Capacity building for health inequality monitoring in Indonesia: enhancing the equity orientation of country health information system

Exploring system drivers of gender inequity in development assistance for health and opportunities for action

Background : Deep-rooted and widespread gender-based bias and discrimination threaten achievement of the Sustainable Development Goals. Despite evidence that addressing gender inequities contributes to better health and development outcomes, the resources for, and effectiveness of, such efforts in development assistance for health (DAH) have been insufficient. This paper explores systemic challenges in DAH that perpetuate or contribute to gender inequities, with a particular focus on the role of external donors and funders. Methods: We applied a co-creation system design process to map and analyze interactions between donors and recipient countries, and articulate drivers of gender inequities within the landscape of DAH. We conducted qualitative primary data collection and analysis in 2021 via virtual facilitated discussions and visual mapping exercises among a diverse set of 41 stakeholders, including representatives from donor institutions, country governments, academia, and civil society. Results: Six systemic challenges emerged as perpetuating or contributing to gender inequities in DAH: 1) insufficient input and leadership from groups affected by gender bias and discrimination; 2) decision-maker blind spots inhibit capacity to address gender inequities; 3) imbalanced power dynamics contribute to insufficient resources and attention to gender priorities; 4) donor funding structures limit efforts to effectively address gender inequities; 5) fragmented programming impedes coordinated attention to the root causes of gender inequities; and 6) data bias contributes to insufficient understanding of and attention to gender inequities. Conclusions : Many of the drivers impeding progress on gender equity in DAH are embedded in power dynamics that distance and disempower people affected by gender inequities. Overcoming these dynamics will require more than technical solutions. Groups affected by gender inequities must be centered in leadership and decision-making at micro and macro levels, with practices and structures that enable co-creation and mutual accountability in the design, implementation, and evaluation of health programs.

Validity of mother-child self-perceived oral health for the assessment of 5 years old children's oral health in Indonesia

BACKGROUND

Early childhood caries (ECC) is a serious condition that has a negative impact on young children's quality of life. Mothers' perceived need for oral health care plays an important role in their children's oral health behavior. This study aimed to compare mother and child self-perceived and dentist-evaluated needs for oral health care.

METHODS

This cross-sectional study included 266 preschool children aged 5 years old and their mothers. A self-administered questionnaire to the mothers and interviews with the children were used to assess the perceived needs of oral health care. The mothers were asked to rate their children's oral health and determine if they needed dental treatment. The children were also asked how they felt about their oral health and whether they had any tooth decay. Agreement between mother and child regarding the child's oral health was assessed. The evaluated needs were assessed clinically using the dmft (decayed, missing, and filled teeth [primary dentition]) and pufa (pulpal involvement, ulceration, fistula, and abscess [primary dentition]) indices. The perceived and evaluated needs were compared using spearman analysis to determine their correlations and the validity of the perceived needs compared to the clinical examination was assessed using the area under the curve (AUC), sensitivity (Sn), specificity (Sp), and likelihood ratio (LR).

RESULTS

The prevalence rate of ECC was 89.4%, with 35% having at least one condition from untreated caries (pufa > 0). Mothers and children have a fair agreement regarding the child's oral health (ICC = 0.335). When comparisons were conducted between perceived and evaluated conditions, Mother's rating about their child's oral health showed the strongest correlation to dmft index (r = 0.372; p < 0.001). Several accuracy parameters done in this study (AUC, Sn, and Sp) did not meet the acceptable threshold. The sensitivity and specificity were the highest when comparing mothers' perceived need for their child's dental treatment to the dmft index (Sn = 96.7%) and pufa index (Sp = 88.1%), respectively.

CONCLUSION

Compared to the dentist's assessment, the mother and child self-reported oral health statuses showed lower accuracy in assessing the child's condition. But, the mothers in this study were better than their 5-year-old children at perceiving their child's oral health care needs. As a result, these subjective assessments can be used as a complement, but not as a substitute, to the actual clinical evaluation.

