Practical Guidance for Incorporating Health Equity Learning_Jennifer Winestock_4.23.13
Practical Guidance for IncorporatingHealth Equity ConsiderationsMCHIP Program Learning MeetingNovember 4, 2011ICF (MCHIP)Jennifer Winestock Luna- Senior M&E AdvisorDebra Prosnitz- Program AssociateDebra Prosnitz, MPHProgram AssociateDebra Prosnitz, MPHProgram Associate
Have you considered improving healthequity as part of MCHIP countryprogramming?• What is your country program doingabout improving health equity?
Session Outline Purpose of MCHIP health equity work Overview of MCHIP Health Equity Guidance andChecklist Examples of Application of the Checklist Small group exercise : understanding health equitywork 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 Learningtheme Developed guidance to help programsincorporate health equity considerations intoprogram designs MCHIP country programs:• Incorporate into new designs; Refine on-going• Document health equity work using MCHIPguidance as framework
MCHIPs definition of health equityHealth equity is both……the improvement of a health outcome of adisadvantaged group……as well as a narrowing of the difference ofthis health outcome between advantaged anddisadvantaged groups……without losing the gains already achievedfor the group with the highest coverage.(MCHIP)
Why health equity guidance wasdeveloped?Challenges: Projects often state that equity is part of programdesign, however they: may not clearly articulate how equity is beingaddressed 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 intoconsideration & decisions to be made
Development of equity guidanceCollaborative effort USAID, MCHIP, CORE*, other technical experts Virtual TAG, discussion sessions to solicitinput from equity experts Including representatives of PVOs, CORE, MCHIP, MEASUREEvaluation, DHS, USAID and Cesar Victora Literature Review (i.e. UNICEF, USAIDs gender group, Davidson Gwatkin)*CORE: network of PVOscommunity-oriented programs
The guidance consists of:1. Check list Series of questions/ discussion points about projectdesigns (www.mchip.net)2. Reference document Considerations for Incorporating health Equity intoProject Designs: A Guide for Community-OrientedMaternal, Neonatal, and Child Health Projects(www.mchip.net)3. Presentations, exercises; to work with teams4. Workbook to keep track of decisions
Guiding assumptions1.Addressing equity means more than working in adisadvantaged geographical region1.Means reaching most disadvantaged within that region2.Making comparisons over time of health outcomesbetween disadvantaged and advantaged groups3.Requires understanding and deciding how to handleunderlying conditions2.Obtaining high coverage levels depends on decisionsmade along a continuum from narrowly targeting adisadvantaged group to a universal approach aimedat all groups
Health Equity Guidance: 6 - Step Process1. Understand the equity issues in the project areaa. Identify inequities in health outcomesb. Understand underlying issues and barriers2. Identify the disadvantaged group or groups3. Decide what is in project’s manageable interest tochange4. Define project-specific equity goals and objectives5. Determine equity strategies and activities6. Integrate equity-focused indicators andmeasurement into M&E framework and PMP
Step 1: Understand health equity issuesHealth Outcomes Do you have quantitativeinformation on inequities inspecific health outcomes? Have you considered ethnicity,gender, education, place ofresidence, socio-economicstatus, religious group, other? Do the gaps in healthoutcomes justify a specialapproach?Underlyingissues/barriers Do you haveinformation on theunderlying conditionsand barriers that leadto inequities? What are the issues?
Step 2: Identify disadvantaged group Which disadvantage group will you focuson? Have you identified an advantaged groupfor comparison? What is that group?
Examples from CSHGPStep 1a Identify inequities in health outcomes In Ecuador, the Center for Human Services (CHS) looked atprovincial data on maternal & child health• Indigenous populations have lower rates of maternal healthcare utilization than mestizo (mixed European descent)populations.• Home births among total population was 46.5%, while forindigenous women it was 71.4%. CHS conducted its own Knowledge, Practice, and Coverage(KPC) survey in the project area to confirm the same findingslocally.
Examples from CSHGPStep 1a Identify inequities in health outcomes Using national (DHS) and local (KPC) data, ChristianReformed World Relief Committee (CRWRC) identifiedgaps in knowledge & coverage between highest & lowestwealth quintiles in project in Bangladesh. In lowest quintile, only 27.3% of women reportedconsuming iron/folate in their last pregnancy, versus57.7% of women in highest quintile.
Examples from CSHGPStep 1b Analyze underlying issues/barriers In Ecuador, CHS conducted focus groups/ key informantinterviews 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 familiespreferred 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 programs manageable interestCARE Nepal Social exclusion ofmarginalized populationscontributes to poorhealthcare practicesConcentrate on: Including marginalized incommunity-level activities Informing them of their rights Advocating for bettertreatment by health workersCHS Ecuador Address cultural differences by: Improving culturalresponsiveness of healthservices Using quality assurancemethods to bring togethercommunity members
Step 4: Develop a project-specific operationaldefinition of equity Not general definition (i.e. MCHIP definition) Allows project stakeholders to know when equityhas been improved Helps communicate exactly what was improvedEx: Equity for children in _X_ group means thatimmunization coverage will increase to at least thebaseline levels for other ethnic groups in the programarea, at the same time that levels for other ethnic groupsdo not decrease.
Examples from CSHGPStep 5 Determine equity strategies and activitiesCARE Nepal Community mobilization in communities with pooresthealth indicators Conducted training for health workers Implemented behavior change communication program Expanded an existing maternity incentive scheme toincrease institutional deliveries (cash transfer).
Examples from CSHGPStep 6 Develop equity-focused M&E CARE Nepal collected data on caste and ethnicity inKPC survey in order to disaggregate healthindicators by marginalized and non-marginalizedpopulations. Through community mobilization strategy, projectcollected community-level data on pregnancyoutcomes disaggregated by marginalized and non-marginalized women.
Worksheets for applying guidance Worksheet 1: Identifying Inequitable HealthOutcomes Health outcome; between/ among which groups;magnitude of the difference; source of information Worksheet 2: Understanding underlying issuesand barriers What are key underlying issues; missing information;equity-based constraints; equity-based opportunities
Small group work: understanding healthequity work in MCHIP country programs Use worksheets to analyze equity details ofcountry 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?