1. Tracking Progress in Child Survival Addressing Inequities Mushtaque Chowdhury, PhD Dean, James P. Grant School of Public Health, BRAC University and Professor of Population and Family Health, Mailman School of Public Health, Columbia University

2. Outline Intra-country inequities in health Lack of equity focus in health MDGs Need for tracking progress for all groups in population, particularly the marginalized A road-map for tracking progress

3. Source: Victora et al (2004)

4. Children Under 1 Year of Age Immunized for Different Groups in Bangladesh (1999-2001) Source: Chowdhury et al (2002)

5. Improving Equity Within Countries Would Prevent 40% of All Child Deaths India 54% Brazil 41% Victora C: Analyses based on DHS data Indonesia 59% Source: Victora et al (2004) Assuming that every child has the same mortality level as the richest 20% in their own country

6. Health MDGs Lack Equity Safeguard Goal 4: Reduce child mortality Goal 5: Improve maternal health Does achievement of the goals measures success? It is possible to reach the MDGs with little or no improvement of the health condition of the poor (Gwatkin)

7. “If health is central to poverty reduction, then issues of equity must be central to health” – UN MDG Task Force on Child health and Maternal health Need to track progress for all groups in the population, particularly the marginalized ones.

8. Pro-poor vs. Pro-equity Place of residence (incl. Urban slums) Religion Occupation Gender Race/Ethnicity Education Socio-economic status incl. income Social capital/Networths Courtesy: Tim Evans (WHO)

9. Tracking Progress in Child Survival for Equity What Needs to be Done?

10. Reframe MDG Targets Goal 4 Reduce by two-thirds, between 1990 and 2015, the under- five mortality rate, ensuring faster progress among the poor and other marginalized groups. Goal 5 Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio, ensuring faster progress among the poor and other marginalized groups. Universal access to reproductive health services by 2015 through the PHC system, ensuring faster progress among the poor and other marginalized groups. Source: Freedman et al (2005)

11. Track Indicators for the Marginalized Groups MDG Indicators Additional indicators including Newborn mortality Access to other services (e.g., reproductive health) Quality of care Resource allocation Health system indicators such as access to EmOC and human resources availability

12. Link Research to Action Identify problem areas (e.g., Groups that are poorly reached) Initiate action research to find what works Implement innovative ways to reach the disadvantaged, and scale up Study the delivery mechanism on a continuous basis for further refinements Report trend in inequities Do advocacy and activism (e.g., popular writing)

13. Develop Innovative Monitoring Methods Simple Rapid Reliable Replicable Affordable

14. Monitoring Utilization of Health Services by the Poorest in Bangladesh A pilot project by MoH, ICDDRB & BRAC To identify an equity sensitive rapid assessment tool for day-to-day use by hospital administrators A community survey establishes % poor and administrators assess if their patients comprise more or less of this % Initial results show most outpatients come from the poorest and richest quintiles A challenge is to identify one robust poverty indicator for use by the administrators

15. Track other MDG Targets that Affect Health Poverty (Food security, Microfinance, etc.) Nutrition Education Women’s empowerment Water & Sanitation Access to medicines 100 million impoverished annually due to lack of access to healthcare (The income erosion thesis)

16. BRAC’s Women-focused Poverty Alleviation Programme Reduces Inequity in Child Survival, Matlab, Bangladesh 1993-1996

17. Track Changes in Capacities Capacity to implement programmes Capacity to monitor progress Coordination

18. At Country-Level, 1. Start with an exhaustive baseline inequity analysis (data available) 2. Continue monitoring child survival with an equity lens (as outlined above) 3. Publish on a 2-yearly basis a report on State of Progress in Child Survival, including simple equity analysis on ‘Who gains how much and why?’

19. Thank you!