Inequality in reproductive, maternal and child health in Nepal: measuring and monitoring health inequalities: a post-workshop report

Measuring and Monitoring Health Inequalities: A Post-Workshop Report Inequality in Reproductive, Maternal and Child Health in Nepal World Health House Indraprastha Estate, Mahatma Gandhi Marg, New Delhi-110002, India Website: www.searo.who.int This post-workshop report presents a summary documentation of participant discussions from a WHO workshop on Measuring and Monitoring Health Inequalities held in April 2014 in Jaipur, India. The aim of the workshop was to assess health inequalities (latest status, change over time and benchmarking) using key reproductive, maternal and child health indicators. In doing so, it was hoped that the workshop would highlight some approaches and tools that may be used for equity monitoring in the SEARO context and highlight the challenges and barriers in measurement and monitoring in the Region. This report is not an exhaustive overview of inequalities in Reproductive, Maternal and Child Health (RMCH) indicators. Such a process would require larger scale of deliberations across multiple stakeholders, which was not possible given the scope of this workshop. The report intends to document discussions as they happened with implications only for participants in taking the knowledge forward in their public health endeavours. Several assessments may be subjective and are only meant to highlight the range of opinions generated. SEA-NUR-466 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 All rights reserved. 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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 (Faculty, Institute for Population and Social Research, Mahidol University, 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 (Faculty, Institute for Population and Social Research, Mahidol University, 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). Measuring and Monitoring Health Disparities: A Post-Workshop Report 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). Inequality in Reproductive, Maternal and Child Health in Nepal 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. Measuring and Monitoring Health Disparities: A Post-Workshop Report 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). Inequality in Reproductive, Maternal and Child Health in Nepal 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. Measuring and Monitoring Health Disparities: A Post-Workshop Report 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%). Inequality in Reproductive, Maternal and Child Health in Nepal 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;  early breastfeeding;  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 Measuring and Monitoring Health Disparities: A Post-Workshop Report 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; Inequality in Reproductive, Maternal and Child Health in Nepal 11  early breastfeeding;  DTP3 vaccination; and  oral rehydration therapy. 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;  antenatal care visit (four or more);  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). Measuring and Monitoring Health Disparities: A Post-Workshop Report 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:  family planning needs satisfied;  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 Inequality in Reproductive, Maternal and Child Health in Nepal 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. (http://apps.who.int/gho/data/node.main.HE-1540?lang=en) Measuring and Monitoring Health Disparities: A Post-Workshop Report 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:  family planning needs satisfied;  DTP3 vaccination;  care-seeking for pneumonia; and  oral rehydration therapy. 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 Inequality in Reproductive, Maternal and Child Health in Nepal 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. Measuring and Monitoring Health Disparities: A Post-Workshop Report 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. (http://apps.who.int/gho/data/node.main.HE-1540?lang=en) 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. Inequality in Reproductive, Maternal and Child Health in Nepal 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:  family planning needs satisfied;  antenatal care visit (four or more);  early breastfeeding;  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);  care-seeking for pneumonia. 