MoRES Activity to Understand Health Program Equity

ADITI RAO: The monitoring results for equity systems is a planning, programming, and monitoring approach conceptualized by UNICEF in 2011, and further developed and evaluated in 2014. This framework builds on the existing human rights-based approach to programming, and is intended to enhance and sharpen country programs for accelerated results for the most disadvantaged populations. In particular, it is based on a determinant framework to identify barriers, bottlenecks, and enabling factors which either constrain or advance the achievement of desired outcomes for disadvantaged population. The framework emphasizes strengthening the capacity of government and partners to regularly monitor intermediate outcomes to enable more effective program implementation and timely course correction in plans and strategies at all levels.

The framework was originally depicted as a cup with four levels, as shown in the image. More recently, it has focused more on the functions of the levels and operationalizing them, and less on the visuals. But let’s go with this. The levels here closely follow the main components of a theory of change or logic model, which many of you might be familiar with. Level one of the framework focuses on situational analysis, strategic planning, and program development. This level looks at the quality of analysis of child deprivation within country situation analyses, as well as how well aligned are policy strategies and plans developed to the results of the analysis.

Specific attention is given to understanding causes of deprivation, and barriers and bottlenecks to their removal. Level two focuses on the inputs and outputs of specific program activities or advocacy initiatives, while level three focuses on early indications of the removal of barriers and bottlenecks identified and progress towards equitable outcomes. Data from this level is often used to iterate and adjust decisions made at levels one and two. Finally, level four looks at intervention coverage and its impact on equity. Once you feel you have an adequate understanding of the framework, we will explore how it can be used to analyze a given scenario, such as challenges arising from hard-to-reach populations for the Global Polio Eradication Initiative in the Pakistan and Afghanistan border region.

Taking this example, consider the GPEI is struggling to reach specific populations in the Pakistan-Afghanistan border region where routine immunization, including polio vaccine coverage, is low. The objective will be to identify bottlenecks in program delivery and think through how the four major levels of the framework that are inputs and situation analysis, process or activities, outputs or outcomes, and impact levels will shed light on the problem outlined. To complete this exercise, one can use the template shown here. Can you think of what you might say for each of these boxes?

In thinking about the first box, inputs and situation analysis, you may consider what is a key deprivation, ie poor vaccination coverage, among which groups does this deprivation persist, and how does risk exposure interact with equity. Thereafter, you may think of activities to alleviate the bottleneck. What kinds of outputs might we look out for which will indicate whether the ultimate outcome has then been achieved? And finally, what has been the intended or unintended impact of the effort? To make this more interesting and challenging, in thinking about hard-to-reach populations, try going through this exercise separately for geographically hard to reach, socially hard to reach, and populations in conflict areas. How might the bottlenecks, activities, outputs, and outcomes differ?

Also important to consider are the assumptions we are making at each step. When implementing program activities, it is immensely helpful to come back to assumptions made at each step to better understand what may have worked or not and how we might iterate processes. Finally, when considering bottlenecks and barriers, and thereafter outlining activities, keep in mind the concepts of intersectionality. Communities can be hard to reach in multiple ways. Often, we rush to adjust one aspect, while entirely ignoring others. This makes finding effective and appropriate solutions challenging, but also more accurate.

The next step to filling out the template we just saw would be to identify strategies to overcome inequity problems, both at the proximal program lover and, more distally, at the policy level. Strategies can be organized across domains. And here are some suggestions. Service delivery, capacity-building, advocacy, behavior change and communication, policy analysis or development. In thinking through strategies, you may use this template to list out the strategies that were used or that you think could be used to address inequities in the GPEI in Pakistan and Afghanistan border regions. I would encourage you all to take a pause at this point and think through this exercise.

In this lecture, we have looked through challenges of reaching the last 1% of polio cases, specifically how it relates to health equity and social justice, what aspects of the program have caused and perpetuated inequity, and what are some actions that have been taken or can be taken to adjust the gaps. We have also looked through some theoretical frameworks which allow us to better understand complexities around issues of equity in program design and implementation, as well as highlight key concepts to keep in mind as we progress. Now let’s come back to the questions posed for consideration at the beginning of the lecture.

There is obviously more than a single right answer to each of these questions, but let’s think through some of them. What are the underlying factors which have led the last 1% of children with polio cases to be consistently underserved, and how do eradication activities confront and address those forces? Here, we can think about political priorities and motivations, systemic structures which favor those in higher socioeconomic positions, living in wealthier circumstances with access to education and basic health services, whereas more vulnerable communities are often afflicted with more than just one disease or burden plunging them in a vicious cycle of poverty. We also discussed how eradication programs by design are required to reach every last individual.

However, the fact that this program has experienced sustained difficulties in reaching the last 1% reveals a weak health system in service delivery, and perhaps the lack of a holistic understanding of the problem. The program is tasked with vaccinating every last child. However, whether the service is adequately and equitably delivered is another question still. What are long-term effects of eradication programs? Are communities fatigued with prolonged activities, or are they also relieved to be receiving health services? Are programs fatigued with intensive activities, or do they continue to be motivated, having reached the last mile? How about can tools for reaching the 1% developed for eradication be transformed for health systems?

A popular argument made to support eradication efforts is that the immense global investment in developing infrastructural capacity, training human resources, creating detailed maps of every corner of the world can and must be transitioned to some other health programs initiatives, as well as strengthen existing tools and capacity. Or, on the other hand, we can argue the tools and processes for a single disease-focused approach cannot adjust or add to more holistic and integrated programs.

Other questions one might consider in implementing programs is how are global goals and local priorities balanced, and how do we reimagine and reorganize our systems and programs so that they are responsive to the needs of all, and especially the most vulnerable, perhaps towards more just and durable future. So I hope I’ve left you all with topics to consider when thinking about achieving health equity and social justice when implementing and designing programs. Thank you all so much for your time.