(Agenda review)The MCHIP EquityGuidance Documents Came out after our project already began. Our project was not designed specifically to address equity, however we found that we encountered a lot of equity issues in our initial project planning phases. The steps we took to address health disparities amongst disadvantaged groups in Ecuador developed quite organically from 1)our USAID/Child Survival Program Scope of work, 2) the wide breadth of experience and different professional diciplines of our project implementing team in country, and 3) was truly informed by the results of our Baseline Assessment. So addressing Health Equity can be a natural process based on the circumstances of the project, as it was in our project. Now that we have some guidance from our colleagues at MCHIP we can expand upon the steps we have already taken in regards to health equity.
Cotopaxi is a mountainous province located in the central Ecuadorian highlands. The province’s indigenous population amounts to 28% of its inhabitants. The major indigenous nationality is the Kichwa, whose members are organized in approximately 850 rural communities in 40 parishes across 7 counties (or “cantons”) . Economic activity is centered on agricultural and farm production for local, provincial and national markets, as well as handcraft production. Cotopaxi Province has one of the highest numbers of maternal deaths due to obstetric hemorrhage in Ecuador, which is why it was selected by CHS as a project area. --------Cotopaxi Population: 384,499 inhabitants, 67% of which live in rural areas (2001 Census Data)Poverty: 90.47% of poverty based on unmet basic necessities in rural areas (2007 SIISE Data) Integrated System of Social Indicators for EcuadorIndigenous: 28% Indigenous: Kichwa-Panzaleo (2008 CODENPE - Population Projection by Cantons & Parishes): Maternal/Newborn Mortality in Cotopaxi: 2008 Census DataThe main direct causes of mortality and morbidity for children under age 5 include acute respiratory infections and diarrheal disease, often in association with malnutrition. Newborn mortality, with the leading cause asphyxia and infections, represents a sizable proportion of under-five child mortality. LocationThe CHS child survival program is implemented in Cotopaxi Province, a mountainous area located in the central Ecuadorian highlands It contains 7 cantons: Latacunga, La Maná, Pangua, Pujilí, Salcedo, Saquisilí, Sigchos, including 11 urban parishes and 38 rural parishes. Cotopaxi has a population of approximately 384,499 inhabitants, 67% of which live in rural areas.As one of the country’s poorest provinces, Cotopaxi reaches 90.47% of poverty based on unmet basic necessities in rural areas. The province’s indigenous population amounts to 28% of its inhabitants. The major indigenous nationality is the Kichwa-Panzaleo, whose members are organized in approximately 850 rural communities. Political organization is based on the prehispanic system of “Ayllus”, based on social groups formed by nuclear and extended families linked through genealogical ties. Economic activity is centered on agricultural and farm production for local, provincial and national markets, as well as handcraft production.Problem statement: Cotopaxi Province has one of the highest numbers of maternal deaths due to obstetric hemorrhage in Ecuador. The main direct causes of mortality and morbidity for children under age 5 include acute respiratory infections (25.8%) and diarrheal disease, often in association with malnutrition. Newborn mortality, with the leading cause asphyxia and infections, represents a sizable proportion of under-five child mortality. Improving demand, access to, and quality of healthcare are greatly needed to improve health status in Cotopaxi. Targeted Population: The project interventions will be implemented in 21 priority rural parishes that meet at least one of two selection criteria known to be associated with higher risk of maternal newborn mortality: a) > 50% of parish population lives in extreme poverty, b) > 50% indigenous Indian ethnic composition
Explanation of the graphic as the fragmented Cotopaxi health system High proportion (40%) of deliveries happen at the community level, which had no connection to the formal health systemA little bit about the Technical Strategy:Support the creation of a Referral Network horizontally & vertically with Referral Workshops (including TBAs)Improvement of quality of EONC services at facilities, increase in demand of servicesLevels:National – Provincial – Cantonal – Parish – Communities - Households
Our central project goal is to reduce maternal and newborn mortality and morbidity in Cotopaxi province through the creation of a highly functioning network of high quality service providers, health extension workers, and social organizations. To do this we are working on 4 strategic lines of action with result-specific strategiesIncrease Access to servicesImprove Quality of servicesImprove Knowledge/Demand for MNC servicesImprove the Policy environment surrounding the coordination between the Formal Health System, Community/Social Organizations, and TBAs--------------Increased availability/ access to a coordinated continuum of high-impact maternal newborn care provided as part of a network of community and facility services. Improved knowledge / demand for evidence-based community and facility MNC services, including improved household health promotion practices.Improved quality of MNC services provided as part of a coordinated network of CHWs and facilitiesImproved policy environment forcoordination among community health workers, health care institutions, and community /social organizations
In relation to the Health Equity Programming guidance from MCHIP Step 1, Understanding Health Equity Issues in Project area, our project in Ecuador accomplished this mostly through our Household Survey, which was part of the Baseline assesment. We collected data from 462 households based on our project indicators, Operations Research indicators, and USAID Rapid Catch indicators. Additionally, we collected qualitative and quantitative data from a TBA assesment
Here’s a scene from our Baseline Assessment which took place in April 2010.
