Academic journal article Bulletin of the World Health Organization

Towards Universal Health Coverage: The Role of Within-Country Wealth-Related Inequality in 28 Countries in Sub-Saharan Africa/Vers Une Couverture De Sante Universelle: Le Role De L'inegalite Intra-Nationale Liee a la Richesse, Dans 28 Pays d'Afrique Sub-saharienne/Hacia la Cobertura Sanitaria Universal: El Papel De la Desigualdad Nacional En Cuanto a Riqueza En 28 Paises del Africa Subsahariana

Academic journal article Bulletin of the World Health Organization

Towards Universal Health Coverage: The Role of Within-Country Wealth-Related Inequality in 28 Countries in Sub-Saharan Africa/Vers Une Couverture De Sante Universelle: Le Role De L'inegalite Intra-Nationale Liee a la Richesse, Dans 28 Pays d'Afrique Sub-saharienne/Hacia la Cobertura Sanitaria Universal: El Papel De la Desigualdad Nacional En Cuanto a Riqueza En 28 Paises del Africa Subsahariana

Article excerpt

Introduction

Established in 2000, the eight Millennium Development Goals (MDGs) represent a global commitment to eliminating poverty. MDG 4 and MDG 5 are devoted to child and maternal health, with 2015 targets of a two-thirds reduction in the 1990 mortality rate for children under 5 years of age, a three-quarters reduction in the 1990 maternal mortality rate and universal access to reproductive health services. (1,2)

Although some promising gains have been made worldwide, in 2008, about 358 000 mothers (3) and 8.8 million children under 5 years of age (4) lost their lives, many from preventable or treatable causes. (3-5)

The African Region of the World Health Organization (WHO) is falling behind on MDG child and maternal health targets. In many countries these are advancing too slowly, stagnating or deteriorating. (1,3-9) Between 1990 and 2008, the worldwide mortality rate for children under 5 years of age dropped by 27%; (8) however, in 2008 more than half of these deaths occurred in sub-Saharan Africa. (5,8) The maternal mortality ratio in the African Region is 900 maternal deaths per 100000 live births--at least double that of any other WHO region. (8) Access to services such as antenatal care and skilled birth attendance in the African Region are among the lowest in the world. (1,3-6,8)

Improving child and maternal health requires health systems to be strengthened through both long-range investments (e.g. development of health facility infrastructure and programmes to train health workers) and initiatives that can be rapidly deployed (e.g. community immunization days, vitamin A campaigns and distribution of insecticide-treated bednets). (4,10,11) In 2010, the Countdown to 2015 decade report made a special appeal for improving the child and maternal health situation in sub-Saharan Africa, calling for renewed and accelerated political and financial commitment to MDG 4 and MDG 5 in this region. (4)

Achieving the child and maternal health MDGs will require policy and programme planners to identify and reach those who are most in need of health services. (2,5,9) To maximize and improve progress towards the MDG targets in Africa, it is important to have strong national and regional monitoring systems (12) that can identify which populations are benefiting from programmes and initiatives, and which are not. (13) Progress on MDG 4 and MDG 5 has been variable across sub-Saharan African countries; also, national indicators may mask inequalities between subgroups of the population, (4,6,8) and improvements at a country level may occur alongside a widening inequality gap. (14) Addressing inequalities and their root causes is an important step towards improving health outcomes. (5)

Measurements of service coverage capture both provision and use of services and interventions, since they express the percentage of people receiving a specified service or intervention among those requiring that service. (13) The health service coverage gap represents an estimate of the increase in coverage needed to achieve universal coverage for a given service. (15) The ability of a programme or initiative to reduce the health service coverage gap is an important indicator of success; comparing the gap across populations can help to target action to reduce disparities. (13,15)

Previous monitoring of health service coverage and the health service coverage gap for several child and maternal health services revealed between-country inequality and varying patterns of within-country wealth-related inequality. (15,16) Further delineation of the coverage gap within countries is needed to more accurately define the current reach of child and maternal health services and to inform programme and policy direction. (17-19) Thus, our objective was to measure the magnitude of within-country wealth-related inequality in the health service coverage gap of maternal and child health indicators and to quantify the contribution of this inequality to the national coverage gap within sub-Saharan African countries. …

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