Improving health equity_Ergo_10.13.11
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MCHIP wants to know if its interventions reach the poor. This presentation outlines two analyses: (1) analyzing beneficiary socioeconomic profiles using asset indices and surveys, and (2) comparing resource allocation to poverty headcounts in targeted areas. Analysis 1 involves interviewing beneficiaries and calculating asset indices to assign socioeconomic quintiles. Analysis 2 uses poverty maps showing poverty rates by region to plot resource allocation per capita against poverty levels. Both require recent survey or census data on assets, services, or poverty levels.
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Improving health equity_Ergo_10.13.11
- 1. Do MCHIP-Supported Interventions Reach the Poor? How can we know? CORE Group’s Spring Meeting Baltimore, May 11, 2011 Alex Ergo, PhD Broad Branch Associates
- 3. Working in well over 30 countries worldwide
- 4. MCHIP supports programming and opportunities for integration in:
- 5. Maternal, Newborn and Child Health
- 6. Immunization, Family Planning, Malaria, HIV/AIDS
- 8. What can be done when equity was not built into the design?
- 10. Analysis 1 – Basic Steps Step 1: Look for a recent household survey that uses an asset index as a proxy for socio-economic position Step 2:Obtain questions used to collect the data necessary for the calculation of the asset index Step 3: Conduct interviews using same questions Step 4: Generate rural/urban-specific asset indices (optional) Step 5:Create rural/urban-specific asset quintiles (optional) Step 6:Calculate the asset index for each respondent Step 7:Assign respondents to socio-economic quintiles Step 8:Assess the distribution of beneficiaries across asset quintiles
- 11. Analysis 1 – Basic Steps Step 1: Look for a recent household survey that uses an asset index as a proxy for socio-economic position Examples: Demographic and Health Survey (DHS) Living Standards Measurement Survey (LSMS) Multiple Indicator Cluster Survey (MICS)
- 12. Analysis 1 – Basic Steps Step 2: Obtain questions used to collect the data necessary for the calculation of the asset indexExample:
- 13. Analysis 1 – Basic Steps Step 3: Interview an adequately large sample of patients attending the facility-based service(s) of interest (exit interviews)ORInterview an adequately large sample of individuals/households benefitting from the community-based intervention (household visits)
- 14. Analysis 1 – Basic Steps Step 4(optional): Create rural/urban-specific asset quintiles Some assets may relate differently to wealth in rural and urban settings E.g. type of flooring material; ownership of poultry If the necessary technical expertise is available, conduct separate Principal Component Analyses for rural and urban data in the original household survey to generate rural/urban-specific asset indices
- 15. Analysis 1 – Basic Steps Step 5(optional):Generate rural/urban-specific asset indices Many assets tend to be more associated with urban wealth than with rural wealth E.g. access to basic services is overall better in urban areas than rural areas Urban households cluster in the richer quintilesRural households cluster in the poorer quintiles
- 16. Analysis 1 – Basic Steps Step 5(optional):Generate rural/urban-specific asset indices Many assets tend to be more associated with urban wealth than with rural wealth
- 18. Analysis 1 – Basic Steps Step 6:Calculate the asset index for each respondent: Using rural/urban-specific weights calculated under step 4 (optional) OR Using the original survey’s weights
- 19. Analysis 1 – Basic Steps Step 6:Calculate the asset index for each respondent: Example: … … …
- 20. Analysis 1 – Basic Steps Step 7:Assign respondents to socio-economic quintiles: Using rural/urban-specific cut-off points calculated under step 4 (optional) OR Using the original survey’s cut-off points
- 21. Analysis 1 – Basic Steps Step 7: Assign respondents to socio-economic quintiles: Example:
- 22. Analysis 1 – Basic Steps Step 8:Assess the distribution of beneficiaries across asset quintiles Example:
- 25. Analysis 2 – Basic Steps 20 Step 1: Look for a recent poverty map of the country (these typically include poverty headcount ratios by region/district/…: i.e. % of the population living below the poverty line) Example: CoulombeH. 2005, Ghana census-based poverty map: district and sub-district level results. Ghana Statistical Service. The estimates relate to the year 2000.