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). Measuring and Monitoring Health Disparities: A Post-Workshop Report 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:  family planning needs satisfied;  antenatal care visit (one);  skilled attendance at birth; and  care-seeking for pneumonia. Absolute inequality by region was relatively less for the following indicators:  antenatal care visit (four or more);  early breastfeeding;  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. Inequality in Reproductive, Maternal and Child Health in Nepal 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). Measuring and Monitoring Health Disparities: A Post-Workshop Report 20 Figure 5: Sex-based inequality in ORT coverage 0 10 20 30 40 50 60 70 80 90 100 1996 2001 2006 2011 P e rc e n ta 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. Inequality in Reproductive, Maternal and Child Health in Nepal 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). Measuring and Monitoring Health Disparities: A Post-Workshop Report 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. Inequality in Reproductive, Maternal and Child Health in Nepal 23 Figure 7: Benchmarking of early breastfeeding 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. Figure 8: Benchmarking of oral rehydration therapy 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. Measuring and Monitoring Health Disparities: A Post-Workshop Report 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). Inequality in Reproductive, Maternal and Child Health in Nepal 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. Measuring and Monitoring Health Disparities: A Post-Workshop Report 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 Inequality in Reproductive, Maternal and Child Health in Nepal 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. Measuring and Monitoring Health Disparities: A Post-Workshop Report 28 6. Data tables T a b l e 1 : S it u a t io n a n a ly s is o f la t e s t s t a t u s S o u r c e : P a r t ic ip a n t s o f W H O w o r k s h o p o n M e a s u r in g a n d M o n it o r in g H e a lt h I n e q u a li t ie s , h e ld i n A p r il 2 0 1 4 in J a ip u r , I n d ia . In d ic a t o r N a t io n a l a v e r a g e I n e q u a li t y A v e r a g e in e q u a li t y s c o r e W e a lt h E d u c a t io n S e x A r e a R e g io n Absolute Relative Absolute Relative Absolute Relative Absolute Relative Absolute Relative Absolute Relative F a m il y p la n n in g n e e d s s a ti s fi e d 3 2 1 2 1 2 1 2 1 2 .0 1 .0 A n te n a ta l c a r e ( a t le a s t o n e v is it ) 3 3 2 3 2 2 1 2 2 2 .5 1 .8 A n te n a ta l c a r e ( a t le a s t fo u r v is it s ) 3 3 2 3 2 2 1 1 1 2 .3 1 .5 B ir th s a tt e n d e d b y s k il le d h e a lt h p e r s o n n e l 3 3 3 3 2 3 2 2 2 2 .8 2 .3 E a r ly i n it ia ti o n o f b r e a s tf e e d in g 3 2 1 3 2 1 1 2 1 2 1 2 .0 1 .2 D T P 3 i m m u n iz a ti o n 1 1 1 1 1 1 1 1 1 2 1 1 .2 1 .0 C a r e - s e e k in g f o r p n e u m o n ia 3 3 1 2 1 1 1 3 2 2 2 2 .2 1 .4 O r a l r e h y d r a ti o n t h e r a p y f o r c h il d r e n w it h d ia r r h o e a 1 2 2 2 1 2 1 2 1 2 2 2 .0 1 .4 R M C H i n te r v e n ti o n s 2 .5 2 .4 1 .6 2 .4 1 .5 1 .3 1 .0 2 .1 1 .3 1 .9 1 .5 S tu n ti n g ( h e ig h t fo r a g e ) in c h il d r e n u n d e r 5 y e a r s 3 3 2 2 2 1 1 2 2 2 2 2 .0 1 .8 U n d e r w e ig h t (w e ig h t fo r a g e ) in c h il d r e n u n d e r 5 y e a r s 2 3 3 3 2 1 1 2 2 2 1 2 .2 1 .8 W a s ti n g ( w e ig h t fo r h e ig h t) i n c h il d r e n u n d e r 5 y e a r s 3 1 2 2 2 1 1 1 1 2 2 1 .4 1 .6 C H o u tc o m e s 2 .7 2 .3 2 .3 2 .3 2 .0 1 .0 1 .0 1 .7 1 .7 2 .0 1 .7 Inequality in Reproductive, Maternal and Child Health in Nepal 29 T a b l e 2 : S it u a t io n a n a ly s is o f t im e t r e n d s S o u r c e : P a r t ic ip a n t s o f W H O w o r k s h o p o n M e a s u r in g a n d M o n it o r in g H e a lt h I n e q u a li t ie s , h e ld i n A p r il 2 0 1 4 in J a ip u r , I n d ia . I n d ic a t o r N a t io n a l a v e r a g e I n e q u a li t y W e a lt h E d u c a t io n S e x A r e a R e g io n Absolute Relative Absolute Relative Absolute Relative Absolute Relative Absolute Relative F a m il y p la n n in g n e e d s s a t is fi e d 1 1 1 3 1 1 1 2 2 A n t e n a t a l c a r e ( a t l e a s t o n e v is it ) 1 2 1 2 1 1 1 2 2 A n t e n a t a l c a r e ( a t l e a s t f o u r v is it s ) 1 3 1 3 1 1 1 1 1 B ir t h s a tt e n d e d b y s k il le d h e a lt h p e r s o n n e l 2 3 2 3 1 3 1 3 2 E a r ly i n it ia t io n o f b r e a s t fe e d in g 1 3 2 3 2 1 1 2 1 2 2 D T P 3 i m m u n iz a t io n 1 1 1 1 1 1 1 1 1 1 1 C a r e - s e e k in g f o r p n e u m o n ia 1 2 2 2 1 2 2 3 2 3 2 O r a l