Measuring universal health coverage in reproductive, maternal, newborn and child health: An update of the composite coverage index

PLoS One. 2020 Apr 29;15(4):e0232350. doi: 10.1371/journal.pone.0232350. eCollection 2020.


Background: Monitoring universal health coverage in reproductive, maternal and child health requires appropriate indicators for assessing coverage and equity. In 2008, the composite coverage index (CCI)-a weighted average of eight indicators reflecting family planning, antenatal and delivery care, immunizations and management of childhood illnesses-was proposed. In 2017, the CCI formula was revised to update the family planning and diarrhea management indicators. We explored the implications of adding new indicators to the CCI.

Methods: We analysed nationally representative surveys to investigate how addition of early breastfeeding initiation (EIBF), tetanus toxoid during pregnancy and post-natal care for babies affected CCI levels and the magnitude of wealth-related inequalities. We used Pearson's correlation coefficient to compare different formulations, and the slope index of inequalities [SII] and concentration index [CIX] to assess absolute and relative inequalities, respectively.

Results: 47 national surveys since 2010 had data on the eight variables needed for the original and revised formulations, and on EIBF, tetanus vaccine and postnatal care, related to newborn care. The original CCI showed the highest average value (65.5%), which fell to 56.9% when all 11 indicators were included. Correlation coefficients between pairs of all formulations ranged from 0.93 to 0.99. When analysed separately, 10 indicators showed higher coverage with increasing wealth; the exception was EIBF (SII = -2.1; CIX = -0.5). Inequalities decreased when other indicators were added, especially EIBF-the SII fell from 24.8 pp. to 19.2 pp.; CIX from 7.6 to 6.1. The number of countries with data from two or more surveys since 2010 was 30 for the original and revised formulations and 15 when all the 11 indicators were included.

Conclusions: Given the growing importance of newborn mortality, it would be desirable to include relevant coverage indicators in the CCI, but this would lead a reduction in data availability, and an underestimation of coverage inequalities. We propose that the 2017 version of the revised CCI should continue to be used.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Child
  • Child Health / economics*
  • Female
  • Healthcare Disparities / economics
  • Humans
  • Infant, Newborn
  • Maternal Health / economics*
  • Maternal-Child Health Services / economics*
  • Pregnancy
  • Socioeconomic Factors
  • Universal Health Insurance / economics

Grants and funding

This study was funded by the Bill & Melinda Gates Foundation (OPP1148933) as part of its funding for the Countdown to 2030 for Women’s, Children’s and Adolescents’ Health and the International Center for Equity in Health, Federal University of Pelotas. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.