Abstract
To monitor progress towards the Millennium Development Goals, it is essential to monitor the coverage of health interventions in subgroups of the population, because national averages can hide important inequalities. In this review, we provide a practical guide to measuring and interpreting inequalities based on surveys carried out in low- and middle-income countries, with a focus on the health of mothers and children. Relevant stratification variables include urban/rural residence, geographic region, and educational level, but breakdowns by wealth status are increasingly popular. For the latter, a classification based on an asset index is the most appropriate for national surveys. The measurement of intervention coverage can be made by single indicators, but the use of combined measures has important advantages, and we advocate two summary measures (the composite coverage index and the co-coverage indicator) for the study of time trends and for cross-country comparisons. We highlight the need for inequality measures that take the whole socioeconomic distribution into account, such as the relative concentration index and the slope index of inequality, although simpler measures such as the ratio and difference between the richest and poorest groups may also be presented for non-technical audiences. Finally, we present a framework for the analysis of time trends in inequalities, arguing that it is essential to study both absolute and relative indicators, and we provide guidance to the joint interpretation of these results.
Highlights
Equity in health has been part of the public health agenda for quite some time in the US, Europe, and Latin America [1,2,3], but interest in health inequities has boomed since the 1990s, with a large number of publications considering definitions [3], measurement [4,5,6], and controversies about health inequalities [7,8]
Reducing inequalities was not a key element in the health-related Millennium Development Goals, it is an important focus of the post-2015 agenda, which involves studying how inequalities change, how they relate to policies and health systems, and how they relate to global processes, such as conflict or economic growth or recession [12]
The need to make a clear link between broad social and economic inequalities and disparities in the coverage of health interventions has been championed by the Social Determinants of Health movement [13,14]
Summary
Equity in health has been part of the public health agenda for quite some time in the US, Europe, and Latin America [1,2,3], but interest in health inequities has boomed since the 1990s, with a large number of publications considering definitions [3], measurement [4,5,6], and controversies about health inequalities [7,8] (throughout this review we will refer to equity when we are considering the concept of fairness/justice and inequality when we are considering the measurement of differences in coverage, which are used to make judgments about equity/inequity). This effect is even more marked for disease episodes: data on oral rehydration therapy, for example, are often based on a much larger sample (which is dependent on the number of diarrhea episodes) in the poorest than in the wealthiest quintile These limitations do not, preclude the widespread and valid use of asset indices for documenting the wide gaps between rich and poor that are present in most low- and middle-income countries, as is evident by the consistent associations between asset indices and more complex measures of socioeconomic position [31] and by the marked inverse associations between asset indices and child mortality and undernutrition [20,21]. Quadrant 3 (top right) includes countries in the worst of the situations in terms of inequality—both
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