r e h y d r a t io n t h e r a p y fo r c h il d r e n w it h d ia r r h o e a 2 2 1 1 1 2 2 3 2 2 1 R M C H i n t e r v e n t io n s 2 .1 1 .4 2 .3 1 .1 1 .5 1 .5 1 .9 1 .3 2 .0 1 .6 S t u n t in g ( h e ig h t f o r a g e ) i n c h il d r e n u n d e r 5 y e a r s 1 3 3 1 1 1 1 2 2 3 3 U n d e r w e ig h t ( w e ig h t f o r a g e ) i n c h il d r e n u n d e r 5 y e a r s 1 2 3 1 1 1 1 2 3 2 2 W a s t in g ( w e ig h t f o r h e ig h t ) in c h il d r e n u n d e r 5 y e a r s 2 2 2 2 1 1 1 2 2 1 1 C H o u t c o m e s 2 .3 2 .7 1 .3 1 .0 1 .0 1 .0 2 .0 2 .3 2 .0 2 .0 Measuring and Monitoring Health Disparities: A Post-Workshop Report 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. Inequality in Reproductive, Maternal and Child Health in Nepal 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 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. Measuring and Monitoring Health Disparities: A Post-Workshop Report 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) Inequality in Reproductive, Maternal and Child Health in Nepal 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 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) Measuring and Monitoring Health Disparities: A Post-Workshop Report 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 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) Inequality in Reproductive, Maternal and Child Health in Nepal 35 T a b l e 8 : R e g io n - b a s e d in e q u a li t y S o u r c e : D a t a w e r e d e r iv e d f r o m t h e r e - a n a ly s is o f p u b li c ly a v a il a b le D e m o g r a p h ic a n d H e a lt h S u r v e y s ( D H S ) m ic r o - d a t a , u s in g t h e s t a n d a r d in d ic a t o r d e f in it io n s a s p u b li s h e d in D H S d o c u m e n t a t io n . T h e a n a ly s is w a s c a r r ie d o u t b y t h e I n t e r n a t io n a l C e n t e r f o r E q u it y in H e a lt h b a s e d in t h e F e d e r a l U n iv e r s it y o f P e lo t a s , B r a z il . T a b l e 8 : R e g io n - b a s e d in e q u a li t y Measuring and Monitoring Health Disparities: A Post-Workshop Report 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 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) Inequality in Reproductive, Maternal and Child Health in Nepal 37 Table 10: National coverage of health services benchmarking against comparable countries In d ic a to r C a lc u la ti o n B a n g la d e s h B h u ta n C a m b o d ia In d ia In d o n e s ia L a o P D R M a ld iv e s M o n g o li a N e p a l P h il ip p in e s T h a il a n d T im o r - L e s te V a n u a t u V ie t N a m 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. 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. Measuring and Monitoring Health Disparities: A Post-Workshop Report 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). Inequality in Reproductive, Maternal and Child Health in Nepal 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. Measuring and Monitoring Health Disparities: A Post-Workshop Report 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. Inequality in Reproductive, Maternal and Child Health in Nepal 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 Measuring and Monitoring Health Disparities: A Post-Workshop Report 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 Public Health Foundation of India New Delhi, India Dr Devaki Nambiar Research Scientist Public Health Foundation of India New Delhi, India Dr Malee Sunpuwan Institute for Population and Social Research Mahidol University Salaya, Phuthamonthon Nakhonpathom, Thailand Dr Pojjana Hunchangsith Institute for Population and Social Research Mahidol University Salaya, Phuthamonthon Nakhonpathom, Thailand Dr Manasigan Kanchanachitra Institute for Population and Social Research Mahidol University Salaya, Phuthamonthon Nakhonpathom, Thailand WHO Secretariat WHO/HQ Dr Ahmad Hosseinpoor Technical Officer World Health Organization Geneva, Switzerland Ms Theadora Swift Koller Technical Officer, Equity World Health Organization Geneva, Switzerland Country Offices Ms Rustini Floranita National Professional Officer World Health Organization Jakarta, Indonesia Dr Paul Francis Technical Officer Maternal and Child Health World Health Organization New Delhi, India Ms Anika Singh Technical Officer Gender, Equity and Human Rights World Health Organization New Delhi, India Regional Office Dr Oscar Jesus Alberto Mujica Advisor, Social Epidemiology, AMOR World Health Organization Washington D.C., U.S.A. Inequality in Reproductive, Maternal and Child Health in Nepal 43 Dr Prakin Suchaxaya Coordinator