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PLOS Medicine | 2014

Equity-oriented monitoring in the context of universal health coverage.

Ahmad Reza Hosseinpoor; Nicole Bergen; Theadora Koller; Amit Prasad; Anne Schlotheuber; Nicole Valentine; John Lynch; Jeanette Vega

As part of the Universal Health Coverage Collection, Ahmad Reza Hosseinpoor and colleagues discuss methodological considerations for equity-oriented monitoring of universal health coverage, and propose recommendations for monitoring and target setting.


Global Health Action | 2015

Promoting health equity: WHO health inequality monitoring at global and national levels

Ahmad Reza Hosseinpoor; Nicole Bergen; Anne Schlotheuber

Background Health equity is a priority in the post-2015 sustainable development agenda and other major health initiatives. The World Health Organization (WHO) has a history of promoting actions to achieve equity in health, including efforts to encourage the practice of health inequality monitoring. Health inequality monitoring systems use disaggregated data to identify disadvantaged subgroups within populations and inform equity-oriented health policies, programs, and practices. Objective This paper provides an overview of a number of recent and current WHO initiatives related to health inequality monitoring at the global and/or national level. Design We outline the scope, content, and intended uses/application of the following: Health Equity Monitor database and theme page; State of inequality: reproductive, maternal, newborn, and child health report; Handbook on health inequality monitoring: with a focus on low- and middle-income countries; Health inequality monitoring eLearning module; Monitoring health inequality: an essential step for achieving health equity advocacy booklet and accompanying video series; and capacity building workshops conducted in WHO Member States and Regions. Conclusions The paper concludes by considering how the work of the WHO can be expanded upon to promote the establishment of sustainable and robust inequality monitoring systems across a variety of health topics among Member States and at the global level.Background Health equity is a priority in the post-2015 sustainable development agenda and other major health initiatives. The World Health Organization (WHO) has a history of promoting actions to achieve equity in health, including efforts to encourage the practice of health inequality monitoring. Health inequality monitoring systems use disaggregated data to identify disadvantaged subgroups within populations and inform equity-oriented health policies, programs, and practices. Objective This paper provides an overview of a number of recent and current WHO initiatives related to health inequality monitoring at the global and/or national level. Design We outline the scope, content, and intended uses/application of the following: Health Equity Monitor database and theme page; State of inequality: reproductive, maternal, newborn, and child health report; Handbook on health inequality monitoring: with a focus on low- and middle-income countries; Health inequality monitoring eLearning module; Monitoring health inequality: an essential step for achieving health equity advocacy booklet and accompanying video series; and capacity building workshops conducted in WHO Member States and Regions. Conclusions The paper concludes by considering how the work of the WHO can be expanded upon to promote the establishment of sustainable and robust inequality monitoring systems across a variety of health topics among Member States and at the global level.


The Lancet Global Health | 2016

State of inequality in diphtheria-tetanus-pertussis immunisation coverage in low-income and middle-income countries: a multicountry study of household health surveys

Ahmad Reza Hosseinpoor; Nicole Bergen; Anne Schlotheuber; Marta Gacic-Dobo; Peter M Hansen; Kamel Senouci; Ties Boerma; Aluísio J. D. Barros

Summary Background Immunisation programmes have made substantial contributions to lowering the burden of disease in children, but there is a growing need to ensure that programmes are equity-oriented. We aimed to provide a detailed update about the state of between-country inequality and within-country economic-related inequality in the delivery of three doses of the combined diphtheria, tetanus toxoid, and pertussis-containing vaccine (DTP3), with a special focus on inequalities in high-priority countries. Methods We used data from the latest available Demographic and Health Surveys and Multiple Indicator Cluster Surveys done in 51 low-income and middle-income countries. Data for DTP3 coverage were disaggregated by wealth quintile, and inequality was calculated as difference and ratio measures based on coverage in richest (quintile 5) and poorest (quintile 1) household wealth quintiles. Excess change was calculated for 21 countries with data available at two timepoints spanning a 10 year period. Further analyses were done for six high-priority countries—ie, those with low national immunisation coverage and/or high absolute numbers of unvaccinated children. Significance was determined using 95% CIs. Findings National DTP3 immunisation coverage across the 51 study countries ranged from 32% in Central African Republic to 98% in Jordan. Within countries, the gap in DTP3 immunisation coverage suggested pro-rich inequality, with a difference of 20 percentage points or more between quintiles 1 and 5 for 20 of 51 countries. In Nigeria, Pakistan, Laos, Cameroon, and Central African Republic, the difference between quintiles 1 and 5 exceeded 40 percentage points. In 15 of 21 study countries, an increase over time in national coverage of DTP3 immunisation was realised alongside faster improvements in the poorest quintile than the richest. For example, in Burkina Faso, Cambodia, Gabon, Mali, and Nepal, the absolute increase in coverage was at least 2·0 percentage points per year, with faster improvement in the poorest quintile. Substantial economic-related inequality in DTP3 immunisation coverage was reported in five high-priority study countries (DR Congo, Ethiopia, Indonesia, Nigeria, and Pakistan), but not Uganda. Interpretation Overall, within-country inequalities in DTP3 immunisation persist, but seem to have narrowed over the past 10 years. Monitoring economic-related inequalities in immunisation coverage is warranted to reveal where gaps exist and inform appropriate approaches to reach disadvantaged populations. Funding None.


