Health inequality monitoring: an overview
ll rights reserved. Publications of the World Health Organization are available on the WHO web
site (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue
Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail:
bookorders@who.int).
Requests for permission to reproduce or translate WHO publications – whether for sale or for
noncommercial distribution – should be addressed to WHO Press through the WHO web site
(http://www.who.int/about/licensing/copyright_form/en/index.html).
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.
Acknowledgements
Ahmad Reza Hosseinpoor (World Health Organization, Geneva, Switzerland) coordinated
the development of this handbook with the assistance of Nicole Bergen (Consultant, Geneva,
Switzerland). The handbook was initially conceptualized by Ahmad Reza Hosseinpoor and
Jennifer H. Lee (Consultant, Los Angeles, United States). The draft was prepared by Ahmad Reza
Hosseinpoor, Nicole Bergen and Kyle Ragins (Intern, World Health Organization) as well as Aluisio
J D Barros (Federal University of Pelotas, Brazil), Sam Harper (McGill University, Canada), Jennifer
H. Lee and Cesar Victora (Federal University of Pelotas, Brazil). The work benefited greatly from
the contribution of Ties Boerma (World Health Organization, Geneva, Switzerland), who reviewed
the handbook and provided valuable comments.
Funding for this project was provided in part by the Public Health Agency of Canada (PHAC) and
by the Rockefeller Foundation. The collaboration of the coordinating project team members from
PHAC is gratefully acknowledged, in particular Jane Laishes, James McDonald and Andrea Long.
John Dawson provided copy-editing support and AvisAnne Julien proofread the document.
Design and layout by Paprika (Annecy, France)
Printed in Luxembourg
Figures
Figure 1.1 Cycle of health monitoring................................................................2
Figure 1.2 Components of a national health sector monitoring, evaluation and
review framework.............................................................................3
Figure 1.3 Example health indicators related to reproductive, maternal and
child health, displayed within a monitoring, evaluation and review
framework........................................................................................5
Figure 2.1 Data sources for health inequality monitoring..................................18
Figure 3.1 Births attended by skilled health personnel in Ghana, by wealth
quintile, DHS 2003 and 2008.........................................................34
Figure 3.2 Contraceptive prevalence (modern methods) in the Philippines, by
education level, DHS 1993 and 2008.............................................35
Figure 3.3 Proportion of women of reproductive age in the Philippines, by
education level, DHS 1993 and 2008.............................................36
Figure 3.4 Slope index of inequality: absolute inequality in smoking prevalence
in a population of men living in 27 middle-income countries, World
Health Survey 2002–2004..............................................................40
Figure 3.5 Relative wealth-based inequality in births attended by skilled
health personnel in Bangladesh and Egypt, represented using
concentration curves, DHS 2007 and 2008....................................43
Figure 3.6 Region-based inequality in DTP3 immunization coverage among
1-year-olds in the Philippines, DHS 2003 and 2008........................48
Figure 3.7 Region-based relative inequality in selected reproductive, maternal
and child health indicators in Egypt shown using (a) ratio and (b)
Theil index, DHS 1995 and 2008.................................................... 51
Figure 3.8 National average gap in coverage of reproductive, maternal and
child health services and within-country wealth-based inequality in
coverage gap in 24 low- and middle-income African countries, DHS
and MICS 2005–2011 ...................................................................54
Figure 4.1 Contraceptive prevalence (modern methods) in Egypt, by wealth
quintile, DHS 1995, 2000 and 2005...............................................60
Figure 4.2 Time trend in measles immunization in Colombia, by place of
residence, DHS 1993, 1998, 2003 and 2008.................................62
vi Handbook on health inequality monitoring
Figure 4.3 Benchmarking the latest status of births attended by skilled health
personnel in Malawi against 22 other low-income African countries,
by wealth quintile, DHS 2005–2010...............................................64
Figure 4.4 Benchmarking the latest status of wealth-based absolute inequality
