Universal health care and equity: evidence of maternal health based on an analysis of demographic and household survey data

Abstract

Introduction: The drive toward universal health coverage (UHC) is central to the post 2015 agenda, and is incorporated as a target in the new Sustainable Development Goals. However, it is recognised that an equity dimension needs to be included when progress to this goal is monitored. WHO have developed a monitoring framework which proposes a target of 80% coverage for all populations regardless of income and place of residence by 2030, and this paper examines the feasibility of this target in relation to antenatal care and skilled care at delivery.

Methodology: We analyse the coverage gap between the poorest and richest groups within the population for antenatal care and presence of a skilled attendant at birth for countries grouped by overall coverage of each maternal health service. Average annual rates of improvement needed for each grouping (disaggregated by wealth quintile and urban/rural residence) to reach the goal are also calculated, alongside rates of progress over the past decades for comparative purposes.

Findings: Marked inequities are seen in all groups except in countries where overall coverage is high. As the monitoring framework has an absolute target countries with currently very low coverage are required to make rapid and sustained progress, in particular for the poorest and those living in rural areas. The rate of past progress will need to be accelerated markedly in most countries if the target is to be achieved, although several countries have demonstrated the rate of progress required is feasible both for the population as a whole and for the poorest.

Conclusions: For countries with currently low coverage the target of 80% essential coverage for all populations will be challenging. Lessons should be drawn from countries who have achieved rapid and equitable progress in the past.

Fig. 1

SBA by wealth quintile grouped by overall coverage rate for 35 countries using data from DHS surveys (most recent available survey 2006–2012). Country groupings are: Very low: Ethiopia, Mali, Bangladesh, Niger. Low: Haiti, Nigeria, Nepal, Madagascar, Kenya, Zambia, India, Tanzania, Guinea. Moderate: Senegal, Mozambique, Uganda, Cote D’Ivoire, Ghana, Philippines, Cameroon. High: Zimbabwe, Burkina Faso, Rwanda, Bolivia, Cambodia, Malawi, Egypt. Very high: Namibia, Indonesia, Benin, Peru, Columbia, Dominican Republic, Jordan, Armenia

Fig. 2

At least four ANC visits coverage by wealth quintile grouped by overall coverage rate for 35 countries using data from DHS surveys (most recent available survey 2006–2012). Country groupings are: Very low: Ethiopia, Bangladesh. Low: Niger, Burkina Faso, Rwanda, Mali, India, Tanzania, Cote D’Ivoire, Malawi, Senegal, Kenya Uganda, Nigeria, Madagascar. Moderate: Nepal, Mozambique, Guinea, Cambodia, Zambia, Benin, Cameroon. High: Zimbabwe, Egypt, Haiti, Bolivia, Namibia, Philippines, Ghana. Very high: Indonesia, Columbia, Peru, Jordan, Dominican Republic, Armenia

Fig. 3

SBA coverage for poorest and richest quintiles in 35 countries (80 % coverage target marked in red: most recent available survey 2006–2012)

Fig. 4

SBA coverage by place of residence grouped by overall coverage rate for 35 countries using data from DHS surveys (most recent available survey 2006–2012)

Fig. 5

4+ ANC coverage by place of residence grouped by overall coverage rate for 35 countries using data from DHS surveys (most recent available survey 2006–2012)

Fig. 6

Progress in SBA for countries with <30 % coverage at baseline survey based on DHS data

Fig. 7

SBA coverage for urban and rural residents, split by wealthiest and poorest quintiles for selected countries based on DHS data (most recent available survey 2006–2012)