BMJ | 2018

Within country inequalities in caesarean section rates: observational study of 72 low and middle income countries

Adeline Boatin; Anne Schlotheuber; Ana Pilar Betrán; Ann-Beth Moller; Aluísio J. D. Barros; Ties Boerma; Maria Regina Torloni; Cesar G. Victora; Ahmad Reza Hosseinpoor

Abstract Objective To provide an update on economic related inequalities in caesarean section rates within countries. Design Secondary analysis of demographic and health surveys and multiple indicator cluster surveys. Setting 72 low and middle income countries with a survey conducted between 2010 and 2014 for analysis of the latest situation of inequality, and 28 countries with a survey also conducted between 2000 and 2004 for analysis of the change in inequality over time. Participants Women aged 15-49 years with a live birth during the two or three years preceding the survey. Main outcome measures Data on caesarean section were disaggregated by asset based household wealth status and presented separately for five subgroups, ranging from the poorest to the richest fifth. Absolute and relative inequalities were measured using difference and ratio measures. The pace of change in the poorest and richest fifths was compared using a measure of excess change. Results National caesarean section rates ranged from 0.6% in South Sudan to 58.9% in the Dominican Republic. Within countries, caesarean section rates were lowest in the poorest fifth (median 3.7%) and highest in the richest fifth (median 18.4%). 18 out of 72 study countries reported a difference of 20 percentage points or higher between the richest and poorest fifth. The highest caesarean section rates and greatest levels of absolute inequality were observed in countries from the region of the Americas, whereas countries from the African region had low levels of caesarean use and comparatively lower levels of absolute inequality, although relative inequality was quite high in some countries. 26 out of 28 countries reported increases in caesarean section rates over time. Rates tended to increase faster in the richest fifth (median 0.9 percentage points per year) compared with the poorest fifth (median 0.2 percentage points per year), indicating an increase in inequality over time in most of these countries. Conclusions Substantial within country economic inequalities in caesarean deliveries remain. These inequalities might be due to a combination of inadequate access to emergency obstetric care among the poorest subgroups and high levels of caesarean use without medical indication in the richest subgroups, especially in middle income countries. Country specific strategies should address these inequalities to improve maternal and newborn health.


International Journal of Epidemiology | 2016

Data Resource Profile: WHO Health Equity Monitor (HEM)

Ahmad Reza Hosseinpoor; Nicole Bergen; Anne Schlotheuber; Cesar G. Victora; Ties Boerma; Aluísio J. D. Barros

