inequality in reproductive, maternal and child...

SEA-NUR-466

Distribution: General

Inequality in Reproductive,

Maternal and Child Health

in Nepal

Measuring and Monitoring Health Inequalities:

A Post-Workshop Report

© World Health Organization 2016

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Printed in India

iii

Contents

Page

Acknowledgements ................................................................................................ v

1. Introduction .................................................................................................. 1

1.1 Equity in health: the Nepal context .................................................... 1

1.2 Nepal’s policy commitment to health equity....................................... 2

2. Methodology ................................................................................................. 3

3. Trends and latest status in maternal and child health indicators ..................... 7

3.1 National coverage of health services, 1996–2011 ............................... 7

3.2 National child nutrition outcomes, 2001–2011 .................................. 8

3.3 Inequality in health services by wealth, 1996–2011 ............................ 9

3.4 Inequality in child health outcomes by wealth, 2001–2011 .............. 11

3.5 Inequality in health services by education, 1996–2011 ..................... 12

3.6 Inequality in child health outcomes by education, 2001–2011 ......... 14

3.7 Inequality in health services by area, 1996–2011 ............................. 14

3.8 Inequality in child health outcomes by area, 2001–2011 .................. 16

3.9 Inequality in health services by region, 1996–2006 .......................... 17

3.10 Inequality in child nutrition outcomes by region, 2001–2006 ........... 19

3.11 Inequality in health services by sex, 1996–2011 ............................... 19

3.12 Inequality in child nutrition outcomes by sex, 2001–2011 ................ 20

4. Benchmarking of Nepal against other countries ........................................... 21

4.1 National coverage ............................................................................ 21

4.2 Absolute and relative inequality ........................................................ 21

iv

5. Situation analysis, 1996–2011 ..................................................................... 24

5.1 Priority health services indicators ...................................................... 24

5.2 Priority equity stratifiers in health services ......................................... 26

5.3 Priority inequalities in child nutrition outcomes................................. 26

6. Data tables.................................................................................................. 28

7. References .................................................................................................. 38

Annexes

1. Definitions of indicators and coding key...................................................... 39

2. List of participants ....................................................................................... 41

3. Workshop Agenda ...................................................................................... 44

v

Acknowledgements

The report was drafted by Dr Devaki Nambiar (Research Scientist, Public

Health Foundation of India (PHFI), and Dr Manasigan Kanchanachitra

(Faculty, Institute for Population and Social Research, Mahidol University,

Thailand) following discussions with workshop participants, trainers and

organizers. It has been cleared for dissemination by all stakeholders.

Particular thanks for this report are due to Shri Mukti Khanal (Director,

Family Health Division, Nepal Department of Health Services, Nepal), Shri

Subas Adhikari (Statistical Officer, National Planning Commission, Nepal

Ministry of Health and Population, Nepal), Shri Dopo (Senior Statistical

Officer, Ministry of Health, Bhutan) and Dr Champika Wickramasinghe

(Director, Health Information and acting Senior Assistant Secretary, Medical

Services, Ministry of Health, Sri Lanka). Inputs from other workshop

participants in the discussions and deliberations at the workshop are

gratefully acknowledged. The discussions and final report gained much

from technical support and guidance provided by Dr Ahmad Reza

Hosseinpoor (WHO/HQ Technical Officer). Dr Devaki Nambiar also

carried out detailed review and technical editing of all reports derived from

this workshop, with assistance of Ms Anne Schlotheuber (WHO/HQ

Technical Officer).

The workshop was organized and coordinated with the efforts and

key inputs of Dr Prakin Suchaxaya (Coordinator, Gender Equity and

Human Rights, WHO-SEARO), Dr Suvajee Good (Health Education

Specialist, WHO-SEARO) and Ms Benedicte Briot (Technical Officer,

Gender, Equity and Human Rights, WHO-SEARO). Dr Ahmad Reza

Hosseinpoor designed and facilitated the workshop. Ms Anne Schlotheuber

contributed to the preparation of the workshop materials. Dr Oscar Jesus

Alberto Mujica (Advisor, Social Epidemiology, WHO-AMRO/PAHO),

Dr Nandita Bhan (Research Scientist, PHFI, India), Dr Pojjana Hunchangsith


Thailand), Dr Manasigan Kanchanachitra (Faculty, Institute for Population

and Social Research, Mahidol University, Thailand), Dr Indranil

Mukhopadhyay (Senior Research Associate, PHFI, India), Dr Devaki

Nambiar (Research Scientist, PHFI, India) and Dr Malee Sunpuwan

vi


Thailand) contributed to the facilitation of the workshop. We also extend

our gratitude to Ms Anita Saxena (Senior Administrative Secretary, Gender

Equity and Human Rights, WHO-SEARO) for her administrative support

and Ms Nirmin Juber (Intern, WHO-SEARO) for her participation.

1

1. Introduction

1.1 Equity in health: the Nepal context

Amidst significant political instability and change, Nepal has made

significant progress in improving the health status of its people. Health

outcome indicators such as life expectancy, maternal mortality ratio, under-

5 mortality rate and infant mortality rate have all improved over the years.

Despite the overall improved health status of the people in Nepal,

inequality remains an issue of concern. Use of health services has

increased and has been associated with a reduction in inequality for many

services and for some health outcomes, but progress has been uneven and

severe inequalities remain. In some cases, there are improvements in equity

issues. Disparities between castes, ethnicities and wealth quintiles have

decreased in contraceptive use, childhood immunization, diarrhoeal

disease control and treatment for acute respiratory infection. Differences

between castes, ethnic groups and wealth quintiles in birth weight or size at

birth have also diminished. Differences in under-5 and infant mortality rates

between castes, ethnic groups and wealth quintiles have decreased.

However, despite the improvements in inequality, large gaps between

castes, ethnicities and wealth quintiles still remain in Nepal and must not be

overlooked.

Disparities in some areas, such as maternity care, have increased for

much of the period, although recent policy initiatives have begun to close

the gaps. The wealthiest women are still 12 times more likely to use a

trained health worker during delivery than the poorest. At the same time,

differences in neonatal mortality rates between Brahmins/Chhetris and

Dalits, and between Newars and Janajatis, have increased.

Measuring and Monitoring Health Disparities: A Post-Workshop Report

2

1.2 Nepal’s policy commitment to health equity

Equity in health was given significant policy thrust through Nepal’s National

Health Policy in 1991. The primary objective of the health policy was to

upgrade the health standards of the majority of the rural population by

extending basic primary health services up to the village level and to

provide the opportunity to the rural populations to access modern medical

facilities. The focus initially was on reducing urban-rural disparities. Equity

was further emphasized in the second long-term health plan from 1997 to

2017. This plan aims to improve access to assure that all people,

particularly those whose health needs are not often met, are able to use

services at rates that are proportional and appropriate to their need for

care. The most vulnerable groups identified are women and children, rural

populations, the poor and those otherwise disadvantaged and marginalized.

Equity received a major thrust as part of Nepal’s people movement in

2006. After this, the Interim Constitution of Nepal in 2007 promised health

as a fundamental right, stating that every citizen shall have the right to basic

free-of-cost health services from the state as provided by law. The Ministry

of Health and Population also endorsed a Health Sector Gender Equality

and Social Inclusion Strategy in 2009, with the aim to increase access and

use of essential health-care services by all citizens, especially by the

disadvantaged, marginalized and backward target groups specified by the

states. The ministry is also committed to improving the quality of health

services, ensuring equal and equitable treatment for all citizens. The notion

of equity as stated in the earlier policies, plan and strategy was reflected in

the Nepal Health Sector Programme II 2010-15, where one of its important

aims is to bring equity in the use of quality health services by all people of

Nepal.

At present, equity in health services is a central concern of every

health plan, strategy and programme. The current Health Management

Information System (HMIS) reports regular service delivery use and

estimates service coverage. However, the current system does not yet

undertake health inequality monitoring; policy and decision-makers need

additional information to make appropriate evidence-informed decisions to

address existing inequity in the health sector of Nepal. There is, therefore, a

strong rationale for inequality monitoring to be performed and introduced

into routine health systems monitoring across the country.

Inequality in Reproductive, Maternal and Child Health in Nepal

3

2. Methodology

Drawing from a larger inventory of reproductive, maternal and child health

indicators for the South-East Asia Region, for Nepal, eight health service

indicators related to reproductive, child and maternal health were

examined. These were: satisfaction with family planning needs; two

indicators of coverage of antenatal care over a 3-year period (at least one

visit by a skilled provider, and four or more visits); the presence of a skilled

birth attendant; early initiation of breastfeeding; DTP3 vaccination; care-

seeking for pneumonia; and access to oral rehydration therapy. These eight

indicators were chosen in the course of group work at the larger regional

meeting.

In addition to the eight health services indicators assessed, we also

looked at three child nutrition outcome indicators: stunting (height for age);

underweight (weight for age); and wasting (weight for height) in children

less than 5 years. Improving nutritional status of children and women has

been recognized as a top priority by the Nepali Government, as

malnutrition remains a major contributor to child health problems.

