Uncovering health inequalities: A path towards leaving no one behind

May 2016

A woman breastfeeds her baby in a dark room in Jakarta, Indonesia.
WHO/A Kari

Having a skilled health professional during childbirth can save the life of a woman and her child. But, in many parts of the world and within many countries, the presence of a health worker during childbirth is often a luxury. If a woman is poor, she is even more likely to deliver without support, putting herself and child at risk.

In Indonesia, this is a familiar story for poor women. Twenty years ago, only 1 in 5 women in the poorest 20% of the population gave birth with support from a skilled attendant.

Through recognizing the inequalities and targeting programmes towards the poorest populations, Indonesia has been able to improve the number of births attended by skilled personnel among the poorest population to 3 out of 5 births in the period 2007 to 2012. However, nearly all births among the richest 20% of the population were supported.

“While we have worked hard to reduce the health inequalities in Indonesia, they still persist,” says Ms Rustini Floranita, WHO National Professional Officer and focal point for gender, equity and human rights in Indonesia. “We need to continue to find ways to uncover and target these gaps so that the most disadvantaged populations have the same health care as the richest populations.”

New WHO tool shows within-country inequalities across the globe

To help countries like Indonesia monitor health inequalities, WHO developed a new toolkit called the Health Equity Assessment Toolkit (HEAT). HEAT is a software package that utilizes data from the WHO Health Equity Monitor and enables health professionals and researchers to explore the health inequalities in their countries. Additionally, users can compare the state of inequality in their country with other countries.

Besides data on the proportion of births attended by skilled personnel, HEAT users can assess variations in coverage of immunization, antenatal care, contraception, and breastfeeding, to name a few of the indicators covered.

In April, WHO hosted a workshop in Indonesia and trained 30 participants from the Ministry of Health, the National Statistical Office of Indonesia, academia, and other UN agencies, how to assess the country’s inequality data in HEAT. At the workshop, participants learned that Indonesia is increasing the women’s and children’s health intervention coverage fastest among the most disadvantaged populations, including the poorest, the least educated and rural residents in most of indicators.

When comparing Indonesia with neighbouring countries, the gaps are more profound. In parts of South-East Asia and Western Pacific regions some countries are providing almost complete coverage for skilled birth attendance in all populations based on economic status, education and place of residence. And, in other countries the gaps are even higher than those in Indonesia.

“The ‘built-in database edition’ of HEAT was received very well by the workshop participants,” says Floranita. “It facilitates analysis and reporting on health inequality and provides interactive and customised tables and graphs that can be downloaded and used. Once we’re able to import our own data, we’ll be able to monitor even more inequalities.”

Utilizing the data in HEAT and other data from household surveys, health facility data, censuses, civil registration, and vital statistics, participants from the workshop plan to develop a national report on state of health inequality in Indonesia, which will help the country ensure no one is left behind in the future.

Equity in the global agenda

Equity is at the heart of the 2030 Agenda for Sustainable Development. In pledging to achieve the Sustainable Development Goals (SDGs), countries have committed to leave no one behind. SDG 3 focuses on ensuring healthy lives for all at all ages, positioning equity as a central issue in health, while SDG 10 calls for a reduction in inequality within and between countries to promote the inclusion and empowerment of all.

However, realizing equity requires identifying where there are inequalities in the first place, and then monitoring the progress made at reducing them.

“Strong health information systems that collect, analyse and report disaggregated data covering all health areas are essential for achieving health equity,” says Ahmad Reza Hosseinpoor, WHO Technical Officer in the Department of Information, Evidence and Research. “HEAT provides evidence on the state of health inequality and can help countries set priorities and establish equity-oriented policies, programs and interventions.”