Moving beyond standard RMNCH coverage indicators
Authors: Farhan Majid
Journal: The Lancet Global Health (2021)

Delivering interventions to improve reproductive, maternal, newborn, and child health (RMNCH) in an equitable manner is a central task of public health systems. The study by Daniel G P Leventhal and colleagues1Leventhal DGP Crochemore-Silva I Vidaletti LP Armenta-Paulino N Barros AJD Victora CG Delivery channels and socioeconomic inequalities in coverage of reproductive, maternal, newborn, and child health interventions: analysis of 36 cross-sectional surveys in low-income and middle-income countries.Lancet Glob Health. 2021; 9: e1101-e1109Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar (August, 2021) did an excellent job of putting together 20 RMNCH coverage indicators in 36 low-income and middle-income countries (LMICs) to improve our understanding of socioeconomic inequality in the coverage of RMNCH services. The authors report the existence of pro-rich patterns (ie, intervention coverage increased as household wealth increased) in most countries and indicators. Environmental interventions were the most unequal. Community-based interventions were more equitably distributed. However, we need to move beyond evaluating the quantity of RMNCH coverage. It is now well recognised that the quality, and not just the quantity, of health-care services is important to measure and track. In 2019, WHO and UNICEF convened a group of experts, the Effective Coverage Think Tank Group, to establish standardised definitions and measurement approaches for effective coverage, initiate discussions on effective coverage indicators (including, but not limited to, RMNCH), and develop priorities for future research on effective coverage.2Marsh AD Muzigaba M Diaz T et al.Effective coverage measurement in maternal, newborn, child, and adolescent health and nutrition: progress, future prospects, and implications for quality health systems.Lancet Glob Health. 2020; 8: e730-e736Summary Full Text Full Text PDF PubMed Scopus (34) Google Scholar Some work has reviewed3Jannati A Sadeghi V Imani A Saadati M Effective coverage as a new approach to health system performance assessment: a scoping review.BMC Health Serv Res. 2018; 18: 1-13Crossref PubMed Scopus (10) Google Scholar and evaluated indicators of quality to study effective coverage across the globe in various ways.4GBD 2019 Universal Health Coverage CollaboratorsMeasuring universal health coverage based on an index of effective coverage of health services in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019.Lancet. 2020; 396: 1250-1284Summary Full Text Full Text PDF PubMed Scopus (91) Google Scholar It is high time that we discuss the quality of coverage alongside the quantity of coverage when measuring the coverage of RMNCH indicators. Furthermore, we need to be more careful about supply-side and demand-side interpretations of RMNCH indicators derived from household surveys. For instance, when exclusive breastfeeding (0–5 months) is measured, what is the meaning of coverage given that mothers are typically responsible for breastfeeding? What health delivery-level variable are we truly measuring? The concern is broader than breastfeeding. Coverage indicators like the number of antenatal care visits are widely used as measures of demand of RMNCH services. In the social sciences, we know that within rich or poor households, parents might contribute to increased inequity by investing resources in different levels across their children (even fetuses) on the basis of concerns regarding equity and efficiency.5Almond D Mazumder B Fetal origins and parental responses.Annu Rev Econ. 2013; 5: 37-56Crossref Scopus (82) Google Scholar Moreover, women in poorer communities and countries might less often choose to vaccinate their children because of factors like extreme poverty. This distinction is important as policies to address supply-side bottlenecks (eg, pay-for-performance models that reward health-care providers for meeting targets) might be very different from those associated with demand-side bottlenecks (eg, monetary transfers to mothers). For effective health policies, we need to assess quality and carefully differentiate between the supply-side and demand-side for optimising RMNCH outcomes in LMICs. I declare no competing interests. Delivery channels and socioeconomic inequalities in coverage of reproductive, maternal, newborn, and child health interventions: analysis of 36 cross-sectional surveys in low-income and middle-income countriesInterventions that are often delivered at community level are usually more equitably distributed than those primarily delivered in fixed facilities or those that require changes in the home environment. Policy makers need to learn from community delivery channels to promote more equitable access to all RMNCH interventions. Full-Text PDF Open Access