Although the situation of chronic malnutrition has improved since 2001,

Nepal remains one of the most malnourished countries in the world, with

concentration being in the mid- and far-west hill and mountainous regions,

and in the central Terai. Unfortunately, the national nutrition action plan,

prepared in 2007, was never finalized. The full definitions of all the

indicators assessed are presented in Annex 1.

Each health indicator selected was assessed across five different

dimensions of inequality: wealth, education, area, region and sex. These

dimensions were chosen as they have been previously used widely in the

literature. Notably, the specific indicator used to stratify individuals into

wealth quintiles was an asset-based index derived from information on

specific household asset ownership collected by Demographic and Health

Surveys (DHS). Asset-based indices derived through principal component

analyses had previously been shown to have a high correlation with other

indicators of socioeconomic positions, such as income and expenditure,

although they do have certain limitations, which have been explored in the

literature (Howe, Hargreaves and Huttly, 2008; Howe et al., 2012; Vyas

and Kumaranayake, 2006).


4

The estimates used for our assessment of inequalities in Nepal were

extracted from the Health Equity Monitor database of the WHO Global

Health Observatory (GHO).1

These estimates are derived from the re-

analysis of the publicly available DHS micro-data. Four rounds of DHS have

been conducted in Nepal – in 1996, 2001, 2006 and 2011 – allowing for

assessment of progress on these indicators across four different time points,

spanning over 15 years.

Calculations of summary measures of inequality (including range

difference, between-group variance and slope index of inequality to

measure absolute inequality and range ratio and Theil index to measure

relative inequality) for each indicator were conducted using HD*Calc, a

publicly available software program specifically designed for the purpose of

performing such calculations (see http://seer.cancer.gov/hdcalc/ for more

information). All visualizations were done using Microsoft Excel. The

calculations of simple summary measures were double-checked using

Excel.

For each indicator, three aspects were assessed: 1) the latest status

(from DHS 2011); 2) the time trend (going as far back as DHS 1996); and

3) benchmarking against other countries in the Asia-Pacific Region and

against national targets. We selected 13 neighbouring countries as

comparison in the benchmarking assessment. We restricted our assessment

to only the low- and middle-income countries in the Asia-Pacific Region (26

countries), of which only 13 countries, other than Nepal, had recent

publicly available international household health data on the selected

indicators (DHS or Multiple Indicator Cluster Survey (MICS) from 2005 to

2010). These countries included Bangladesh, Bhutan, Cambodia, India,

Indonesia, Lao People’s Democratic Republic, Maldives, Mongolia,

Philippines, Thailand, Timor-Leste, Vanuatu and Viet Nam. In cases where

recent data for a specific country were not available, that country was

dropped from the assessment.

1 Data were derived from the re-analysis of publicly available Demographic and Health Surveys (DHS) micro-data,

using the standard indicator definitions as published in DHS documentation. The analysis was carried out by the

International Center for Equity in Health, based in the Federal University of Pelotas, Brazil. In some cases there

may be slight differences between these results and those reported in DHS country reports due to differences in

the calculation of indicator numerators and/or denominators. Disaggregated data were extracted from the WHO

Health Equity Monitor database in December 2013, and subsequent updates are likely to have occurred.

(http://apps.who.int/gho/data/node.main.HE-1540?lang=en).


5

These countries, and the Asia-Pacific Region overall, are quite diverse.

Nonetheless, by comparing Nepal with these countries, we hoped to

expand our understanding of the broader context with which to interpret

information on health inequalities. Countries of the Asia-Pacific Region may

share many similar underlying causes of health inequalities, meaning that

inequalities in certain health indicators may be challenging across the

Region (AP-Health GAEN, 2011). Through a benchmarking comparison

with other countries in the Region, we can develop a greater understanding

of the context with which to assess priority areas where action is warranted

to reduce health inequalities in Nepal.

All assessments were conducted during a week-long workshop on

inequality monitoring from 8 to 11 April, 2014, in Jaipur, India (a full list of

participants is provided in Annex 2).

Participants from Nepal and Sri Lanka, assisted by trainers from

technical institutes in India and Thailand, discussed tables and graphs

demonstrating the values of indicators by each equity stratifier and

summary measures of inequality for Nepal. A template was filled with

notes, drawing from Excel chart views and discussion of summary measures

of inequality in HD*Calc. During the plenary session, the best and worst

performing indicators were presented and discussed.

Participants were asked to examine the national coverage, absolute

inequality and relative inequality for each indicator based on

benchmarking, time trend and latest status (Table 1, 2 and 3). Participants

scored each indicator in these subcategories on a scale of 1 to 3:

“1” (green) indicated that no action was needed;

“2” (yellow) indicated that action was needed; and

“3” (red) indicated urgent need for action.

During the final plenary, sample indicators showing key aspects of

health inequality analysis across benchmarking, trend and latest status

analytic approaches were identified and discussed.

It should be noted that there was some degree of subjectivity on the

part of workshop participants in assigning these scores. To make the process

more reflexive and objective, group members developed decision rules for

interpreting the data and prioritizing the need for action. These decision

rules are summarized in Box 1.


6

Box 1: Decision rules for priority-setting inequality monitoring results

Overall

All inequality should be addressed with action (i.e. action must be taken even if the

wealthiest quintile is not doing early breastfeeding).

For certain services, such as satisfaction with family planning services, we do not require

or expect 100% coverage. Therefore, even if coverage is lower than 100%, action may

not be required.

Benchmarking

Looking at national averages, for indicators whose programmatic response will be linked

(e.g. under-5 stunting and under-5 underweight), if urgent action is needed for one, at

least some action is needed on others as well.

Trend

Inequality should always be decreasing; if it is not changing, then some action (not

urgent) is required.

Indicators that show great variation over time require action. Especially if data are only

there for fewer than four time-points, reported data may be considered unreliable. To

address this, the action recommended is improved sensitivity and specificity in

monitoring this indicator.

Latest status

Action to address absolute inequality is required when the range difference of an

indicator exceeds 10 units, and if between-group variance is around or above 30 units.

Action to address relative inequality is required when the range ratio exceeds 1.5 and

the Theil index value is around or above 30 units.

Urgent action is needed to address absolute inequality if range difference exceeds 20

points and for ordinal stratifiers, if the absolute value of the slope index of inequality

exceeds 30 units.

Urgent action is needed to address relative inequality if the range ratio exceeds 3 and

similarly high values are observed on the Theil index (around or above 50 units

recognized).


7

The situation analysis developed during the workshop was finalized by

a small subset of workshop participants with assistance from WHO. This

report is intended as a preliminary document demonstrating how maternal

and child health inequalities may be understood, reported and used for

priority-setting in Nepal. The activities described here should be

undertaken by a larger and wider range of stakeholders from government,

academia and civil society and be equipped with comprehensive

information about Nepal’s maternal and child health burdens and

programmes, involvement with the country’s health information

management systems as well as DHS processes, and a role in the use of

health systems monitoring for decision-making at the national level.

Certain terminology related to health inequality monitoring may not

be familiar to all audiences. The WHO handbook on health inequality

monitoring, which describes the terminology and additional considerations

for health inequality monitoring, can be reviewed for more information

(WHO, 2013).

3. Trends and latest status in maternal and child

health indicators

3.1 National coverage of health services, 1996–2011

Between 1996 and 2011, Nepal increased national coverage of all eight

indicators assessed. These indicators are as follows:

family planning needs satisfied;

antenatal care (one visit);

antenatal care (four or more visits);

presence of a skilled attendant at birth;

early breastfeeding;

DTP3 immunization;

care-seeking for pneumonia;

oral rehydration therapy for children.


8

The greatest increase in coverage between 1996 and 2011 took place

in antenatal care. The proportion of households reporting four or more

visits increased from 9% in DHS 1996 to 51.6% coverage in 2011, while

the proportion of households reporting one visit grew from 23.7% in DHS

1996 to 59.4% according to DHS 2011 (Table 4). DTP3 immunization also

showed a 38.3-point increase from 53.5% coverage in 1996 to 91.8% in

DHS 2011. The remaining indicators showed modest increases, ranging

from a 25-point to a 30-point increase. The one exception was a plateau

effect in the indicator for satisfaction of family planning needs, which grew

from 47.5% in DHS 1996 to 66.1% in DHS 2006, and was 65% in DHS

2011.

Latest status: These gains notwithstanding, only DTP3 immunization

(91.8%) and oral rehydration therapy for children with diarrhoea (46.7%)

are indicators that are close to or surpass national targets of 100% and 40%

respectively. Moderate coverage was seen for family planning, antenatal

care (one visit), which is above 50%. All other indicators were below 45%

and far from national targets: these include the presence of a skilled

attendant at birth (national coverage of 40.5% as against the national target

of 60%), early initiation of breastfeeding (at 44.9% as against a national

target of 60%) and care-seeking for pneumonia (43.2% national coverage).

3.2 National child nutrition outcomes 2001–2011

DHS data on child nutrition outcomes were examined for 2001, 2006 and

2011, as these data were not available for 1996. The greatest declines were

seen for stunting (height for age) in children under 5 years, reducing almost

17 points over a decade, from 57.2% in 2001 to 40.3% in DHS 2011.

