Addressing Poverty-Equity in Health Program Design, Implementation and Evaluation Karen Foreit 9 October 2009

What does it mean to address poverty ? Design interventions to reduce poverty-related inequalities in health status Monitor program uptake by the poor Assess changes in identified health inequalities

Design interventions to reduce poverty-related inequalities in health status

Monitor program uptake by the poor

Assess changes in identified health inequalities

Who and what do we want to address? Who are the poor? Which health indicators show inequalities? Other factors in addition to poverty?

Who are the poor?

Which health indicators show inequalities?

Other factors in addition to poverty?

Who are the poor? Relative poverty Rank people within the same country or region based on tangible assets or other characteristics DHS “wealth quintiles” Absolute poverty Compare people against a standardized poverty line, based on income or expenditures World Bank “Living Standards Measurement”

Relative poverty

Rank people within the same country or region based on tangible assets or other characteristics

DHS “wealth quintiles”

Absolute poverty

Compare people against a standardized poverty line, based on income or expenditures

World Bank “Living Standards Measurement”

Do not line up with absolute poverty Interpreting quintiles

Do not line up with absolute poverty

Do not line up with absolute poverty The middle matters Interpreting quintiles

Do not line up with absolute poverty

The middle matters

60% of the population belongs to Quintiles 2-4 What do we lose by leaving out the middle?

60% of the population belongs to Quintiles 2-4

What do we lose by leaving out the middle?

Which is the priority group? Is there only one priority group?

Which is the priority group?

Is there only one priority group?

Do not line up with absolute poverty The middle matters Other factors may be associated with poverty Interpreting quintiles

Do not line up with absolute poverty

The middle matters

Other factors may be associated with poverty

Ethnic Inequality Bolivia: Llano region vs. Altiplano Peru: Coast vs. Sierra Ethnicity

Bolivia:

Llano region vs. Altiplano

Peru:

Coast vs. Sierra

70% Urban-rural confound with quintiles Mali 26% 70% Place of residence source: Mali DHS

70% Urban-rural confound with quintiles Mali 26% 70% Place of residence source: Mali DHS

Do not line up with absolute poverty The middle matters Other factors may be associated with poverty Not all health indicators show the same poverty-related inequalities Interpreting quintiles

Do not line up with absolute poverty

The middle matters

Other factors may be associated with poverty

Not all health indicators show the same poverty-related inequalities

source: Honduras 2005/6 DHS

Disentangling quintile and residence Mali source: Mali DHS

Designing a pro-poor intervention Focused to benefit the poor Usually involves additional resources for the poor redistributing existing resources away from better-off populations/areas towards the poor/poverty areas adding new resources to overall budget Consider other factors associated with poverty Many barriers faced by the poor are non-financial

Focused to benefit the poor

Usually involves additional resources for the poor

redistributing existing resources away from better-off populations/areas towards the poor/poverty areas

adding new resources to overall budget

Consider other factors associated with poverty

Many barriers faced by the poor are non-financial

Are services physically accessible to the poor? Increase ability to pay Where are the poor? no yes Where are the services? Improve physical access Language, class discrimination or other social factors may be more important than ability to pay or service availability

Monitoring progress Whom does the intervention seek to reach? poverty status, geographic location, etc. how many of them are there? Whom does the intervention actually reach? number of people reached, services provided client characteristics (poverty status, residence, etc.)

Whom does the intervention seek to reach?

poverty status, geographic location, etc.

how many of them are there?

Whom does the intervention actually reach?

number of people reached, services provided

client characteristics (poverty status, residence, etc.)

Data needed for monitoring Baseline desirable but not necessary Time series (repeated measures) preferable At the geographic level of the intervention Consider client intercept surveys to measure client characteristics (especially poverty)

Baseline desirable but not necessary

Time series (repeated measures) preferable

At the geographic level of the intervention

Consider client intercept surveys to measure client characteristics (especially poverty)

Closing thoughts Use national surveys to identify subgroups and specific health indicators Consider place of residence and other social factors Design focused interventions and use geographic targeting whenever possible Use client intercept surveys to measure uptake by the poor Impact evaluation and attribution of change to program interventions may not always be feasible

Use national surveys to identify subgroups and specific health indicators

Consider place of residence and other social factors

Design focused interventions and use geographic targeting whenever possible

Use client intercept surveys to measure uptake by the poor

Impact evaluation and attribution of change to program interventions may not always be feasible

Addressing Poverty: a guide for considering poverty-related and other inequities in health. http://www.cpc.unc.edu/measure/publications Quick Poverty Score Toolkit: User's Guide and Spreadsheet . http://www.cpc.unc.edu/measure/publications The DHS Wealth Index: Approaches for Rural and Urban Areas . http://www.measuredhs.com/pubs Making Family Planning Part of the PRSP Process: a guide for incorporating family planning programs into poverty reduction strategy papers http://www.healthpolicyinitiative.com/index.cfm?id=publications A couple of resources

Addressing Poverty: a guide for considering poverty-related and other inequities in health.

http://www.cpc.unc.edu/measure/publications

Quick Poverty Score Toolkit: User's Guide and Spreadsheet . http://www.cpc.unc.edu/measure/publications

The DHS Wealth Index: Approaches for Rural and Urban Areas . http://www.measuredhs.com/pubs

Making Family Planning Part of the PRSP Process: a guide for incorporating family planning programs into poverty reduction strategy papers

http://www.healthpolicyinitiative.com/index.cfm?id=publications

Thank you!