Explanation of the TableOur Household Survey showed us that in Cotopaxi the health coverage of antenatal, skilled delivery, and early post-partum care is decent overall. However, when the data is stratified by ethnic group the coverage for indigenous populations is significantly lower, and resembles figures from other low resource disadvantaged populations.
Here’s an interesting finding from the householdSurvey. Among the women who reported that they do not utilize skilled delivery care, the most common reason they noted was “Traditional Practices.” Many people would assume that it would beeconomic or geographyical constraints but you can see from the data that tradition plays a large role in the low rates of skilled delivery care amongst indigenous groups.
It’s not only women giving birth who have barriers interacting with the formal health system but Traditional Birth Attendants as well. Our TBA Assessment found that there were no functioning referal processes between TBAs and Ministry of Health facilities. The MOH does not even follow the guidelines from a separate government department, the office of cross-cultural health. The lack of trust between TBAs and the formal health system forms a double barrier between mothers and EONC services. This sour relationship between the TBAs and MOH is key to understanding the barriers between the Ecuadorian institutions and the disadvantaged indigenous populations.
Our baseline assessment showed us that in Cotopaxi there is lower coverage for EONC services for indigenous women, compared to non indigenous women. Our data confirmed that indigenous populations were indeed disadvantaged, which lines up with MCHIP’s Step 2, which is to identify a disadvantaged group to focus on.
Step 3 of the equity guidance is to Decide what is in the project’s “manageable interest” to change. In the case of CHS, based on our baseline findings and cost considerations we decided to prioritize parishes that met one or both of 2 criteria: over 50% poverty and/or over 50%. This resulted in the selection of 21 parishes out of 40 in the province to work with. This was a logical way for us to invest our resources to reduce maternal and newborn mortality and morbidity in Cotopaxi province. It made sense to work with the indigenous indian community and other poorer communities because that is where we found the highest rates of mortality rates in the province.
As far as the other Equity steps (4-6)are concerned, we have not taken many deliberate actions in our project in Cotopaxi. Since we did not plan equity into our overall program design from the beginning, it would be difficult to overhaul our entire technical strategy and M&E plan at this point. However, now that we have some technical guidance on equity, the project team will be able to better recognize activities and strategies that overlap with equity considerations. For example, the improvement of referal services in Cotopaxi involves referral training sessions for both facility personnel and TBAs alike. Our project has already supported the creation of what is known in Ecuador as a “micronetwork”, which is an active coordination between health facilities and social/community organizations at the parish level and TBAs in a formal committee. These committees create an open dialogue between TBAs, communities, and health providers to address the cultural responsiveness of institutional childbirth services and respect/tolerance of traditional practices, which will inturn increases the utilization of EONC services amongst disadvantaged indigenous populations once TBAs and women have more trust in the formal health system. We are also training TBAs to provide higher quality services in prenatal care, obstetric emergencies, and post-partum cares. In regards to M&E, our project is able to stratify selected indicators at the baseline and endline points to look at data on advantaged vs. disadvantaged groups. The parishes we are working in were chosen because of their high proportions of poor and indigenous women, which provides us with more data on disadvantaged populations. ------------Formation of Micronetworks at the Parish Level– Parish Health Councils: MOH staff, Social Security Staff, TBAs, Health Extension WorkersStep 6 : Baseline looks at all parishes.
