1. Practical Steps for Incorporating Health Equity into the Quality Improvement Process Jennifer Winestock Luna Senior M&E Advisor ICF Macro (MCHIP) September 26, 2011 ISEqH 6th International Conference: Making Policy a Health Equity Building Process

2. Concern How can we ensure that findings about health inequities and the factors that lead to them are translated into program activities that improve quality and increase equity?

3. Overview of Presentation 1.6-step process to incorporate heath equity into program planning  Guidance developed by USAID’s Maternal Child Health Integrated Program (MCHIP) 2.Examples from on-going projects 3.Suggestions for facility focused QI

4. Why did we developed this 6-step process? Challenges:  Programs often state that equity is part of the design, however:  How equity is being addressed may not be clearly articulated  Stakeholders often have different ideas of what equity means  M&E systems may not be set up to measure equity  Budgets for activities and M&E are usually limited

5. The guidance for 6-step process 1.Check list  Series of questions/ discussion points about project designs (www.mchip.net)www.mchip.net 2.Reference document  Considerations for Incorporating health Equity into Project Designs: A Guide for Community-Oriented Maternal, Neonatal, and Child Health Projects (www.mchip.net)www.mchip.net 3.Presentations, exercises; to work with teams 4.Workbook to keep track of decisions

6. The guidance for 6-step process  Targets professionals who design & implement programs  Provides a systematic process that ensures  Equity is incorporated into designs  Improvements can be demonstrated and explained  A shared understanding among stakeholders  Not prescriptive; does not promote one approach  Presents series of concepts & approaches to take into consideration & decisions to be made

7. Definition of health equity Health equity is both the improvement of a health outcome of a disadvantaged group as well as a narrowing of the difference of this health outcome between advantaged and disadvantaged groups--without losing the gains already achieved for the group with the highest coverage. (MCHIP)

8. Guiding assumptions 1.Addressing equity means more than working in a disadvantaged geographical region 1. Means reaching most disadvantaged within that region 2. Making comparisons over time of health outcomes between disadvantaged and advantaged groups 3. Requires understanding and deciding how to handle underlying conditions 2.Obtaining high coverage levels depends on decisions made along a continuum from narrowly targeting a disadvantaged group to a universal approach aimed at all groups

9. 6-step process: 1.Understand the equity issues in the project area a. Identify inequities in health outcomes b. Understand underlying issues and barriers 2.Identify the disadvantaged group on which to focus 3.Decide what is in project’s manageable interest to change 4.Define equity goals, objectives, and a project-specific definition of equity 5.Determine equity strategies and activities 6.Develop equity-focused M&E

10. Highlights from guidance

11. Step 1 Step 1 : Understand health equity issues Health Outcomes  Do you have quantitative information on inequities in specific health outcomes?  Which are inequitable?  Do the gaps in health outcomes justify a special approach to reduce the inequities? Underlying issues/barriers  Do you have information on the underlying conditions and barriers that lead to inequities?  What are the issues?

12. Step 2 Step 2 : Identify disadvantaged group to focus on  Have you identified a disadvantaged group?  Consider different situations (i.e. ethnic group, education, place of residence, socio- economic status.)  Have you identified an advantaged group for comparison?

13. Step 3 Step 3 : Define health equity specific goals, objectives and a project specific definition Goal  Does the goal include reducing the gap between a disadvantaged group and an advantaged group, while maintaining the gains of the advantaged group? Objectives  Are there objectives that specify gaps that will be reduced between a disadvantaged group and an advantaged group?  Are there objectives for improving the underlying conditions?

14. Step 4 Step 4 : Project specific operational definition  Not General definition  Lets project stakeholders know when equity has been improved  Helps communicate exactly what was improved Ex: Immunization coverage for children in X ethnic group will increase at least to baseline levels for other ethnic groups in program area at the same time levels for other ethnic groups do not decrease.

15. Examples from USAID Child Survival and Health Grants (CSHGP)

16. CSHGP  Community oriented integrated health programs  Grants to NGOs since 1985; Currently 37 projects  Improve quality at:  Community level  Lower level health facilities  Increase links between communities and health facilities

17. Step 1a Identify inequities in health outcomes  In Ecuador, the Center for Human Services (CHS) looked at provincial data on maternal & child health  Learned that indigenous populations have lower rates of maternal health care utilization than mestizo (mixed European descent) populations.  Rate of home births among total population was 46.5%, while for indigenous women it was 71.4%.  CHS conducted their own Knowledge, Practice, and Coverage (KPC) survey in the project area to confirm the same findings locally.

18. Step 1a Identify inequities in health outcomes  Using national (DHS) and local (KPC) data, Christian Reformed World Relief Committee (CRWRC) identified gaps in knowledge & coverage between highest & lowest wealth quintiles in project in Bangladesh.  In lowest quintile of project area, only 27.3% of women reported consuming iron/folate in their last pregnancy, versus 57.7% of women in highest quintile.

19. Step 1b Understand underlying issues/barriers  In Ecuador, CHS conducted focus groups/ key informant interviews with TBAs; Found barriers:  Cultural differences  No confidence in health services; health workers mistreat  Indigenous communities located far from health centers  CHS reviewed national data; found Indigenous families preferred home births:  Active presence of family member; Emotional support  Use of traditional teas, food; choice of delivery position  Room temperature, clothing, lighting  Absence of authoritarian clinician

20. Step 2 Identifying disadvantaged group  Using Participatory Rural Appraisal (PRA), CRWRC Bangladesh worked with community members to identify the poorest villages in each “union” of the project area.

21. Step 3 Decide what is in manageable interest to change CARE Nepal  Social exclusion of marginalized populations contributes to poor healthcare practices: Concentrate on:  Including marginalized in community-level activities  Informing them of their rights  Advocating for better treatment by health workers CHS Ecuador  Address cultural differences by:  Improving cultural responsiveness of health services  Using quality assurance methods to bring together community members

22. Step 5 Determine equity strategies and activities CARE Nepal:  Community mobilization in communities with poorest health indicators  Conducted training for health workers  Implemented behavior change communication program  Expanded an existing maternity incentive scheme to increase institutional deliveries (cash transfer).

23. Step 6 Develop equity focused M&E  CARE Nepal collected data on caste and ethnicity in KPC survey in order to disaggregate health indicators by marginalized and non-marginalized populations.  Through community mobilization strategy, project collected community-level data on pregnancy outcomes disaggregated by marginalized and non- marginalized women.

24. How can we be sure that traditional facility focused QI efforts address issues that prevent underserved populations from using health services?

25. For Facility QI process 1.Include both community & client perspectives 1. Health equity situation in the catchment area 2. Characteristics of client population; how it compares to characteristics of community population Are most clients from one ethnic group, while there are multiple ethnic groups in catchment area? 2.Incorporate equity into health facility performance standards 3.Measure how health equity changes over time in both in clients & catchment population

26. Sources  Community leaders  Ask who disadvantaged groups are; causes  Focus groups  Underlying conditions specific to area  Rapid community surveys  Health outcomes, service utilization  Clinic records, exit interviews Catchment area

27. Thank you www.mchip.net www.mchipngo.net