1. Equity Considerations for Designing Integrated Community Based Maternal Neonatal and Child Health Programs Debra Prosnitz, Jennifer Winestock Luna, Leo Ryan ICF International

2. Background Private Voluntary Organizations (PVOs) participating in USAID’s Child Survival and Health Grants Program (CSHGP) have long been concerned with reaching the most vulnerable populations with life-saving health programs. In recent years, PVOs have made a particular effort to focus on achieving health equity within underserved and isolated communities. However, projects often have different ideas of what equity means, how it should be addressed, and often don’t integrate equity measures into monitoring and evaluation. To advance health equity in maternal, newborn and child health (MNCH) programming, the Maternal Child Health Integrated Program (MCHIP) developed a methodology which provides a systematic process of incorporating equity into project designs, improving how equity is demonstrated and explained, and ensuring a shared understanding among stakeholders.

3. 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

4. Guiding Principles 1. Addressing equity means more than working in a disadvantaged geographical region  Means reaching most disadvantaged within that region  Making comparisons over time of health outcomes between disadvantaged and advantaged groups.  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.

5. Common issues and barriers that result in inequitable access to healthcare, inequitable coverage of evidence-based interventions, and inequitable health outcomes are:  Harmful norms and practices  Burden of care (i.e. women cannot leave livelihood to seek preventive care or treatment)  Low literacy  Distance/lack of transportation  Language  Health services not culturally acceptable  Poor treatment by health staff  Stigma or violence (toward disadvantaged group)  Unequal power relationships between disadvantaged and advantaged groups (i.e. unequal representation in community structures)

6. Six-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

7. It may not be possible to work on all aspects of equity at the same time, nor to specially target all disadvantaged groups and demonstrate increased equity. It is important to carefully considered how to handle underlying issues and barriers. Considerations for Step 3 include:  Is it possible to change the conditions?  If not, how will you work with these conditions to improve health, without exacerbating the underlying conditions that cause inequity?  Make sure that your program is either accommodating or transformative, in how it handles underlying barriers and conditions. ExploitativeAccommodatingTransformative

8. 4. Define equity goals, objectives, and a project-specific definition of equity 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.  Determine equity strategies and activities 6. Develop equity-focused M&E

9. Grantees of USAID’s Child Survival and Health Grants Program (CSHGP) have applied the guidance in early stages of program implementation. Examples from these projects provide some preliminary lessons on incorporating and equity focus into programs, and demonstrate potential impact of the methodology in health equity and MNCH programs.

10. Christian Reformed World Relief Committee (CRWRC) Netrokona District, Bangladesh Implementing in Netrokona District, a drastically under-performing district prioritized by the Government. Prioritize the poor and marginalized within the project area First identified the wealth inequity by reviewing secondary data; then confirmed these findings with their own local Knowledge, Practice, and Coverage data by adding in questions about household assets to compare socio-economic quintiles; and next conducted Participatory Rural Appraisal to better understand the inequities between wealth quintiles and their causes. People’s Institutions: A community mobilization strategy that addresses social exclusion (low social capital, which involves degree of social contact and perceived support and trust). Groups formed through this strategy may also work on literacy and income generation, two other underlying factors for inequity. Source: CRWRC

11. Center for Human Services (CHS) Cotopaxi Province, Ecuador  Formative research showed higher rates of maternal/newborn morbidity and mortality among the indigenous and extreme poor; and lower rates of health care utilization among the indigenous population as compared to the mestizo populations. Prioritized marginalized populations:  >50% poverty level (national survey data)  >50% indigenous Indian population (national survey data)  Focus groups with Trained Traditional Midwives (TTMs) to better understand why indigenous women were not accessing services: cultural differences between the indigenous population and the primarily mestizo health workers; lack of confidence in health services; and mistreatment by health workers as major barriers  Strategies and Activities:  Fostering inclusion of the indigenous members in local community groups  Increasing awareness of rights of health service users  Improving cultural responsiveness of health facilities by bringing together community members, local government representatives, and health workers to incorporate cultural elements in obstetric and newborn care that meet women’s demands. (This method has been incorporated into MOH Guidelines.)  Training existing TTMs  Strengthening parish health outreach teams to bring services to women’s homes.

12. Note to Pubs: This image goes with the CHS Ecuador text in the slide above

13. CARE Nepal Kailali and Doti District, Nepal  Focus on marginalized populations within project area: Dalit, disadvantaged Janjatis, disadvantaged non-Dalit Tarai caste group, and religious minorities  To further identify inequities, used a special technique called SATH (Self-Applied Technique for quality Health) to find out who does not access care and the reasons why  Activities focus on social inclusion of the marginalized, increasing knowledge and understanding both of health and rights, and advocating for better treatment by health workers (improving quality of care in the health system)

14. Self-Applied Technique for quality Health (SATH) Prioritized VDC/HF On site coaching (FCHV, Mothers, MIL, FIL, PW, PNM Husbands, Peoples Org,) in MG meeting Ward categorization  Social mapping  HMIS data analysis VDC/HF prioritization at district level Ensure regular MG meeting and increase utilization of health services Feedback/Reflection Analysis of HMIS data, interaction among HF staff, HFOMC members, MG representative, WRF, WAF and other community members, stakeholders Feedback/reflection Documentation and dissemination of processes, learning and changes Capacity building of FCHV & HWs Include RBA, Advocacy and Social Inclusion Issues Key MNH messages based on BCC strategy Self assessment and evaluation Healthy and prosperous family / community Improvement in maternal and neonatal health by reducing morbidity and mortality Note to Pubs: This image goes with the CARE Nepal text in the slide above

15. Tools and References Checklist for Health Equity Programming  Series of questions/ discussion points about project designs (www.mchipngo.net)www.mchipngo.net Equity Guidance document  Considerations for Incorporating health Equity into Project Designs: A Guide for Community-Oriented Maternal, Neonatal, and Child Health Projects (www.mchipngo.net)www.mchipngo.net Worksheets and presentations to guide teams through equity-integrated program planning

16. Special thanks to Claire Boswell, Alan Talens, Kathleen Hill, Andrew Gall, Khrist Roy, and Dipak Tiwari for their contributions and sharing their experiences.