Inequalities in effective coverage of the maternal healthcare continuum in Cameroon: a cascade analysis from service contact to input-adjusted coverage – BMC Health Services Research

Evaluating Healthcare Effectiveness to Advance Sustainable Development Goal 3

The Effective Coverage (EC) Cascade Framework: A Tool for Monitoring Universal Health Coverage

The Effective Coverage (EC) cascade framework is a critical model for evaluating population-level access to healthcare services, directly supporting the monitoring of Sustainable Development Goal 3 (Good Health and Well-being), particularly Target 3.8 concerning Universal Health Coverage (UHC). The framework assesses multiple dimensions of healthcare delivery:

• Service Utilization: The initial contact and access to health services by the population in need.
• System Inputs: The readiness of the health system, including adequate staffing, equipment, and infrastructure, which is fundamental to achieving SDG 3.
• Quality of Care: The delivery of services according to evidence-based standards, a cornerstone of effective UHC.
• Health Outcome: The ultimate goal of healthcare intervention, measuring the proportion of the population in need that achieves a positive health outcome.

This model is essential for measuring progress towards reducing maternal mortality (SDG Target 3.1) and ending preventable deaths of newborns (SDG Target 3.2) by moving beyond simple contact metrics to assess true health system effectiveness.

Standardizing Measurement for Global Health Goals

To create a standardized approach for measuring EC in line with global health targets, the WHO/UNICEF Effective Coverage Think Tank established a comprehensive seven-step cascade. This consensus model provides a granular pathway for assessing healthcare performance from need to outcome, which is vital for achieving the health-related SDGs.

1. Population in Need: The total population requiring a specific health service.
2. Service Contact Coverage: The proportion of the population in need that contacts a qualified health provider.
3. Input-Adjusted Coverage: The proportion that contacts a provider at a facility with adequate resources (readiness).
4. Intervention Coverage: The proportion that receives the necessary healthcare intervention from a qualified provider at a ready facility.
5. Quality-Adjusted Coverage: The proportion that receives care meeting established quality standards.
6. User Adherence-Adjusted Coverage: The proportion that receives quality care and adheres to provider instructions.
7. Outcome-Adjusted Coverage: The proportion that receives quality care, adheres to instructions, and experiences the desired health outcome.

Adaptation for the Maternal Health Care (MHC) Continuum

This study adapted the standard framework to specifically assess the completion of the Maternal Health Care (MHC) continuum. This focus is critical for accelerating progress on SDG Target 3.1 (reduce the global maternal mortality ratio) and SDG 5 (Gender Equality) by ensuring women receive continuous, quality care throughout all phases of pregnancy. The adapted framework introduces “Service continuum coverage,” defined as the proportion of women who receive timely and continuous care from qualified staff at a ready facility. The final stage measures “input-adjusted coverage across the MHC continuum,” which evaluates a health facility’s capacity to deliver effective services, thereby providing a robust indicator of health system strength for maternal care.

Methodology for Assessing Progress on SDG 3 in Cameroon

Data Sources for National Health Assessment

To construct the EC cascade for MHC in Cameroon, two nationally representative data sources were utilized, demonstrating a partnership approach (SDG 17) to data utilization for national planning.

• The 2018 Cameroon Demographic and Health Survey (CDHS): Provided population-level data on the utilization of MHC services, including antenatal, delivery, and postnatal care.
• The 2015 Cameroon Emergency Obstetric and Neonatal Care Assessment (EONCA): Offered facility-level data on the availability and quality of MHC services, assessing the system’s capacity to deliver on SDG 3 commitments.

These surveys provide representative data for the entire country, for urban and rural areas, and for 12 distinct regions, enabling an analysis of health inequalities (SDG 10).

Data Linkage and Coverage Estimation Strategy

An ecological approach was employed to integrate population-level data from the CDHS with facility-level data from the EONCA. This linkage is crucial for generating a comprehensive picture of healthcare delivery and identifying gaps in achieving UHC (SDG 3.8).

Estimation of Input-Adjusted Coverage

The selection of items for input-adjusted coverage was aligned with WHO guidelines to ensure adherence to global standards for quality maternal and newborn care. The methodology involved several key steps:

1. Health facilities were stratified by type, managing authority, and region to allow for a nuanced analysis of service readiness.
2. Facility readiness scores for Antenatal Care (ANC) and Intra- and Postpartum Care (IPC) were calculated based on the availability of essential items across multiple domains.
3. These readiness scores were linked to service utilization indicators from the population survey to generate estimates of the input-adjusted coverage index (IAC).
4. The analysis produced distinct indicators for both ANC and IPC to evaluate the full continuum of maternal care, a critical factor for reducing maternal mortality (SDG Target 3.1).