Gender, Equity and Human Rights World Health Organization New Delhi, India Dr Suvajee Good Health Education Specialist World Health Organization New Delhi, India Ms Benedicte Briot Technical Officer Gender, Equity and Human Rights World Health Organization New Delhi, India Measuring and Monitoring Health Disparities: A Post-Workshop Report 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 Inequality in Reproductive, Maternal and Child Health in Nepal 45 13:30-17:00 Best and worst RMCH indicators according to trend of inequality and average Group work and Plenary presentation Best and worst RMCH indicators according to benchmarking Group work and Plenary presentation 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 Plenary presentation and Q&A Conclusions and closure Measuring and Monitoring Health Inequalities: A Post-Workshop Report Inequality in Reproductive, Maternal and Child Health in Nepal World Health House Indraprastha Estate, Mahatma Gandhi Marg, New Delhi-110002, India Website: www.searo.who.int This post-workshop report presents a summary documentation of participant discussions from a WHO workshop on Measuring and Monitoring Health Inequalities held in April 2014 in Jaipur, India. The aim of the workshop was to assess health inequalities (latest status, change over time and benchmarking) using key reproductive, maternal and child health indicators. In doing so, it was hoped that the workshop would highlight some approaches and tools that may be used for equity monitoring in the SEARO context and highlight the challenges and barriers in measurement and monitoring in the Region. This report is not an exhaustive overview of inequalities in Reproductive, Maternal and Child Health (RMCH) indicators. Such a process would require larger scale of deliberations across multiple stakeholders, which was not possible given the scope of this workshop. The report intends to document discussions as they happened with implications only for participants in taking the knowledge forward in their public health endeavours. Several assessments may be subjective and are only meant to highlight the range of opinions generated. SEA-NUR-466

Measuring and Monitoring Health Inequalities: A Post-Workshop Report Inequality in Reproductive, Maternal and Child Health in Nepal World Health House Indraprastha Estate, Mahatma Gandhi Marg, New Delhi-110002, India Website: www.searo.who.int This post-workshop report presents a summary documentation of participant discussions from a WHO workshop on Measuring and Monitoring Health Inequalities held in April 2014 in Jaipur, India. The aim of the workshop was to assess health inequalities (latest status, change over time and benchmarking) using key reproductive, maternal and child health indicators. In doing so, it was hoped that the workshop would highlight some approaches and tools that may be used for equity monitoring in the SEARO context and highlight the challenges and barriers in measurement and monitoring in the Region. This report is not an exhaustive overview of inequalities in Reproductive, Maternal and Child Health (RMCH) indicators. Such a process would require larger scale of deliberations across multiple stakeholders, which was not possible given the scope of this workshop. The report intends to document discussions as they happened with implications only for participants in taking the knowledge forward in their public health endeavours. Several assessments may be subjective and are only meant to highlight the range of opinions generated. SEA-NUR-466 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 All rights reserved. Requests for publications, or for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – can be obtained from SEARO Library, World Health Organization, Regional Office for South-East Asia, Indraprastha Estate, Mahatma Gandhi Marg, New Delhi 110 002, India (fax: +91 11 23370197; e-mail: searolibrary@who.int). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. This publication does not necessarily represent the decisions or policies of the World Health Organization. 