This presentation has made to health workers who have more than two decades of experience of managing/implementing public health programs in Nepal, especially at district level and below.

1. Monitoring Health Inequity
Deepak K Karki
National Centre for AIDS and STD Control

2. Outline
 What is Inequity in health?
 How to monitor it?

3. Equality and Equity
• Equality = sameness
• Inequality = unequal
• Equity = fairness
• Inequity = unfair or unjust

4. Inequity vs. inequality
• Health inequity: unjust
differences in health
between persons of
different social groups;
a normative concept
• Health inequality:
observable health
differences between
subgroups within a
population; can be
measured and
monitored

5. Equity is
• Defined as the quality of being fair, unbiased,
and just.
• Equity involves ensuring that everyone has
access to the resources, opportunities, power
and responsibility they need to reach their
full, healthy potential as well as making
changes so that unfair differences may be
understood and addressed.
• Like an open door, equity is about providing a
welcome invitation and making sure that the
door stays unlocked and open for everyone.

6. Equity in healthcare
• Many factors influence health including genetic factors,
meaning that complete equality of health is never
achievable.
• Equalising health can be considered as paternalistic
because it does not allow for individual preferences.
• Aristotle’s formal theory of distributive justice makes the
distinction between vertical and horizontal equity:
• Horizontal equity refers to equity between people with the
same health care needs
• Vertical equity refers to those with unequal needs should
receive different or unequal health care

7. Thus, health equity is …
• Absence of avoidable or remediable differences
among groups of people, whether those groups
are defined socially, economically,
demographically, or geographically.
• Providing fair amount (and approach) of
interventions (health care) based on the
demand of health care (need)

8. What is health inequality
monitoring?
• Health inequality monitoring describes the
differences and changes in health indicators in
subgroups of a population
• Special considerations:
• the need for two different types of intersecting data:
health indicator and equity stratifier data
• the use of statistical measurements of inequality
• the challenges of reporting on different health
indicators by different dimensions of inequality

9. Why to monitor inequality in health
care?
• To provide information for policies, programmes
and practices to reduce health inequity
• To evaluate the progress of health interventions
• To show a more-complete representation of
population health than the national average
• Indicates the situation in population subgroups
• Disadvantaged subgroups may impede improvements
in national figures

10. Total health inequality versus social
inequality in health
• Total inequality: the overall distribution of
health
• Consider only health indicator variables (no equity
stratifiers)
• Social inequality: health inequalities between
social groups
• Indicate situations of inequity, where differences
between social groups are unjust or unfair

11. Measuring health inequalities can
be achieved by;
 Measuring health need
(measuring demand through health needs assessment)
 Measuring access to health care
(measuring supply)
 Measuring quality of health care

12. Measuring health inequity

13. 3 steps in
measuring
health inequity

14. Equity stratifiers
• Also called ‘dimensions of inequality’
• Acronym PROGRESS summarizes the equity stratifiers most frequently
assessed in health inequality monitoring
• For example: PROGRESS
Place of residence (rural, urban, etc.)
Race or ethnicity
Occupation
Gender
Religion
Education
Socioeconomic status
Social capital or resources

15. Monitoring health inequality
• Fosters accountability and continuous improvement
within health systems
• Helps identify and track health differences between
subgroups, providing evidence and feedback to
strengthen equity-oriented policies, programs and
practices
• Provides evidence to inform and promote equity-
oriented health initiatives, including the movement
towards universal health coverage

16. Why to monitor equity in health?
• A specific type of health monitoring
• Specific purpose of informing policies, programs
and practices to reduce differences in health that
are unfair and unjust
• Provides a foundation for incorporating equity into
evidence based health planning, and also assessing
whether current health initiatives promote equity

17. Types of data sources
Alldataforhealthinequality
monitoring
Surveillance systems
Population-based
sources
Censuses
Vital registration
systems
Household surveys
Institution-based
sources
Resource records
(e.g. number of hospitals)
Service records
(e.g. number of immunizations
provided)
Individual records
(e.g. hospital charts)