Underweight (weight for age) in children under 5 years declined from 43%

in DHS 2001 to 28.5% in DHS 2011, close to a 14.5 point decadal

decrease. Wasting (weight for height) in children under 5 years actually

increased from 11.3% in DHS 2001 to 12.7% in DHS 2006, subsequently

declining in DHS 2011 to 10.9%.

Latest status: Nepal’s target for stunting was 28% of the population;

according to DHS 2011, the prevalence of stunting was 40.3%. The target

for prevalence of underweight in Nepal has been met: as per DHS 2011,

the prevalence of stunting was 28.5% as against the national target of 29%.

With regard to wasting, the national target of 5% is about half the

prevalence reported in DHS 2011 (10.9%).


9

3.3 Inequality in health services by wealth, 1996–2011

Of the eight health service indicators assessed, Nepal achieved decreases in

wealth-based inequality for two – between DHS 1996 and DHS 2011

(Table 5). The indicators that showed decreases in wealth-based inequality

include satisfaction in family planning and DTP3 vaccination. DTP3

vaccination, in particular, achieved an important reduction in inequality

during this 15-year span. The absolute inequality decreased from 41.1

percentage points in 1996 to 10.3 percentage points in 2011. Similarly in

relative inequality, the relative ratio decreased from 2.0 to 1.1 in the same

period. DTP3 vaccination coverage started out in 1996 with observable

wealth-based inequality.

However, coverage in the lower quintiles increased more rapidly than

the highest quintile (where it was already approaching 100% coverage),

which led to convergence among quintiles. There was also a significant

reduction in wealth-based inequality in satisfaction in family planning, with

the absolute gap between the wealthiest and poorest quintiles going from

35.1 percentage points in 1996 to 16.2 percentage points in 2011. The

relative ratio of family planning satisfaction also reduced significantly, from

2.1 to 1.3.

Wealth-based inequality increased, however, in five of the eight

health service indicators considered, particularly in terms of absolute

inequality. These indicators include:

antenatal care visit (four or more);

presence of a skilled birth attendant;


care-seeking for pneumonia; and

oral rehydration therapy.

The presence of skilled birth attendant coverage had the highest level

of absolute gap between the wealthiest and poorest quintiles, increasing

from 30.8 percentage points in 1996 to 74.2 percentage points in 2011.

The gap widened rapidly primarily in the 5-year interval from 2006 to

2011. The level of coverage in the wealthiest quintile in 1996 was vastly

different from the rest of the population, and all lower quintiles improved


10

coverage slower than the wealthiest quintile, leading to increased inequality

overall. The slope index of inequality also shows a significant increase from

27.1 to 82.9 in the same period. However, the relative ratio during this 15-

year period declined from 11.6 to 7.0 (Figure 1).

Having at least one antenatal care visit showed little change in

inequality. The absolute inequality increased from 51.9 to 57.9, while the

relative ratio decreased from 6.7 to 2.6.

Figure 1: Wealth-based inequality in births attended by skilled health personnel

Source: Disaggregated data were extracted from the WHO Health Equity Monitor database in December

2013, and subsequent updates are likely to have occurred. (http://apps.who.int/gho/data/node.main.HE-

1540?lang=en)

Latest status: In DHS 2011, four of the eight health service indicators

showed lower levels of wealth-based inequality, with the absolute gap

between wealthiest and poorest quintile of less than 20 percentage points.

It should be noted, however, that this level of absolute inequality is still

considered high according to our decision rule in Box 1, but within the set

of indicators assessed, these indicators are considered to be in a ‘lower’

range. The indicators with absolute levels of inequality with less than a 20

percentage-point gap include:

family planning;

http://apps.who.int/gho/data/node.main.HE-1540?lang=en



11


DTP3 vaccination; and


All of these indicators, on the one hand, had relative ratios of

inequality of less than 1.5. The lowest level of absolute and relative

inequality was in DTP3 vaccination coverage with a difference between

poorest and wealthiest of 10.3 percentage points and a relative ratio of 1.1.

On the other hand, four of the eight indicators had high levels of

wealth-based inequality in DHS 2011, with an absolute gap between

wealthiest and poorest quintiles of over 20 percentage points. These

indicators included:

one antenatal care visit;


presence of a skilled birth attendant; and

care-seeking for pneumonia.

Three out of these four indicators had absolute gaps between 57

percentage points to 74 percentage points, with relative ratios ranging from

2.6 to 7.0. The indicator with the highest level of inequality was the

presence of a skilled birth attendant.

3.4 Inequality in child health outcomes by wealth 2001–2011

Wealth-based inequality in child health outcomes did not show substantial

change from 2001 to 2011. However, two of the three indicators show a

slight increase in inequality in both absolute and relative measures. The gap

between the poorest and the wealthiest quintiles in stunting in children

under 5 years increased from 25.5 to 31.3, with the relative ratio going

from 1.6 to 2.3 from 2001 to 2011. The wealth-based inequality of

underweight children also increased in absolute terms from 26.4 to 30.5,

with the relative ratio increasing from 2.0 to 4.1 in the same period.

Wasting in children seem to be the only indicator with the absolute

measure decreasing from 6.5 to 5.5 and relative range ratio from 2.0 to 1.7

(Figure 2).


12

Figure 2: Wealth-based inequality in wasting

Source: Disaggregated data were extracted from the WHO Health Equity Monitor database in

December 2013, and subsequent updates are likely to have occurred.

(http://apps.who.int/gho/data/node.main.HE-1540?lang=en)

Latest status: In DHS 2011, stunting and underweight of children

under 5 years still showed significant wealth-based inequality with the

absolute difference between the wealthiest and the poorest over 30

percentage points. The relative ratios of these two indicators were also

higher than 2. Wasting in children showed little wealth-based inequality

with the absolute difference of 5.5 percentage points and relative range

ratio of 1.7.

3.5 Inequality in health services by education, 1996–2011

Nepal achieved decreases in education-based inequality in three of the

eight health service indicators considered (Table 6). These three indicators

are as follow:


antenatal care visit (one); and

DTP3 vaccination.

DTP3 vaccination is the health indicator that achieved the highest

level of inequality reduction in terms of absolute differences, from 32.9



13

percentage points in 1996 to 11.2 percentage points in 2011. The relative

ratio also reduced substantially, from 1.7 in 1996 to 1.1 in 2011. Having

one antenatal care visit also achieved great reduction in education-based

inequality during the 15-year period, particularly the relative ratio that

declined from 4.3 to 1.7, and absolute difference declined from 53.3

percentage points to 33.5 percentage points in 15 years.

On the contrary, having antenatal care of four or more visits had an

increase in education-based inequality in absolute terms. The absolute

difference between the higher educated and lower educated increased

from 35.2 percentage points to 45.8 percentage points, although the

relative ratio decreased significantly from 8.8 to 2.5, due to a faster increase

in coverage levels in the no education group.

Early breastfeeding also saw a widening of education-based inequality.

The absolute difference increased significantly from 2.2 percentage points

to 21.0 percentage points within the 15-year span, with the slope of

inequality index from 2.3 to 34.9. In this case, the level of early

breastfeeding coverage was similar in all education groups in 1996 at

approximately 20%. However, the level of coverage increased much more

rapidly in the group with secondary or higher education level, reaching

56.2% in 2011, compared with 35.2% in the no education group in the

same year (Figure 3).

Figure 3: Education-based inequality in early breastfeeding

Source: Disaggregated data were extracted from the WHO Health Equity Monitor

database in December 2013, and subsequent updates are likely to have occurred.




14

The presence of skilled birth attendant, care-seeking for pneumonia,

and oral rehydration therapy did not achieve any significant change in

education-based inequality. The change in absolute inequality during the

15-year period was smaller than 4 percentage points.

Latest status: In DHS 2011, four of the eight service indicators had an

absolute difference of education-based inequality of less than 15

percentage points. These four indicators are as follows:


DTP3 vaccination;

care-seeking for pneumonia; and


The relative ratios of these indicators also did not exceed 1.3. The

remaining four indicators had an absolute difference ranging from 21.0

percentage points to 40.9 percentage points with antenatal care of four or

more visits having the highest absolute inequality.

3.6 Inequality in child health outcomes by education 2001–2011

All three indicators of child health outcomes that were assessed achieved a

modest decrease in education-based inequality. All of these indicators saw

a reduction of approximately 3 percentage points. However, only wasting

of children under 5 years achieved a reduction in the relative range ratio

from 2.5 to 1.9.

Latest status: Underweight of children under 5 years had the highest

level of absolute and relative education-based inequality in DHS 2011, with

the absolute difference of 21.5 percentage points and relative range ratio of

2.3. Wasting in children under 5 years had the lowest absolute difference in

inequality at 6.3 percentage points.