The Health Equity Monitor (HEM) is one component theme of the Global Health Observatory, the main statistics repository of the World Health Organization (WHO). Launched in 2013, HEM is a collaboration between: the WHO Department of Information, Evidence and Research (Geneva, Switzerland); the WHO Gender, Equity and Human Rights Team (Geneva, Switzerland); and the International Center for Equity in Health (ICEH) based in the Federal University of Pelotas (Pelotas, Brazil). HEM was created as a resource to promote and enable global and national health inequality monitoring, particularly within lowand middle-income countries, where data availability may be limiting. The practice of health inequality monitoring requires health data that are disaggregated by population subgroups (i.e. by dimensions of inequality); to this end, HEM contains high-quality, disaggregated health data that are comparable across countries and over time. Currently, reproductive, maternal, newborn and child health (RMNCH) is the featured topic of HEM, which contains indicators categorized under the following subthemes: reproductive health interventions; maternal health interventions; newborn and child health interventions; RMNCH interventions (composite index); and health outcomes. Data are disaggregated by dimensions of inequality including education, economic status, place of residence, subnational region and child’s sex (where applicable). The two main components of HEM are the data repository and the theme page. The HEM data repository contains re-analysed (secondary) data taken from large-scale, nationally representative household health surveys: Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS). The primary data were collected at the household level from women aged 15–49 years. The HEM data repository contains data from nearly 250 DHS and MICS conducted in 94 countries during 1993–2013 (Table 1); almost three-quarters of these countries had surveys available from at least two time points. The data repository covers 34 RMNCH indicators, which are grouped by specified themes. The tables of the repository can be filtered according to indicator, dimension of inequality, country, year and data source. The HEM theme page supports the interpretation and reporting of the data from the repository. It contains a range of resources such as:


BMC Medical Research Methodology | 2016

Health Equity Assessment Toolkit (HEAT): software for exploring and comparing health inequalities in countries

Ahmad Reza Hosseinpoor; Devaki Nambiar; Anne Schlotheuber; Daniel D. Reidpath; Zev Ross

BackgroundIt is widely recognised that the pursuit of sustainable development cannot be accomplished without addressing inequality, or observed differences between subgroups of a population. Monitoring health inequalities allows for the identification of health topics where major group differences exist, dimensions of inequality that must be prioritised to effect improvements in multiple health domains, and also population subgroups that are multiply disadvantaged. While availability of data to monitor health inequalities is gradually improving, there is a commensurate need to increase, within countries, the technical capacity for analysis of these data and interpretation of results for decision-making. Prior efforts to build capacity have yielded demand for a toolkit with the computational ability to display disaggregated data and summary measures of inequality in an interactive and customisable fashion that would facilitate interpretation and reporting of health inequality in a given country.MethodsTo answer this demand, the Health Equity Assessment Toolkit (HEAT), was developed between 2014 and 2016. The software, which contains the World Health Organization’s Health Equity Monitor database, allows the assessment of inequalities within a country using over 30 reproductive, maternal, newborn and child health indicators and five dimensions of inequality (economic status, education, place of residence, subnational region and child’s sex, where applicable).Results/ConclusionHEAT was beta-tested in 2015 as part of ongoing capacity building workshops on health inequality monitoring. This is the first and only application of its kind; further developments are proposed to introduce an upload data feature, translate it into different languages and increase interactivity of the software. This article will present the main features and functionalities of HEAT and discuss its relevance and use for health inequality monitoring.


Global Health Action | 2018

Capacity building for health inequality monitoring in Indonesia: enhancing the equity orientation of country health information system

Ahmad Reza Hosseinpoor; Devaki Nambiar; Jihane Tawilah; Anne Schlotheuber; Benedicte Briot; Massee Bateman; Tamzyn M. Davey; Nunik Kusumawardani; Theingi Myint; Mariet Tetty Nuryetty; Sabarinah Prasetyo; Rustini Floranita

ABSTRACT Background: Inequalities in health represent a major problem in many countries, including Indonesia. Addressing health inequality is a central component of the Sustainable Development Goals and a priority of the World Health Organization (WHO). WHO provides technical support for health inequality monitoring among its member states. Following a capacity-building workshop in the WHO South-East Asia Region in 2014, Indonesia expressed interest in incorporating health-inequality monitoring into its national health information system. Objectives: This article details the capacity-building process for national health inequality monitoring in Indonesia, discusses successes and challenges, and how this process may be adapted and implemented in other countries/settings. Methods: We outline key capacity-building activities undertaken between April 2016 and December 2017 in Indonesia and present the four key outcomes of this process. Results: The capacity-building process entailed a series of workshops, meetings, activities, and processes undertaken between April 2016 and December 2017. At each stage, a range of stakeholders with access to the relevant data and capacity for data analysis, interpretation and reporting was engaged with, under the stewardship of state agencies. Key steps to strengthening health inequality monitoring included capacity building in (1) identification of the health topics/areas of interest, (2) mapping data sources and identifying gaps, (3) conducting equity analyses using raw datasets, and (4) interpreting and reporting inequality results. As a result, Indonesia developed its first national report on the state of health inequality. A number of peer-reviewed manuscripts on various aspects of health inequality in Indonesia have also been developed. Conclusions: The capacity-building process undertaken in Indonesia is designed to be adaptable to other contexts. Capacity building for health inequality monitoring among countries is a critical step for strengthening equity-oriented national health information systems and eventually tackling health inequities.