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 (Faculty, Institute for Population and Social Research, Mahidol University, 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 (Faculty, Institute for Population and Social Research, Mahidol University, 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). Measuring and Monitoring Health Disparities: A Post-Workshop Report 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). Inequality in Reproductive, Maternal and Child Health in Nepal 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. Measuring and Monitoring Health Disparities: A Post-Workshop Report 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). Inequality in Reproductive, Maternal and Child Health in Nepal 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. Measuring and Monitoring Health Disparities: A Post-Workshop Report 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%). Inequality in Reproductive, Maternal and Child Health in Nepal 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;  early breastfeeding;  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 Measuring and Monitoring Health Disparities: A Post-Workshop Report 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; Inequality in Reproductive, Maternal and Child Health in Nepal 11  early breastfeeding;  DTP3 vaccination; and  oral rehydration therapy. 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;  antenatal care visit (four or more);  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). Measuring and Monitoring Health Disparities: A Post-Workshop Report 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:  family planning needs satisfied;  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 Inequality in Reproductive, Maternal and Child Health in Nepal 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. (http://apps.who.int/gho/data/node.main.HE-1540?lang=en) Measuring and Monitoring Health Disparities: A Post-Workshop Report 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:  family planning needs satisfied;  DTP3 vaccination;  care-seeking for pneumonia; and  oral rehydration therapy. 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 Inequality in Reproductive, Maternal and Child Health in Nepal 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. Measuring and Monitoring Health Disparities: A Post-Workshop Report 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. (http://apps.who.int/gho/data/node.main.HE-1540?lang=en) 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. Inequality in Reproductive, Maternal and Child Health in Nepal 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:  family planning needs satisfied;  antenatal care visit (four or more);  early breastfeeding;  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);  care-seeking for pneumonia. 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). Measuring and Monitoring Health Disparities: A Post-Workshop Report 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:  family planning needs satisfied;  antenatal care visit (one);  skilled attendance at birth; and  care-seeking for pneumonia. Absolute inequality by region was relatively less for the following indicators:  antenatal care visit (four or more);  early breastfeeding;  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. Inequality in Reproductive, Maternal and Child Health in Nepal 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). Measuring and Monitoring Health Disparities: A Post-Workshop Report 20 Figure 5: Sex-based inequality in ORT coverage 0 10 20 30 40 50 60 70 80 90 100 1996 2001 2006 2011 P e rc e n ta 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. Inequality in Reproductive, Maternal and Child Health in Nepal 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). Measuring and Monitoring Health Disparities: A Post-Workshop Report 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. Inequality in Reproductive, Maternal and Child Health in Nepal 23 Figure 7: Benchmarking of early breastfeeding 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. Figure 8: Benchmarking of oral rehydration therapy 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. Measuring and Monitoring Health Disparities: A Post-Workshop Report 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). Inequality in Reproductive, Maternal and Child Health in Nepal 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. Measuring and Monitoring Health Disparities: A Post-Workshop Report 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 Inequality in Reproductive, Maternal and Child Health in Nepal 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. Measuring and Monitoring Health Disparities: A Post-Workshop Report 28 6. Data tables T a b l e 1 : S it u a t io n a n a ly s is o f la t e s t s t a t u s S o u r c e : P a r t ic ip a n t s o f W H O w o r k s h o p o n M e a s u r in g a n d M o n it o r in g H e a lt h I n e q u a li t ie s , h e ld i n A p r il 2 0 1 4 in J a ip u r , I n d ia . In d ic a t o r N a t io n a l a v e r a g e I n e q u a li t y A v e