in births attended by skilled health personnel in Vanuatu against
11 other low- and middle-income Asia-Pacific countries, DHS and
MICS 2005–2010...........................................................................65
Figure 4.5 Benchmarking time trend in under-five mortality rate in Zambia
against 12 other middle-income countries, by place of residence,
DHS 1996–2000 and 2006–2010..................................................66
Figure 4.6 Patterns of health inequality, shown using coverage of births
attended by skilled health personnel in Bangladesh, Gambia, Jordan
and Viet Nam, by wealth quintile, DHS and MICS 2005–2007 .......68
Figure 4.7 Coverage of selected maternal health service indicators in the
Philippines, by wealth quintile, DHS 2008.......................................69
Figure 4.8 Wealth-based inequality in stunting among children under five in
70 countries, DHS and MICS 2005–2011 ......................................74
Figure 4.9 Wealth-based inequality and national average in stunting among
children under five in 70 countries, DHS and MICS 2005–2011......75
Figure 4.10 Relative wealth-based inequality and national prevalence in smoking
in (a) men and (b) women in 48 low- and middle-income countries,
World Health Survey, 2002–2004................................................... 77
Figure 4.11 Under-five mortality rate in Nigeria, by place of residence and wealth,
DHS 2008 .....................................................................................78
Figure 4.12 Four-quadrant view of benchmarking time trends in infant mortality
rate in 20 African countries over a five-year period, wealth-based
inequality versus national average..................................................80
Figure 4.13 Time trends in inequality in subgroups in the case of (a) increasing
prevalence and (b) decreasing prevalence of a health indicator,
highlighting different scenarios for absolute and relative inequality .81
Figure 4.14 Time trends in births attended by skilled health personnel, in (a)
Cambodia, (b) Nepal and (c) Cameroon, by wealth quintile, DHS and
MICS 1996–2010...........................................................................82
vii
Figure 5.1 Time trend of selected reproductive, maternal and child health
service indicators in the Philippines, by wealth quintile, DHS 1998,
2003 and 2008..............................................................................95
Figure 5.2 Time trend of (a) antenatal care (at least four visits), (b) antenatal care
(at least one visit), (c) family planning needs satisfied and (d) vitamin
A supplementation among children under five in the Philippines, by
wealth quintile, DHS 1998, 2003 and 2008....................................96
Figure 5.3 Benchmarking the latest status of wealth-based absolute inequality
in births attended by skilled health personnel in the Philippines
against 11 other low- and middle-income Asia-Pacific countries,
DHS and MICS 2005–2010............................................................
site (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue
Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail:
bookorders@who.int).
Requests for permission to reproduce or translate WHO publications – whether for sale or for
noncommercial distribution – should be addressed to WHO Press through the WHO web site
(http://www.who.int/about/licensing/copyright_form/en/index.html).
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.
Acknowledgements
Ahmad Reza Hosseinpoor (World Health Organization, Geneva, Switzerland) coordinated
the development of this handbook with the assistance of Nicole Bergen (Consultant, Geneva,
Switzerland). The handbook was initially conceptualized by Ahmad Reza Hosseinpoor and
Jennifer H. Lee (Consultant, Los Angeles, United States). The draft was prepared by Ahmad Reza
Hosseinpoor, Nicole Bergen and Kyle Ragins (Intern, World Health Organization) as well as Aluisio
J D Barros (Federal University of Pelotas, Brazil), Sam Harper (McGill University, Canada), Jennifer
H. Lee and Cesar Victora (Federal University of Pelotas, Brazil). The work benefited greatly from
the contribution of Ties Boerma (World Health Organization, Geneva, Switzerland), who reviewed
the handbook and provided valuable comments.
Funding for this project was provided in part by the Public Health Agency of Canada (PHAC) and
by the Rockefeller Foundation. The collaboration of the coordinating project team members from
PHAC is gratefully acknowledged, in particular Jane Laishes, James McDonald and Andrea Long.
John Dawson provided copy-editing support and AvisAnne Julien proofread the document.