3.7 Inequality in health services by area, 1996–2011

Nepal achieved important reductions in area-based inequality, particularly

in three of the eight health service indicators assessed (Table 7). These


15

indicators include satisfaction in family planning, one antenatal care visit

and DTP3 vaccination. All of these indicators were able to narrow the

absolute gap between rural and urban areas by more than 10 percentage

points from 1996 to 2011. DTP3 vaccination achieved the greatest

reduction in absolute inequality between rural and urban areas, where the

difference decreased from 25.4 percentage points in 1996 to 3.4

percentage points in 2011. The relative ratio for DTP3 vaccination also

declined from 1.5 to 1.0. Antenatal care of four or more visits also achieved

a reduction in area-based inequality, although the reduction was quite

modest, with the absolute inequality decreasing from 29.8 percentage

points to 24.4 percentage points.

However, there are three health service indicators that saw an

increase in area-based inequality. These indicators are early breastfeeding,

care-seeking for pneumonia and oral rehydration therapy. Early

breastfeeding and oral rehydration therapy had a low level of area-based

inequality in 1996 with an absolute inequality of 0.9 percentage point and

0 percentage point respectively. However, in 2011, the absolute inequality

of both indicators increased to 6.2 and 8.2 respectively. Interestingly, early

breastfeeding coverage started out to be slightly higher in the rural area in

1996, but the level of coverage increased rapidly in urban area leading to

an increased inequality.

For presence of a skilled birth attendant, there was no significant

change in area-based inequality. The absolute difference between the two

areas slightly increased from 39.3 percentage points to 41.9 percentage

points. However, the relative ratio greatly reduced from 6.5 to 2.1 during

the 15-year period as the level of coverage in rural areas increased

relatively more rapidly than in urban areas (Figure 4).

Latest status: In DHS 2011, three of the eight health service

indicators had low area-based inequality of less than 10 percentage points.

DTP3 vaccination, in particular, had very low area-based inequality of 3.4

percentage points, and a relative ratio of 1.0. The other two indicators with

low area-based inequality are early breastfeeding (6.3 percentage points)

and oral rehydration therapy (8.2 percentage points). These two indicators

also had low relative ratio of 1.1 and 1.2 respectively.


16

Four health service indicators, however, still had area-based inequality

of more than 20 percentage points. The absolute difference ranged from

23.4 percentage points (care-seeking for pneumonia) to 41.9 percentage

points (presence of skilled birth attendant). The presence of skilled birth

attendant also had the highest relative ratio of 2.1.

Figure 4: Area-based inequality in presence of a skilled birth attendant

Source: Disaggregated data were extracted from the WHO Health Equity Monitor

database in December 2013, and subsequent updates are likely to have occurred.


3.8 Inequality in child health outcomes by area 2001–2011

There was no significant change in the area-based inequality in any of the

child health outcomes indicators assessed. Underweight in children under 5

years had the highest change in area-based inequality, with the absolute

difference going from 16.1 percentage points to 13.6 percentage points.

Wasting in children under 5 years saw an increase in inequality in DHS

2006, where the absolute difference was 6.1.

Latest status: In DHS 2011, wasting in children under 5 years had

very low absolute area-based inequality of 2.7 percentage points. The level

of inequality in stunting and underweight of children are also considered to

be relatively low at 14.6 percentage points and 13.6 advantage points

respectively.



17

3.9 Inequality in health services by region 1996–20062

From DHS 1996 to DHS 2001, Nepal saw an increase in region-based

inequality, and a decline in inequality between DHS 2001 and 2006 for

the following indicators:




oral rehydration therapy for children with diarrhoea.

For these four aforementioned indicators, relative region-based

inequality roughly followed the pattern of absolute inequality; that is, an

increase followed by a decline. However, the trends for individual regions

were inconsistent across indicators. For instance, it was observed that

between DHS 2001 and DHS 2006, coverage of early breastfeeding

dropped steeply in mid-western Nepal, while in the central region, it grew,

with the other three regions plateauing over a 5-year period. In contrast,

when looking at family planning satisfaction, we observed relative region-

based inequality declining over this period, albeit by a small margin. We

noted a steep increase in coverage of family planning services between

DHS 2001 and DHS 2006 in the far-western region.

A different trend was seen for a number of other indicators. From

DHS 1996 to DHS 2001, Nepal saw a slight decrease in region-based

inequality, followed by an increase in inequality between DHS 2001 and

2006 for the following indicators:

antenatal care visit (one);


Relative inequality followed the trend of absolute inequality based on

region for these two indicators: inequality decreased slightly, and then

increased again in DHS 2006. We noted that the increase in inequality was

partly due to the steep increase in antenatal care (one visit) coverage in

2 To examine region-based inequality for health service indicators, we compared DHS 1996, DHS 2001 and DHS

2006 figures. We were unable to compare the five geographic regions in DHS 1996, DHS 2001 and DHS 2006

(eastern, central, western, mid-western and far-western) to the three topographical regions reported in DHS 2011

(mountain, hill and terai).


18

mid-western Nepal between DHS 2001 and DHS 2006, along with a

plateau in coverage across all other regions. Further, while pneumonia care

coverage increased in most regions, especially in the mid-western region,

coverage in the central region seemed to plateau between DHS 2001 and

DHS 2006.

A consistent trend of declining region-based inequality – in both

absolute and relative summary measures – from DHS 1996 to DHS 2006

was seen for DTP3 immunization. A different trend was observed for skilled

attendance at birth: absolute region-based inequality increased while

relative inequality decreased. In the case of this last indicator, it may be

noted that while coverage increased in central, western and mid-western

regions of Nepal between DHS 2001 and DHS 2006, it plateaued in the

other two regions, even declining slightly in eastern Nepal.

Latest status: Region-based inequality in absolute terms – range

differences over 10 and between-group variance at or surpassing 30 – was

observed in DHS 2006 for the following indicators:


antenatal care visit (one);

skilled attendance at birth; and


Absolute inequality by region was relatively less for the following

indicators:



DTP3 immunization; and

oral rehydration therapy for children with diarrhoea.

We observed high-range differences for three of the eight indicators

(antenatal care visit (one); skilled attendance at birth; and care-seeking for

pneumonia) thereby Theil index figures were not particularly high for any of

the eight, suggesting that when population sizes of each region are

considered, relative inequality by region is not high.


19

3.10 Inequality in child nutrition outcomes by region 2001–20063

From DHS 2001 to DHS 2006, Nepal saw a slight increase in absolute

region-based inequality, a considerable increase in absolute region-based

inequality, and a decline in absolute region-based inequality in wasting.

Latest status: The degree of both absolute and relative region-based

inequality in under-5 stunting was alarmingly high according to DHS 2006

(the range difference was 18.2, the between-group variance was 31.2, the

range ratio 1.5 and the Theil index score was 180.1). Underweight

prevalence had moderate region-based inequality – both absolute and

relative. Under-5 wasting in Nepal is characterized as having a high range

ratio (1.7), although the Theil index figure (0.02) suggests that region-based

relative inequality is not a major concern.

3.11 Inequality in health services by sex, 1996–2011

From DHS 1996 to DHS 2011, we found very little change in sex-based

inequality across the four measured indicators. In fact, the small inequalities

that existed in DHS 2001 and DHS 2006 between males and females

declined by DHS 2011 in two of them (DTP3 immunization and care-

seeking for pneumonia).

The one exception was oral rehydration therapy for children with

diarrhoea, where inequality appears to have increased (Figure 5). We found

that while in DHS 1996, coverage for males was slightly higher than that of

females (15.9% versus 13.4%) as coverage grew for both sexes, so did

inequality over the subsequent 15 years (52.9% coverage for males versus

38.1% coverage for females in DHS 2011).

3 To examine region-based inequality for child nutrition outcome indicators, we compared DHS 2001 and DHS

2006 figures. No regional figures for stunting, underweight and wasting were publicly available for DHS 1996.

Further, we were unable to compare the five geographic regions in DHS 2001 and DHS 2006 (eastern, central,

western, mid-western and far-western) to the three topographical regions reported in DHS 2011 (mountain, hill

and terai).


20

Figure 5: Sex-based inequality in ORT coverage

0

10

20

30

40

50

60

70

80

90

100

1996 2001 2006 2011

Pe

rce

nta

ge

female

male

Source: Disaggregated data were extracted from the WHO Health Equity Monitor database in December

2013, and subsequent updates are likely to have occurred. (http://apps.who.int/gho/data/node.main.HE-

1540?lang=en)

Latest status: In DHS 2011, virtually no absolute or relative sex-based

inequality was observed in three of the four indicators. In the case of oral

rehydration therapy, however, coverage for males was found to be higher

compared with females; the range difference between the two was 14.8

while the range ratio was 1.4.

3.12 Inequality in child nutrition outcomes by sex 2001–2011

Between DHS 2001 and DHS 2011, we found no sex-based absolute or

relative inequality in stunting, underweight or wasting.

Latest status: In DHS 2011, there was no absolute or relative

inequality by sex in any of the three indicators of child nutrition assessed.




21

4. Benchmarking of Nepal against other countries

4.1 National coverage

Nepal was benchmarked against 13 other low- and middle-income

countries in the Asia-Pacific Region. These countries include Bangladesh,

Bhutan, Cambodia, India, Indonesia, Lao People’s Democratic Republic,

Maldives, Mongolia, Philippines, Thailand, Timor-Leste, Vanuatu and Viet

Nam.

