Towards monitoring health equity, based on routine data in Iran Ardeshir Khosravi PhD, Iranian MOH&ME

Outline of the presentation The Iranian Primary Health Care System The Iranian Primary Health Care System The Iranian Vital Horoscope The Iranian Vital Horoscope Challenges of the Iranian Health System Challenges of the Iranian Health System An Overview of the Tehran Urban HEART Project An Overview of the Tehran Urban HEART Project Indicators for Monitoring of Health Equity in Iran Indicators for Monitoring of Health Equity in Iran Selection criteria for indicators Selection criteria for indicators Executive points Executive points Challenges Challenges

Introduction After announcement of the Alma Ata declaration, Iran redesigned, as many other countries did, its health system based on PHC criteria. After announcement of the Alma Ata declaration, Iran redesigned, as many other countries did, its health system based on PHC criteria. As a result of establishing of the PHC network, health indicators for Iran, particularly in rural areas, have improved. As a result of establishing of the PHC network, health indicators for Iran, particularly in rural areas, have improved. The key role of the PHC network in improving the health situation in Iran is improving accessibility to basic health care particularly for vulnerable people in remote areas, who, before the PHC network was set up, did not have adequate access to these basic services. The key role of the PHC network in improving the health situation in Iran is improving accessibility to basic health care particularly for vulnerable people in remote areas, who, before the PHC network was set up, did not have adequate access to these basic services.

Where Are the Facilities Located? CITY Health Center Health House Village Road Satellite village MasterPlan

The Islamic Republic of Iran’s “health houses” each serve about 1500 people and are responsible for a sharp drop in mortality over the last two decades, with life expectancy increasing to 71 years in 2006 from 63 years in 1990.

Vital Horoscope The Vital Horoscope, which is a facility-based data source, was established by the Iranian Ministry of Health and Medical Education (MOH&ME) in 1988 The Vital Horoscope, which is a facility-based data source, was established by the Iranian Ministry of Health and Medical Education (MOH&ME) in 1988 This data source has been designed to collect and display vital events such as births, and deaths as well as family planning activities within the community This data source has been designed to collect and display vital events such as births, and deaths as well as family planning activities within the community

Vital Horoscope Physically, this is a sheet of paper 50 cm by 70 cm large, always kept pinned to a wall in the Health House Physically, this is a sheet of paper 50 cm by 70 cm large, always kept pinned to a wall in the Health House Throughout the year, monthly tallies of vital events are entered on the chart, which is sent to the District Health Centre at the end of the year, where the data are entered into a customized computer program (called Zij) and are sent to the upper levels for consolidation Throughout the year, monthly tallies of vital events are entered on the chart, which is sent to the District Health Centre at the end of the year, where the data are entered into a customized computer program (called Zij) and are sent to the upper levels for consolidation

Birth by weight, sex months, age and delivery condition Population by age and sex Maternal mortality Mortality by age and sex Causes of death in children <5 Family planning coverage by method Monthly death and live birth Mortality >5 Mortality 1-5 Mortality>1 Birth Main village Satellite village

Advantages of VH This is the only data source that contains health and demographic information by village, district and province in Iran. This is the only data source that contains health and demographic information by village, district and province in Iran. Based on this data source several important indicators of health outcomes (about 214) such as mortality (e.g. maternal mortality rate and infant mortality rate) and fertility (e.g. age specific fertility rates) can be measured. Based on this data source several important indicators of health outcomes (about 214) such as mortality (e.g. maternal mortality rate and infant mortality rate) and fertility (e.g. age specific fertility rates) can be measured.

Neonatal, infant and child mortality rates according to the Vital Horoscope for rural areas, Iran, Neonatal, infant and child mortality rates according to the Vital Horoscope for rural areas, Iran,

Child mortality rates based on the Vital Horoscope for rural areas by Province, Iran,

Challenges of the Iranian Health System The success of establishing primary health care has resulted in significant improvements in maternal and child health, along with the control of infectious diseases. This has changed the epidemiological profile of Iran, with a transition to an increasing burden due to non-communicable disease and injuries. The success of establishing primary health care has resulted in significant improvements in maternal and child health, along with the control of infectious diseases. This has changed the epidemiological profile of Iran, with a transition to an increasing burden due to non-communicable disease and injuries. Associated with this are some other challenges, such as: Associated with this are some other challenges, such as: increasing urbanization with related changes in people’s lifestyles; increasing urbanization with related changes in people’s lifestyles; increased privatization of health system; increased privatization of health system; inequitable distribution of resources and health status, with high out- of-pocket payments for curative services among the needy, who are not adequately protected from catastrophic health expenditures. inequitable distribution of resources and health status, with high out- of-pocket payments for curative services among the needy, who are not adequately protected from catastrophic health expenditures. Aggregated health data particularly from routine data that does not generate evidence on status of the health situation of separate population Aggregated health data particularly from routine data that does not generate evidence on status of the health situation of separate population

