Background The Millennium Developments Goals had a significant impact on the countries’ commitment to health and on key outcomes as maternal and child mortality, which showed important reductions. The Sustainable Development Goals that followed have more ambitious goals. Measuring progress is critical to keep the momentum and the pace of change. We assessed the progress made over three decades, using the composite coverage index (CCI) as an indicator of universal health care for RMNCH, estimating its coverage and related wealth inequality.

Methods We used data from nationally representative health surveys to estimate the CCI, calculated as a weighted average of eight key coverage indicators along the RMNCH continuum of care. We also calculated the slope index of inequality (SII) to represent CCI wealth-related absolute inequality. Using data from 329 surveys done in 101 countries from 1993 to 2021, we estimated how those two indicators changed over time using multilevel linear models, with the survey estimates at level 1 and the countries at level 2. The changes were estimated for all countries, country income levels, and world regions. A test for interaction was performed for each grouping to check whether trends were different. We also checked the linearity of all trends.

Results Globally, we found relevant changes in both coverage and inequality. The CCI increased from 49% in 1993 to 71% in 2021, an average absolute annual change (AAAC) of 0.77 percentage points (pp) per year (0.69; 0.86). At the same time, absolute inequality decreased by 0.68 pp per year (-0.77; -0.59), starting with a richest vs. poorest difference of 33 pp in 1993 down to 14 pp in 2021. Looking at countries by income level, low-income countries presented the steepest increase in CCI (0.84 pp), followed by lower-middle-income countries (0.63 pp), while upper-middle-income countries did not present a significant increase (-0.03 pp). South Asia made, by far, the fastest progress in CCI (1.26 pp). Regarding inequality reductions, lower-middle-income countries (-0.82 pp), East Asia & Pacific (-1.01 pp), and Latin America & Caribbean (-0.92 pp) were the best performers. West & Central Africa was on the slow end of coverage and inequality, finishing the period with the lowest CCI and highest SII.

Conclusion The CCI has been widely used in the global monitoring literature as a synthetic coverage indicator. There has been significant progress in both RMNCH coverage and inequality. However, this progress is uneven across countries, and some regions are lagging behind.