Objective: The National Family Health Survey‐4 in India provided the first nationally representative estimates of hysterectomy among women aged 15–49. This paper aims to examine the national and state‐level age‐specific prevalence of hysterectomy, individual and household level factors associated with the procedure, and state‐level indicators that may explain variation across states.Design: Cross‐sectional, nationally representative household survey.Setting: National Family Health Survey was conducted across all Indian states and union territories between 2015 and 2016.Population: The survey covered 699 686 women between the ages of 15 and 49 years.Methods: Descriptive analyses and multivariate logistic regression.Main outcome measures: Women who reported ever having a hysterectomy and age at hysterectomy.Results: Age‐specific prevalence of hysterectomy was 0.36% (0.33,0.39) among women aged 15‐29; 3.59% (3.45,3.74) among women aged 30‐39; and 9.20% (8.94,9.46) among women 40‐49 years. There was considerable variation in prevalence by state. Four states reported age‐specific prevalence similar to high‐income settings. Approximately two‐thirds of hysterectomies were conducted in private facilities, with similar patterns across age groups. At the national level, higher age and parity (at least two children); not having had formal schooling; rural residence (adjusted odds ratio [AOR] 1.36; 95% CI 1.27,1.45; P < 0.01) and higher wealth status were associated with higher odds of hysterectomy. Previously sterilised women had lower odds (AOR 0.64; 95% CI 0.61,0,68; P < 0.01) of reporting hysterectomy. Exploratory analyses suggest state‐level factors associated with prevalence of hysterectomy include caesarean section, female illiteracy, and women's employment.Conclusions: Hysterectomy patterns among women aged 15–49 in India indicate the critical need to ensure treatment options for gynaecological morbidity and to address hysterectomy among young women in particular.Funding: This study was part of the RASTA initiative of the Population Council's India country office under the Evidence Project supported by USAID.Tweetable Hysterectomy patterns in India highlight the need for alternatives to treat gynaecological morbidity among younger women.

As a key step in advancing the sustainable development goals, the World Health Organisation (WHO) has placed emphasis on building capacity for measuring and monitoring health inequalities. A number of resources have been developed, including the Health Equity Assessment Toolkit (HEAT), a software application that facilitates the assessment of within-country health inequalities. Following user demand, an Upload Database Edition of HEAT, HEAT Plus, was developed. Launched in July 2017, HEAT Plus allows users to upload their own databases and assess inequalities at the global, national or subnational level for a range of (health) indicators and dimensions of inequality. The software is open-source, operates on Windows and Macintosh platforms and is readily available for download from the WHO website. The flexibility of HEAT Plus makes it a suitable tool for both global and national inequality assessments. Further developments will include interactive graphs, maps and translation into different languages.

Background: Achieving the Sustainable Development Goal of ‘ensuring healthy lives and promoting well-being for all at all ages’ necessitates regular monitoring of inequality in the availability of health-related infrastructure and access to services, and in health risks and outcomes. Objectives: To quantify subnational regional inequality in Indonesia using a composite index of public health infrastructure, services, behavioural risk factors and health outcomes: the Public Health Development Index (PHDI). Methods: PHDI is a composite index of 30 public health indicators from across the life course and along the continuum of care. An overall index and seven topic-specific sub-indices were calculated using data from the 2013 Indonesian Basic Health Survey (RISKESDAS) and the 2011 – Village Potential Survey (PODES). These indices were analysed at the national, province and district levels. Within-province inequality was calculated using the Weighted Index of Disparity (IDISW). Results: National average PHDI overall index was 54.0 (out of a possible 100); scores differed between provinces, ranging from 43.9 in Papua to 65.0 in Bali. Provinces in western regions of Indonesia tended to have higher overall PHDI scores compared to eastern regions. Large variations in province averages were observed for the non-communicable diseases sub-index, environmental health sub-index and infectious diseases sub-index. Provinces with a similar number of districts and with similar overall scores on the PHDI index showed different levels of relative within-province inequality. Greater within-province relative inequalities were seen in the environmental health and health services provisions sub-indices as compared to other indices. Conclusions: Achieving the goal of ensuring healthy lives and promoting well-being for all at all ages in Indonesia necessitates having a more focused understanding of district-level inequalities across a wide range of public health infrastructure, service, risk factor and health outcomes indicators, which can enable geographical comparison while also revealing areas for intervention to address health inequalities.

Immunization through vaccines among children has contributed to improved childhood survival and health outcomes globally. However, vaccine coverage among children is unevenly distributed across settings and populations. The measurement of inequalities is essential for understanding gaps in vaccine coverage affecting certain sub-populations and monitoring progress towards achieving equity. Our study aimed to characterize the methods of reporting inequalities in childhood vaccine coverage, inclusive of the settings, data source types, analytical methods, and reporting modalities used to quantify and communicate inequality. We conducted a scoping review of publications in academic journals which included analyses of inequalities in vaccination among children. Literature searches were conducted in PubMed and Web of Science and included relevant articles published between 8 December 2013 and 7 December 2023. Overall, 242 publications were identified, including 204 assessing inequalities in a single country and 38 assessing inequalities across more than one country. We observed that analyses on inequalities in childhood vaccine coverage rely heavily on Demographic Health Survey (DHS) or Multiple Indicator Cluster Surveys (MICS) data (39.3%), and papers leveraging these data had increased in the last decade. Additionally, about half of the single-country studies were conducted in low- and middle-income countries. We found that few studies analyzed and reported inequalities using summary measures of health inequality and largely used the odds ratio resulting from logistic regression models for analyses. The most analyzed dimensions of inequality were economic status and maternal education, and the most common vaccine outcome indicator was full vaccination with the recommended vaccine schedule. However, the definition and construction of both dimensions of inequality and vaccine coverage measures varied across studies, and a variety of approaches were used to study inequalities in vaccine coverage across contexts. Overall, harmonizing methods for selecting and categorizing dimensions of inequalities as well as methods for analyzing and reporting inequalities can improve our ability to assess the magnitude and patterns of inequality in vaccine coverage and compare those inequalities across settings and time.

Background Like many other low- and middle-income countries, India faces challenges of recruiting and retaining health workers in rural areas. Efforts have been made to address this through contractual appointment of health workers in rural areas. While this has helped to temporarily bridge the gaps in human resources, the overall impact on the experience of rural services across cadres has yet to be understood. This study sought to identify motivations for, and the challenges of, rural recruitment and retention of nurses, doctors and specialists across types of contract in rural and remote areas in India's largely rural north-eastern states of Meghalaya and Nagaland. Methods A qualitative study was undertaken, in which 71 semi-structured interviews were carried out with doctors (n = 32), nurses (n = 28) and specialists (n = 11). In addition, unstructured key informant interviews (n = 11) were undertaken, along with observations at health facilities and review of state policies. Data were analysed using Ritchie and Spencer's framework method and the World Health Organization's 2010 framework of factors affecting decisions to relocate to, stay in or leave rural areas. Results It was found that rural background and community attachment were strongly associated with health workers’ decision to join rural service, regardless of cadre or contract. However, this aspiration was challenged by health-systems factors of poor working and living conditions; low salary and incentives; and lack of professional growth and recognition. Contractual health workers faced unique challenges (lack of pay parity, job insecurity), as did those with permanent positions (irrational postings and political interference). Conclusion This study establishes that the crisis in recruiting and retaining health workers in rural areas will persist until and unless health systems address the core basic requirements of health workers in rural areas, which are related to health-sector policies. Concerted attention and long-term political commitment to overcome system-level barriers and governance may yield sustainable gains in rural recruitment and retention across cadres and contract types.