1. Practical Guidance for Incorporating
Health Equity Considerations
MCHIP Program Learning Meeting
November 4, 2011
ICF (MCHIP)
Jennifer Winestock Luna
- Senior M&E Advisor
Debra Prosnitz- Program Associate
Debra Prosnitz, MPH
Program Associate
Debra Prosnitz, MPH
Program Associate

2. Have you considered improving health
equity as part of MCHIP country
programming?
• What is your country program doing
about improving health equity?

3. Session Outline
 Purpose of MCHIP health equity work
 Overview of MCHIP Health Equity Guidance and
Checklist
 Examples of Application of the Checklist
 Small group exercise : understanding health equity
work in MCHIP country programs
 Plenary discussion of exercise, challenges, next steps

4. Purpose of MCHIP Health Equity Work
 Overall mandate to improve health outcomes
 Improving health equity is a Program Learning
theme
 Developed guidance to help programs
incorporate health equity considerations into
program designs
 MCHIP country programs:
• Incorporate into new designs; Refine on-going
• Document health equity work using MCHIP
guidance as framework

5. MCHIP's definition of health equity
Health equity is 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)

6. MCHIP’s Health Equity Guidance

7. Why health equity guidance was
developed?
Challenges:
 Projects often state that equity is part of program
design, however they:
 may not clearly articulate how equity is being
addressed
 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

8. 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 into
consideration & decisions to be made

9. Development of equity guidance
Collaborative effort
 USAID, MCHIP, CORE*, other technical experts
 Virtual TAG, discussion sessions to solicit
input from equity experts
 Including representatives of PVOs, CORE, MCHIP, MEASURE
Evaluation, DHS, USAID and Cesar Victora
 Literature Review
 (i.e. UNICEF, USAID's gender group, Davidson Gwatkin)
*CORE: network of PVOs
community-oriented programs

10. The guidance consists of:
1. Check list
 Series of questions/ discussion points about project
designs (www.mchip.net)
2. Reference document
 Considerations for Incorporating health Equity into
Project Designs: A Guide for Community-Oriented
Maternal, Neonatal, and Child Health Projects
(www.mchip.net)
3. Presentations, exercises; to work with teams
4. Workbook to keep track of decisions

11. Guiding assumptions
1.Addressing equity means more than working in a
disadvantaged geographical region
1.Means reaching most disadvantaged within that region
2.Making comparisons over time of health outcomes
between disadvantaged and advantaged groups
3.Requires understanding and deciding how to handle
underlying conditions
2.Obtaining high coverage levels depends on decisions
made along a continuum from narrowly targeting a
disadvantaged group to a universal approach aimed
at all groups

12. Health Equity Guidance: 6 - Step Process
1. Understand the equity issues in the project area
a. Identify inequities in health outcomes
b. Understand underlying issues and barriers
2. Identify the disadvantaged group or groups
3. Decide what is in project’s manageable interest to
change
4. Define project-specific equity goals and objectives
5. Determine equity strategies and activities
6. Integrate equity-focused indicators and
measurement into M&E framework and PMP

14. Highlights from Checklist

15. Step 1: Understand health equity issues
Health Outcomes
 Do you have quantitative
information on inequities in
specific health outcomes?
 Have you considered ethnicity,
gender, education, place of
residence, socio-economic
status, religious group, other?
 Do the gaps in health
outcomes justify a special
approach?
Underlying
issues/barriers
 Do you have
information on the
underlying conditions
and barriers that lead
to inequities?
 What are the issues?

16. Step 2: Identify disadvantaged group
 Which disadvantage group will you focus
on?
 Have you identified an advantaged group
for comparison?
 What is that group?

17. Examples from CSHGP
Step 1a Identify inequities in health outcomes
 In Ecuador, the Center for Human Services (CHS) looked at
provincial data on maternal & child health
• Indigenous populations have lower rates of maternal health
care utilization than mestizo (mixed European descent)
populations.
• Home births among total population was 46.5%, while for
indigenous women it was 71.4%.
 CHS conducted its own Knowledge, Practice, and Coverage
(KPC) survey in the project area to confirm the same findings
locally.

18. Examples from CSHGP
Step 1a Identify inequities in health outcomes
 Using national (DHS) and local (KPC) data, Christian
Reformed World Relief Committee (CRWRC) identified
gaps in knowledge & coverage between highest & lowest
wealth quintiles in project in Bangladesh.
 In lowest quintile, only 27.3% of women reported
consuming iron/folate in their last pregnancy, versus
57.7% of women in highest quintile.

19. Examples from CSHGP
Step 1b Analyze underlying issues/barriers
 In Ecuador, CHS conducted focus groups/ key informant
interviews 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 families
preferred 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

20. Examples from CSHGP
Step 3 Decide on program's manageable interest
CARE Nepal
 Social exclusion of
marginalized populations
contributes to poor
healthcare practices
Concentrate on:
 Including marginalized in
community-level activities
 Informing them of their rights
 Advocating for better
treatment by health workers
CHS Ecuador
 Address cultural differences by:
 Improving cultural
responsiveness of health
services
 Using quality assurance
methods to bring together
community members

21. Step 4: Develop a project-specific operational
definition of equity
 Not general definition (i.e. MCHIP definition)
 Allows project stakeholders to know when equity
has been improved
 Helps communicate exactly what was improved
Ex: Equity for children in _X_ group means that
immunization coverage will increase to at least the
baseline levels for other ethnic groups in the program
area, at the same time that levels for other ethnic groups
do not decrease.

22. Examples from CSHGP
Step 5 Determine equity strategies and activities
CARE Nepal
 Community mobilization in communities with poorest
health indicators
 Conducted training for health workers
 Implemented behavior change communication program
 Expanded an existing maternity incentive scheme to
increase institutional deliveries (cash transfer).

23. Examples from CSHGP
Step 6 Develop equity-focused M&E
 CARE Nepal collected data on caste and ethnicity in
KPC survey in order to disaggregate health
indicators by marginalized and non-marginalized
populations.
 Through community mobilization strategy, project
collected community-level data on pregnancy
outcomes disaggregated by marginalized and non-
marginalized women.

24. Worksheets for applying guidance
 Worksheet 1: Identifying Inequitable Health
Outcomes
 Health outcome; between/ among which groups;
magnitude of the difference; source of information
 Worksheet 2: Understanding underlying issues
and barriers
 What are key underlying issues; missing information;
equity-based constraints; equity-based opportunities

25. Small group work: understanding health
equity work in MCHIP country programs
 Use worksheets to analyze equity details of
country 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

26. Plenary discussion
 Examples from groups of
 Inequitable health outcomes
 Underlying conditions
 Next steps for program learning
 How should guidance be used?

27. Thank you
www.mchip.net