Which Interventions should be Included in National Health System Assessment Framework? Selecting Essential Interventions Based on Effective Coverage Approach
2 Health Services Management, Iranian Center of Excellence in Health Management, Health Services Management Department, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
3 Pharmacoeconomics and Pharmaceutical Management, Tabriz Health Services Management Research center, Health Economics Department, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
Citation: Sadeghi V, et al. Which Interventions should be Included in National Health System Assessment Framework? Selecting Essential Interventions Based on Effective Coverage Approach. Ann Med Health Sci Res. 2019;9: 542- 549
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Background: Coverage of population with essential health services should be regulated into any local framework for monitoring progress towards UHC. Aim: The present study was conducted to find out the essential health care interventions in Iran UHC monitoring system.
Methods: 23 experts participated in this study. Semi structured questionnaires were completed and data were analyzed using quantitative content analysis. Findings: Interventions in each following level were extracted reflecting Iranian health system priorities; Promotion services: modifying non-communicable diseases risk factors, training and counseling regarding sexual and mental health, prevention of smoking and substance abuse and promotion of safety and traffic culture. Preventive care: diabetes and hypertension screening, prenatal and antenatal care, HIV/Aids and hepatitis screening, breast, cervical and lung cancer screening, prevention of osteoporosis and DPT and Tetanus immunization. Treatment: treatment of diabetes and hypertension, mental disorders, HIV/Aids, cardiovascular disease, upper respiratory infections; surgical treatments for trauma and accidents, arthritis and disc, hospital care for prematurity and smoking cessation. Rehabilitation services: rehabilitation of cardiovascular diseases, cancer, trauma and accidents, musculoskeletal disorders and mental illnesses. Prevalence rate, mortality, disease related complications, and burden of disease were among the most frequent criteria for selecting essential interventions.
Conclusion: Selecting the optimal set of interventions is generally the starting point of the designing an assessment framework. Every country based on their health needs as well as epidemiology and demographic situations needs to create measures to assess coverage of essential interventions selected based on logical criteria.
Delivering health care interventions is the central task of health systems. Tracking performance and identifying whether the tasks are implemented well or not can help guide decisionmaking processes and lead to good policy formulation in way of make improvements in health systems.  Assessment of health system interventions and programs in low and middle-income countries provides data on the individuals who should be targeted for the detection, care and treatment of health problems and where additional resources and efforts are to be targeted. 
Currently, what is emphasized in Universal Health Coverage (UHC) as a broader international effort in the health sector as well as a part of the post-2015 health systems development agenda, is the importance of population coverage with high quality interventions.  The World Health Organization (WHO) defines UHC as a situation where all people who need health services (prevention, promotion, treatment, rehabilitation and palliative care) receive them, without incurring financial hardship.  As UHC was perceived as a crucial component of sustainable development, its promoting has been the paramount part of most of low and middle income countries’ health system development strategy.  However, discussions on the suitability of UHC often focus on its capability to monitor and its function in improvement of health systems. [6,7]
In 2003, the concept of effective coverage was introduced and its measurement was suggested by WHO to be incorporated into health system performance assessment based on preliminary efforts of Shengelia and colleagues in early of 2000.  In their introduced concept, effective coverage that combines three widely used components of need, utilization, and quality of healthcare interventions, were defined formally as “the fraction of potential health gain that can be delivered through an intervention by the health system that is actually delivered. [1,8]
As it was mentioned above, UHC is defined as the proportion of population in need of an intervention who are using an effective intervention without falling into financial hardship.  Effective coverage unites intervention need, use, and quality into a simple but data-rich metric, reflecting the core components of UHC (19). The measurement of effective coverage for a range of diseases and conditions along with financial protection represents a critical component to move and track progress towards UHC.  In other words, measuring coverage of the population with essential and effective health services (effective coverage), is exactly what comprises the UHC monitoring framework.  These are why the effective coverage has been suggested as a metric for monitoring UHC. 