18. Data source mapping
• Involves cataloguing and describing all data sources
available (district or other administrative units) to
determine which sources can be used for health
inequality monitoring
• Process of data source mapping can also identify
important gaps that indicate where a country lacks
data about health indicators or equity stratifiers

19. Step 1:
• Creating a list of available data by source type
(census, administrative, household survey, etc.),
name, and year(s) of data collection
Data source Type Data Sources Years of data collection Notes
Administrative Live births by attendance Annual
Vital Registration
Vital Registers (Births and
deaths)
On going
Survey
Demographic Health
Surveys
2001 2006 2011
Data sources at the national level

20. Step 2
• Consider the availability of equity stratifier information
within each data source, listed by year
SN Data source and year
Equity stratifier
Income Education Sex
Place of
residence
Province
or region
1 Live births by attendance
2
Vital registration (births and
deaths)
3 DHS 2006
4 DHS 2011
Data sources with information on specified equity stratifiers

21. Step 3
• A selection of reproductive, maternal and child health
subtopics related to health services
Reproductive, maternal and child
health subtopic
Data source and number
Reproductive health services 3 4 5 6 ……..
Maternal health services 1 3 4 5 6
Preventive care for children 3 4 5 6 ……..
Data sources with information on specified health topics

22. Step 4
• The final step involves compiling all lists
Reproductive, maternal and
child health subtopic
Data source and number
Income Education Sex
Place of
residence
Province
or region
Reproductive health services 3,4,5, 3,4,5,6 NA 3,4,5,6… 3,4,5,6…
Maternal health services 3,4,5, 3,4,5,6 NA 3,4,5,6… 3,4,5,6…
Preventive care for children 3,4,5, 3,4,5,6 3,4,5 3,4,5,6… 3,4,5,6…
Compiling data source information on specified equity stratifiers and health topics

23. Data analysis
• Difference and Ratio (simple measures of inequality)
were used to measure inequality by every type of equity
stratifier
Equity Stratifier
Simple measures of inequalities
Absolute Relative
Wealth Difference Ratio
Education Difference Ratio
Region Difference Ratio
Sex Difference Ratio
Area Difference Ratio

24. Reporting inequality
• Thoroughly review all of the results (including
national average, disaggregated data, and simple
and complex measures of inequality) and
consider their importance within the context of
the Nepal

25. Defining priority areas
• Assessing the situation
• Defining priorities
• Using priority setting to implement change

26. Health Equity Monitor -
Compendium of Indicator (WHO, May 2014)
• Adolescent fertility rate
• Antenatal care coverage- at least four
visits (%)
• Antenatal care coverage- at least one
visit (%)
• BCG immunization coverage among 1-
year-olds (%)
• Births attended by skilled health
personnel (%)
• Births by caesarean section (%)
• Children aged <3 years stunted (%)
• Children aged <3 years underweight (%)
• Children aged <5 years sleeping under
insecticide-treated nets (%)
• Children aged <5 years stunted (%)
• Children aged <5 years underweight (%)
• Children aged <5 years with ARI
symptoms taken to facility (%)
• Children aged <5 years with diarrhoea
receiving oral rehydration therapy and
continued feeding (%)
• Children aged 6-59 months who
received vitamin A supplementation (%)

27. Compendium of Indicator
• Contraceptive prevalence- modern
and traditional methods (%)
• Contraceptive prevalence- modern
methods (%)
• Diphtheria, tetanus toxoid and
pertussis (DTP3) immunization
coverage among 1-year-olds (%)
• Early initiation of breastfeeding (%)
• Family planning needs satisfied (%)
• Full immunization coverage among 1-
year-olds (%)
• Infant mortality rate
• Measles (MCV) immunization
coverage among 1-year-olds (%)
• Polio (Pol3) immunization
coverage among 1-year-olds (%)
• Pregnant women sleeping under
insecticide-treated nets (%)
• Total fertility rate
• Under-five mortality rate

28. Remember !
• Equity is a social justice
• Equity is for equality
• Equity is for making the society fair in obtaining
resources and helping people live healthier