r a g e in e q u a li t y s c o r e W e a lt h E d u c a t io n S e x A r e a R e g io n Absolute Relative Absolute Relative Absolute Relative Absolute Relative Absolute Relative Absolute Relative F a m il y p la n n in g n e e d s s a ti s fi e d 3 2 1 2 1 2 1 2 1 2 .0 1 .0 A n te n a ta l c a r e ( a t le a s t o n e v is it ) 3 3 2 3 2 2 1 2 2 2 .5 1 .8 A n te n a ta l c a r e ( a t le a s t fo u r v is it s ) 3 3 2 3 2 2 1 1 1 2 .3 1 .5 B ir th s a tt e n d e d b y s k il le d h e a lt h p e r s o n n e l 3 3 3 3 2 3 2 2 2 2 .8 2 .3 E a r ly i n it ia ti o n o f b r e a s tf e e d in g 3 2 1 3 2 1 1 2 1 2 1 2 .0 1 .2 D T P 3 i m m u n iz a ti o n 1 1 1 1 1 1 1 1 1 2 1 1 .2 1 .0 C a r e - s e e k in g f o r p n e u m o n ia 3 3 1 2 1 1 1 3 2 2 2 2 .2 1 .4 O r a l r e h y d r a ti o n t h e r a p y f o r c h il d r e n w it h d ia r r h o e a 1 2 2 2 1 2 1 2 1 2 2 2 .0 1 .4 R M C H i n te r v e n ti o n s 2 .5 2 .4 1 .6 2 .4 1 .5 1 .3 1 .0 2 .1 1 .3 1 .9 1 .5 S tu n ti n g ( h e ig h t fo r a g e ) in c h il d r e n u n d e r 5 y e a r s 3 3 2 2 2 1 1 2 2 2 2 2 .0 1 .8 U n d e r w e ig h t (w e ig h t fo r a g e ) in c h il d r e n u n d e r 5 y e a r s 2 3 3 3 2 1 1 2 2 2 1 2 .2 1 .8 W a s ti n g ( w e ig h t fo r h e ig h t) i n c h il d r e n u n d e r 5 y e a r s 3 1 2 2 2 1 1 1 1 2 2 1 .4 1 .6 C H o u tc o m e s 2 .7 2 .3 2 .3 2 .3 2 .0 1 .0 1 .0 1 .7 1 .7 2 .0 1 .7 Inequality in Reproductive, Maternal and Child Health in Nepal 29 T a b l e 2 : S it u a t io n a n a ly s is o f t im e t r e n d s S o u r c e : P a r t ic ip a n t s o f W H O w o r k s h o p o n M e a s u r in g a n d M o n it o r in g H e a lt h I n e q u a li t ie s , h e ld i n A p r il 2 0 1 4 in J a ip u r , I n d ia . I n d ic a t o r N a t io n a l a v e r a g e I n e q u a li t y W e a lt h E d u c a t io n S e x A r e a R e g io n Absolute Relative Absolute Relative Absolute Relative Absolute Relative Absolute Relative F a m il y p la n n in g n e e d s s a t is fi e d 1 1 1 3 1 1 1 2 2 A n t e n a t a l c a r e ( a t l e a s t o n e v is it ) 1 2 1 2 1 1 1 2 2 A n t e n a t a l c a r e ( a t l e a s t f o u r v is it s ) 1 3 1 3 1 1 1 1 1 B ir t h s a tt e n d e d b y s k il le d h e a lt h p e r s o n n e l 2 3 2 3 1 3 1 3 2 E a r ly i n it ia t io n o f b r e a s t fe e d in g 1 3 2 3 2 1 1 2 1 2 2 D T P 3 i m m u n iz a t io n 1 1 1 1 1 1 1 1 1 1 1 C a r e - s e e k in g f o r p n e u m o n ia 1 2 2 2 1 2 2 3 2 3 2 O r a l r e h y d r a t io n t h e r a p y fo r c h il d r e n w it h d ia r r h o e a 2 2 1 1 1 2 2 3 2 2 1 R M C H i n t e r v e n t io n s 2 .1 1 .4 2 .3 1 .1 1 .5 1 .5 1 .9 1 .3 2 .0 1 .6 S t u n t in g ( h e ig h t f o r a g e ) i n c h il d r e n u n d e r 5 y e a r s 1 3 3 1 1 1 1 2 2 3 3 U n d e r w e ig h t ( w e ig h t f o r a g e ) i n c h il d r e n u n d e r 5 y e a r s 1 2 3 1 1 1 1 2 3 2 2 W a s t in g ( w e ig h t f o r h e ig h t ) in c h il d r e n u n d e r 5 y e a r s 2 2 2 2 1 1 1 2 2 1 1 C H o u t c o m e s 2 .3 2 .7 1 .3 1 .0 1 .0 1 .0 2 .0 2 .3 2 .0 2 .0 Measuring and Monitoring Health Disparities: A Post-Workshop Report 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. Inequality in Reproductive, Maternal and Child Health in Nepal 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 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. Measuring and Monitoring Health Disparities: A Post-Workshop Report 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) Inequality in Reproductive, Maternal and Child Health in Nepal 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 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) Measuring and Monitoring Health Disparities: A Post-Workshop Report 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 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) Inequality in Reproductive, Maternal and Child Health in Nepal 35 T a b l e 8 : R e g io n - b a s e d in e q u a li t y S o u r c e : D a t a w e r e d e r iv e d f r o m t h e r e - a n a ly s is o f p u b li c ly a v a il a b le D e m o g r a p h ic a n d H e a lt h S u r v e y s ( D H S ) m ic r o - d a t a , u s in g t h e s t a n d a r d in d ic a t o r d e f in it io n s a s p u b li s h e d in D H S d o c u m e n t a t io n . T h e a n a ly s is w a s c a r r ie d o u t b y t h e I n t e r n a t io n a l C e n t e r f o r E q u it y in H e a lt h b a s e d in t h e F e d e r a l U n iv e r s it y o f P e lo t a s , B r a z il . T a b l e 8 : R e g io n - b a s e d in e q u a li t y Measuring and Monitoring Health Disparities: A Post-Workshop Report 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 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) Inequality in Reproductive, Maternal and Child Health in Nepal 37 Table 10: National coverage of health services benchmarking against comparable countries In d ic a to r C a lc u la ti o n B a n g la d e s h B h u ta n C a m b o d ia In d ia In d o n e s ia L a o P D R M a ld iv e s M o n g o li a N e p a l P h il ip p in e s T h a il a n d T im o r - L e s te V a n u a t u V ie t N a m 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. 