"There needs to be ongoing flexibility and creativity in our ways of approaching health equity," said John Borrazzo of the U.S. Agency for International Development (USAID) at a recent Global Health Initiative event at the Wilson Center. Borrazzo is the chief of the Maternal and Child Health Division in the Bureau for Global Health. He moderated a discussion on practical strategies to improving access to health services for the world's poor and other marginalized groups, with panelists Mickey Chopra, chief of health and associate director of programmes at UNICEF; Davidson Gwatkin, senior fellow at the Results for Development Institute and senior associate at Johns Hopkins Bloomberg School of Public Health; Cesar Victoria, professor of epidemiology at the Federal University of Pelotas in Brazil; and Jennifer Luna, senior monitoring and evaluation adviser for the Maternal and Child Health Integrated Program (MCHIP).
MDG 4: An Equity Approach
"Massive benefits can be gained by reaching the poorest and most marginalized," said Chopra. "It's actually more cost effective to have an equity-based approach; it's not just right in principle, it's right in practice."
While there has been some progress in reducing the rates of mortality for children under five (the UN's Millennium Development Goal 4), Chopra said "there has to be a change" if they are going to be achieved completely. Most of the 30 percent decline in child mortality so far has been in Asian countries, while Africa as a whole remains stagnant. Further, two-thirds of the 35 countries that have made significant progress to meet MDG 4 show worsening inequalities between the highest and lowest income brackets of the population.
In the majority of countries, the "rich are still capturing most of the benefits of new investments and interventions," said Chopra. "The challenge at the program and policy levels is to understand why there is this gap between the richest and the poorest in terms of uptake of critical interventions."
Delivery channels are faced with "bottlenecks" that prevent services from reaching marginalized communities, said Chopra. Clinic-based services often lack adequate human resources, consistency in the quality of service, and can be very expensive. Population-oriented services, which include government and NGO-led outreach and scheduled services at health facilities, are often challenged with low demand and lack of continuity, while availability and cost of health commodities are barriers for community-based interventions delivered through local organizations or social marketing campaigns.
Shifting delivery of services within channels, appropriately shifting delivery to different channels, or improving the performance of an established delivery channel could help increase uptake of treatment and prevention among poor and marginalized communities, concluded Chopra. He stressed that progress need not come at the expense of the poor. According to a UNICEF report, Ghana, Eritrea, Nepal and Malawi have all reduced under-five mortality and inequality by prioritizing providing essential services to the most marginalized communities first.
Designing Equity-Based Health Programs
"Performance variability in terms of equity across countries is very large," said Gwatkin. "In some places a given technique can work well and in others it can be a complete flop."
To pick the right technique for the right place, Gwatkin advocated for an iterative approach to program design and implementation, beginning with setting targets in terms of the poor population group of concern. After fully assessing country-specific conditions, a set of potential pro-poor interventions can be selected, based on an analysis of current interventions and suggested alternatives as well successful interventions in other countries. Each of these interventions should be delivered to a large, representative area, he said.
"The next step is to find out how well you have done," said Gwatkin, stressing the importance of assessing and monitoring interventions with a specific focus on the marginalized target group. Successful approaches should be expanded, while those that are not having the intended benefits of helping the poorest communities should be modified or abandoned.
In sum, said Gwatkin, "It's more promising to focus on designing a process to fit techniques to individual country settings than to focus on the techniques themselves." Doing this helps effectively integrate equity concerns into the design and implementation of programs, and as a result, he said, can have a major impact on improving the lives of the poorest people in developing countries.
Analyzing Equity to Maximize Impact
"It's always possible and useful to include equity in monitoring and evaluation, however, it has to be planned ahead of time," said Victoria.
The Countdown to 2015 Initiative is an effort to monitor progress made towards the health-related Millennium Development Goals globally. The Countdown's efforts not only aim to promote access to health services at the aggregate level but also specifically to ensure the equitable distribution and uptake of health services among disadvantage populations, said Victoria.
Generally, in countries with high coverage of preventative and treatment services, like Brazil, there is "bottom inequity," said Victoria, in which the poor are much worse off than everyone else. Targeting the poor specifically in such countries is therefore essential to improving equity.
Alternately, Victoria continued, countries with low coverage at all levels, like Cambodia or Haiti, suffer from "top inequity," in which the rich are typically much better off the rest of the population. These countries should work towards increasing coverage for all people and focus on the poor after there are some universal gains, he said.
"Analyzing the shapes of inequity curves can help drive decisions about delivery channels and targeting…and can lead to practical strategies for maximizing the impact of interventions," concluded Victoria.
Health Equity: From Evidence to Practice
"Projects often state that they are really interested in equity, but when you read the project descriptions, you don't see exactly what they mean by equity or how they plan on addressing it," said Luna, speaking of her work at MCHIP.
Luna presented the Health Equity Guidance Document that outlines a systematic, six-step process for professionals who design and implement community-oriented projects to ensure equity is effectively integrated into their programs:
1) Understand the equity issues in the project area
2) Identify the disadvantaged group on which to focus
3) Decide what is in the project's manageable interest to change
4) Define equity goals, objectives, and a project-specific definition of equity
5) Determine equity strategies and activities
6) Develop equity-focused monitoring and evaluation
Luna stressed that there is no "one size fits all" strategy: "This approach is not a prescriptive one; it presents a series of concepts and approaches to take into consideration and then make decisions." But for program implementers on the ground, she said, these guidelines and tools "should help lead to a coherent health equity strategy and can serve as a basis for dialogue among stakeholders."
Drafted by Ramona Godbole and edited by Schuyler Null and Meaghan Parker
Calyn Ostrowski, Global Health Initiative, 202-691-4341