Responses to the challenges In response to the above mentioned challenges, the Iranian government is considering the following strategies: redesigning primary health care activities based on a family physician scheme and finding ways of involving private providers more effectively in the delivery of health services, both preventive and curative; redesigning primary health care activities based on a family physician scheme and finding ways of involving private providers more effectively in the delivery of health services, both preventive and curative; designing of electronic health records designing of electronic health records including SDH approaches and reducing health equity in the policy making and planning in various levels of the Iranian health system including SDH approaches and reducing health equity in the policy making and planning in various levels of the Iranian health system

An Overview of Urban HEART Project Urban Health Equity assessment and Responsiveness Tool is a project to assess and response to health inequities in urban settings (Tehran) which was developed by WHO, with below objectives: To identify gaps or differences in urban health providing indices and opportunities according to geographical regions and gender, economic, social and racial groups To identify gaps or differences in urban health providing indices and opportunities according to geographical regions and gender, economic, social and racial groups To plan and run effective interventions based on equity status assessment in health and health determinants To plan and run effective interventions based on equity status assessment in health and health determinants To strengthen intersectoral actions and community participation through indices measurement as well as running effective interventions To strengthen intersectoral actions and community participation through indices measurement as well as running effective interventions

Example of Matrices District Male 10+ Unemploym ent rate Female 10+ Unemploym ent rate Employme nt rate FFCI Catastrophic costs Un-insured family head Non Food Costs Food costs Proportion of Non-Food Costs to total costs Person per room Area per capita Resident in normal home Urban HEART- Tehran

Example of Maps Urban HEART Project- Tehran, Jan 2011

Fair Financial Contribution Urban HEART Project- Tehran, Jan 2011

Selection Criterion for Health Equity Indicators

Stakeholders How were the focal point and various stakeholders identified? How were the focal point and various stakeholders identified? Each indicator has an ‘in charge’ organisation. Each indicator has an ‘in charge’ organisation. All organisations were involved from the beginning All organisations were involved from the beginning Who were the main stakeholders? Who were the main stakeholders? MOH, Statistical Center, Education Dep, Housing Dep, Welfare Org, Insurance Org, Energy Dep, MOH, Statistical Center, Education Dep, Housing Dep, Welfare Org, Insurance Org, Energy Dep, Medical Universities, other universities Medical Universities, other universities National experts National experts

Domains for indicators measurement

Executive Points According to the request from the High Health Council, the Iranian cabinet in the meeting dated 2 January 2011 has approved the Monitoring of Health equity and its indicators According to the request from the High Health Council, the Iranian cabinet in the meeting dated 2 January 2011 has approved the Monitoring of Health equity and its indicators Health Equity Indices calculate annually by gender, education, economics status, age and the place of residency (including urban, rural and slum areas) in each district in the case of necessity and possibility Health Equity Indices calculate annually by gender, education, economics status, age and the place of residency (including urban, rural and slum areas) in each district in the case of necessity and possibility Data from routine information system as well as surveillance system is the main source of data for measuring health equity indices. Data from national surveys will be used in specific subjects Data from routine information system as well as surveillance system is the main source of data for measuring health equity indices. Data from national surveys will be used in specific subjects Health Council at the district level is responsible to collect, analysis and disseminate the result of measuring health equity indices. Health Council at the district level is responsible to collect, analysis and disseminate the result of measuring health equity indices. Health councils supports/advocates appropriate interventions on reducing inequalities in health at district level, between districts of the province and national level Health councils supports/advocates appropriate interventions on reducing inequalities in health at district level, between districts of the province and national level

Challenges Changing various processes in different organizations to generate valid and reliable disaggregated data based on routine system Changing various processes in different organizations to generate valid and reliable disaggregated data based on routine system Allocation financial resources for monitoring and response to health inequalities in various domains Allocation financial resources for monitoring and response to health inequalities in various domains Coordination various organization at different levels (district, province, national) Coordination various organization at different levels (district, province, national)

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