Nepal was very successful in achieving a high national coverage in

DTP3 vaccination. Compared with other countries in the Region, it has the

fifth highest level of coverage at 91.8%. This level of coverage is

comparable with four other countries with the highest coverage levels in the

Region (Bangladesh, Maldives, Mongolia and Thailand).

However, Nepal ranked on the lower end in seven of the eight health

service indicators assessed; it was in the bottom third or worse in these

seven indicators. For care-seeking for pneumonia, Nepal ranked better than

only one other country, Bangladesh. For antenatal care of one visit,

satisfaction in family planning and presence of skilled birth attendant, Nepal

ranked better than two other countries in terms of coverage; conversely,

antenatal care of four or more visits, early breastfeeding and oral

rehydration therapy ranked better than three other countries.

4.2 Absolute and relative inequality

When benchmarked against other similar countries in the Region in terms of

wealth-based inequality, Nepal ranked on the lower end in both absolute

and relative terms for most health service indicators, with the exception of

DTP3 vaccination, where Nepal was among the countries with the least

absolute and relative wealth-based inequality. Only Bangladesh, Maldives,

Mongolia and Thailand fared better in terms of inequality (Figure 6).


22

Figure 6: Benchmarking of DTP3 vaccination

Source: Data were derived from the re-analysis of publicly available Demographic and Health Surveys (DHS)

micro-data, using the standard indicator definitions as published in DHS documentation. The analysis was carried

out by the International Center for Equity in Health based in the Federal University of Pelotas, Brazil. Graphs were

created at World Health Organization headquarters and used during the workshop.

Nepal, however, ranked towards the bottom end in terms of wealth-

based inequality for other health service indicators including antenatal care

(both one and four visits), care-seeking for pneumonia, satisfaction in family

planning and presence of skilled birth attendant. Inequalities in early

breastfeeding and oral rehydration therapy were more difficult to

benchmark, since different countries had different inequality patterns

(Figures 7 and 8).

For Nepal, inequality arose since coverage was concentrated in the

higher quintile groups; for countries such as Maldives, however, services

were concentrated in the lower quintile groups. In Maldives and Viet Nam,

for example, both early breastfeeding and oral rehydration therapy had a

higher level of coverage among poorer quintiles than in the wealthier

quintiles; the opposite is true for Nepal. Regardless of where the

concentration lies, there exists inequality that must be addressed.


23

Figure 7: Benchmarking of early breastfeeding





Figure 8: Benchmarking of oral rehydration therapy






24

5. Situation analysis, 1996–2011

5.1 Priority health services indicators

The most inequitable health service indicator across all equity stratifiers was

skilled attendance at birth: wealth, education and region-related absolute

inequality were high. In fact, a 74.2 percentage-point difference in

coverage was found between poorest and wealthiest quintiles according to

DHS 2011 (Table 5). Adjusting for population size, this indicator remains

highly unequal: the slope index of inequality was high as well (82.9). The

range ratio of 7 was the highest across all service indicators as was the

relative concentration index of 0.3. We also observed a 40.9 and 41.9

percentage-point difference, respectively, for education and area-based

inequality for skilled attendance at birth (Tables 6 and 7).

When looking at trend data, we noted that absolute inequality was

increasing for skilled birth attendance across all relevant stratifiers: wealth,

education, area and region. Absolute inequality also seemed to be

increasing for antenatal care (at least four visits). For this indicator, the range

difference across the three education categories increased from 35.2 in

DHS 1996 to 45.8 in DHS 2011, while the slope index of inequality

increased from 45.5 in DHS 1996 to 76.5 in DHS 2011. While relative

inequality by wealth and education were also increasing in the 15-year

period studied, we found that area and region-based inequality declined

during the same period.

For early initiation of breastfeeding, wealth and education-based

absolute inequality increased between DHS 1996 and DHS 2011, in both

absolute and relative terms. Area-based inequality also registered an

increase reflected in a range difference between urban and rural of 0.9 in

DHS 1996 increasing to a range difference between urban and rural of 6.2

in DHS 2011; this was reflected in a minor increase in relative inequality

over the same period. Sex-based absolute inequality also increased by a

small margin; the difference between males and females went from 0.56 in

DHS 1996 to 2.1 in DHS 2011. For this indicator, however, absolute and

relative inequality by region declined between DHS 1996 and DHS 2006

(data for DHS 2011 were unavailable).


25

We also noted that over time, while wealth and education-related

inequality were not emerging as urgent priority areas for action to address

inequality, the same could not be said for pneumonia care-seeking or ORT

coverage indicator. For these indicators, we found that area and region

inequalities were apparent. For instance, the range difference in care-

seeking for pneumonia between urban and rural areas more than doubled

from DHS 1996 to DHS 2011, while between-group variance across

regions for this same indicator grew more than five-fold between DHS

1996 and DHS 2006.

DTP3 immunization showed declines in both absolute and relative

inequality from DHS 1996 onwards, suggesting that by DHS 2011, once

the threshold of 85% coverage was achieved, the absolute wealth-related

inequality reduced by one fourth over a 15-year period (from 41.1 in DHS

1996 to 10.3 in DHS 2011). The relative wealth-related inequality, as

measured by range ratio, also halved (from 2.0 in DHS 1996 to 1.1 in DHS

2011). A similar trend was seen across stratifiers. In DHS 1996, although

less than 50% of those with no maternal education had received DTP

immunization, the proportion grew to 86.1% in DHS 2011. Coverage was

above 95% for those with higher levels of education. In terms of inequality,

this translated into major reductions in absolute and relative inequality (as

indicated by a slope index of inequality reduction from 52.9 in DHS 1996

to 19.1 in DHS 2011 and a relative concentration index of 1 in DHS 1996

and nearing 0 in DHS 2011).

Other than this indicator, we also noted that inequality was reduced

for the indicator measuring satisfaction with family planning services, which

saw reductions in inequality in all stratifiers except for the Region, and a

ceiling effect of coverage among those with secondary or higher levels of

maternal education, such that the slope index of inequality as per DHS

2011, was 17.8.

When benchmarked on wealth-based inequality against other

countries in the Region, Nepal fared poorly on all indicators but DTP3

immunization. From this vantage, all seven health service indicators

appeared to require immediate action to address both absolute and relative

inequality.


26

5.2 Priority equity stratifiers in health services

When looking at latest status, absolute inequality across stratifiers tended to

trigger the greatest call for action (Table 1). More specifically, wealth- and

education-related absolute inequality were the highest prioritized on

average, for six of the eight indicators. Relative inequality was identified as

a medium priority for wealth, education and regional stratifiers.

Looking at trend data, education-related absolute inequality emerged

as the area in need for most urgent action, followed by wealth and region

(Table 2). For these stratifiers, we noted that at least two indicators required

urgent action, and six or more indicators required some action. Area-based

inequality emerged as a priority for action over time for only three

indicators, though it is noteworthy that these pertain to skilled birth

attendance, pneumonia health-seeking and access to ORT - all indicators

that require the presence of key infrastructure and health delivery

processes, particularly in rural areas.

Sex-related inequality was seen as less in need for action. In fact, apart

from access to oral rehydration therapy, range differences were never

higher than 3 percentage points for males compared with females and for

none of the eight indicators analysed did range ratios exceed 1.5,

considering both DHS 1996 and DHS 2011.

5.3 Priority inequalities in child nutrition outcomes

The prevalence of stunting, underweight and wasting among children under

5 years were assessed by wealth, education, sex, area and region. Wealth-

related inequality, in both absolute and relative terms, was highest across all

three indicators for Nepal, with slope indices of inequality above 30 points

for under 5 stunting and underweight and over 5 for wasting as per DHS

2011. Education-related absolute inequality was also of concern across

indicators, and further, area-based and regional inequality were also of

some concern, although this trend varied somewhat over time, and by

indicator.

A key observation from trend data was that wealth-related inequalities

in stunting appeared to be on the rise in the decade between DHS 2001


27

and DHS 2011, with a disparity between the richest and poorest quintiles

increasing from 25.5 percentage points in DHS 2001 to 31.2 percentage

points in DHS 2011. This was the highest margin of inequality seen in

nutrition indicators. Regional inequality for this indicator showed a similar

trend, although the reference points were DHS 2001 and DHS 2006:

between-group variance grew from 15.2 in DHS 2001 to 31.3 in DHS

2006, while the Theil index registered an increase from 0.002 in DHS 2001

to 0.01 in DHS 2006.

Underweight showed a decadal doubling of relative wealth-related

inequality (represented by a range ratio going from 2.0 in DHS 2001 to 4.1

in DHS 2011 and the relative concentration index increasing from -0.1 to -

0.2).

For no stratifier was wasting identified as needing immediate action,

although it was thought that wealth, education and area-based inequalities

in wasting do require policy attention. For instance, both absolute and

relative area-based inequality in wasting appear to be on the rise in Nepal,

evidenced by an urban-rural gap increasing from 2.2 percentage points in

DHS 2001 to 2.7 percentage points in DHS 2011 (the range ratio also

increased from 1.2 in DHS 2001 to 1.3 in DHS 2011).

