Equity-Oriented Monitoring in the Context of Universal Health Coverage

et al. (2014) Equity-Oriented Monitoring in the Context of Universal Health Coverage. PLoS Med 11(9): e1001727. doi:10.1371/journal.pmed.1001727 Equity-Oriented Monitoring in the Context of Universal Health Coverage Ahmad Reza Hosseinpoor 0 Nicole Bergen 0 Theadora Koller 0 Amit Prasad 0 Anne Schlotheuber 0 Nicole Valentine 0 John Lynch 0 Jeanette Vega 0 0 1 Department of Health Statistics and Information Systems, World Health Organization , Geneva, Switzerland, 2 Gender , Equity and Human Rights, World Health Organization , Geneva , Switzerland , 3 Centre for Health Development, World Health Organization, Kobe, Japan, 4 Department of Public Health, Environmental and Social Determinants of Health, World Health Organization , Geneva , Switzerland , 5 School of Population Health, University of Adelaide , Adelaide , Australia , 6 Rockefeller Foundation, New York, New York , United States of America Monitoring inequalities in health is fundamental to the equitable and progressive realization of universal health coverage (UHC). A successful approach to global inequality monitoring must be intuitive enough for widespread adoption, yet maintain technical credibility. This article discusses methodological considerations for equity-oriented monitoring of UHC, and proposes recommendations for monitoring and target setting. Inequality is multidimensional, such that the extent of inequality may vary considerably across different dimensions such as economic status, education, sex, and urban/ rural residence. Hence, global monitoring should include complementary dimensions of inequality (such as economic status and urban/rural residence) as well as sex. For a given dimension of inequality, subgroups for monitoring must be formulated taking into consideration applicability of the criteria across countries and subgroup heterogeneity. For economic-related inequality, we recommend forming subgroups as quintiles, and for urban/ rural inequality we recommend a binary categorization. Inequality spans populations, thus appropriate approaches to monitoring should be based on comparisons between two subgroups (gap approach) or across multiple subgroups (whole spectrum approach). When measuring inequality absolute and relative measures should be reported together, along with disaggregated data; inequality should be reported alongside the national average. We recommend targets based on proportional reductions in absolute inequality across populations. Building capacity for health inequality monitoring is timely, relevant, and important. The development of high-quality health information systems, including data collection, analysis, interpretation, and reporting practices that are linked to review and evaluation cycles across health systems, will enable effective global and national health inequality monitoring. These actions will support equity-oriented progressive realization of UHC. - In recent years the monitoring of health inequalitiesdefined as the observed health differences between subgroups of a populationhas gathered momentum at the global level [14]. Monitoring health inequalities can be considered a platform for assessing health inequitya normative concept referring to avoidable and unjust health differences between subgroups of a population, stemming from a form of social disadvantage [5]. Global monitoring of within-country health inequalities (i.e., crosscountry comparisons of within-country inequalities based on standardized indicators and measurement approaches) is an important practice in the promotion of health equity, as it facilitates comparisons across borders and over time, and enables countries to perform benchmarking and learn from the experiences of one another [6]. Concurrent national-level inequality monitoring is valuable beyond its contribution to global monitoring to take into account context-specific factors and priorities. As the end-date of the Millennium Development Goals draws nearer, plans for the post-2015 global development framework include a concentrated focus on universal health coverage (UHC) [7], a movement that is a longstanding and growing priority for the World Health Organization and its member states [8], and endorsed by the United Nations General Assembly [9]. The N The equitable realization of universal health coverage requires an equity-oriented approach to monitoring; equity advocates should be unified in proposing a technically sound platform for monitoring that is easy to understand and communicate. N Global monitoring should include complementary dimensions of inequality (such as economic status and urban/rural residence, in addition to sex), adopt a gap or whole spectrum approach, and conceptualize economicrelated measures using quintiles. N Both absolute and relative measures of inequality as well as disaggregated data should be reported, and national averages should be presented alongside inequality monitoring. N Targets for global monitoring of health inequalities should be based on proportional reduction of absolute inequality. N Countries can develop capacity for health inequality monitoring by strengthening health information systems for data collection, analysis, reporting, and dissemination. ultimate goal of UHC is directly linked to eliminating inequities: to ensure that all people who need health services are able to get them, without experiencing undue financial hardship [8,10]. However, unless they are designed with an equity-oriented approach, movements toward UHC may facilitate early and/or accelerated gains for advantaged subgroups, while leaving others behind [11]. This trickle down implementation may worsen the situation for disadvantaged populations according to the inverse care law [12], and may exacerbate inequalities if universality is not fully achieved [13]. Thus, monitoring inequalities is fundamental to track the impact of health interventions that aim for universality, to ensure that the process leaves no disadvantaged group behind, and to promote concurrent or hastened progress among the most disadvantaged and across the social gradient [14]. Recommendations surrounding the post-2015 development agenda [7,15] as well as UHC [8,16,17] have called for focused attention on monitoring the reduction of inequalities [8,16,17]. Indeed, the emerging global movement toward UHC presents opportunities for the widespread promotion and mainstreaming of health inequality monitoring at the global level. Advocates for health equity would be judicious to adopt a united front to rally for equity-related indicators and targets that are likely to be accepted and implemented by diverse stakeholders. Establishing methods and targets for global monitoring facilitates global comparisons that are meaningful and substantive ways of measuring and reporting progress in a set of common indicators. Global monitoring of health inequality requires an overarching and unified approach. Global monitoring for UHC must be straightfo (...truncated)