UNEDITED Issues in health information 3 Integrating Equity into Health Information Systems UNEDITED 2 TABLE OF CONTENTS 1. OVERVIEW4 2. HEALTH EQUITY INDICATORS7 2.1: General considerations7 2.2: Criteria and rationale for selecting health-equity indicators.7 2.3: Measuring health status and determinants 9 2.4: Measuring social position and stratification .10 3. RECOMMENDED MEASURES OF HEALTH STATUS AND HEALTH DETERMINANTS16 3.1: Health status measures16 3.2: Measures of determinants of health 18 3.3: Measures of health care.19 3.4: Measure of social and economic consequences of ill health.21 4. LINKING EQUITY-RELEVANT DATA BETWEEN INFORMATION SOURCES.23 4.1: The need to link data.23 4.2: A taxonomy for assessing health information status.24 4.3: Useful types of linkages between databases .27 5. ASSESSMENT OF WHAT IS NEEDED AND RECOMMENDATIONS32 5.1: Information needs and recommendations for equity sensitivity .32 5.2: National and subnational HIS .32 5.3: Vital registration systems33 5.4: Census.34 5.5: Small-area data sources and DSS36 5.6: Cross-country household surveys .37 5.7: Country-sponsored surveys.42 5.8: Administrative data sources42 5.9: Geographical information systems (GIS)43 5.10: Trends over time .44 5.11: Linked records.44 6. ENCOURAGING A CULTURE OF EQUITY IN HEALTH.46 6.1: Preamble46 6.2: The contribution of an effective HIS in promoting health equity.46 6.3: Encouraging the use of equity data at the country level .48 6.4: Research49 UNEDITED 3 6.5: Training.49 6.6: Demand for equity-sensitive data50 6.7: Broad social involvement in equity development.51 6.8: Culture of equity recommendations54 7. REFERENCES.57 ANNEX I: DEFINITION OF TERMS59 ANNEX II: CATEGORIZATION OF WHO MEMBER STATES ACCORDING TO LEVEL OF INFORMATION AVAILABILITY FOR EQUITY ANALYSIS60 ANNEX III: VITAL REGISTRATION.63 ANNEX IV SMALL-AREAS SURVEYS:64 ANNEX V: CENSUS65 ANNEX VI: HOUSEHOLD SURVEYS.66 ANNEX VII: COUNTRY-SPECIFIC INCOME AND EXPENDITURE SURVEYS.69 ANNEX VIII: COUNTRIES WITH MORE THAN ONE DHS SURVEY.70 ANNEX IX: EXAMPLES OF PROJECTS USING DIFFERENT DATA SOURCES TO IDENTIFY EQUITY CONCERNS AND TRANSLATE THEM INTO POLICY71 ANNEX X: CRITERIA FOR SELECTING INDICATORS FOR COMPARING SELECTED HEALTH/HEALTH DETERMINANT MEASURES WITH SOCIAL STRATA72 ANNEX XI: SELECTED SURVEYS AND RESOURCES.76 UNEDITED 4 1. OVERVIEW Improving the ability of health information systems (HIS) to support efforts to address health-equity challenges should be viewed as a core objective. Inequities in health, its key determinants (including access to health care) and in the consequences of ill health occur among populations as a result of unfair discrimination based upon socioeconomic and other societal factors. There is a growing recognition of ongoing and often increasing health inequities both in developed and developing countries. Despite this recognition, health information systems continue to lag behind in terms of providing the information needed to assess and address health inequities. Without empirical demonstrations of such inequities, as well as a country-level capacity to use this information for effective planning, movement towards equity is unlikely to occur. The deficit in information on inequities both between and within countries has been partly maintained by the historic structure of the HIS in which data analysis by equity- related stratifiers is usually not possible, and different data sources cannot be linked. Global leadership has also been slow to address this problem, though attention at the global level has increased in recent years. The challenge now is to determine the information needs for addressing health inequities; to shape health information systems to meet those needs; to promote sensitization to equity issues; and develop the skills required to use information for effective planning and policy-making. In addition to increasing the availability of various data sources within countries, improvements need to be made in terms of the equity-relevant information included in those sources. To assess health equity adequately, equity indicators must be constructed. This requires having both a health measure (or measure of determinant of health) as well as an equity stratifier (such as a measure of socioeconomic position, sex, age, ethnicity/race, and/or geographical position), and the ability to disaggregate information according to these stratifiers. This can be accomplished either by ensuring that appropriate equity stratifiers and health measures are available in each data source, or by creating mechanisms to link records between data sources. For example, effective linkages can be created by including a unique identifier or geographical code in a variety of data sources. Because information on these various issues is usually spread out among several data sources, the ability to link such sources is essential, assuming that the information is collected at all. At present, only 39 of 1