Practical Guidance for Incorporating Health Equity

Considerations

MCHIP Program Learning MeetingNovember 4, 2011

ICF (MCHIP)Jennifer Winestock Luna- Senior M&E AdvisorDebra Prosnitz- Program Associate

Debra Prosnitz,  MPH Program Associate Debra Prosnitz,  MPH Program Associate

Have you considered improving health equity as part of MCHIP country programming?

• What is your country program doing about improving health equity?

Session Outline

Purpose of MCHIP health equity work

Overview of MCHIP Health Equity Guidance and Checklist Examples of Application of the Checklist

Small group exercise : understanding health equity work in MCHIP country programs

Plenary discussion of exercise, challenges, next steps

Purpose of MCHIP Health Equity Work

Overall mandate to improve health outcomes

Improving health equity is a Program Learning theme Developed guidance to help programs

incorporate health equity considerations into program designs

MCHIP country programs:• Incorporate into new designs; Refine on-

going• Document health equity work using MCHIP

guidance as framework

MCHIP's 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)

MCHIP’s Health Equity Guidance

Why health equity guidance was developed?

Challenges: Projects often state that equity is part of

program design, however they: may not clearly articulate how equity is being

addressed have different ideas of what equity means do not have M&E set up to measure equity have limited budgets for activities and M&E

The guidance

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

Development of equity guidance

Collaborative effort USAID, MCHIP, CORE*, other technical

experts

Virtual TAG, discussion sessions to solicit input from equity experts Including representatives of PVOs, CORE, MCHIP,

MEASURE Evaluation, DHS, USAID and Cesar Victora

Literature Review (i.e. UNICEF, USAID's gender group, Davidson Gwatkin)*CORE: network of PVOs

community-oriented programs

The guidance consists of:

1. Check list Series of questions/ discussion points about

project designs (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)

3. Presentations, exercises; to work with teams

4. Workbook to keep track of decisions

Guiding assumptions1.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

Health Equity Guidance: 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 or groups3. Decide what is in project’s manageable

interest to change4. Define project-specific equity goals and

objectives 5. Determine equity strategies and activities 6. Integrate equity-focused indicators and

measurement into M&E framework and PMP

Highlights from Checklist

Step 1: Understand health equity issuesHealth Outcomes Do you have quantitative

information on inequities in specific health outcomes?

Have you considered ethnicity, gender, education, place of residence, socio-economic status, religious group, other?

Do the gaps in health outcomes justify a special approach?

Underlying issues/barriers

Do you have information on the underlying conditions and barriers that lead to inequities?

What are the issues?

Step 2: Identify disadvantaged group

Which disadvantage group will you focus on?

Have you identified an advantaged group for comparison? What is that group?

Examples from CSHGPStep 1a Identify inequities in health outcomes

In Ecuador, the Center for Human Services (CHS) looked at provincial data on maternal & child health

• Indigenous populations have lower rates of maternal health care utilization than mestizo (mixed European descent) populations.

• Home births among total population was 46.5%, while for indigenous women it was 71.4%.

CHS conducted its own Knowledge, Practice, and Coverage (KPC) survey in the project area to confirm the same findings locally.

Examples from CSHGPStep 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, only 27.3% of women reported consuming iron/folate in their last pregnancy, versus 57.7% of women in highest quintile.

Examples from CSHGPStep 1b Analyze underlying issues/barriers

In Ecuador, CHS conducted focus groups/ key informant interviews with TBAs and identified following 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

Examples from CSHGPStep 3 Decide on program's manageable interest

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

Step 4: Develop a project-specific operational definition of equity

Not general definition (i.e. MCHIP definition) Allows project stakeholders to know when

equity has been improved Helps communicate exactly what was

improved

Ex: Equity for children in _X_ group means that immunization coverage will increase to at least the baseline levels for other ethnic groups in the program area, at the same time that levels for other ethnic groups do not decrease.

Examples from CSHGP 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).

Examples from CSHGPStep 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.

Worksheets for applying guidance

Worksheet 1: Identifying Inequitable Health Outcomes Health outcome; between/ among which

groups; magnitude of the difference; source of information

Worksheet 2: Understanding underlying issues and barriers What are key underlying issues; missing

information; equity-based constraints; equity-based opportunities

Small group work: understanding health equity work in MCHIP country programs

Use worksheets to analyze equity details of country programs - 30 minutes

Volunteer programs – Who volunteers? Divide into groups

Choose facilitator, recorder Make sure have copies of worksheets Fill out what is possible

Plenary discussion of highlights

Plenary discussion

Examples from groups of Inequitable health outcomes Underlying conditions

Next steps for program learning How should guidance be used?

Thank you

www.mchip.net