- 26. Analysis 2 – Basic Steps 21 Step 2: Indicate areas of intervention on poverty map Example: Vietnam poverty map
- 27. Analysis 2 – Basic Steps 22 Step 3: Calculate resource allocation per capita by district
- 28. 23 Analysis 2 – Basic Steps Step 4: Plot US$ per capita against poverty headcount ratio Nzema East
Editor's Notes
- MCHIP defines health equity as both the improvement of a health outcome of a disadvantaged group as well as a narrowing of the difference of this health outcome between advantaged and disadvantaged groups--without losing the gains already achieved for the group with the highest coverage.MCHIP seeks to incorporate equity considerations into its programming at all phases of the scaling up processMCHIP generates practical learning about how to address equity issues along the continuum of program design, implementation, monitoring and evaluation
- Thisapproachaddresses the question: what proportion of program clients are poor? Whilethisdoes not translate directlyinto program coverage (the proportion of the poorwho use services), increasing the numbers of poor clients is a necessary first step in reducingpoverty-relatedinequity.Depending on how the program isstructured and whatkind of generalizationsitwishes to draw, the number of sampled sites can range from a single site (as in the case of a program operating a single clinic or hospital) to multiple, randomly-selected sites (e.g., to draw a profile of a geographic area such as a district).Twooperationalcriteriashouldbeconsideredwhenselecting a measurementmethod for monitoring client characteristics:• Feasibility (the instrument canbecorrectlyadministered as an interview taking no more than 5-10 minutes by local partnerswith minimal training and easilyanalyzed)• Reasonablyaccurate/reliable (the instrument shouldbe capable of detecting a difference of 10- 15% in the proportion of clients whowouldbeclassified as “poor” across sites or over time)Client interceptsurveysusing short, focused interviews meetthesecriteria and canyieldreliable information for program monitoring and decision-making.1 It is not necessarythat the instrument correctlyclassify 100% of individual program beneficiaries, as long as the number of clients incorrectlyidentified as “poor” isroughlyequal to the number of clients incorrectlyidentified as “not poor”.Designing client interceptsurveys. The typical client interceptsurveyattempts to interview all clients presenting for services during a specified time frame; the greater the client volume, the fewernumber of daysneeded to collectenough interviews for analysis.2 Clients canbeinterviewedwhilethey are waiting to see the service provider or afterthey have completed the visit. The advantage of interviewing in the waiting room isthatitdoes not add time to the client’svisit; the advantage of interviewingat exit isthat the client canbeasked about the services he/she has justreceived.In either case, only a smallnumber of questions shouldbeasked, preferably close-ended (i.e. withpre- definedresponsecategories). Close-ended questions are easier to administer, data enter, and analyze. Time per interview shouldbe short, preferably no more than 10 minutes, especially for exit interviews. Many clients willalready have spentconsiderable time traveling to the service and waiting to beseen and willbeanxious to be on theirway. A 10-minute interview usuallymeans no more than 15 questions.Interviewers shouldbetrained to attempt to interview all clients waiting for or leaving the service. This reducesbiasthatmightbeintroduced if the interviewers choosewhich clients to interview. Verbal consent shouldbeobtained, assuring the client thathis/hernamewill not berecorded and thathe/sheis free to refuse to beinterviewed or to refuse to answerspecific questions. Interviewingshouldbemonitored to ensurethattheseprocedures are followed.The choice of questions to assesssocioeconomicstatusisdictated by the local context and mayvaryfrom one part of the country to another. Reference periodsshouldbe as specific as possible—for example, instead of asking how often the client usuallymakes a particularpurchase, itisbetter to ask how oftenhe/she made it in the last week. Items that show markedseasonal fluctuations shouldbeavoided; if theycannotbeavoided or if they are of program interest (such as treatment for diarrhea), successive surveysshouldbeconductedat the same time eachyear.An increasingnumber of locally-tested instruments to identifypovertystatus are availablefrom USAID microenterpriseprojects. The MicroenterpriseResults and AccountabilityAct of 2004 mandated USAID to develop and field test at least twolow-costpovertymeasurementmethods and targethalf of microenterpriseresources to clients who are “very poor”.3 Consequently, many country-specificpovertyassessmenttoolscanbedownloadedfrom the internet and adapted for use by reproductive health programs.4 Sample questionnaires are provided in Appendix 2.