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 Vital Horoscope Challenges of the Iranian Health System

An Overview of the Tehran Urban HEART Project

Indicators for Monitoring of Health Equity in Iran

Selection criteria for indicators Executive points Challenges

Introduction 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 .

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

180002400 Master

Plan

The Islamic Republic of Iran’s 17 000 “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

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

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 >5Mortality 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.

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, 1993-2007

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 20080

5

10

15

20

25

30

35

40

45

50

Neonatal Mortaltiy Infant MortalityChild Mortality

Child mortality rates based on the Vital Horoscope for rural areas by Province, Iran, 1993-2007

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.

Associated with this are some other challenges, such as: increasing urbanization with related changes in

people’s lifestyles; 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.

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;

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

Monitoring of Health Equity

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 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

Example of MatricesDistrict

Male 10+ Unemploym

ent rate

Female 10+ Unemploym

ent rate

10-15 Employme

nt rateFFCI Catastrophic

costsUn-insured

family headNon

Food Costs

Food costs

Proportion of Non-Food

Costs to total costs

Person per

room

Area per

capita

Resident in normal

home

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

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

Availability of data from routine information source and surveillance system

Strengthen of proposed indices to measure inequalities in health

Ability of indices to cover a broad spectrum of issues

Possibility to compare internationally

Ability to use common indices on health promotion as well as urban development plan

Stakeholders How were the focal point and various

stakeholders identified? Each indicator has an ‘in charge’

organisation. All organisations were involved from the

beginning Who were the main stakeholders?

MOH, Statistical Center, Education Dep, Housing Dep, Welfare Org, Insurance Org, Energy Dep,

Medical Universities, other universities National experts

Domains for indicators measurement

Health

Physical environment

& infrastructur

e

Social & Human

DevelopmentEconomics Developme

nt

Governanc

e

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

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

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

Challenges

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

Coordination various organization at different levels (district, province, national)

Thanks for your attention