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. Measuring and Monitoring Health Disparities: A Post-Workshop Report 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). Inequality in Reproductive, Maternal and Child Health in Nepal 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. Measuring and Monitoring Health Disparities: A Post-Workshop Report 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. Inequality in Reproductive, Maternal and Child Health in Nepal 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 Measuring and Monitoring Health Disparities: A Post-Workshop Report 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 Public Health Foundation of India New Delhi, India Dr Devaki Nambiar Research Scientist Public Health Foundation of India New Delhi, India Dr Malee Sunpuwan Institute for Population and Social Research Mahidol University Salaya, Phuthamonthon Nakhonpathom, Thailand Dr Pojjana Hunchangsith Institute for Population and Social Research Mahidol University Salaya, Phuthamonthon Nakhonpathom, Thailand Dr Manasigan Kanchanachitra Institute for Population and Social Research Mahidol University Salaya, Phuthamonthon Nakhonpathom, Thailand WHO Secretariat WHO/HQ Dr Ahmad Hosseinpoor Technical Officer World Health Organization Geneva, Switzerland Ms Theadora Swift Koller Technical Officer, Equity World Health Organization Geneva, Switzerland Country Offices Ms Rustini Floranita National Professional Officer World Health Organization Jakarta, Indonesia Dr Paul Francis Technical Officer Maternal and Child Health World Health Organization New Delhi, India Ms Anika Singh Technical Officer Gender, Equity and Human Rights World Health Organization New Delhi, India Regional Office Dr Oscar Jesus Alberto Mujica Advisor, Social Epidemiology, AMOR World Health Organization Washington D.C., U.S.A. Inequality in Reproductive, Maternal and Child Health in Nepal 43 Dr Prakin Suchaxaya Coordinator Gender, Equity and Human Rights World Health Organization New Delhi, India Dr Suvajee Good Health Education Specialist World Health Organization New Delhi, India Ms Benedicte Briot Technical Officer Gender, Equity and Human Rights World Health Organization New Delhi, India Measuring and Monitoring Health Disparities: A Post-Workshop Report 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 Inequality in Reproductive, Maternal and Child Health in Nepal 45 13:30-17:00 Best and worst RMCH indicators according to trend of inequality and average Group work and Plenary presentation Best and worst RMCH indicators according to benchmarking Group work and Plenary presentation 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 Plenary presentation and Q&A Conclusions and closure Measuring and Monitoring Health Inequalities: A Post-Workshop Report Inequality in Reproductive, Maternal and Child Health in Nepal World Health House Indraprastha Estate, Mahatma Gandhi Marg, New Delhi-110002, India Website: www.searo.who.int This post-workshop report presents a summary documentation of participant discussions from a WHO workshop on Measuring and Monitoring Health Inequalities held in April 2014 in Jaipur, India. The aim of the workshop was to assess health inequalities (latest status, change over time and benchmarking) using key reproductive, maternal and child health indicators. In doing so, it was hoped that the workshop would highlight some approaches and tools that may be used for equity monitoring in the SEARO context and highlight the challenges and barriers in measurement and monitoring in the Region. This report is not an exhaustive overview of inequalities in Reproductive, Maternal and Child Health (RMCH) indicators. Such a process would require larger scale of deliberations across multiple stakeholders, which was not possible given the scope of this workshop. The report intends to document discussions as they happened with implications only for participants in taking the knowledge forward in their public health endeavours. Several assessments may be subjective and are only meant to highlight the range of opinions generated. SEA-NUR-466