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

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.