The first step in designing a health system assessment framework with effective coverage or any other measurement strategy is selecting the optimal set of interventions that will be assessed or monitored. But based on what criteria this set of interventions should be included in the assessment framework of the UHC or health system of a particular country? Presenting a health system assessment framework completely depends on the kind and level of interventions selected for monitoring. If this task is not performed well, the assessment results may lead to misunderstanding and misguided decision making in the process of development of health system delivery.
To date, several global frameworks have been developed in order to track progress to UHC and health system performance assessment. Preparing a local and country level framework, however, according to health profile and characteristics of each country is inevitable.
As it is mentioned, coverage of population with needed quality interventions is one of the main components of UHC. In order to set goals to move to UHC and track any efforts in this area, therefore, two main questions should be answered to first:
• What are the essential and needed interventions in monitoring context and
• What are the main criteria for selecting these interventions?
The aim of this study as a part of broader project is to answer these main questions in Iran health system.
This study was performed as part of a broader project aimed to provide a framework for assessing effective coverage of health services in Iran in 2017. In this paper, we present a start point of this project which includes selecting essential and high priority interventions for assessment as the first and main step of assessing effective coverage of health systems.
We designed a semi-structured data collection tool including two parts: the first was to gather demographic characteristics of the participants such as gender, age, educational background and field of study, work experience, and current position. The second and main body of the questionnaire included two main questions concerning the essential interventions of health system in full spectrum of promotion, prevention, treatment and rehabilitation as well as the criteria for suggesting or selecting each intervention. The participants were purposively selected based on their academic and research background or job experiences making them have insights to the subject. The questionnaires were completed through individual interview sessions, holding expert panels, and electronically via e-mail. Aim of the work was presented at the beginning of the interview meetings and panels and then the participants were asked to complete the questionnaires. For the participants to whom the questionnaire was sent electronically, we sent a fifteenminute video-including the aim of the project along with the questionnaire and requested them to complete the questionnaire after watching that.
We applied a deductive quantitative analysis approach and used descriptive quantitative content analysis method to analyze the collected data. Words and phrases were selected as coding unit based on the research questions and the concepts to be identified. A coding scheme was designed for developing coding classification rules including assigning 0 and 1 to two main categories namely interventions and criteria and 1 to 4 to four subcategories namely four ranges of services (promotion, prevention, treatment, and rehabilitation) respectively in each main category. During the coding process, each numerical code was assigned to the proper category. The numeric codes were assigned to the data manually by the first author (VS). For the coding process, we prepared a coding form in Access 2010 database which then was transferred into STATA 14 for descriptive analysis.
Twenty three experts participated in the study and 16 completed questionnaires were collected. Some of the panel participants jointly completed the questionnaire because they were from the same expert groups such as health or treatment. The majority of participants were faculty members and about 80% with work experiences up to 10 years. Table 1 summarizes the other demographic characteristics of the participants in the study.
|Sub-group||Frequency (n)||Percent (%)|
|Specialty||Health Services Management||4||17.39|
|Current position||Faculty member||9||39.13|
|PhD student/Health expert||3||13.04|
|Head of university/Faculty member||1||4.35|
|Head of hospital/Faculty member||1||4.35|
|Head of Educational Deputy/Faculty member||1||4.35|
|Head of Education Development Center||1||4.35|
Table 1: Demographic characteristics of the participants in the study.
Based on descriptive analysis of collected data, the observed records in each of the four levels of intervention delivery are shown in Table 2. As this table shows, the records are almost appropriately distributed among the main (interventions and criteria) and the secondary categorizes (promotion to rehabilitation). However, the highest and lowest frequencies of records were related to prevention and rehabilitation levels, respectively.
|Intervention delivery level|
Table 2: Descriptive analysis of the observed records.
