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Effective coverage measures are now recommended to measure progress towards universal health coverage and assess health system performance.

A systematic review, published in the Journal of Global Health, aimed to examine how effective coverage measures of life-saving interventions from childbirth to children up to the age of nine years have been defined in the literature and how well these effective coverage measures fit the proposed health-service coverage cascade.

Traditionally, measures of maternal, newborn and child health interventions have focused on contact or intervention coverage—defined as the proportion of a population in need of a service or intervention that received the service. Contact coverage however tends to overestimate the positive health impacts and doesn’t account for the content or quality of care delivered. Effective coverage moves beyond contact coverage by introducing the dimension of quality of care.

In 2020 a group of experts laid out recommendations for standardising effective coverage measurement in maternal, newborn, child and adolescent health and nutrition. They recommended that effective coverage be explained using health-service coverage cascades applied at the population level. The group identified challenges to operationalising the cascade, including defining content and data sources. In response, a systematic review was carried out searching seven scientific journal databases and the reference lists of earlier reviews. The review identified 64 effective coverage measures across 33 relevant studies for closer examination.


The most frequently examined interventions were around childbirth and the immediate newborn period. No studies examined measured among children aged five to nine years. The review identified a lack of harmonisation in how effective coverage measures have been defined and constructed.

  • Where multiple interventions were delivered within a single service such as childbirth, postnatal care and sick child care, studies either reported a combined effective coverage measure or separate effective coverage measures for each intervention delivered.
  • No studies were identified that captured all components of the cascade. Studies adjusted contact coverage for different steps of the cascade; the step most frequently adjusted for was process quality based on women or care givers’ self-reports in household surveys.
  • The individual items used to construct measures varied across studies. While some selected tracer items others defined more comprehensive measures. For example, the total number of ‘inputs’ included in a measure ranged from one to 127.

Conclusions and recommendations

The study authors conclude that there is a need for greater harmonisation of effective coverage definitions to allow for comparisons across settings and over time. The findings also highlight that a shift in measurement approach will be required if the coverage cascade is to be adopted.

In the short term this review suggests the need for greater specificity and transparency in the reporting of effective coverage measures. In the longer term it requires global guidance on best practices. The mapping of existing effective coverage measures against the cascade presented in this review provides a useful starting point.


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Josephine Exley

Research Fellow

Prateek Anand Gupta

Montpellier, France

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Professor Joanna Schellenberg

IDEAS Co-Principal Investigator and Professor

Kathleen Strong

Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland

Jennifer Harris Requejo

Division of Data, Analytics, Planning & Monitoring, United Nations Children's Fund, New York, USA

Ann-Beth Moller

UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland

Allisyn Moran

Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland

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Professor Tanya Marchant

IDEAS Principal Investigator and Professor