Strengthening and expanding health inequality monitoring for the advancement of health equity: a review of WHO resources and contributions

As part of its commitment to advance health equity, the World Health Organization (WHO) has a developed area of work to promote and strengthen health inequality monitoring. This includes an emphasis on the collection, analysis and use of disaggregated health data, which are central to evidence-informed decision making. The aim of this paper is to review WHO's work on health inequality monitoring, namely the 2022-27 Inequality monitoring and analysis strategy and corresponding activities, resources and tools. The strategy has three goals pertaining to: strengthening capacity for health inequality monitoring; generating and disseminating the latest evidence on health inequality and supporting data disaggregation; and developing and refining health inequality monitoring methods, resources and best practices. In alignment with these goals, WHO has published reference materials focused on conceptual approaches to health inequality monitoring, which are applied in the global State of Inequality report series. The Health Inequality Monitoring eLearning channel on OpenWHO and capacity building workshops and webinars facilitate the uptake and application of inequality monitoring practices across diverse settings and stakeholders. A key tool available to support the analysis and reporting aspects of health inequality monitoring is the Health Equity Assessment Toolkit (HEAT) application, which allows users to explore data interactively. The Health Inequality Data Repository, a collection of the largest publicly available database of disaggregated data from around the globe, further enables inequality monitoring and analyses. This collection of resources is an important contribution to promote health inequality monitoring across diverse settings. The uptake of evidence from health inequality monitoring remains crucial to the advancement of equity as part of global health and development initiatives.

Health Equity Assessment Toolkit (HEAT and HEAT Plus): exploring inequalities in the COVID-19 pandemic era

BACKGROUND

The Sustainable Development Goals have helped to focus attention on the importance of reducing inequality and 'leaving no one behind'. Monitoring health inequalities is essential for providing evidence to inform policies, programmes and practices that can close existing gaps and achieve health equity. The Health Equity Assessment Toolkit (HEAT and HEAT Plus) software was developed by the World Health Organization to facilitate the assessment of within-country health inequalities.

RESULTS

HEAT contains a built-in database of disaggregated health data, while HEAT Plus allows users to upload and analyze inequalities using their own datasets. Version 4.0 of the software incorporated enhancements to the toolkit's capacity for equity assessments. This includes a multilingual interface, interactive and downloadable visualizations, flexibility to analyze inequalities using any dataset of disaggregated data, and the built-in calculation of 19 summary measures of inequality. This paper outlines the improved features and functionalities of the HEAT and HEAT Plus software since their original release, highlighted through an example of how the toolkit can be used to assess inequalities in the COVID-19 pandemic era.

CONCLUSIONS

The features of the HEAT and HEAT Plus software make it a valuable tool for analyzing and reporting inequalities related to the COVID-19 pandemic, as well as its indirect impacts on inequalities in other health and non-health areas, providing evidence to inform equity-oriented interventions and strategies.

Exploring system drivers of gender inequity in development assistance for health and opportunities for action

Background: Deep-rooted and widespread gender-based bias and discrimination threaten achievement of the Sustainable Development Goals. Despite evidence that addressing gender inequities contributes to better health and development outcomes, the resources for, and effectiveness of, such efforts in development assistance for health (DAH) have been insufficient. This paper explores systemic challenges in DAH that perpetuate or contribute to gender inequities, with a particular focus on the role of external donors and funders. Methods: We applied a co-creation system design process to map and analyze interactions between donors and recipient countries, and articulate drivers of gender inequities within the landscape of DAH. We conducted qualitative primary data collection and analysis in 2021 via virtual facilitated discussions and visual mapping exercises among a diverse set of 41 stakeholders, including representatives from donor institutions, country governments, academia, and civil society. Results: Six systemic challenges emerged as perpetuating or contributing to gender inequities in DAH: 1) insufficient input and leadership from groups affected by gender bias and discrimination; 2) decision-maker blind spots inhibit capacity to address gender inequities; 3) imbalanced power dynamics contribute to insufficient resources and attention to gender priorities; 4) donor funding structures limit efforts to effectively address gender inequities; 5) fragmented programming impedes coordinated attention to the root causes of gender inequities; and 6) data bias contributes to insufficient understanding of and attention to gender inequities. Conclusions: Many of the drivers impeding progress on gender equity in DAH are embedded in power dynamics that distance and disempower people affected by gender inequities. Overcoming these dynamics will require more than technical solutions. Groups affected by gender inequities must be centered in leadership and decision-making at micro and macro levels, with practices and structures that enable co-creation and mutual accountability in the design, implementation, and evaluation of health programs.