Thank you for all for your attention, and thank you very much to my colleagues at MCHIP for inviting me here to present on behalf of the CHS-Ecuador Child Survival Program. I’m happy to respond to any questions you have about our project.
Considerations For Incorporating Health Equity in Project Design_Gall_5.12.11
Health Equity in Practice: Cotopaxi, Ecuador<br />Cotopaxi EONC Project<br />USAID/CSHGP - CHS/Ecuador<br />Presenter:<br />Mr. Andrew J Gall<br />Contributors<br />Dr. Kathleen HillDr. Jorge Hermida<br />
Brief Introduction to CHS-Ecuador Child Survival Project<br />Process of addressing equity issues: <br />Step 1: Understanding equity issues in project area<br />Step 2: Identify disadvantaged group to focus on<br />Step 3: Decide what is in project’s manageable interest to change<br />Concluding thoughts about steps 4-6 for the CHS-Ecuador Child Survival Project<br />Agenda<br />
Cotopaxi Provincial Health System: Fragmented; no continuum of care; inequitable access; poor quality of care<br />1,500 deliveries<br />Ministry of Health(3,000 deliveries)<br />Social Security <br />NGOs<br />Privateproviders<br />Provincial Hospital (Surgery & Blood 4 hours)<br />CountyHospitals<br />AmbulatoryHealth Centers (ParishLevel)<br />TBAs<br />(CommunityLevel)(3,000 deliveries)<br />
Brief Introduction to CHS-Ecuador Child Survival Project<br />Goal/Impact<br />To reduce maternal and newborn mortality and morbidity in Cotopaxi province<br />Strategic Objective<br />Improved household health promotion practices and utilization of a continuum of high-impact community- and facility-based maternal newborn services provided as part of a coordinated network of CHW’s, health facilities and social organizations. <br />Results/Outcomes<br />1<br />2<br />3<br />4<br />Increased availability/ access to a coordinated continuum of high-impact maternal newborn care provided as part of a network of community and facility services. <br />Improved knowledge / demand for evidence-based community and facility MNC services, including improved household health promotion practices.<br />Improved quality of MNC services provided as part of a coordinated network of CHWs and facilities<br />Improved policy environment forcoordination among community health workers, health care institutions, and community /social organizations<br />
Baseline Assessment addressed Steps 1a. and1b.<br />Methods: <br />Random selection 462 households rural parishes Cotopaxi Province (using census data)<br />Household Survey Questionnaire focused on: Project, OR and Rapid Catch Indicators <br />TBA assessment (qualitative and quantitative)<br />Equity Checklist Step 1: Understanding Health Equity Issues in Project Area<br />
Baseline Assessment Results Continued<br />HH Survey: Main reasons given by women for delivery at home included: <br />Traditional Practices: 37%<br />Geographical barriers: 18%<br />Not enough time: 23%<br />Lack of money: 6%<br />
TBA focus groups highlighted TBA perceived lack of recognition by MOH facility providers<br />Lack of functional referral processes between TBAs and MOH institutions. For example, MOH facility health personnel do not respect TBA referral forms recommended by MOH provincial cross-cultural health (“Salud intercultural”) guidelines.<br />TBA Assessment Results<br />
Step 2: Identify Disadvantaged Group to Focus on<br />Baseline assessment results confirm lower coverage of high impact maternal newborn services for indigenous women as compared with non-indigenous women. <br />
Based on baseline assessment results and cost considerations, final project strategy: <br /><ul><li>Prioritize parishes that meet one or both of 2 criteria: </li></ul>A. > 50% poverty level (national survey data)<br />B. > 50% indigenous Indian population (national survey data)<br />Geographic Scope: <br />21/40 (52.5%) Cotopaxi parishes targeted<br />Step 3: Decide what is in project’s manageable interest to change<br />
Step 4: Define equity goals, objectives and operational definition:<br />Step 5: Determine Equity Strategy<br /> Increase coverage and quality of high impact home-based MNH services (provided by TBAs & parish micronetwork health teams)<br />Improve cultural responsiveness of institutional childbirth services<br />Improve referral systems<br />Step 6: Develop Equity Focused M&E<br />Our project prioritizes parishes with high proportions of poor and indigenous women<br />Could stratify selected indicators at baseline/endline for advantaged vs. disadvantaged groups<br />Concluding Thoughts: Steps 4-6<br />