Monitoring Health Inequities in Low-and-Middle-Income Countries: Who Is – and Is Not – Counted and Included in Government Health Statistics?

Abstract

This dissertation examines which populations and places are excluded from health data in low- and middle-income countries (LMICs) and the implications of this invisibility on how population health inequities are understood and addressed. The first study utilizes data from 173 Demographic Health Surveys and Multiple Indicator Cluster Surveys (MICS) to estimate changes in average birth registration coverage in 67 LMICs between 1999 and 2015 and examine whether absolute and relative wealth and urban/rural inequities in birth registration widened or narrowed. In the majority of countries which had not achieved complete birth registration, we find that average improvements in birth registration were not met with reductions in wealth and urban/rural inequities. The second study combines semi-structured interviews with the staff of six population-based cancer registries (PBCRs) in India with a literature review of studies based on PBCR data to understand and document practices of registration, efforts to include rural populations in cancer registries, and efforts to collect, analyze and report data on social inequalities in cancer. Qualitative results suggest that PBCRs in India have developed additional approaches to cancer registration, including conducting village and home visits to interview cancer patients in rural areas. Results of the literature review indicate that few studies which utilize PBCR data are explicitly designed to use PBCR data to measure social inequities in cancer in India. The third study is a mixed methods study which combines an analysis of the 2014 Nepal MICS survey and 18 key informant interviews with organizations in the child protection sector in Nepal to understand uses of child protection data, to highlight invisibilities in data, and to provide recommendations to improve data, including the possibility of a national monitoring system. We find the burden of violent discipline (82%), child labor (37%), child marriage (12%), and their co-occurrence, is high in Nepal. Respondents described using large-scale surveys, case data from the police and court system, newspapers, community consultations, and child participation to guide their work. These studies underscore the importance of strengthening routine public health data to measure and monitor health inequities and demonstrate the benefits of monitoring equity in health outcomes instead of relying solely on averages in order to reduce health inequities which are unfair, unjust, and avoidable.