We present the main findings of this study in two parts: First, essential interventions proposed by the participants in order to be included in effective coverage assessment framework in four levels, and then in the next step, the main criteria for selecting these interventions. Findings in each two parts are presented based on the most frequently stated cases. Table 3 summarizes priority interventions in four domains of care according to the participants’ points of view.
|Intervention scope||Condition/Disease||Target Group||Target|
|Training||Risk factors (nutrition, physical activity)||Middle aged and adults||Modifying non-communicable and chronic disease risk factors, Improving lifestyle|
|Training, Consultation||Sexual health||Students and teenagers||Prevention of sexual problems|
|Training, Consultation||Mental health||Students and teenagers||Prevention of mental illnesses|
|Training||Traffic culture||the public||Promotion of community safety|
|Prevention||Smoking, substance abuse||Prevention of smoking and substance abuse|
|Screening||Non-communicable and chronic diseases (Diabetes, hypertension)||Adults||Prevention of cardiovascular diseases|
|Care||Prenatal, antenatal and childbirth||Pregnant women||Prevention of pregnancy Complications on mother and child|
|Identifying Positive Cases||Infectious diseases(HIV/Aids and hepatitis)||High risk groups||Early diagnosis and treatment|
|Screening||Breast cancer||Women||Early diagnosis and treatment|
|Screening||Cervical cancer||Women||Early diagnosis and treatment|
|Screening||Lung cancer||Adults||Early diagnosis and treatment|
|Immunization||DPT vaccination||adults||Prevention of vaccine-Preventable diseases|
|Immunization||Tetanus vaccination||Pregnant women||Prevention of vaccine-Preventable diseases|
|Control||Non-communicable and chronic disease (Diabetes, hypertension)||Patients||Prevention of complications and cardiovascular disease|
|Treatment||mental disorders (depression)||Patients||Prevention of illness progression or acute condition|
|Treatment||infectious Diseases(HIV/Aids)||Patients||increase longevity|
|Surgery||Trauma and accidents||Injured people with trauma and disabled people||Improving quality of life|
|Treatment||Cardiovascular disease||patients||Increase longevity|
|Surgery||orthopedic (arthritis, disc)||people with hard Musculoskeletal disorders||Improving quality of life|
|Treatment||Respiratory infections (upper)|
|Treatment||Neonatal diseases (prematurity)||Neonates||Reducing infant mortality|
|Cessation||Smoking and addiction||Smokers and addicts||Prevention of related Complications|
|Rehabilitation||Cardiovascular diseases (Myocardial infarction, stroke )||Stroke patients and patients with heart surgery history||Prevention of attack recurrence or its complications|
|Rehabilitation||cancer||patients||Improving quality of life in patient and patient family|
|Rehabilitation||Trauma and accidents||Injured people with trauma and disabled people||Improving quality of life|
|Rehabilitation||Musculoskeletal disorders (lumbar disc)||Patients with surgery history or disabled people||Improving quality of life, returning to job|
Table 3: High priority interventions mentioned by the experts.
Promotion: As to promotion services, the words such as training and consultation were used by the participants to specify interventions. The most frequent codes were related to non-communicable and chronic diseases risk factors such as physical activity and nutrition. The other essential interventions according to experts’ viewpoints included training and counseling on sexual health and mental health, especially at school age. Also, prevention of smoking and substance abuse and promotion of safety and traffic culture were among the mentioned essential interventions. The main target groups in this area were adults and school students [Table 3].
Prevention: As it was mentioned, the most observed codes (31%) were related to preventive services. The most frequent word suggested by the experts in this area was screening and identifying new cases with 21 records. Among chronic conditions, diabetes and hypertension obtained high rank of records. The other high priority interventions in this group were cancers. Moreover, the experts focused on pregnancy care and immunization. As Table 3 shows, the main target groups in preventive services were women and adults.
Treatment: The participants tried to specify interventions of this category through words of control, treatment, and surgery. Among chronic conditions like the ones mentioned in prevention services, diabetes and hypertension obtained high frequency of records. The other priorities in this area were related to surgical treatments including trauma and accidents and orthopedic conditions. The target group of this domain was obviously patients. The other selected treatment interventions have been shown in Table 3.
Rehabilitation: According to the participants’ opinions, rehabilitation of cardiovascular diseases obtained the highest records. At this level, the majority of observed codes were related to the mentioned interventions and the number of unique codes and codes with low frequency were lower than the other levels indicating the high agreement among experts opinions at this level compared to the others. Rehabilitation of cardiovascular diseases, especially stroke and myocardial infarction, cancers, trauma and accidents, musculoskeletal disorders and mental illnesses were among high priority suggested interventions.
