1. Equity: We are all working toward it: What do we mean, and how can we improve our efforts? Jennifer Luna – MCHIP Dr. Todd Nitkin – CORE M&E/ MTI CORE Fall Meeting – October 7, 2009

2. Overview of the Session Part of a process to provide recommendations for the PVO community, CSHGP projects and MCHIP country programs on addressing equity in community oriented health programs 1. Discussion on emerging findings of Equity TAG process - MCHIP 2. Presentations of 3 PVO experiences 3. Discussion of next steps for developing practical equity guidance

3. Equity TAG Process  Purpose: to gather expert opinions on improving maternal and child health equity for use in project designs  Process began August 2009  Opinions solicited from representatives of PVOs, CORE, MCHIP, MEASURE Evaluation, DHS, and USAID.

4. Guiding questions:  Which are areas of equity most critical to focus on?  How should grantees determine this for projects? What information is needed?  How could CSHGP projects demonstrate improvements in equity?  What information, methodologies, analysis and expertise would be needed?  Key resources

5. Expert Responses 1.Questions for us to consider as we develop recommendations 2.Specific opinions One suggestion – Develop a flow chart of process incorporating equity into projects  Comments can be grouped into 7 steps, which is the beginning of a flow chart

6. Seven steps: 1.Determine why we are addressing equity  What are we trying to solve? 2.Identify disadvantaged groups to focus on 3.Decide if equity or universal coverage approach is most appropriate 4.Determine strategies to improve equity 5.Set up M&E system to track improvements in equity 6.Implement equity strategies 7.Evaluate

7. Step-1: Why are we addressing equity? What are we trying to solve? Two possibilities:  Using an equity approach as a means to improve health outcomes.  Approaching equity as a desired outcome in and of itself (in addition to health)

8. Step-1: Using an Equity approach as: Means  Assess equity issue as background information  Figure out how to work within its confines (or around it) or address it minimally.  Proceed with health program Desired outcome  Identify inequitable issue  Determine how inequitable issue affects health outcome  Design intervention that affects both equity issue and health outcome  Track changes in equity issue throughout program

9. Step 1: Gender Integration Continuum USAID/Gender working group developed concept  Allows for hybrid approaches  Starts with extreme of a design that improves health outcome, but increases gender inequity (should not be done)  Design that works within the confines of gender inequity, but does not try to change gender issue  Design that attempts to transform inequitable gender norms and behaviors as part of health intervention

10. Step 1: We need a definition of what equity means for us  Should this specify improved health outcomes?  Most TAG experts state equity should relate to health outcomes (not for example: education, income)  Equity should be tied to actual coverage level  Bring coverage for everyone up to an acceptable level Avoid keeping everyone at a low level  Equity could also refer to health workers  Employment by gender; Training by gender; Risks by gender for employed workers i.e. Needle stick injuries are more frequent in cleaners who tend to be female (immunization field)

11. Definitions from literature:  Inequity = “differences in health that are not only unnecessary and avoidable, but in addition unfair and unjust.” (M. Whitehead) (In other words, inequalities in health outcome that are avoidable and unfair)  Equity = “Minimizing avoidable disparities in health and its determinants – including but not limited to health care – between groups of people who have different levels of underlying social attributes. “ (WHO)

12. Definitions from Literature  Equity = “ acceptable variations in health that are randomly distributed across social groupings such as gender, occupation, race/ethnicity and are not associated with education, income or access to health care.” (F. Peter and T. Evans)

13. MCHIP Definition Equity - PMP  Equity in coverage of MNCH services  Specifically:  Increased equity means an increase of at least 10% for the lowest two quintiles (asset based wealth quintile analysis)  MCHIP will refine this definition based on results of TAG process

14. Step 2: Identify disadvantaged group to focus on Multiple categories:  David Gwatkin uses term “PROGRESS”  Place of residence, race, occupation, gender, religion, education, socio-economic status Each category could be divided into multiple levels:  Quintiles for economic status  Two levels for simplified analysis  Projects must prioritize

15. Step 2: Identify disadvantaged group to focus on Suggestions for design stage:  Review secondary data  Use participatory process with communities  Communities identify most disadvantaged group  Qualitative studies  i.e. Key informant interviews of key stakeholders Suggestion to emphasize inequities due to:  Poverty; Gender; Urban/ Rural

16. Step 3: Decide if equity or universal coverage approach is most appropriate  Is coverage so low in entire project area that everyone needs help?  Are there approaches that reach everyone including the underserved?  Vaccination campaigns have shown with data that they reach across all wealth quintiles effectively

17. Step 3: Decide if equity or universal coverage approach is most appropriate  Which approach is most efficient in improving coverage for the most people?  More resources may be needed to reach underserved populations; more people may ultimately be reached with same resources by universal approach  Suggestion is to develop a tool to measure the long term sustainability of an equity approach.

