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      Measuring Coverage in MNCH: New Findings, New Strategies, and Recommendations for Action

      research-article
      1 , * , 2 , 3 , 4 , 4 , 1 , 4 , the CHERG Working Group on Improving Coverage Measurement
      PLoS Medicine
      Public Library of Science

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          Abstract

          Measuring Coverage in Maternal and Child Health: New Findings, New Strategies and Recommendations for Action In this overview of the PLOS Medicine Collection on “Measuring Coverage in Maternal and Child Health, Jennifer Bryce and colleagues discuss how and why some of the indicators now being used to track intervention coverage may not provide fully reliable measurements, draw together strategies proposed across the Collection for improving these measurements and make recommendations for action.

          Abstract

          Considerable progress has been made in reducing maternal, newborn, and child mortality worldwide, but many more deaths could be prevented if effective interventions were available to all who could benefit from them. Timely, high-quality measurements of intervention coverage—the proportion of a population in need of a health intervention that actually receives it—are essential to support sound decisions about progress and investments in women's and children's health. The PLOS Medicine “Measuring Coverage in MNCH” Collection of research studies and reviews presents systematic assessments of the validity of health intervention coverage measurement based on household surveys, the primary method for estimating population-level intervention coverage in low- and middle-income countries. In this overview of the Collection, we discuss how and why some of the indicators now being used to track intervention coverage may not provide fully reliable coverage measurements, and how a better understanding of the systematic and random error inherent in these coverage indicators can help in their interpretation and use. We draw together strategies proposed across the Collection for improving coverage measurement, and recommend continued support for high-quality household surveys at national and sub-national levels, supplemented by surveys with lighter tools that can be implemented every 1–2 years and by complementary health-facility-based assessments of service quality. Finally, we stress the importance of learning more about coverage measurement to strengthen the foundation for assessing and improving the progress of maternal, newborn, and child health programs.

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          Most cited references17

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          Health service coverage and its evaluation.

          Health service coverage is considered as a concept expressing the extent of interaction between the service and the people for whom it is intended, this interaction not being limited to a particular aspect of service provision but ranging over the whole process from resource allocation to achievement of the desired objective. For the measurement of coverage, several key stages are first identified, each of them involving the realization of an important condition for providing the service; a coverage measure is then defined for each stage, namely the ratio between the number of people for whom the condition is met and the target population, so that a set of these measures represents the interaction between the service and the target population. This definition of coverage allows for variations, which are called "specific coverage", by limiting the target population to specific subgroups differentiated by certain conditions related to service provision or by demographic or socioeconomic factors.The evaluation of coverage on the basis of these concepts enables management to identify bottlenecks in the operation of the service, to analyse the constraining factors responsible for such bottlenecks, and to select effective measures for service development.
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            Effect of the Integrated Management of Childhood Illness strategy on childhood mortality and nutrition in a rural area in Bangladesh: a cluster randomised trial.

            WHO and UNICEF launched the Integrated Management of Childhood Illness (IMCI) strategy in the mid-1990s to reduce deaths from diarrhoea, pneumonia, malaria, measles, and malnutrition in children younger than 5 years. We assessed the effect of IMCI on health and nutrition of children younger than 5 years in Bangladesh. In this cluster randomised trial, 20 first-level government health facilities in the Matlab subdistrict of Bangladesh and their catchment areas (total population about 350 000) were paired and randomly assigned to either IMCI (intervention; ten clusters) or usual services (comparison; ten clusters). All three components of IMCI-health-worker training, health-systems improvements, and family and community activities-were implemented beginning in February, 2002. Assessment included household and health facility surveys tracking intermediate outputs and outcomes, and nutrition and mortality changes in intervention and comparison areas. Primary endpoint was mortality in children aged between 7 days and 59 months. Analysis was by intention to treat. This study is registered, number ISRCTN52793850. The yearly rate of mortality reduction in children younger than 5 years (excluding deaths in first week of life) was similar in IMCI and comparison areas (8.6%vs 7.8%). In the last 2 years of the study, the mortality rate was 13.4% lower in IMCI than in comparison areas (95% CI -14.2 to 34.3), corresponding to 4.2 fewer deaths per 1000 livebirths (95% CI -4.1 to 12.4; p=0.30). Implementation of IMCI led to improved health-worker skills, health-system support, and family and community practices, translating into increased care-seeking for illnesses. In IMCI areas, more children younger than 6 months were exclusively breastfed (76%vs 65%, difference of differences 10.1%, 95% CI 2.65-17.62), and prevalence of stunting in children aged 24-59 months decreased more rapidly (difference of differences -7.33, 95% CI -13.83 to -0.83) than in comparison areas. IMCI was associated with positive changes in all input, output, and outcome indicators, including increased exclusive breastfeeding and decreased stunting. However, IMCI implementation had no effect on mortality within the timeframe of the assessment. Bill & Melinda Gates Foundation, WHO's Department of Child and Adolescent Health and Development, and US Agency for International Development.
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              Access, utilization, quality, and effective coverage: an integrated conceptual framework and measurement strategy.