Intervention selection criteria
In this section, we present the most important criteria for choosing essential services based on the participants’ opinions. Prevalence rate of diseases or conditions was the main selection criterion in all of four intervention levels with the highest record. The other priority criteria were mortality, prevention of complications, severity of following complications, and burden of disease. Some high priority criteria were choosing the cause in special areas such as quality of life and being among main causes of hospitalization, which were the selection criteria in rehabilitation and treatment respectively. Other criteria have been shown in Table 4.
|Prevention of complications||9||7||16|
|Quality of life||1||15||16|
|Severity of following complications||3||6||4||13|
|Burden of disease||1||5||5||1||12|
|Impact on health promotion||5||3||8|
|Prevention of death||4||5||4||8|
|The main cause of hospitalization||7||7|
Table 4: High priority selection criteria mentioned by the experts.
First step in designing and implementing effective coverage as a performance assessment tool is selection of essential interventions.  It is obvious that given the broad range of health services delivered by health systems, it is impossible to include all health services in the national health system assessment framework. [11,12] Achieving the optimal set of interventions, therefore, is inevitable. It is clear that this optimal set of interventions vary across countries as a function of national epidemiology and other characteristics.  In health system assessment efforts, priority interventions which could both address the most important health needs of population and be a good set of proxies at all levels of the health system and at full spectrum of services from promotion and prevention to treatment and rehabilitation should be considered. 
As the first attempt in developing practical concept of effective coverage in Mexico, effective coverage was measured for some proxy public health interventions.  However; there have been some criticisms on this effort due to lack of obvious selection process of interventions. 
In addition to covering all range of services, a proper effective coverage assessment framework should create a good balance between services, various sex and age groups and communicable and Non-Communicable Disease (NCDs) within each area (promotion to rehabilitation).  As the findings of the study show, a good distribution of interventions has been made among all range of the services based on the participants’ points of view. This distribution is also evident among services in different age and sex groups as well as communicable and noncommunicable diseases [Table 3].
It is more important to pay attention to these issues in designing performance assessment frameworks in low and middle income countries experiencing epidemiological transition. Monitoring effective coverage of health system in these countries should include both sets of interventions focusing on communicable diseases, maternal and child health, and interventions with a focus on addressing NCDs, mental health, and injuries for adolescents, adults, and the elderly. [15,16] Iran is such a country that experiences a rapid epidemiological transition with an increase in the burden of NCDs.  Therefore, considering these chronic conditions such as hypertension and diabetes with high prevalence rate is necessary, as the estimated effective coverage for them in practical efforts is very low in similar contexts. [2,13,16,18,19]
After promotion of risk factors in adults, sexual and mental health education and consultation at school ages have been one of the priority areas in promotion services based on the participants’ opinions. Based on WHO statistics, neuropsychiatric conditions has the greatest burden of disease after cardiovascular diseases and diabetes with the highest amount in years of healthy life loss due to disability (YLD) among other diseases [Figure 1].
The suggested interventions in prevention care included screening NCDs, especially diabetes and hypertension and common cancers, maternal and child interventions, immunization, and identifying positive cases of infectious diseases. Measuring effective coverage of maternal and child health interventions was one of the selection priorities in the majority of practical efforts having been ever done on measuring effective coverage. [2,13,16,20] It also was a high priority area proposed by the 2001 technical consultation for selecting interventions for effective coverage assessment because of their ability to produce a significant health gain in a relatively short time, their correspondence to the priorities and objective needs of the countries, existence of ample evidence for their effectiveness and being a response to a significant health problem at national and regional levels.  Furthermore, there is relatively little additional cost to obtaining the data for calculating effective coverage for these interventions. 
Other preventive services, such as vaccination, have also been the subject of assessment in practical experiences of effective coverage. [22-24] Effective coverage of these obligatory public health functions, are important in contributing to the achievement of health system goals. 