18. Step 4: Determine strategies to improve equity Questions:  When do most PVOs think about strategies for addressing equity?  When should they think about equity? Ideal situation described by TAG experts is in the beginning of project

19. Step 4: Determine strategies to improve equity Process involves:  Formulating equity focused goals and objectives for situational & baseline analysis Example  Goal: assess how health outcomes vary with ethnicity and geographic location  Objective: determine whether there were any differences in health outcomes and health related behaviors between ethnic groups which would affect the DIP

20. Step 4: Determine strategies to improve equity Identifying:  Barriers or enabling factors to achieving good health outcomes in disadvantaged groups  Differences in behaviors that affect health outcomes  Which health outcomes are low for which group  One example: Exclusive breastfeeding found to be lowest for highest wealth group

21. Step 4: Determine strategies to improve equity Qualitative analysis  i.e. Participatory learning and action; mapping, focus groups; key informant interviews  Example:  Implemented using purposive sampling based on ethnic group  Important for determining type of messages, communication channels based on language or cultural differences

22. Step 4: Determine strategies to improve equity  Quantitative analysis:  Design baseline survey so that data can be disaggregated by groups  Make sure sample size is large enough and that sampling is performed in a manner that allows for comparing groups.

23. Step 5: Set up an M&E system to track improvements in equity Most TAG experts stated that setting up a system was important.  Measure indictors so that they can be disaggregated into groups that are the focus of Equity efforts  Collect qualitative information from different groups  If disadvantaged group is stigmatized, may be difficult to collect information.  Best to track information at community level with buy-in from the community

24. Step 5: Set up an M&E system to track improvements in equity Question for TAG experts: How can CSHGP better document the process of implementing activities that focus on equity?  Response: Make it a requirement in DIPs, Annual Reports, Mid-term and Final evaluations

25. Step 6: Implement Equity Strategies  Implement based on findings from previous steps  Include M&E system  Adjust strategies as needed

26. Step 7: Evaluate Range of experiences and suggestions  Quintile analysis  Asset based, used by DHS and PVOs (Concern Worldwide)  Requires more sophisticated analysis expertise than for a KPC  Steps include determination of indictor variables, calculation of indicator weights and the index value. Indictor variables are selected from household assets and utility services

27. Step 7: Evaluate  Using IYCF data as approximation to wealth scale  Used by Concern Worldwide  Found differences in urban Haiti; but not in rural Burundi

28. Step 7: Evaluate Suggestion:  Using KPC data, measure health outcomes disaggregated by inequity category being addressed (gender, ethnicity)  Mortality comparisons could be modeled using LIST tool  Same expertise as currently needed for KPC

29. Step 7: Evaluate Keep in mind for KPC:  Sample size must be adequate for disaggregation  Total sample size could be increased  Sampling can be stratified by category  Separate surveys can be conducted for each group  Simplest if number of categories and levels within categories are limited  (i.e. Poorest half/ Richest half; Female/Male)

30. Step 7: Evaluate Using LQAS: Example  Lots (supervision areas) would be made of different sub-sets of group being studied Group: Ethnicity (Ethnic groups); Place of residence (Urban/Rural  Decision table would be used to see if each group met the target  Discussion with stakeholders (district level, communities) about results

31. Resources – suggested by TAG  10 best resources on health equity. Davidson Gwatkin HPP 2007  Equity in Access to Public Health. SEARO Working Paper  WHO Social Determinants Group  Poverty Inequality and Health: An international perspective. Edited by D.Leon and G. Walt  Challenging Inequities in Health: From ethics to action. Edited by T.Evans, MWhitehead, et al

32. Resources – suggested by TAG  NGO facilitation of a government c-based maternal and neonatal health programme in rural India: improvements in equity. A.Baqui et al. HPP 2008  All of the health equity poverty papers by A.Wagstaff  Cesar Victora’s work in Brazil on universal coverage

33. Resources – suggested by TAG  Analyzing Health Equity Using household Survey Data.  Owen O’Doneel., Eddy Van Doorslaer, Adam Wagstaff and Magnus Lindelow.  WBI Learning Series. TheWorld Bank. Washington DC 2008  Equity and child-survival strategies. EK Mulholland,a L Smith,b I Carneiro,b H Becherc & D Lehmannd. Bulletin of the World Health Organization | May 2008.

34. Resources – suggested by TAG  Achieving health equity: from root causes to fair outcomes Michael Marmot (on behalf of the Commission on Social Determinants of Health). www.thelancet.com Published online September 6, 20073.  MEASURE Evaluation Publication:  Addressing Poverty: A guide for considering poverty-related and other inequities in health prepared by Karen Foreit, April 2008. www.cpc.unc.edu/measure

35. Equity TAG Participants  Karen Foreit (Futures)  Sunita Kishor (ICF MACRO –DHS)  Karen LeBan (CORE)  Todd Nitkin (CORE M&E/ MTI)  Michelle Kouletio (Concern Worldwide)  Michal Avni (USAID)  Robert Steinglass (JSI/MCHIP)  ICF MACRO/MCHIP  Jim Ricca  Jennifer Yourkavitch  Michel Pacque  Debra Prosnitz  Jennifer Luna  Alan Talens (CRWRC)  Laban Tsuma (PLAN)

36. Questions for groups 1.What type of guidance or resource would be most helpful to the PVO community to strengthen equity components of project designs? 2.What next steps do you suggest to move the Equity TAG process further?