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  • Is governance, gross domestic product, inequality, population size or country surface area associated with coverage and equity of health interventions? Ecological analyses of cross-sectional surveys from 80 countries

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Is governance, gross domestic product, inequality, population size or country surface area associated with coverage and equity of health interventions? Ecological analyses of cross-sectional surveys from 80 countries
  1. Fernando C Wehrmeister,
  2. Inácio Crochemore M da Silva,
  3. Aluisio J D Barros,
  4. Cesar G Victora
  1. International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
  1. Correspondence to Dr Fernando C Wehrmeister, International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil; fwehrmeister{at}equidade.org

Abstract

Objective To assess associations between national characteristics, including governance indicators, with a proxy for universal health coverage in reproductive, maternal, newborn and child health (RMNCH).

Design Ecological analysis based on data from national standardised cross-sectional surveys.

Setting Low-income and middle-income countries with a Demographic and Health Survey or a Multiple Indicator Cluster Survey since 2005.

Participants 1 246 710 mothers and 2 129 212 children from 80 national surveys.

Exposures of interest Gross domestic product (GDP), country surface area, population, Gini index and six governance indicators (control of corruption, political stability and absence of violence, government effectiveness, regulatory quality, rule of law, and voice and accountability).

Main outcomes Levels and inequality in the composite coverage index (CCI), a weighted average of eight RMNCH interventions. Relative and absolute inequalities were measured through the concentration index (CIX) and slope index of inequality (SII) for CCI, respectively.

Results The average values of CCI (70.5% (SD=13.3)), CIX (5.3 (SD=5.1)) and mean slope index (19.8 (SD=14.7)) were calculated. In the unadjusted analysis, all governance variables and GDP were positively associated with the CCI and negatively with inequalities. Country surface showed inverse associations with both inequality indices. After adjustment, among the governance indicators, only political stability and absence of violence was directly related to CCI (β=6.3; 95% CI 3.6 to 9.1; p<0.001) and inversely associated with relative (CIX; β=−1.4; 95% CI −2.4 to −0.4; p=0.007) and absolute (SII; β=−5.3; 95% CI –8.9 to −1.7; p=0.005) inequalities. The strongest associations with governance indicators were found in the poorest wealth quintile. Similar patterns were observed for GDP. Country surface area was inversely related to inequalities on CCI.

Conclusions Levels and equity in RMNCH interventions are positively associated with political stability and absence of violence, and with GDP, and inversely associated with country surface area.

  • maternal health
  • child health
  • epidemiology
  • public health

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: http://creativecommons.org/licenses/by/4.0/

https://doi.org/10.1136/bmjgh-2017-000437

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    Footnotes

    • Handling editor Seye Abimbola

    • Contributors FCW and CGV conceived the idea of the paper, conducted the analysis and write the first draft of the paper. AJDB and ICMS contributed to data analysis and revise the manuscript. All authors approved the final version of the manuscript.

    • Funding Wellcome Trust Foundation (grant number: 101815/Z/13/Z) and Bill & Melinda Gates Foundation (grant number: OPP1135522).

    • Competing interests None declared.

    • Patient consent Detail has been removed from this case description/these case descriptions to ensure anonymity. The editors and reviewers have seen the detailed information available and are satisfied that the information backs up the case the authors are making.

    • Ethics approval All ethical issues were warranted by the original institutions that led the DHS and MICS surveys in each country.

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

    • Data sharing statement Data for coverage and CCI are available at http://www.who.int/gho/health_equity/assessment_toolkit/en/ and information on governance indicators are available at http://info.worldbank.org/governance/wgi/. Upon request, the dataset used in these analyses could be shared.