Measuring health inequalities is indispensable for progress in improving the health situation in the Region of the Americas, where the analysis of average values is no longer sufficient. Analyzing health inequalities is a fundamental tool for action that seeks greater equity in health. There are various measurement methods, with differing levels of complexity, and choosing one rather than another depends on the objective of the study. The purpose of this article is to familiarize health professionals and decision-making institutions with methodological aspects of the measurement and simple analysis of health inequalities, utilizing basic data that are regularly reported by geopolitical unit. The calculation method and the advantages and disadvantages of the following indicators are presented: the rate ratio and the rate difference, the effect index, the population attributable risk, the index of dissimilarity, the slope index of inequality and the relative index of inequality, the Gini coefficient, and the concentration index. The methods presented are applicable to measuring various types of inequalities and at different levels of analysis.

Background In 1994, the Lady Health Workers (LHWs) Programme was established in Pakistan to increase access to essential primary care services and support health systems at the household and community levels. In Khyber Pakhtunkhwa (KPK) province in northern Pakistan, eye care is among the many unmet needs that LHWs were trained to address, including screening and referral of people with eye conditions to health facilities. However, despite an increase in referrals by LHWs, compliance with referrals in KPK has been very low. We explored the role of LHWs in patient referral and the barriers to patient compliance with referrals. Methods Qualitative methodology was adopted. Between April and June 2019, we conducted eight focus group discussions and nine in-depth interviews with 73 participants including patients, LHWs and their supervisors, district managers and other stakeholders. Data were analysed thematically using NVivo software version 12. Results LHWs have a broad understanding of basic health care and are responsible for a wide range of activities at the community level. LHWs felt that the training in primary eye care had equipped them with the skills to identify and refer eye patients. However, they reported that access to care was hampered when referred patients reached hospitals, where disorganised services and poor quality of care discouraged uptake of referrals. LHWs felt that this had a negative impact on their credibility and on the trust and respect they received from the community, which, coupled with low eye health awareness, influenced patients’ decisions about whether to comply with a referral. There was a lack of trust in the health care services provided by public sector hospitals. Poverty, deep-rooted gender inequities and transportation were the other reported main drivers of non-adherence to referrals. Conclusions Results from this study have shown that the training of LHWs in eye care was well received. However, training alone is not enough and does not result in improved access for patients to specialist services if other parts of the health system are not strengthened. Pathways for referrals should be agreed and explicitly communicated to both the health care providers and the patients.

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