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Effective coverage of primary care services in eight high-mortality countries
  1. Hannah H Leslie1,
  2. Address Malata2,
  3. Youssoupha Ndiaye3,
  4. Margaret E Kruk1
  1. 1 Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
  2. 2 Kamuzu College of Nursing, Malawi University of Science and Technology, Limbe, Southern Region, Malawi
  3. 3 Planning, Research and Statistics, Ministry of Health and Social Action, Dakar, Senegal
  1. Correspondence to Dr Hannah H Leslie; hleslie{at}


Introduction Measurement of effective coverage (quality-corrected coverage) of essential health services is critical to monitoring progress towards the Sustainable Development Goal for health. We combine facility and household surveys from eight low-income and middle-income countries to examine effective coverage of maternal and child health services.

Methods We developed indices of essential clinical actions for antenatal care, family planning and care for sick children from existing guidelines and used data from direct observations of clinical visits conducted in Haiti, Kenya, Malawi, Namibia, Rwanda, Senegal, Tanzania and Uganda between 2007 and 2015 to measure quality of care delivered. We calculated healthcare coverage for each service from nationally representative household surveys and combined quality with utilisation estimates at the subnational level to quantify effective coverage.

Results Health facility and household surveys yielded over 40 000 direct clinical observations and over 100 000 individual reports of healthcare utilisation. Coverage varied between services, with much greater use of any antenatal care than family planning or sick-child care, as well as within countries. Quality of care was poor, with few regions demonstrating more than 60% average performance of basic clinical practices in any service. Effective coverage across all eight countries averaged 28% for antenatal care, 26% for family planning and 21% for sick-child care. Coverage and quality were not strongly correlated at the subnational level; effective coverage varied by as much as 20% between regions within a country.

Conclusion Effective coverage of three primary care services for women and children in eight countries was substantially lower than crude service coverage due to major deficiencies in care quality. Better performing regions can serve as examples for improvement. Systematic increases in the quality of care delivered—not just utilisation gains—will be necessary to progress towards truly beneficial universal health coverage.

  • Child Health
  • Health Systems Evaluation
  • Maternal Health
  • Cross-sectional Survey
  • Health Services Research

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See:

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  • Contributors MEK and HHL developed the study question. HHL conducted all analyses and drafted the manuscript. All authors contributed to the analysis plan, revised the manuscript and approved the final version for publication.

  • Funding Bill & Melinda Gates Foundation OPP1161450.

  • Competing interests None declared.

  • Ethics approval Harvard University Human Research Protection Program.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement All data used in this analysis are publicly available from the Demographic and Health Survey Program ( and UNICEF (

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