Addressing Poverty-Equity in Health Program Design, Implementation and Evaluation Karen Foreit 9 October 2009
What does it mean to  address poverty ? <ul><li>Design interventions to reduce poverty-related inequalities in health stat...
Who  and  what  do we want to address? <ul><li>Who are the poor? </li></ul><ul><li>Which health indicators show inequaliti...
Who are the poor? <ul><li>Relative poverty </li></ul><ul><li>Rank people within the same country or region based on tangib...
<ul><li>Do not line up with absolute poverty </li></ul>Interpreting quintiles
 
<ul><li>Do not line up with absolute poverty </li></ul><ul><li>The middle matters </li></ul>Interpreting quintiles
<ul><li>60% of the population belongs to Quintiles 2-4 </li></ul><ul><li>What do we lose by leaving out the middle? </li><...
<ul><li>Which is the priority group? </li></ul><ul><li>Is there only one priority group? </li></ul>
<ul><li>Do not line up with absolute poverty </li></ul><ul><li>The middle matters </li></ul><ul><li>Other factors may be a...
Ethnic Inequality <ul><li>Bolivia:  </li></ul><ul><ul><li>Llano region vs. Altiplano </li></ul></ul><ul><li>Peru:  </li></...
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
<ul><li>Do not line up with absolute poverty </li></ul><ul><li>The middle matters </li></ul><ul><li>Other factors may be a...
source: Honduras 2005/6 DHS
Disentangling quintile and residence Mali source: Mali DHS
Designing a pro-poor intervention <ul><li>Focused to benefit the poor </li></ul><ul><li>Usually involves  additional resou...
Are services physically accessible to the poor? Increase ability to pay Where are the poor? no yes Where are the services?...
Monitoring progress <ul><li>Whom does the intervention  seek  to reach? </li></ul><ul><ul><li>poverty status, geographic l...
Data needed for monitoring <ul><li>Baseline desirable but not necessary </li></ul><ul><li>Time series (repeated measures) ...
Closing thoughts <ul><li>Use national surveys to identify subgroups and specific health indicators </li></ul><ul><li>Consi...
<ul><li>Addressing Poverty: a guide for considering poverty-related and other inequities in health. </li></ul><ul><li>  ht...
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Addressing Poverty-Equity in Health Program Design, Implementation and Evaluation

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  • By definition, 20% of the population must fall into each wealth quintile. Percentage falling below absolute poverty lines may vary from country to country and within countries by place of residence.
  • Mozambique 71% rural, 62% urban under national poverty line Guatemala 7 4% rural, 27% urban under poverty line India 30% rural, 25% urban under poverty line It is clear from this chart that the lower three quintiles in Mozambique may consist entirely of people below the national poverty line, whereas in India people in the middle quintile would all be ABOVE the national poverty line.
  • Ethnic differences may also be associated with inequalities in health, not only because of lack of access to services but also because the service staff speak a different language and/or service practices (such as pelvic examinations) run counter to cultural norms. The highlands regions of Bolivia and Peru are home to high concentrations of indigenous women (who speak Quechua or Aymara rather than Spanish). Note the geographic differences in modern method contraceptive use. Similar comparisons could be made by language spoken at home (data available in DHS data set but not published in final reports).
  • In Mali only 3% of rural women were classified as “wealthy”
  • Comparing Quintile 1 to Quintile 5 may be comparing urban residents as a whole with poorest rural residents Cannot be solved by cross-tabulating quintile by place of residence Rank urban and rural populations into their own, separate quintiles
  • in Mali, poverty-inequalities in modern method use are found only in urban areas and rural women show low levels of use regardless of relative poverty status.
  • Data sources Program expenditures Household survey Census Program service records Client intercept surveys
  • Addressing Poverty-Equity in Health Program Design, Implementation and Evaluation

