The report focuses attention on reducing inequalities between subgroups of the population, using interactive ways for users to explore health data. The objective of this report is to showcase best practices in reporting the state of inequality in low-and middle-income countries using high-quality data, sound and transparent analysis methods, and user-oriented, comprehensive reporting.

The state of inequality reports on reproductive, maternal, newborn and child health report delivers both promising and disappointing messages about the situation in low-and middle-income countries. On the one hand, within-country inequalities have narrowed, with a tendency for national improvements driven by faster improvements in disadvantaged subgroups. In certain indicators and countries, these improvements have been substantial. On the other hand, however, inequalities still persist in most reproductive, maternal, newborn, and child health (RMNCH) indicators. The extent of within-country inequality differed by dimension of inequality and by country, country income group and geographical region. There is still much progress to be made in reducing inequalities in RMNCH.

Maternal health intervention indicators demonstrated pronounced within-country inequalities. The largest gaps in coverage-between the richest and poorest, the most and least educated, and urban and rural areas- were reported for births attended by skilled health personnel, followed by antenatal care coverage (at least four visits). Inequalities were also reported in antenatal care coverage (at least one visit), though to a lesser extent than the two above-mentioned maternal health interventions.

The proportion of births attended by skilled health personnel differed by up to 80 percentage points between the richest and poorest subgroups; this difference was 37 percentage points or higher in half of countries.

In half countries, antenatal care coverage (at least four visits) differed by at least 25 percentage points between the most and least educated, and the richest and poorest.

Reproductive health intervention indicators also indicated a situation of inequality.

The use of modern contraception was at least twice as high among women with secondary schooling or higher than among women with no education in nearly half of countries.

Immunization indicators demonstrated low to moderate coverage gaps across different dimensions of inequality.

Countries demonstrated no – or very low levels of – sex- related inequality in immunization coverage. The difference in immunization coverage between boys and girls did not exceed 10 percentage points in any study country.

Looking at BCG, polio, measles and DTP3 immunization among one-year-olds, in each case there was a difference of less than 5 percentage points between coverage in rural and urban areas in half of countries.

Over one third of countries reported a gap of less than 5 percentage points between BCG immunization coverage in the richest and poorest subgroups.

Indicators related to care-seeking for sick children showed higher inequality in care-seeking for pneumonia symptoms than for diarrhea. There were divergent patterns across countries in the level of inequality in the early initiation of breastfeeding.

In half of countries, there was as least an 18 percentage point gap in care-seeking for children with pneumonia symptoms between the poorest and richest subgroups.

About the same number of countries reported pro-poor inequality in early initiation of breastfeeding (higher prevalence of breastfeeding in the poorest than in the richest subgroup) as reported pro-rich inequality (higher prevalence in the richest than in the poorest subgroup). Overall, there was no prevailing pattern in economic-related inequality in breastfeeding practices across countries.

While current national averages and improvements over time are important indications of progress on a global level, reporting inequalities within countries reveals the different experiences of rural and urban residents, the poor and the rich, the educated and non-educated, and females and males. Monitoring the state of inequality, which includes tracking the change over time, unravels how progress in national averages is realized by population subgroups.

Health inequality monitoring is an essential step towards health equity. It has broad applications and can be conducted across diverse health topics. Applying the best practices in health inequality monitoring presents an opportunity to share the state of inequality with stakeholders, indicate areas in need of improvement and track progress over time.

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Dr. Shima Naghavi, Director of International Affairs