no evidence, no equity · 2019-06-17 · equity database • 115 countries • ... planning...
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NO EVIDENCE, NO EQUITYHOW CAN WE DO MORE TO IDENTIFY WHO IS BEING LEFT BEHIND?Aluísio J D BarrosInternational Center for Equity in HealthFederal University of Pelotas, Brazil
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Megadatabase
115 countries349 surveys
Dissemination Monitoring
Accountability
Science Patterns and trends
DeterminantsForecasting
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www.countdown2015mnch.org
DisseminationMain partner: Countdown to 2030 (née to 2015)
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Equity database• 115 countries• 349 surveys• > 5 million women• > 10 million children• Indicators
• Preventive interventions, treatment of common illnesses
• Mortality, nutrition, fertility
• Stratifiers• Wealth quintiles• Woman’s education• Woman’s age• Subnational units• Urban/rural residence• Child’s sex• And more...
All estimates with std errors & asymmetric CIs
Routine reanalysis of national health surveys
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Science
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How to improve on equity analyses?
From survey data!
• Combined indicators• Improved presentation• Advance with stratifiers SDG 17.18
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Combined indicators - revised CCI• Composite coverage index
• Very useful for country comparisons and benchmarking• Time trend analyses
• The revised version includes new interventions and some existing ones were replaced
𝐦𝐦𝐦𝐦𝐦𝐦𝐦𝐦𝐦𝐦 + 𝐀𝐀𝐀𝐀𝐀𝐀𝟒𝟒 + 𝑆𝑆𝑆𝑆𝑆𝑆2 + 𝑀𝑀𝑆𝑆𝑀𝑀 + 𝑆𝑆𝐵𝐵𝐵𝐵 + 2 ∗ 𝐷𝐷𝐷𝐷𝐷𝐷3
4 + 𝐎𝐎𝐎𝐎𝐦𝐦 + 𝐵𝐵𝑆𝑆𝐶𝐶𝐶𝐶𝐷𝐷2
5
𝐦𝐦𝐦𝐦𝐦𝐦𝐦𝐦𝐦𝐦 + 𝐀𝐀𝐀𝐀𝐀𝐀𝟒𝟒 + 𝑆𝑆𝑆𝑆𝑆𝑆2 + 𝑀𝑀𝑆𝑆𝑀𝑀 + 𝑆𝑆𝐵𝐵𝐵𝐵 + 2 ∗ 𝐷𝐷𝐷𝐷𝐷𝐷3
4 + 𝑪𝑪𝑪𝑪𝑪𝑪𝑪𝑪𝑪𝑪𝑪𝑪𝑪𝑪4
• For more finely stratified analyses, a more robust version
Family planning Pregnancy
careImmunization
Treatment of illnesses
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Totally revised country equity profile for Countdown
Maps
Equiplots
Infographs
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The last SDG – more stratifiers!
17.18 Data, monitoring and accountability
Calls for disaggregation by- Income- Gender- Age- Race/ethnicity- Migratory status- Disability- Geographic location- and other characteristics
relevant in national contexts
But not the least
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Wealth quintiles or deciles?Improving on wealth inequalities
Further hidden inequalities in skilled attendant at birth
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Deciles highlight differences between rich and poor more than quintiles
MalawiMaldivesBurundiRwanda
EgyptCambodia
South AfricaNepal
HondurasLesotho
JordanColombia
NamibiaGambia
Sierra LeoneGhana
TajikistanPhilippines
ArmeniaUgandaLiberia
IndonesiaPeru
ZimbabweGabon
BangladeshComoros
TogoChad
ZambiaIndia
AfghanistanCongo DR
GuatemalaKenya
Timor LesteTanzania
Burkina FasoMyanmar
NigerHaiti
PakistanSenegal
MozambiqueEthiopia
YemenGuineaAngola
0 10 20 30 40 50 60 70 80 90 100Composite coverage index (%)
D1 D2 D3 D4 D5
D6 D7 D8 D9 D10
Wealth deciles
Inequalities in the CCI looking at 10 groups of wealth
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Focusing on countries with high inequality
• SII > 25 pct points• CCI is an average
• Attenuates differences and patterns
• Still some countries• Richer way ahead• Poorer way behind
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Absolute income in place of relative wealth
Comparing countries at different income levels
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How CCI increases with income0
2040
6080
100
Com
posit
e co
vera
ge in
dex
(%)
.5 1 5 10 15 20 30 40 50 100
Annual household income in 1000 I$ (PPP)
Q1 (poorest) Q2 Q3 Q4 Q5 (richest)
Prediction line 95% CI
• 94 countries• 470 quintiles• Coverage increases with income
• Variability decreases
• Multilevel linear model to estimate expected coverage
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Overachievers and underachievers
Countries with less than 20 p.p. for Q1
compared to prediction
Countries with more than 20 p.p. for Q1
compared to prediction
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New approach to gender - women’s empowerment: the SWPER
Attitude to violence
Social independence
Decision making
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SWPER World Map
Standardized score makes country comparisons possible
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Interseccionality: full vaccination by wealth and empowerment
Countries by wealth tertiles and empowerment tertiles
Children of more empowered women tend to present higher levels of full vaccination
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Under-5 mortality rates by ethnicity
Many groups are small and precision is low
But the spread in mortality rates is astounding in some countries
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Ethnicity and skilled attendant at birth
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What else?• Intersectionality
• Wealth x urban/rural• Wealth x subnational units, etc.
• Migration• Few surveys have information, analyses of specific situations
• Adolescents, age• More focus on adolescent health• Differences across age groups in RMNCH coverage
• Gender• Empowerment, violence, differential mortality, female headed
households• Disability
• Seldom inquired in surveys, we need more info• Geography
• More focus on geospatial analyses• Changes in survey design needed for better precision
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In summary• Important advances regarding the use of a wider range of
stratifiers• The increasing sizes of surveys with time help
• Income can give a fresh understanding of wealth inequalities
• Some stratifiers are easier than others• Ethnicity, migration, disability are complicated
• Hard to classify• Limited data from surveys
Investment needed for more data of better quality!
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