Global Health Action | 2018

National health inequality monitoring: current challenges and opportunities

Ahmad Reza Hosseinpoor; Nicole Bergen; Anne Schlotheuber; Ties Boerma

ABSTRACT National health inequality monitoring needs considerably more investment to realize equity-oriented health improvements in countries, including advancement towards the Sustainable Development Goals. Following an overview of national health inequality monitoring and the associated resource requirements, we highlight challenges that countries may encounter when setting up, expanding or strengthening national health inequality monitoring systems, and discuss opportunities and key initiatives that aim to address these challenges. We provide specific proposals on what is needed to ensure that national health inequality monitoring systems are harnessed to guide the reduction of health inequalities.


Global Health Action | 2018

Health Equity Assessment Toolkit Plus (HEAT Plus): software for exploring and comparing health inequalities using uploaded datasets

Ahmad Reza Hosseinpoor; Anne Schlotheuber; Devaki Nambiar; Zev Ross

ABSTRACT As a key step in advancing the sustainable development goals, the World Health Organisation (WHO) has placed emphasis on building capacity for measuring and monitoring health inequalities. A number of resources have been developed, including the Health Equity Assessment Toolkit (HEAT), a software application that facilitates the assessment of within-country health inequalities. Following user demand, an Upload Database Edition of HEAT, HEAT Plus, was developed. Launched in July 2017, HEAT Plus allows users to upload their own databases and assess inequalities at the global, national or subnational level for a range of (health) indicators and dimensions of inequality. The software is open-source, operates on Windows and Macintosh platforms and is readily available for download from the WHO website. The flexibility of HEAT Plus makes it a suitable tool for both global and national inequality assessments. Further developments will include interactive graphs, maps and translation into different languages.


Global Health Action | 2018

Subnational regional inequality in access to improved drinking water and sanitation in Indonesia: results from the 2015 Indonesian National Socioeconomic Survey (SUSENAS)

Tin Afifah; Mariet Tetty Nuryetty; Cahyorini; Dede Anwar Musadad; Anne Schlotheuber; Nicole Bergen; Richard Johnston

ABSTRACT Background: Universal and equitable access to safe and affordable drinking water and adequate sanitation and hygiene in Indonesia are vital to ensure healthy lives and promote well-being for all at all ages. Objectives: To quantify subnational regional inequality in access to improved drinking water and sanitation in Indonesia. Methods: Data about access to improved drinking water and sanitation were derived from the 2015 Indonesian National Socioeconomic Survey (SUSENAS) and disaggregated by 510 districts across the 34 provinces of Indonesia. Two summary measures of inequality, mean difference from mean and weighted index of disparity, were calculated to quantify within-province absolute and relative inequality, respectively. Results: While the majority of Indonesian households had access to improved drinking water (71.0%) and sanitation (62.1%), there were large variations between and within provinces. Access to improved drinking water ranged from 93.4% in DKI Jakarta to 41.1% in Bengkulu, and access to improved sanitation ranged from 89.3% in Jakarta to 23.9% in East Nusa Tenggara. Provinces with similar numbers of districts and similar overall averages showed variable levels of absolute and/or relative inequality. Certain districts reported very low levels of access to improved drinking water and/or sanitation. Conclusions: There are inequalities in access to improved drinking water and sanitation by subnational region in Indonesia. Monitoring within-country inequality in these indicators serves to identify underserved areas, and is useful for developing approaches to improve inequalities in access that can help Indonesia make progress towards the 2030 Agenda for Sustainable Development.

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Nicole Bergen

World Health Organization

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Ties Boerma

World Health Organization

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Aluísio J. D. Barros

Universidade Federal de Pelotas

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Devaki Nambiar

Public Health Foundation of India

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Cesar G. Victora

Universidade Federal de Pelotas

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Amit Prasad

World Health Organization

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Ann-Beth Moller

World Health Organization

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