As Figure 1 shows, ischemic heart disease, stroke, road injury, hypertensive heart disease, diabetes mellitus and preterm birth complication were among the top 10 causes of death in Iran in 2012. Moreover, cardiovascular diseases and diabetes, cancers, musculoskeletal diseases, maternal and neonatal problems and injuries were among the top ranks of the burden of disease. All of these are along with the participants’ viewpoints, especially in treatment services, representing Iran’s health system priorities.
While, a comprehensive assessment framework should capture all levels of services, [10,15,26] based on our review, however, there has not been any practical effort on measuring effective coverage of rehabilitation services until now. Rehabilitation reduces hospital stays and thereby costs, it also reduces disability, and improves quality of life.  Due to high rates of myocardial infarction, stroke and trauma in Iran, therefore, the assessment of rehabilitation services related to them is essential for achieving the mentioned goals.
In order to develop a global framework and guide countries to design a local framework to assess UHC, the Bellagio meeting has proposed a set of criteria for selection of intervention coverage indicators for the countries that have limited capacity to monitor progress. Some of these main criteria include public health priority, proven interventions with large health impact, measurability (numerator & need), quality component, universality, equity, data availability, and potential financial risks to users.  Also, it has been recommended that some considerations should be considered regarding the selection of interventions in assessing effective coverage including burden of disease, affordable interventions, and special considerations of social priority. 
According to the participants’ point of views, prevalence rate was the most frequent criterion for selecting essential interventions [Table 4] one of which represents public health priority. Mortality, disease related complications, and burden of disease were among other important criteria recommended by the experts. Table 4 shows the other main criteria.
So far, a number of key criteria have been suggested in theoretical discussions and then have been applied in practical experiences. Criteria for selection of interventions in Mexico were based on the projected impact of interventions on the burden of disease, affordability, potential impact on health disparities, and the ability to extrapolate from those interventions to others.  To measure the effective coverage of health interventions in China, Liu and his colleagues selected those interventions that represent China’s major health problems that target the most common diseases and their risk factors. However, on the basis of data availability, they could measure effective coverage only for a few numbers of interventions.  Although Martinez and his colleagues have not explicitly pointed to intervention selection criteria in their work, an appropriate combination of interventions in various fields’ condition on the comparability of data between the countries under study was a concern.  Leading causes of mortality, [28,29] high maternal mortality ratio,  high occurrence and prevalence rate [18,30] and conflict in coverage rate of different sources  were among the important selection criteria which have been ever used for assessing effective coverage of health interventions in other efforts around the World.
It should be noted that choice of a priority set of interventions is not strictly a technocratic undertaking and it needs to reflect local values, priorities and perceptions. No single indicator is likely to meet all criteria equally well and countries should choose options in a way to meet their own needs. 
Choosing appropriate tracer indicators for assessing health system and monitoring the achievement of goals such as the Millennium Development Goals and Universal Health coverage is very important. High priority interventions vary across countries reflecting their special situations. Therefore, designing local assessment framework based on the global ones can help achieve national health system goals.
For health system assessment or UHC monitoring, we need a focus on the level and distribution of coverage of essential health interventions aimed at the key causes of disease and injury burdens. Selecting the optimal set of interventions is generally the starting point of designing an assessment framework. Every country based on their epidemiology situations, demographic profiles, their health needs as well as levels of socioeconomic development needs to create simple and sound measures to assess coverage of essential interventions selected based on logical criteria then try to design health information systems to collect relevant and related data. What we presented in this paper was a preliminary attempt to identify interventions addressing the main causes of ill health, ranging from promotion to rehabilitation in Iran.
The research was conducted as a part of a broader project. The whole project was funded by Tabriz University of Medical Science.
The authors declare that they have no competing interests.
Availability of Data and Materials
We agree to share our data and materials.
Ethics Approval and Consent to Participate
Ethical permission to conduct this study was obtained from Tabriz University of Medical Science (IR.TBZMED.REC.1395.769). The participants had the right to freely participate in the study and fill out the questionnaire.
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