Capacity building, local ownership and implementation of a multi-level HIV/AIDS positive health, dignity, and prevention initiative in Mozambique: approach, challenges and lessons learned

Mozambique has for many years suffered from a high burden of HIV with an estimated prevalence of 11.1% among adults age 15–49 years. In response, Positive Health, Dignity, and Prevention (or Positive Prevention as it is known in Mozambique), was developed as a method of integrating HIV care and prevention via capacity building. Through comprehensive holistic care, HIV transmission is prevented while simultaneously promoting the health of people living with HIV/AIDS. Our initiative used a three-tiered approach, and included activities at national, provincial, and community levels. In order to change patient behavior and successfully train health-care workers in Positive Prevention, it was therefore considered necessary to work at multiple levels of influence. This ensured that the individual-level behavior change of PLHIV and health-care providers was maximized through supportive environments and policies. Related national-level achievements included the establishment of a Positive Prevention technical working group; the development of a Positive Prevention policy document; training national policy-makers on Positive Prevention; the development and distribution of a nationally approved Positive Prevention training package; the integration of Positive Prevention into existing Ministry of Health curricula; the development and approval of national data collection forms; and the drafting of a related national strategy. The framework and key activities of the Mozambique Positive Prevention Program may help to inform and assist others involved in similar work, as well as advancing country or local ownership of HIV/AIDS treatment, care and prevention efforts. By using a three-tiered approach, a supportive system was created. This was critical to both optimizing Positive Prevention provision and building long-term capacity. In order for related efforts to be successful in other settings, we encourage implementing partners to also work at multiple levels, with local ownership principles in mind, in order that Positive Prevention programs may have the greatest possible effect.

Analyzing and improving national and local child protection data in Nepal: A mixed methods study using 2014 Multiple Indicator Cluster Survey (MICS) data and interviews with 18 organizations

BACKGROUND

Globally, progress to improve data on child protection outcomes has been slower than efforts to improve data on child nutrition, vaccination and development outcomes in the under-five age group. The Sustainable Development Goals included several child protection targets further necessitating the need to track progress on child protection, but few studies have examined the varied data landscape for child protection within countries.

OBJECTIVE

This mixed-methods study aims to examine (1) the prevalence of child protection outcomes in Nepal, (2) the types of data the child protection sector uses, and (3) recommendations to improve the collection, analysis and use of child protection data.

PARTICIPANTS AND SETTING

We used: (a) secondary data from the nationally-representative 2014 Nepal MICS which surveyed over 13,000 households to measure the national prevalence of child labor, child marriage, and violent discipline, and (b) primary data from 18 qualitative key informant interviews with organizations in Nepal's child protection sector.

METHODS

We conducted descriptive quantitative analyses of the secondary data and thematic inductive and deductive qualitative analyses of transcripts of key informant interviews.

RESULTS

The burden of violent discipline (82%), child labor (37%), child marriage (12%), and their co-occurrence is high in Nepal. Respondents described using a range of data sources which included: large-scale surveys, case data from the police, court system, newspapers, community consultations, and child participation. Recommendations to improve data included developing a national child protection information system, ensuring the definitions of child protection outcomes were comparable across data sources, and improving the dissemination of data.

Building capacity for health equity analysis in the WHO South-East Asia Region

"Leaving no one behind" is at the heart of the agenda of the Sustainable Development Goals, requiring that health systems be vigilant to how interventions can be accessed equitably by all, including population subgroups that face exclusion. In the World Health Organization (WHO) South-East Asia Region, inequalities can be found across and within countries but there has been a growing commitment to examining and starting to tackle them. Over the past decade in particular, WHO has been developing an armamentarium of tools to enable analysis of health inequalities and action on health equity. Tools include the Health Equity Assessment Toolkit in built-in database and upload database editions, as well as the Innov8 tool for reorientation of national health programmes. Countries across the region have engaged meaningfully in the development and application of these tools, in many cases aligning them with, or including them as part of, ongoing efforts to examine inequities in population subgroups domestically. This paper reflects on these experiences in Bangladesh, India, Indonesia, Nepal, Sri Lanka and Thailand, where efforts have ranged from workshops to programme reorientation; the creation of assemblies and conferences; and collation of evidence through collaborative research, reviews/synthesis and conferences. This promising start must be maintained and expanded, with greater emphasis on building capacity for interpretation and use of evidence on inequalities in policy-making. This may be further enhanced by the use of innovative mixed methodologies and interdisciplinary approaches to refine and contextualize evidence, with a concomitant shift in attention, developing solutions to redress inequities and anchor health reform within communities. There are many lessons to be learnt in this region, as well as mounting political and popular will for change.

