Epilogue

Although progress has been made in advancing equity in certain aspects of health, the persistence of wide inequities in other areas is a stark reminder of the work still to be done to rectify injustice and unfairness. Robust health inequality monitoring systems and practices are needed to identify and address health inequities and ensure no one is left behind in the pursuit of better health for all.

This book is a comprehensive and contemporary resource for health inequality monitoring, consolidating foundational and emerging knowledge in the field. It supports the expansion and strengthening of health inequality monitoring practices for different applications worldwide, in service of the broader goal of advancing health equity.

Reflections and insights

Health inequality monitoring is a multistep process that begins with some key questions: Inequality of what? Inequality among whom? It then requires the sourcing and analysis of suitable inequality data. This leads to the formulation of key messages and effective reporting of the evidence, to the right audience, at the right time. The application of evidence to support actions that advance health equity then requires ongoing monitoring to track progress and promote accountability.

Health inequality monitoring draws upon diverse skills, inputs and expertise. Collaborative health inequality monitoring is strengthened by the contributions of subject matter experts (including people with lived experiences), skilled data analysts, communication experts, decision-makers and advocates. This book guides the practice of health inequality monitoring by explaining key concepts and how they may be adapted and applied to different settings, populations, levels of measurement (individual, household or small area), health topics and inequality dimensions.

Each iteration of inequality monitoring requires careful consideration and judgement in navigating a unique set of circumstances. This book underscores the importance of integrating universal and context-specific approaches to monitoring. The use of universal monitoring frameworks and approaches facilitates comparisons across settings and over time and promotes alignment with monitoring protocols for tracking global and regional goals. Context-specific elements allow monitoring to capture more localized considerations and priorities, which may lead more directly to actions at the national or subnational levels. As such, monitoring inequalities across different dimensions of inequality is an important step to increase recognition of these factors and how they affect health and health determinants.

Approaches to some of the more technical aspects of inequality monitoring, including assessing data availability, data analysis and reporting, have been developed and refined by the scientific community over decades. This book has collected and conveyed this rich body of foundational knowledge, offering a detailed overview of concepts and, where applicable, standardized guidance for the application of knowledge. For example, it overviews established and emerging sources of disaggregated data, illustrating their strengths, limitations and uses. It presents a comprehensive set of summary measures of health inequality, delving into their applications, calculation methods and interpretation, and their inherent assumptions, value judgements and limitations. It provides guidance on effective reporting practices to ensure evidence-informed key messages reach diverse audiences and motivate remedial action. As the field of health inequality monitoring continues to advance, the contents of this book serve as a base and reference for further methodological refinement.

Generating impact towards the goal of health equity is the central motivation for health inequality monitoring – that is, harnessing data to advance health equity. Understanding and addressing inequities in health is a common concern worldwide and has the potential to accelerate progress towards health and development goals, including the Sustainable Development Goals (SDGs). The use of data for such impact can be enabled through strengthened equity-oriented health information systems, effective communication efforts, and strategic policy-making. Although the actions of the health sector can reduce inequities in health, many of the factors for equitably improving population health and well-being lie beyond the health sector. Thus, tackling health inequities also requires monitoring and action on social determinants of health. This signals the importance of establishing multisectoral collaborations and acknowledging and addressing the structural roots of health inequities at the societal level.

Present realities

The current landscape of health inequality monitoring is highly variable. The availability of disaggregated data, capacity for analysis and reporting, and support for equity-oriented and evidence-informed decision-making can look very different across countries, population groups and health topics.

The World Health Organization and its partners are working to build capacity and expand the practice of inequality monitoring – and its impact – in settings and health topics where it is underused. A collection of tools facilitates the application of standardized processes, including data source-mapping, preparation of disaggregated data, calculation of summary measures of health inequality, and creation of figures and maps. These tools, together with capacity-strengthening resources, help to streamline aspects of inequality monitoring and make them more accessible to wider audiences.

In some contexts, the frontiers for sourcing data and the analytical possibilities for health inequality monitoring are expanding rapidly. Calls for intersectional data analysis are growing. The amount of data generated from digital sources – and techniques to analyse and derive meaning from them – are increasing quickly, bringing new opportunities and challenges. In some settings, the collection of disaggregated health and health-related data through more traditional means, such as censuses and household surveys, is becoming more efficient and yielding higher-quality data on expanded topic areas. Methods for linking between data sources are further advancing the usability and quality of data for inequality monitoring. Major concerns remain, however, pertaining to data governance and ownership, privacy, exclusionary practices and biases, and access to technology.

The adoption of the United Nations Sustainable Development Agenda (2015–2030) signalled high-level political support for monitoring in general and resulted in the development of a global monitoring framework. The centrality of tackling inequalities as part of the Agenda, and its emphasis on monitoring and accountability, set the stage for routine health inequality monitoring. The evidence derived from inequality monitoring is essential to track progress towards the SDGs and to identify where targeted support is needed to advance population health. National governments, multilateral organizations and various implementing agencies are more consciously integrating inequality analysis and monitoring into evaluation activities. To a large extent, this has been part of fulfilling their commitments to achieving the SDGs and other health and development agendas.

Future directions

Although the advancement of health equity and health for all have been expressed as priorities for health and development initiatives for over half a century, they continue to be relevant aspirations into the future. There has been substantial progress in understanding and addressing certain forms of health inequalities in some areas of health – although many health inequalities continue to persist or remain unacknowledged or poorly characterized. Regular and recurring health inequality monitoring is vital to generate evidence to track changes in health inequalities and to explore and expose emerging forms of inequalities. The practice of inequality monitoring should be strengthened, expanded and invested in – and it should be made a routine part of health information systems. To this end, inequality monitoring can serve its purpose as a warning system.

Mainstreaming health inequality monitoring as a regular part of the design and functioning of country health information systems, including programme evaluation and planning, can help to create a demand for evidence about inequalities. High-quality disaggregated health data are the key data inputs to monitoring inequalities in health, and efforts are needed to ensure they are available for a wide selection of relevant health indicators and inequality dimensions. The emerging importance of nontraditional data-collection processes will continue to change the landscape of such evidence and fill these gaps but necessitates innovative approaches to ensure data are used effectively and responsibly.

A key challenge lies in establishing clear pathways for the use of this evidence to drive equity-oriented action, which is contingent on political and popular support. This process continues to be meaningfully advanced across different contexts, benefitting from shared experiences and lessons learnt. Alongside the results of inequality monitoring analyses, the co-development of other forms of evidence – including further quantitative and qualitative studies – is needed to deepen and extend understandings of the process and multiple impacts of inequalities, and for effective solutions. The integration of multiple forms of knowledge can yield insights into the drivers of inequalities and reveal new aspects for exploration or continued monitoring.

The Sustainable Development Agenda has made strides in highlighting the explicit links across social, economic and environmental domains, underscoring the interdependent relationship between health and other sectors. This points to the need for strong collaborations to enable progress in advancing the art and science of health inequality monitoring and promoting its impact on improving population health.