Good afternoon everyone. I am going to present a social accountability tool called equity monitoring that was developed following the 2015 earthquakes in Nepal.
So why equity monitoring?
The 2015 earthquakes resulted in over 9000 deaths, massive loss of infrastructure and a large scale disaster response and recovery program.
Given deeply embedded gender inequality and social exclusion in Nepal, there was concern that the health recovery effort may fail to reach the most vulnerable.
The Government’s existing social audit methodology provided a platform to engage with communities, this was adapted into an equity monitoring tool to monitor gaps in access to and the quality of health services to improve the recovery effort.
Equity monitoring sought to: Build ownership at each level of engagement, including in design………..and sampling, selection of local NGO facilitators. Take a participatory approach: Listen to community women and men, local leaders and providers on barriers and bottlenecks to health services and health risks Have a strong focus on engaging vulnerable people at risk of being excluded, such as remote dwellers, people with disability Stimulate action at the local or VDC level Provide evidence to district authorities so they can act Strengthen partnership between government agencies, communities and non-government actors.
The thinking behind equity monitoring was that local evidence and space for local voices could foster commitment and ownership to address equity gaps in health services.
Equity monitoring was implemented in 3 earthquake affected districts, Dolakha, Ramechap and Sindupalchowk in the first half of 2016.
In each district, district health officials classified local government areas, known as VDCs at that time, into three categories: accessible, remote and highly affected. Six of each type of VDC were selected as the sample for equity monitoring.
??? Number of VDCs in each district. R = 42; D = about 50 ??? Highly affected could be in remote or accessible areas.
Notes: DHO wanted a higher number of VDCs to get as much coverage as possible due to the challenges they faced in getting out to VDCs
This diagram shows in brief how equity monitoring worked.
First, the DHO contracted a local NGO to collect community and health facility data using a variety of rapid methods including focus group discussions, a health scorecard and health facility assessment. In each VDC, the NGO shared headline findings at a meeting with community women and men, VDC officials, political parties, and health providers and facilitated the development of a local VDC action plan.
Snapshot findings were shared with the DHO after data collection in each VDC. Critical gaps such as staffing and drug stockouts prompted immediate action.
At district level, the community and facility data from the 18 VDCs was complemented by an analysis of district HMIS data and select stakeholder consultations.
NGOs shared the findings with the DHO who in turn presented them to the District Disaster Response Committee and sector meetings, and this fed into the District Integrated Action Plan supporting VDC recovery.
NHSSP staff trained the local NGO and supported District Statistical Officer analyse HMIS data
A participatory evaluation found that:
The process led to three key areas of improvement: Local action: It created space for community women and men, health providers and local leaders to discuss findings and plan action together. For example funds were raised to xx, sites were cleared of rubble, and temporary hut provided for the health facility in Ramechap. The process also strengthened the connection between local VDCs and health facilities and the district management as district management responded to gaps and more actively monitored the local situation. DHOs reported how they were better informed: NGOs reached areas that DHOs find difficult to monitor. The data provided a nuanced picture of ground realities and reduced the blind spots from relying on HMIS. It also brought gender inequality and social exclusion alive through human stories and the words of local people. DHOs also reported how the evidence provided justification for targeting resources to specific areas at a time of great demand. Empowered DHOs to act: rapid response to staffing gaps and drug stock-outs reflected better decision-making; they reported an increased willingness to publicly share information (eg names of staff on leave and rejoining dates, medicines out of stock); led to equity targeted activities being included in annual plans and budgets with 80% completed in the year (eg GBV prevention campaigns, CHU establishment); improved their coordination of development assistance; and increased demands that DHOs made on the Ministry to address equity gaps, eg vacant sanctioned posts, relocation of facilities…
No evidence that recovery efforts favoured some areas over others but context factors such as lack of roads and transportation impeded access in remote and highly affected areas. Pre-existing disadvantage (remoteness, poverty, sociall exclusion) persisted except when emergency clinics were located in remote and underserved populations and overcame the geographical and cost barriers these populations typically faced
Stimulated DHOs to extend analysis to neighbouring VDCs.
Key reflections are: Government ownership was essential for the methodology to be tried and impactful. NHSSP brokering role maintaining standards and managing conflict of interest eg selection of NGO. Trust in the NGO and the data produced encouraged DHOs to use the findings. EM increased understanding and empathy for exclusion among DHOs and the barriers different populations face in accessing quality care Low capacity of local NGOs and competing demands meant they needed continuing support throughout the project Scope to prune the package of tools for a more rapid response MoH concluded that equity monitoring is a relevant tool in post-disaster recovery contexts and included the methodology in its community participation toolbox and for use in other high priority settings such as remote areas.
Equity monitoring in a post-disaster context in Nepal: building local ownership, listening to community voices and service provider challenges
Equity monitoring in a post-disaster
context in Nepal: building local ownership,
listening to community voices and service
Deborah Thomas, Sitaram Prasai, Rekha Rana,
Massive impact of 2015
earthquakes: 9,000 deaths, 8
million affected, destruction of
health infrastructure and
Deeply embedded gender
inequality, social and
Risk of leaving the most
vulnerable out of the health
Government’s social audit
method not suited to a post-
Key principles of equity monitoring
listen to community people,
local leaders and health
providers on barriers to, and
bottlenecks in service
delivery and health risks.
Strong focus on the
experience of vulnerable
Stimulate local action.
Provide evidence to district
authorities so they can
Where and when • Dolakha, Ramechap and Sindupalchowk
• January-July 2016
• Sample of VDCs in each district:
6 Highly earthquake affected
The equity monitoring approach
Analysis at District level
Local VDC level
District responds to gaps and monitors actions
NGO feeds findings to district
Results: Evidence, voice and facilitation…
Led to local action
• Created space for
and local leaders to
discuss and plan action
• Raised funds, cleared
connection with and
demands on District
• Reached areas DHOs
find difficult to monitor.
• Provided nuanced
picture of ground
realities and reduced
the blind spots from
relying on HMIS.
• Brought gender
inequality and social
• Justified targeting
Empowered DHOs to act
• Rapid response to staff
gaps and drug stock-
• Increased public
• Equity targeted
activities included in
annual district plan and
budget and 80%
• Improved coordination
• Increased demands on
the Ministry to close
No evidence that recovery efforts favoured some areas but contextual factors (lack
of roads and transportation) impeded access in remote and highly affected areas
Government ownership of
the process was essential.
Trust in local NGO and data
produced encouraged use by
understanding of exclusion.
Low capacity of local
district NGOs; competing
demands post disaster.
Prune package of tools.
Approach relevant for post-
disaster recovery and other
high priority settings such
as remote areas; part of
Ministry social audit toolbox.