Key Indicators for the MHC Continuum

• ANC Service Contact: Proportion of women with at least one ANC visit from a skilled provider in a health facility.
• ANC Service Continuum: Proportion of women with at least four ANC visits who received at least seven essential ANC services.
• IPC Service Contact: Proportion of women assisted by a skilled attendant during delivery in a health facility.
• IPC Service Continuum: Proportion of women assisted by a skilled attendant at delivery who also received a postpartum visit within 48 hours.

These indicators were then used to calculate input-adjusted coverage estimates, providing a robust measure of the quality and effectiveness of the maternal health system in the context of the Sustainable Development Goals.

Analysis of Sustainable Development Goals in the Article

1. Which SDGs are addressed or connected to the issues highlighted in the article?

• SDG 3: Good Health and Well-being: The entire article is dedicated to this goal. It focuses on a framework (the EC cascade) to evaluate and measure the effectiveness of healthcare services, specifically for “maternal, newborn, child, and adolescent health and nutrition.” The stated objective of improving maternal healthcare is to achieve “positive health outcome[s]” and is described as “a critical factor in improving women’s health outcomes and preventing maternal mortality.” This directly aligns with the core mission of SDG 3 to ensure healthy lives and promote well-being for all at all ages.

2. What specific targets under those SDGs can be identified based on the article’s content?

• Target 3.1: By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births.
  
  The article explicitly connects its methodology to this target by stating that assessing the completion of Maternal Health Care (MHC) is “a critical factor in improving women’s health outcomes and preventing maternal mortality.” The framework measures the continuum of care, including antenatal, delivery, and postpartum services, which are essential for reducing maternal deaths.
• Target 3.2: By 2030, end preventable deaths of newborns and children under 5 years of age.
  
  The article’s scope includes “maternal, newborn, child, and adolescent health.” It also mentions that one of the data sources, the EONCA, was used to “assess facilities’ capacity to deliver emergency obstetric and newborn care.” By measuring the effective coverage of these services, the framework directly addresses the system’s ability to prevent newborn deaths.
• Target 3.8: Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.
  
  This target is central to the article. The concept of “Effective Coverage (EC)” is a cornerstone of measuring Universal Health Coverage (UHC). The article’s framework evaluates multiple dimensions of UHC, including:
  • Access and Utilization: It measures “service contact coverage,” defined as the “proportion of the population in need who came into contact with qualified staff.”
  • Quality of Essential Health-Care Services: It assesses “quality-adjusted coverage” (care received according to quality standards) and “input-adjusted coverage,” which accounts for “service readiness—defined as a health facility’s capacity to deliver specific, effective services.”
  • System Capacity: The analysis of “system inputs (e.g., staffing, equipment, and infrastructure)” and “facility readiness” directly measures the capacity of the health system to provide quality care, a key component of UHC.

3. Are there any indicators mentioned or implied in the article that can be used to measure progress towards the identified targets?

Yes, the article is fundamentally about a framework for measurement and is rich with specific indicators used to assess healthcare coverage and quality.

1. Effective Coverage (EC): The primary metric, defined as “the proportion of a population in need of a service that experiences a positive health outcome as a result of receiving it.” This is a high-level outcome indicator for overall health system performance.
2. Service Contact Coverage: The article defines and uses this indicator to measure initial access. Specific examples calculated include:
   • “The proportion of women who, during their last pregnancy, had at least one ANC visit from a skilled health personnel in a health facility.”
   • “The proportion of women assisted at delivery by a skilled attendant in a health facility.”
3. Service Continuum Coverage: This indicator measures the completeness of care. Specific examples calculated include:
   • “The proportion of women who had at least four ANC visits from a skilled provider in a health facility and received at least seven essential ANC services.”
   • “The proportion of those who were both assisted at delivery by a skilled attendant in a health facility and received a postpartum visit within 48 h of delivery.”
4. Facility Readiness Score: This is a crucial indicator of health system capacity. The article describes its calculation based on “structural characteristics (equipment, infrastructure, drugs, human resources, and guideline compliance).” It measures a facility’s ability to provide quality care.
5. Input-Adjusted Coverage (IAC): This composite indicator combines service utilization with facility readiness (“service continuum” multiplied by “facility readiness scores”). It provides a more accurate measure of the proportion of the population receiving care from a facility that is adequately equipped and staffed, directly measuring progress towards quality universal health coverage.

4. Summary Table of SDGs, Targets, and Indicators

Source: bmchealthservres.biomedcentral.com