              Health systems can primarily improve the health of individuals and populations by delivering high-quality interventions to those who may benefit from them. We propose a concept of effective coverage as the probability that individuals will receive health gain from an intervention if they need it. Understanding the extent to which health systems are delivering key interventions to those who will benefit from them and the factors that explain gaps in delivery are a critical input to decision-making at the local, national and global levels. We develop an integrated conceptual framework for monitoring and analyzing the delivery of high-quality interventions to those who need them. This framework can help clarify the inter-relationships between notions of access, demand for care, utilization, and coverage on the one hand and highlight the requirements for health information systems that can sustain this type of analysis. We discuss measurement strategies and demonstrate the concept by means of a simple simulation model.
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                Author and article information

                Contributors
                Role: Academic Editor
                Journal
                PLoS Med
                PLoS Med
                PLoS
                plosmed
                PLoS Medicine
                Public Library of Science (San Francisco, USA )
                1549-1277
                1549-1676
                May 2013
                May 2013
                7 May 2013
                : 10
                : 5
                : e1001423
                Affiliations
                [1 ]Institute for International Programs, Department of International Health, The Johns Hopkins University, Baltimore, Maryland, United States of America
                [2 ]MEASURE DHS, ICF International, Calverton, Maryland, United States of America
                [3 ]Population Council, New York, New York, United States of America
                [4 ]Statistics and Monitoring Section, Division of Policy and Strategy, United Nations Children's Fund, New York, New York, United States of America
                Clinical Senior Lecturer in Maternal & Fetal Medicine and Honorary Consultant in Obstetrics, Women's Health Academic Centre, Kings College, London, United Kingdom
                Author notes

                The authors have declared that no competing interests exist.

                Wrote the first draft of the manuscript: JB. Contributed to the writing of the manuscript: JB FA AB AH HN JR TW SA AB KB HC FC TE CW EH TH AK LL AM BR DR JR CS JS OT. ICMJE criteria for authorship read and met: JB FA AB AH HN JR TW SA AB KB HC FC TE CW EH TH AK LL AM BR DR JR CS JS OT. Agree with manuscript results and conclusions: JB FA AB AH HN JR TW SA AB KB HC FC TE CW EH TH AK LL AM BR DR JR CS JS OT.

                ¶ Membership of the CHERG Working Group on Improving Coverage Measurement is provided in the Acknowledgments.

                Article
                PMEDICINE-D-12-03249
                10.1371/journal.pmed.1001423
                3646206
                23667340
                fbae6188-6164-4e06-b3ab-cf934387c492
                Copyright @ 2013

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                Page count
                Pages: 9
                Funding
                This work was conducted under the auspices of the Child Health Epidemiology Reference Group (CHERG) for WHO and UNICEF, with financial support from The Bill & Melinda Gates Foundation through their grant to the US Fund for UNICEF. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Review
                Medicine
                Global Health
                Non-Clinical Medicine
                Health Care Policy
                Child and Adolescent Health Policy
                Health Statistics
                Health Systems Strengthening
                Health Care Quality
                Health Services Research
                Socioeconomic Aspects of Health
                Public Health
                Child Health
                Women's Health
                Social and Behavioral Sciences
                Economics
                Health Economics
                Health Care Sector

                Medicine
                Medicine

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