As in the case of health service indicators, sex-based inequalities were

not of concern for any of the child nutrition indicators.


28

6. Data tables

Tab

le 1

: Situatio

n analy

sis

of la

test status

Source: P

artic

ipan

ts o

f W

HO

w

orksh

op

on

M

easu

rin

g and

M

on

ito

rin

g H

ealth

In

eq

ualitie

s, h

eld

in

Ap

ril 2

01

4 in

Jaip

ur, In

dia

.

In

dic

ato

r

Natio

nal

average

In

eq

uality

Average

ineq

uality s

co

re

Wealt

h

Ed

ucatio

n

Sex

Area

Regio

n

Absolute

Relative

Absolute

Relative

Absolute

Relative

Absolute

Relative

Absolute

Relative

Absolute

Relative

Fam

ily p

lannin

g n

eed

s s

atisfied

3

2

1

2

1

2

1

2

1

2.0

1

.0

Ante

nata

l care (at

least

one v

isit)

3

3

2

3

2

2

1

2

2

2.5

1

.8

Ante

nata

l care (at

least

fou

r v

isits)

3

3

2

3

2

2

1

1

1

2.3

1

.5

Bir

ths a

ttend

ed

by s

kille

d h

ealth

personnel

3

3

3

3

2

3

2

2

2

2.8

2

.3

Early

initia

tion o

f b

reastf

eed

ing

3

2

1

3

2

1

1

2

1

2

1

2.0

1

.2

DTP

3 im

muniz

ation

1

1

1

1

1

1

1

1

1

2

1

1.2

1

.0

Care-seekin

g f

or p

neu

monia

3

3

1

2

1

1

1

3

2

2

2

2.2

1

.4

Oral rehyd

ration t

herap

y f

or

child

ren w

ith d

iarrhoea

1

2

2

2

1

2

1

2

1

2

2

2.0

1

.4

RM

CH

inte

rventions

2.5

2

.4

1.6

2

.4

1.5

1

.3

1.0

2

.1

1.3

1

.9

1.5

Stu

nting (heig

ht

for a

ge) in

child

ren

und

er 5

years

3

3

2

2

2

1

1

2

2

2

2

2.0

1

.8

Und

erw

eig

ht

(weig

ht

for a

ge) in

child

ren u

nd

er 5

years

2

3

3

3

2

1

1

2

2

2

1

2.2

1

.8

Wasting (w

eig

ht

for h

eig

ht)

in

child

ren u

nd

er 5

years

3

1

2

2

2

1

1

1

1

2

2

1.4

1

.6

CH

ou

tcom

es

2.7

2

.3

2.3

2

.3

2.0

1

.0

1.0

1

.7

1.7

2

.0

1.7


29

Tab

le 2

: Situatio

n analy

sis

of tim

e trend

s

Source: P

artic

ipan

ts o

f W

HO

w

orksh

op

on

M

easu

rin

g and

M

on

ito

rin

g H

ealth

In

eq

ualitie

s, h

eld

in

Ap

ril 2

01

4 in

Jaip

ur, In

dia

.

In

dic

ato

r

Natio

nal

average

In

eq

uality

Wealt

h

Ed

ucatio

n

Sex

Area

Regio

n

Absolute

Relative

Absolute

Relative

Absolute

Relative

Absolute

Relative

Absolute

Relative

Fam

ily p

lannin

g n

eed

s s

atis

fied

1

1

1

3

1

1

1

2

2

Antenatal care (at least o

ne vis

it)

1

2

1

2

1

1

1

2

2

Antenatal care (at least f

ou

r v

isits)

1

3

1

3

1

1

1

1

1

Bir

ths a

ttend

ed

by s

kille

d health p

ersonnel

2

3

2

3

1

3

1

3

2

Early

initia

tio

n o

f b

reastfe

ed

ing

1

3

2

3

2

1

1

2

1

2

2

DTP

3 im

muniz

atio

n

1

1

1

1

1

1

1

1

1

1

1

Care-seekin

g f

or p

neu

monia

1

2

2

2

1

2

2

3

2

3

2

Oral rehyd

ratio

n t

herap

y fo

r c

hild

ren w

ith d

iarrhoea

2

2

1

1

1

2

2

3

2

2

1

RM

CH

interventio

ns

2

.1

1.4

2

.3

1.1

1

.5

1.5

1

.9

1.3

2

.0

1.6

Stu

ntin

g (heig

ht f

or a

ge) in c

hild

ren u

nd

er 5

years

1

3

3

1

1

1

1

2

2

3

3

Und

erw

eig

ht (

weig

ht f

or a

ge) in c

hild

ren u

nd

er 5

years

1

2

3

1

1

1

1

2

3

2

2

Wastin

g (w

eig

ht fo

r h

eig

ht)

in c

hild

ren u

nd

er 5

years

2

2

2

2

1

1

1

2

2

1

1

CH

ou

tcom

es

2

.3

2.7

1

.3

1.0

1

.0

1.0

2

.0

2.3

2

.0

2.0


30

Table 3: Situation analysis of benchmarking latest status

Indicator National

average

Inequality

Wealth

Absolute Relative

Family planning needs satisfied 3 3 3

Antenatal care (at least one visit) 3 3 3

Antenatal care (at least four visits) 3 3 3

Births attended by skilled health personnel 3 3 3

Early initiation of breastfeeding 3 3 3

DTP3 immunization 1 1 1

Care-seeking for pneumonia 3 3 3

Oral rehydration therapy for children with diarrhoea 1 3 3

RMCH interventions

3 3

Stunting (height for age) in children under 5 years 3 3 2

Underweight (weight for age) in children under 5 years 2 3 2

Wasting (weight for height) in children under 5 years 3 2 3

CH outcomes

2.7 2.3

Source: Participants of WHO workshop on Measuring and Monitoring Health Inequalities, held in April 2014 in

Jaipur, India.


31

Table 4: Nepal national coverage

Indicator Year Percent Coverage

fps 1996 47.6

2011 65.0

anc13 1996 23.7

2011 59.4

anc43 1996 9.0

2011 51.6

sba3 1996 9.6

2011 40.5

ebreast3 1996 18.2

2011 44.9

dtpv 1996 53.5

2011 91.8

carepold 1996 18.2

2011 43.2

ort 1996 14.7

2011 46.7

stunt5 2001 57.2

2011 40.3

uweight5 2001 43

2011 28.5

wast5 2001 11.3

2011 10.9



out by the International Center for Equity in Health based in the Federal University of Pelotas, Brazil.


32

Table 5: Wealth-based inequality

Indicator Year Q1 Q2 Q3 Q4 Q5 Q5-

Q1 Q5/Q1

Slope

index of

inequality

(SII)

Relative

concentration

index (RCI)

fps 1996 32.7 40.7 44.5 48.1 67.7 35.1 2.1 40.5 0.146

2011 57.0 62.5 63.3 66.5 73.2 16.2 1.3 18.0 0.048

anc13 1996 9.1 17.1 19.7 27.1 61.0 51.9 6.7 49.9 0.352

2011 35.2 47.3 60.8 77.8 93.1 57.9 2.6 70.3 0.199

anc43 1996 2.8 4.6 5.8 8.6 31.5 28.7 11.3 25.5 0.493

2011 29.9 42.0 49.3 66.2 87.5 57.6 2.9 65.2 0.208

sba3 1996 2.9 5.2 6.4 9.1 33.7 30.8 11.6 27.1 0.481

2011 12.4 27.7 42.6 57.6 86.6 74.2 7.0 82.9 0.332

ebreast3* 1996 21.0 17.5 16.7 15.5 19.8 -1.2 0.9 -3.8 -0.041

2011 38.4 40.7 44.6 52.4 53.2 14.8 1.4 20.1 0.072

dtpv 1996 40.5 46.7 51.8 61.1 81.6 41.1 2.0 43.0 0.133

2011 88.1 89.7 90.5 96.7 98.4 10.3 1.1 12.6 0.024

carepold * 1996 11.6 16.6 18.6 22.4 26.6 15 2.3 17.5 0.166

2011 30.2 35.1 54.6 45.6 50.1 19.9 1.7 25.3 0.092

ort* 1996 11.2 12.4 16.0 18.4 20.1 8.9 1.8 11.5 0.134

2011 46.5 45.6 38.0 56.4 54.1 7.6 1.2 9.2 0.043

stunt5 2001 67.7 61.1 54.1 53.3 42.2 -25.5 0.6 -28.3 -0.082

2011 56.2 45.3 35.0 30.0 24.9 -31.3 0.4 -39.6 -0.168

uweight5 2001 51.8 46.7 44.7 38.1 25.4 -26.4 0.5 -27.9 -0.105

2011 40.4 32.0 28.4 21.9 9.9 -30.5 0.2 -33.3 -0.197

wast5 2001 12.9 13.1 12.1 9.9 6.6 -6.3 0.5 -6.9 -0.095

2011 12.3 11.5 13.0 8.1 7.5 -4.8 0.6 -5.6 -0.090

Source: Disaggregated data were extracted from the WHO Health Equity Monitor database in December 2013,

and subsequent updates are likely to have occurred. (http://apps.who.int/gho/data/node.main.HE-1540?lang=en)



