1. Monitoring health equity for social marketing programs in Nepal Rebecca Firestone, Nirali Chakraborty, Mahesh Paudel, Nicole Bellows 9 th World Congress on Health Economics 7-10 July 2013 Contact: rfirestone@psi.orgrfirestone@psi.org

2. Background + Objectives Nepal Under-5 mortality 48/1,000 live births Maternal mortality 170/100,000 live births Data sources: UNICEF, World Bank How do we know that programs are reaching target populations equitably? Implementers need reliable and actionable measures of equity in program performance. We aim to: 1.Estimate socio-economic distributions of health outcomes from survey data using an SES measure benchmarked against a national reference population 2.Estimate socio-economic distributions of programmatic exposure 3.Disaggregate outcomes by exposure level PSI implements malaria prevention and family planning in Nepal using social marketing strategies

3.  Data –Population-representative 2011 survey of 1078 households on family planning in 23 districts where PSI operates, measuring Modern contraceptive use Exposure to any IUD messages, to PSI-branded communications on IUDs –Population-representative 2010 survey of 3327 households on malaria prevention in 13 districts where PSI operates, measuring Any bednet and any LLIN use (children <5, pregnant women) Exposure to PSI-branded communications on LLINs, home visit on LLIN use  Analysis –Wealth index constructed using asset values – means, standard deviations, PCA weights – from 2011 Nepal DHS2011 Nepal DHS –Wealth quintiles and concentration indices calculated for all measures –Significance testing Chi-square test for equality of proportions for quintile estimates 95% CI for each quintile Standard errors of concentration indices to test H0 T-test differences in means to compare concentration indices exposed and unexposed Methods

4. Modern Contraceptive Use and Exposure to Communications by National Wealth Distribution CI PSI= 0.056* CI DHS = 0.055* * statistically significant at p<0.05; CI = concentration index CI Unexposed = 0.071* CI Exposed = 0.006 54% of women exposed, H0: CI exposed =CI unexposed p=0.026 CI Unexposed = 0.004 CI Exposed = 0.015 41% of women exposed, H0: CI exposed =CI unexposed p=0.686 n=1036

5. Malaria Prevention Outcomes and Exposure to Communications for Children < 5 (n=1805) by National Wealth Distribution CI under LLIN= -0.035* CI under any net= 0.012* CI Unexposed = -0.0.129* CI Exposed = -0.049* 67% of children exposed, H0: CI exposed =CI unexposed p<0.001 * statistically significant at p<0.05; CI = concentration index CI Unexposed = -0.051* CI Exposed = -0.022* 30% of children, H0: CI exposed =CI unexposed p=0.188

6.  Distribution of LLINs favored the poor among children <5. For any bednet use and contraceptive use, the wealthy fared slightly better  Population in areas where PSIS operates had higher levels of contraceptive use than DHS, but comparable level of equity  All outcomes tended to be more equitably distributed among those exposed compared to unexposed  Social marketing programs can reach the poor and contribute to equitable health outcomes  Equity monitoring can be used to adjust implementation strategies to ensure programs are reaching target populations as intended  Further reading at http://www.biomedcentral.com/1471- 2458/13/S2/S6 http://www.biomedcentral.com/1471- 2458/13/S2/S6 Findings and Recommendations