, there is considerable variability in the terminology used and the choices of effectiveness decay steps included in the measures. Results frequently illustrate a profound loss of service effectiveness due to health system factors. However, policy and practice rarely address these factors, and instead favour narrowly targeted technical interventions.

Operationalising effective coverage measurement of facility based childbirth in Gombe State; a comparison of data sources

Estimating effective coverage of childbirth care requires linking population based data sources to health facility data. For effective coverage to gain widespread adoption there is a need to focus on the feasibility of constructing these measures using data typically available to decision makers in low resource settings. We estimated effective coverage of childbirth care in Gombe State, northeast Nigeria, using two different combinations of facility data sources and examined their strengths and limitations for decision makers. Effective coverage captures information on four steps: access, facility inputs, receipt of interventions and process quality. We linked data from the 2018 Nigerian Demographic and Health Survey (NDHS) to two sources of health facility data: (1) comprehensive health facility survey data generated by a research project; and (2) District Health Information Software 2 (DHIS2). For each combination of data sources, we examined which steps were feasible to calculate, the size of the drop in coverage between steps and the resulting estimate of effective coverage. Analysis included 822 women with a recent live birth, 30% of whom attended a facility for childbirth. Effective coverage was low: 2% based on the project data and less than 1% using the DHIS2. Linking project data with NDHS, it was feasible to measure all four steps; using DHIS2 it was possible to estimate three steps: no data was available to measure process quality. The provision of high quality care is suboptimal in this high mortality setting where access and facility readiness to provide care, crucial foundations to the provision of high quality of care, have not yet been met. This study demonstrates that partial effective coverage measures can be constructed from routine data combined with nationally representative surveys. Advocacy to include process of care indicators in facility summary reports could optimise this data source for decision making.