33

Table 6: Education-based inequality

Indicator Year None Primary Secondary+ Secondary-

None

Secondary/

None SII RCI

fps 1996 45.9 46.0 60.9 15 1.3 16.1 0.031

2011 70.3 61.1 60.0 -10.3 0.9 -17.8 -0.039

anc13 1996 16.1 39.6 69.4 53.3 4.3 76.8 0.269

2011 45.3 54.0 78.8 33.5 1.7 55.1 0.133

anc43 1996 4.5 14.7 39.7 35.2 8.8 45.5 0.424

2011 30.1 53.2 75.9 45.8 2.5 76.5 0.213

sba3 1996 5.1 14.9 42.7 37.6 8.4 46.8 0.403

2011 23.8 35.1 64.7 40.9 2.7 66.8 0.236

ebreast3 1996 18.0 18.0 20.2 2.2 1.1 2.3 0.010

2011 35.2 44.7 56.2 21 1.6 34.9 0.112

dtpv 1996 48.5 68.3 81.4 32.9 1.7 52.9 0.078

2011 86.1 95.3 97.3 11.2 1.1 19.1 0.030

ort 1996 12.8 22.0 25.1 12.3 2.0 20.7 0.108

2011 43.1 42.4 55.1 12 1.3 17.9 0.1054

stunt5 2001 61.4 50.5 39.8 -21.6 0.6 -32.9 -0.1057

2011 47.5 41.2 29.3 -18.2 0.6 -29.6 -0.104

uweight5 2001 47.8 34.5 23.9 -23.9 0.5 -37.4 -0.1086

2011 37.9 26.1 16.4 -21.5 0.4 -35.9 -0.2178

wast5 2001 12.8 9.3 5.1 -7.7 0.4 -11.2 -0.1099

2011 13.4 11.6 7.1 -6.3 0.5 -10.1 -0.131





34

Table 7: Area-based inequality

Indicator Year Rural

Coverage

Urban

Coverage

Urban-

Rural Urban/Rural

fps 1996 45.1 69.8 24.7 1.5

2011 63.4 75.5 12.1 1.2

anc13 1996 20.7 67.3 46.6 3.3

2011 56.2 89.6 33.4 1.6

anc43 1996 7.0 36.8 29.8 5.3

2011 49.2 73.6 24.4 1.5

sba3 1996 7.1 46.5 39.4 6.5

2011 36.7 78.5 41.8 2.1

ebreast3 1996 18.2 17.4 -0.8 1

2011 44.3 50.5 6.2 1.1

dtpv 1996 52.0 77.4 25.4 1.5

2011 91.5 94.9 3.4 1

carepold 1996 17.6 28.5 10.9 1.6

2011 40.6 64.0 23.4 1.6

ort 1996 14.7 14.7 0 1

2011 45.9 54.1 8.2 1.2

stunt5 2001 58.3 42.7 -15.6 0.7

2011 41.6 26.9 -14.7 0.6

uweight5 2001 44.1 28.0 -16.1 0.6

2011 29.8 16.2 -13.6 0.5

wast5 2001 11.5 9.3 -2.2 0.8

2011 11.2 8.5 -2.7 0.8





35

Tab

le 8

: Regio

n-based

in

equality

Source: D

ata w

ere d

eriv

ed

fro

m th

e r

e-an

aly

sis

of p

ublicly

availab

le D

em

ograph

ic and

H

ealth

Su

rveys (D

HS) m

icro

-d

ata, u

sin

g th

e stand

ard

in

dic

ato

r

defin

itio

ns as p

ub

lish

ed

in

DH

S d

ocu

men

tatio

n. Th

e an

aly

sis

w

as carrie

d o

ut b

y th

e In

tern

atio

nal C

en

ter fo

r Eq

uity in

H

ealth

based

in

the Fed

eral U

niv

ersity o

f

Pelo

tas, B

razil.

Tab

le 8

: Regio

n-based

in

equality


36

Table 9: Sex-based inequality

Indicator Year Male Female Male-Female Male/Female

ebreast3 1996 17.9 18.5 -0.6 1.0

2011 45.9 43.8 2.1 1.0

dtpv 1996 54.9 52.2 2.7 1.1

2011 92.3 91.3 1.0 1.0

carepold 1996 18.2 18.2 0.0 1.0

2011 43.1 43.2 -0.1 1.0

ort 1996 15.9 13.4 2.5 1.2

2011 52.9 38.1 14.8 1.4

stunt5 2001 57.2 57.2 0.0 1.0

2011 41.2 39.3 1.9 1.0

uweight5 2001 42.6 43.4 -0.8 1.0

2011 29.1 27.9 1.3 1.0

wast5 2001 12.4 10.3 2.1 1.2

2011 11.9 10.0 1.9 1.2





37

Table 10: National coverage of health services benchmarking against

comparable countries

Ind

icato

r

Calc

ula

tio

n

Ban

gla

desh

Bh

uta

n

Cam

bo

dia

Ind

ia

Ind

on

esia

Lao

PD

R

Mald

ives

Mo

ngo

lia

Nep

al

Ph

ilip

pin

es

Th

ail

an

d

Tim

or-Leste

Van

uatu

Vie

t N

am

Survey Year 2011 2010 2010 2005 2012 2011 2009 2010 2011 2008 2005 2009 2007 2010

anc13

Coverage 54.6 97.2 90.5 73.1 95.9 54.2 99.4 99.0 59.4 91.0 97.8 85.7 84.3 93.7

SII 65.7 5.5 24.4 54.2 19.2 78.2 2.5 -0.3 65.3 34.2 3.5 30.1 12.0 32.0

RCI 0.2 0.0 0.0 0.1 0.0 0.3 0.0 0.0 0.2 0.1 0.0 0.1 0.0 0.0

anc43

Coverage 25.5 77.3 61.7 35.8 87.4 36.9 85.4 81.4 51.6 76.8 NA 54.7

59.6

SII 49.3 34.9 45.1 70.6 34.3 79.7 -7.1 2.8 61.2 41.4 NA 34.3

72.8

RCI 0.3 0.1 0.1 0.4 0.1 0.4 0.0 0.0 0.2 0.1 NA 0.1

0.2

carepold

Coverage 33.2 NA 75.8 68.7 74.4 NA 78.7 NA 43.2 45.9 NA 69.6

SII 29.8 NA 7.1 22.3 18.0 NA 7.2 NA 25.1 14.6 NA 20.6

RCI 0.2 NA 0.0 0.1 0.0 NA 0.0 NA 0.1 0.0 NA 0.1

dtpv

Coverage 93.4 NA 84.8 55.4 72.2 55.5 97.9 92.7 91.8 85.6 93.6 66.4 63.4 73.9

SII 10.9 NA 25.3 55.6 38.0 53.0 -1.1 4.1 13.3 28.7 -3.4 24.6 23.1 30.9

RCI 0.0 NA 0.0 0.2 0.1 0.2 0.0 0.0 0.0 0.1 0.0 0.1 0.1 0.1

ebreast3

Coverage 46.6 59.0 66.9 24.0 51.6 39.1 63.5 71.4 44.9 52.5 49.6 81.6 71.9 39.7

SII -7.2 7.4 5.6 18.4 -2.8 22.3 -12.9 -6.5 20.0 -12.7 -13.5 7.2 13.6 -26.9

RCI 0.0 0.0 0.0 0.1 0.0 0.1 0.0 0.0 0.1 0.0 0.0 0.0 0.0 -0.1

fps

Coverage 84.3 NA 75.6 81.6 88.6 NA 55.9 NA 65.0 69.4 NA 42.1

SII -2.8 NA 17.0 22.4 2.7 NA 0.7 NA 17.9 13.4 NA 32.8

RCI 0.0 NA 0.0 0.0 0.0 NA 0.0 NA 0.0 0.0 NA 0.1

fullv

Coverage 86.0 NA 78.8 43.7 65.7 43.7 92.9 78.5 87.1 79.5 89.7 52.6 38.0 60.7

SII 19.3 NA 28.4 53.7 35.9 39.9 -5.8 1.5 12.2 30.3 -7.6 10.0 20.0 27.1

RCI 0.0 NA 0.1 0.2 0.1 0.2 0.0 0.0 0.0 0.1 0.0 0.0 0.1 0.1

sba3

Coverage 31.7 64.4 75.9 48.8 85.1 41.5 96.8 98.8 40.5 64.3 97.3 31.8 74.0 92.9

SII 60.3 72.8 52.6 74.8 46.7 84.0 11.5 2.2 74.6 79.1 9.2 64.6 39.2 46.9

RCI 0.3 0.2 0.1 0.3 0.1 0.4 0.0 0.0 0.3 0.2 0.0 0.4 0.1 0.1

NA – Not available.



out by the International Center for Equity in Health based in the Federal University of Pelotas, Brazil.


38

7. References

AP-HealthGAEN. An Asia Pacific spotlight on health inequity: Taking

action to address the social and environmental determinants of health

inequity in Asia Pacific. Report of the Asia Pacific hub of Global Action for

Health Equity Network. 2011.