Design and layout by Paprika (Annecy, France)
Printed in Luxembourg
Figures
Figure 1.1 Cycle of health monitoring................................................................2
Figure 1.2 Components of a national health sector monitoring, evaluation and
review framework.............................................................................3
Figure 1.3 Example health indicators related to reproductive, maternal and
child health, displayed within a monitoring, evaluation and review
framework........................................................................................5
Figure 2.1 Data sources for health inequality monitoring..................................18
Figure 3.1 Births attended by skilled health personnel in Ghana, by wealth
quintile, DHS 2003 and 2008.........................................................34
Figure 3.2 Contraceptive prevalence (modern methods) in the Philippines, by
education level, DHS 1993 and 2008.............................................35
Figure 3.3 Proportion of women of reproductive age in the Philippines, by
education level, DHS 1993 and 2008.............................................36
Figure 3.4 Slope index of inequality: absolute inequality in smoking prevalence
in a population of men living in 27 middle-income countries, World
Health Survey 2002–2004..............................................................40
Figure 3.5 Relative wealth-based inequality in births attended by skilled
health personnel in Bangladesh and Egypt, represented using
concentration curves, DHS 2007 and 2008....................................43
Figure 3.6 Region-based inequality in DTP3 immunization coverage among
1-year-olds in the Philippines, DHS 2003 and 2008........................48
Figure 3.7 Region-based relative inequality in selected reproductive, maternal
and child health indicators in Egypt shown using (a) ratio and (b)
Theil index, DHS 1995 and 2008.................................................... 51
Figure 3.8 National average gap in coverage of reproductive, maternal and
child health services and within-country wealth-based inequality in
coverage gap in 24 low- and middle-income African countries, DHS
and MICS 2005–2011 ...................................................................54
Figure 4.1 Contraceptive prevalence (modern methods) in Egypt, by wealth
quintile, DHS 1995, 2000 and 2005...............................................60
Figure 4.2 Time trend in measles immunization in Colombia, by place of
residence, DHS 1993, 1998, 2003 and 2008.................................62
vi Handbook on health inequality monitoring
Figure 4.3 Benchmarking the latest status of births attended by skilled health
personnel in Malawi against 22 other low-income African countries,
by wealth quintile, DHS 2005–2010...............................................64
Figure 4.4 Benchmarking the latest status of wealth-based absolute inequality
in births attended by skilled health personnel in Vanuatu against
11 other low- and middle-income Asia-Pacific countries, DHS and
MICS 2005–2010...........................................................................65
Figure 4.5 Benchmarking time trend in under-five mortality rate in Zambia
against 12 other middle-income countries, by place of residence,
DHS 1996–2000 and 2006–2010..................................................66
Figure 4.6 Patterns of health inequality, shown using coverage of births
attended by skilled health personnel in Bangladesh, Gambia, Jordan
and Viet Nam, by wealth quintile, DHS and MICS 2005–2007 .......68
Figure 4.7 Coverage of selected maternal health service indicators in the
Philippines, by wealth quintile, DHS 2008.......................................69
Figure 4.8 Wealth-based inequality in stunting among children under five in
70 countries, DHS and MICS 2005–2011 ......................................74
Figure 4.9 Wealth-based inequality and national average in stunting among
children under five in 70 countries, DHS and MICS 2005–2011......75
Figure 4.10 Relative wealth-based inequality and national prevalence in smoking
in (a) men and (b) women in 48 low- and middle-income countries,
World Health Survey, 2002–2004................................................... 77
Figure 4.11 Under-five mortality rate in Nigeria, by place of residence and wealth,
DHS 2008 .....................................................................................78
Figure 4.12 Four-quadrant view of benchmarking time trends in infant mortality
rate in 20 African countries over a five-year period, wealth-based
inequality versus national average..................................................80
Figure 4.13 Time trends in inequality in subgroups in the case of (a) increasing
prevalence and (b) decreasing prevalence of a health indicator,
highlighting different scenarios for absolute and relative inequality .81
Figure 4.14 Time trends in births attended by skilled health personnel, in (a)
Cambodia, (b) Nepal and (c) Cameroon, by wealth quintile, DHS and
MICS 1996–2010...........................................................................82
vii
Figure 5.1 Time trend of selected reproductive, maternal and child health
service indicators in the Philippines, by wealth quintile, DHS 1998,
2003 and 2008..............................................................................95
Figure 5.2 Time trend of (a) antenatal care (at least four visits), (b) antenatal care
(at least one visit), (c) family planning needs satisfied and (d) vitamin
A supplementation among children under five in the Philippines, by
wealth quintile, DHS 1998, 2003 and 2008....................................96
Figure 5.3 Benchmarking the latest status of wealth-based absolute inequality
in births attended by skilled health personnel in the Philippines
against 11 other low- and middle-income Asia-Pacific countries,
DHS and MICS 2005–2010............................................................