Applying the Innov8 approach for reviewing national health programmes to leave no one behind: lessons learnt from Indonesia

The World Health Organization's Innov8 Approach for Reviewing National Health Programmes to Leave No One Behind is an eight-step process that supports the operationalization of the Sustainable Development Goals' commitment to 'leave no one behind'. In 2014-2015, Innov8 was adapted and applied in Indonesia to review how the national neonatal and maternal health action plans could become more equity-oriented, rights-based and gender-responsive, and better address critical social determinants of health. The process was led by the Indonesian Ministry of Health, with the support of WHO. It involved a wide range of actors and aligned with/fed into the drafting of the maternal newborn health action plan and the implementation planning of the newborn action plan. Key activities included a sensitization meeting, diagnostic checklist, review workshop and in-country work by the review teams. This 'methods forum' article describes this adaptation and application process, the outcomes and lessons learnt. In conjunction with other sources, Innov8 findings and recommendations informed national and sub-national maternal and neonatal action plans and programming to strengthen a 'leave no one behind' approach. As follow-up during 2015-2017, components of the Innov8 methodology were integrated into district-level planning processes for maternal and newborn health, and Innov8 helped generate demand for health inequality monitoring and its use in planning. In Indonesia, Innov8 enhanced national capacity for equity-oriented, rights-based and gender-responsive approaches and addressing critical social determinants of health. Adaptation for the national planning context (e.g. decentralized structure) and linking with health inequality monitoring capacity building were important lessons learnt. The pilot of Innov8 in Indonesia suggests that this approach can help operationalize the SDGs' commitment to leave no one behind, in particular in relation to influencing programming and monitoring and evaluation.

Data source mapping: an essential step for health inequality monitoring

The task of health inequality monitoring is not possible without the availability of appropriate and high-quality data at various levels. Data source mapping – a process by which data sources are systematically enlisted, their properties detailed and each source appraised for the purposes of monitoring – is an essential initial step for health inequality monitoring. We outline a simple process along with a template for data source mapping and its application in Indonesia, concluding with the lessons learned from this process, in terms of both challenges as well as the opportunities and advantages arising from the use of equity-related data from the Indonesian health information system.

Health Equity Assessment Toolkit Plus (HEAT Plus): software for exploring and comparing health inequalities using uploaded datasets

As a key step in advancing the sustainable development goals, the World Health Organisation (WHO) has placed emphasis on building capacity for measuring and monitoring health inequalities. A number of resources have been developed, including the Health Equity Assessment Toolkit (HEAT), a software application that facilitates the assessment of within-country health inequalities. Following user demand, an Upload Database Edition of HEAT, HEAT Plus, was developed. Launched in July 2017, HEAT Plus allows users to upload their own databases and assess inequalities at the global, national or subnational level for a range of (health) indicators and dimensions of inequality. The software is open-source, operates on Windows and Macintosh platforms and is readily available for download from the WHO website. The flexibility of HEAT Plus makes it a suitable tool for both global and national inequality assessments. Further developments will include interactive graphs, maps and translation into different languages.

Tools and approaches to operationalize the commitment to equity, gender and human rights: towards leaving no one behind in the Sustainable Development Goals

The objective of this article is to present specific resources developed by the World Health Organization on equity, gender and human rights in order to support Member States in operationalizing their commitment to leave no one behind in the health Sustainable Development Goals (SDGs), and other health-related goals and targets. The resources cover: (i) health inequality monitoring; (ii) barrier analysis using mixed methods; (iii) human rights monitoring; (iv) leaving no one behind in national and subnational health sector planning; and (v) equity, gender and human rights in national health programme reviews. Examples of the application of the tools in a range of country contexts are provided for each resource.