Howe LD, Hargreaves JR, Huttly SR. Issues in the construction of wealth

indices for the measurement of socio-economic position in low-income

countries. Emerging Themes in Epidemiology. 2008;5:3.

doi:10.1186/1742-7622-5-3.

Howe LD, Galobardes B, Matijasevich A, et al. Measuring socio-economic

position for epidemiological studies in low- and middle-income countries:

a methods of measurement in epidemiology paper. International Journal

of Epidemiology. 2012;41(3):871-886. doi:10.1093/ije/dys037.

Vyas S, Kumaranayake L. Constructing socio-economic status indices: how

to use principal components analysis. Health Policy and Planning. 2006,

21(6):459-468. doi: 10.1093/heapol/czl029

World Health Organization. Handbook on health inequality monitoring:

with a special focus on low- and middle-income countries. Geneva:

World Health Organization; 2013

(http://apps.who.int/iris/bitstream/10665/85345/1/9789241548632_eng.p

df).


39

Annex 1

Definitions of indicators and coding key

Code Indicator Definition

anc13 /

anc15

Antenatal care

coverage (at least

one visit)

Percentage of women aged 15-49 years with a live birth

in the 3 years (anc13) or 5 years (anc15) preceding the

survey, attended at least once during pregnancy by

skilled health personnel for reasons related to the

pregnancy. Skilled health personnel include doctors,

nurses, midwives and other medically-trained personnel,

as defined according to each country.

anc43 /

anc45

Antenatal care

coverage (at least

four visits)

Percentage of women aged 15-49 years with a live birth

in the 3 years (anc43) or 5 years (and45) preceding the

survey, attended at least four times during pregnancy by

any provider (skilled or unskilled) for reasons related to

the pregnancy.

carepold

Children aged less

than 5 years with

pneumonia

symptoms taken to

a health facility

Percentage of children aged 0-59 months with

pneumonia symptoms in the two weeks prior to the

survey who were taken to an appropriate health

provider.

dtpv

DTP immunization

coverage among 1-

year-olds

Percentage of 1-year-olds who have received three doses

of DTP (diphtheria-pertussis-tetanus) vaccine.

ebreast3

/

ebreast5

Early initiation of

breastfeeding

Percentage of children who were put to the breast within

one hour of birth in the 3 years (ebreast3) or 5 years

(ebreast5) preceding the survey.

fps Demand for family

planning satisfied

Percentage of women aged 15-49 years, married or in

union, who are currently using any method of

contraception, among those in need of contraception.

Women in need of contraception include those who are

fecund but report wanting to space their next birth or

stop child bearing altogether.

sba3 /

sba5

Births attended by

skilled health

personnel

Percentage of live births attended during delivery by

skilled health personnel, in the 3 years (sba3) or 5 years

(sba5) preceding the survey. Skilled health personnel

include doctors, nurses, midwives and other medically-

trained personnel, as defined according to each country.


40

Code Indicator Definition

ort

Children aged less

than 5 years with

diarrhoea receiving

oral rehydration

therapy and

continued feeding

Percentage of children aged 0-59 months who had

diarrhoea in the two weeks prior to the survey and were

treated with oral rehydration therapy - oral rehydration

salts or an appropriate household solution - and

continued feeding.

stunt5

Stunting prevalence

in children aged <

5 years

Percentage of children aged 0-59 months who are

stunted (defined as more than two standard deviations

below the median height-for-age of the WHO Child

Growth Standards).

wast5

Underweight

prevalence in

children aged < 5

years

Percentage of children aged 0-59 months who are

underweight (defined as more than two standard

deviations below the median weight-for-age of the WHO

Child Growth Standards).

uweight

Wasting prevalence

in children aged <

5 years

Percentage of children 0-59 months who are wasted

(defined as more than two standard deviations below the

median weight-for-height of the WHO Child Growth

Standards).

For more-detailed definitions of health indicators, including the criteria used to calculate numerator and

denominator values, see the World Health Organization Indicator and Measurement Registry:

http://apps.who.int/gho/indicatorregistry/App_Main/indicator_registry.aspx.

http://apps.who.int/gho/indicatorregistry/App_Main/indicator_registry.aspx


41

Annex 2

List of participants

Bangladesh

Mr Monir Ahmed

Statistical Officer

Bangladesh Bureau of Statistics

Ministry of Planning

Dhaka, Bangladesh

Bhutan

Mr Dopo

Statistical Officer

Planning Policy Division

Ministry of Health

Thimphu, Bhutan

India

Mr Ankit Mishra

Assistant Director (Statistics)

Ministry of Health and Family Welfare

New Delhi, India

Mr Mitter Sain

Director

Programme Implementation Wing

Ministry of Statistics and Programme

Implementation

New Delhi, India

Indonesia

Mrs Mariet Tetty Nuryetty

Head of Sub-Directorate of Health Statistics

and Housing

Bureau of Central Statistics

Jakarta, Indonesia

Mrs Istiqomah Andjari Karnomo

Staff of Division of Information Dissemination

and Analysis

Center for Data and Information

Ministry of Health

Jakarta, Indonesia

Maldives

Ms Aishath Naaz

Assistant Research Officer

Ministry of Health and Gender

Male, Maldives

Ms Aishath Maharath

Lecturer

Faculty of Health Science/Maldives National

University

Male, Maldives

Myanmar

Dr (Ms) Ohn Mar Kyi

Deputy Director (Health Information)

Department of Health Planning

Naypyitaw, Myanmar

Nepal

Mr Mukti Khanal

Deputy Director

HMIS, DHS

Ministry of Health and Population

Kathmandu, Nepal

Mr Subhash Adhikari

Statistical Officer

National Planning Commission

Ministry of Health and Population

Kathmandu, Nepal

Sri Lanka

Dr (Mrs) S C Wickramasinghe

Director-Health Information

Ministry of Health

Colombo , Sri Lanka


42

Thailand

Mrs Chujit Nacheeva

Statistician

Health Information Division

Bureau of Policy and Strategy

Office of the Permanent Secretary

Ministry of Public Health

Nonthaburi, Thailand

Timor-Leste

Mr Miguel Maria

Monitoring and Evaluation Officer

Planning and Monitoring Department

Ministry of Health

Dilli, Timor-Leste

Special Invitees

Dr Nandita Bhan

Research Scientist

Public Health Foundation of India

New Delhi, India

Dr Indranil Mukhopadhyay

Senior Research Associate


New Delhi, India

Dr Devaki Nambiar

Research Scientist


New Delhi, India

Dr Malee Sunpuwan

Institute for Population and Social Research

Mahidol University

Salaya, Phuthamonthon

Nakhonpathom, Thailand

Dr Pojjana Hunchangsith


Mahidol University



Dr Manasigan Kanchanachitra


Mahidol University



WHO Secretariat

WHO/HQ

Dr Ahmad Hosseinpoor

Technical Officer

World Health Organization

Geneva, Switzerland

Ms Theadora Swift Koller

Technical Officer, Equity


Geneva, Switzerland

Country Offices

Ms Rustini Floranita

National Professional Officer


Jakarta, Indonesia

Dr Paul Francis

Technical Officer

Maternal and Child Health


New Delhi, India

Ms Anika Singh

Technical Officer

Gender, Equity and Human Rights


New Delhi, India

Regional Office

Dr Oscar Jesus Alberto Mujica

Advisor, Social Epidemiology, AMOR


Washington D.C., U.S.A.


43

Dr Prakin Suchaxaya

Coordinator



New Delhi, India

Dr Suvajee Good

Health Education Specialist


New Delhi, India

Ms Benedicte Briot

Technical Officer



New Delhi, India


44

Annex 3

Workshop Agenda

Tuesday, 8 April 2014

13:30-14:00 Registration

14:00-17:30

Opening session: Welcome remarks

Introduction of participants

General introduction and objectives Presentation

How health inequalities are currently being

assessed in your country? Challenges of

monitoring health equity

Group work and

plenary discussion

Monitoring health inequalities Presentation

Summary measures of health inequality Presentation

Wednesday, 9 April 2014

09:00-12:30

Introducing reproductive, maternal and child

health (RMCH) indicators and datasets

Presentation

Interactive visualization of health data Presentation

Introducing HD* Calc software Demonstration

Assessing inequalities in example health service

indicators by wealth and region using HD*Calc

Hands-on

13:30-17:00

Latest status of inequality in RMCH Hands-on/Group work

Trend of inequality in RMCH Hands-on/Group work

Thursday, 10 April 2014

09:00-12:30

Benchmarking: comparing example countries

with other countries of the Region in terms of

inequality in RMCH

Hands-on/Group work

State of inequality in RMCH - Situation analysis

Excel sheet

Presentation

Best and worst RMCH indicators according to

latest status of inequality and average

Group work and

Plenary presentation


45

13:30-17:00


trend of inequality and average

Group work and



benchmarking

Group work and


Friday, 11 April 2014

09:00-12:30 Filling in the repot and preparing the

presentation

Group work

13:30-17:00

State of inequality in RMCH - Concluding

situation analysis and priority setting


and Q&A

Conclusions and closure

inequality in reproductive, maternal and child...

Documents