    1. 1. Addressing Poverty-Equity in Health Program Design, Implementation and Evaluation Karen Foreit 9 October 2009
    2. 2. What does it mean to address poverty ? <ul><li>Design interventions to reduce poverty-related inequalities in health status </li></ul><ul><li>Monitor program uptake by the poor </li></ul><ul><li>Assess changes in identified health inequalities </li></ul>
    3. 3. Who and what do we want to address? <ul><li>Who are the poor? </li></ul><ul><li>Which health indicators show inequalities? </li></ul><ul><li>Other factors in addition to poverty? </li></ul>
    4. 4. Who are the poor? <ul><li>Relative poverty </li></ul><ul><li>Rank people within the same country or region based on tangible assets or other characteristics </li></ul><ul><ul><li>DHS “wealth quintiles” </li></ul></ul><ul><li>Absolute poverty </li></ul><ul><li>Compare people against a standardized poverty line, based on income or expenditures </li></ul><ul><ul><li>World Bank “Living Standards Measurement” </li></ul></ul>
    5. 5. <ul><li>Do not line up with absolute poverty </li></ul>Interpreting quintiles
    6. 7. <ul><li>Do not line up with absolute poverty </li></ul><ul><li>The middle matters </li></ul>Interpreting quintiles
    7. 8. <ul><li>60% of the population belongs to Quintiles 2-4 </li></ul><ul><li>What do we lose by leaving out the middle? </li></ul>
    8. 9. <ul><li>Which is the priority group? </li></ul><ul><li>Is there only one priority group? </li></ul>
    9. 10. <ul><li>Do not line up with absolute poverty </li></ul><ul><li>The middle matters </li></ul><ul><li>Other factors may be associated with poverty </li></ul>Interpreting quintiles
    10. 11. Ethnic Inequality <ul><li>Bolivia: </li></ul><ul><ul><li>Llano region vs. Altiplano </li></ul></ul><ul><li>Peru: </li></ul><ul><ul><li>Coast vs. Sierra </li></ul></ul>Ethnicity
    11. 12. 70% Urban-rural confound with quintiles Mali 26% 70% Place of residence source: Mali DHS
    12. 13. 70% Urban-rural confound with quintiles Mali 26% 70% Place of residence source: Mali DHS
    13. 14. <ul><li>Do not line up with absolute poverty </li></ul><ul><li>The middle matters </li></ul><ul><li>Other factors may be associated with poverty </li></ul><ul><li>Not all health indicators show the same poverty-related inequalities </li></ul>Interpreting quintiles
    14. 15. source: Honduras 2005/6 DHS
    15. 16. Disentangling quintile and residence Mali source: Mali DHS
    16. 17. Designing a pro-poor intervention <ul><li>Focused to benefit the poor </li></ul><ul><li>Usually involves additional resources for the poor </li></ul><ul><ul><li>redistributing existing resources away from better-off populations/areas towards the poor/poverty areas </li></ul></ul><ul><ul><li>adding new resources to overall budget </li></ul></ul><ul><li>Consider other factors associated with poverty </li></ul><ul><ul><li>Many barriers faced by the poor are non-financial </li></ul></ul>
    17. 18. 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
    18. 19. Monitoring progress <ul><li>Whom does the intervention seek to reach? </li></ul><ul><ul><li>poverty status, geographic location, etc. </li></ul></ul><ul><ul><li>how many of them are there? </li></ul></ul><ul><li>Whom does the intervention actually reach? </li></ul><ul><ul><li>number of people reached, services provided </li></ul></ul><ul><ul><li>client characteristics (poverty status, residence, etc.) </li></ul></ul>
    19. 20. Data needed for monitoring <ul><li>Baseline desirable but not necessary </li></ul><ul><li>Time series (repeated measures) preferable </li></ul><ul><li>At the geographic level of the intervention </li></ul><ul><li>Consider client intercept surveys to measure client characteristics (especially poverty) </li></ul>
    20. 21. Closing thoughts <ul><li>Use national surveys to identify subgroups and specific health indicators </li></ul><ul><li>Consider place of residence and other social factors </li></ul><ul><li>Design focused interventions and use geographic targeting whenever possible </li></ul><ul><li>Use client intercept surveys to measure uptake by the poor </li></ul><ul><li>Impact evaluation and attribution of change to program interventions may not always be feasible </li></ul>
    21. 22. <ul><li>Addressing Poverty: a guide for considering poverty-related and other inequities in health. </li></ul><ul><li> http://www.cpc.unc.edu/measure/publications </li></ul><ul><li>Quick Poverty Score Toolkit: User's Guide and Spreadsheet . http://www.cpc.unc.edu/measure/publications </li></ul><ul><li>The DHS Wealth Index: Approaches for Rural and Urban Areas . http://www.measuredhs.com/pubs </li></ul><ul><li>Making Family Planning Part of the PRSP Process: a guide for incorporating family planning programs into poverty reduction strategy papers </li></ul><ul><li>http://www.healthpolicyinitiative.com/index.cfm?id=publications </li></ul>A couple of resources
    22. 23. Thank you!

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