Addressing Equity in Public Health

2014
Addressing
Equity in Health
Karen Foreit, PhD
MS-15-105
Addressing Equity in
Health
KarenForeit,PhD
MEASUREEvaluation
This guide was made possible by support from the U.S. Agency for International Development (USAID) under
the terms of Cooperative Agreement GPO-A-00-03-00003-00. The opinions expressed are those of the authors
and do not necessarily reflect the views of USAID or the United States government. MS-15-105
January 2014
TableofContents
AddressingEquityinHealth.........................................................................................3
EquityinHealth............................................................................................................4
PolicyApproachtoEquity..........................................................................................13
TheBasis:EngagingandEmpoweringtheExcluded..................................................24
Analysis:QuantifyingandUnderstandingBarriers....................................................34
AdvocacyandDialogue:IntegratingEquityGoals.....................................................46
Action:TargetResources&ImplementYardstickstoMeasureProgress..................51
Recap.........................................................................................................................65
FinalExam..................................................................................................................67
AddressingEquityinHealth
PURPOSE
Healthandpovertyareintertwined.Itisoftenthepoorandothervulnerablegroupswhoexperience
theburdenofdisease,whichcanplungethemdeeperintopoverty.Recognitionofthesefactshasput
healthandpovertyissueshighontheinternationalagenda.Despitethebestofintentions,however,
healthresourcesandprogrameffortsoftenfailtoreachthoseingreatestneed.
Asaresult,itisimperativethatpolicymakersandprogrammanagersbetterengagethepoorandother
excluded groups in the design of policies, programs, and financing mechanisms to make certain that
theymeettheneedsofthesegroups.ThiscoursepresentstheEQUITYFrameworkforHealth,which
provides practical guidance on how to ensure that the voices of the poor are actively engaged in
policymakingandthatpropoorstrategiesareincorporatedthroughoutthepolicytoactionprocess.
OBJECTIVES
Attheendofthiscourse,youwillbeableto:
Defineinequalityandinequity
Usesurveydatatoidentifyinequalitiesandinequitiesinhealthutilizationindicators
DefinethestepsinvolvedintheEQUITYFrameworkforHealth
Listthreewaysinwhichtoengagethetraditionallyexcluded
Identifysupplysideanddemandsidebarriersthatmayhindertheachievementofmore
equitablehealthoutcomes
Nametwoexamplesofopportunitiesforintegration
Definetargetingandrequired
Provideanexampleofanindicatorforprogramdesign,implementation,serviceuptake,and
equityimpacts
TIME
Thiscoursetakesapproximatelytwohourstocomplete.Itfollowsaninteractiveversionfoundonthe
MEASUREEvaluationWebsiteat:https://www.cpc.unc.edu/measure/training/onlinecourses
EquityinHealth
Equity in health stems from the principle that health is a basic human
right.Thiswasfirstarticulatedin1946,intheConstitutionoftheWorld
Health Organization (WHO) and repeated in other international
documents,suchasthe1948UniversalDeclarationofHumanRightsand
the1976InternationalCovenantonEconomic,SocialandCulturalRights.
Intheyearsthatfollowed,theinternationalcommunitycametorealize
that achieving universal good health would require reducing the
differences in health status between countries and between groups in
thesamecountry.
In a nowclassic paper published in 1992, Margaret Whitehead laid out
definitionsanddistinctionsbetweeninequalityandinequityinhealth.
Inequalityisastatisticalmeasure;
Inequityhasamoralandethicaldimension;
Not all inequalities are inequities; inequity refers to differences
thatare:
o Unnecessaryandavoidable;and
o Unfairandunjust
Equityinhealthmeansthateveryoneshouldhaveanequalopportunity
to attain his or her full health potential. Many of the poorer health
outcomesandgreaterhealthrisksexperiencedbydisadvantagedgroups,
such as the poor, ethnic minorities, women, or others, relative to more
advantagedsocialgroupscanbeclassifiedashealthinequities.
DEFINITION OF
INEQUITY
Highlights
Itisinevitablethatsome
individualswillhave
poorerhealththan
othersduetogenetics,
lifestylechoices,
accidentsandother
factors.Whatis
importantisthat
belongingtoaparticular
groupshouldnotstand
inthewayofgood
health.
Healthcanbemeasuredinmanyways.TheWHOconsidersthreebroad
dimensions:
1)Accesstohealthgoodsandservices
WHAT DOES
EQUITY IN HEALTH
COVER?
Achievingequityinhealthmeansthatallmembersofsocietyhaveequal
access to at least basic health goods and services. This means reducing
physical barriers, such as distance and/or lack of transport, economic
Highlights
barriers,suchashighprices,andsocialculturalbarriers,suchasprovider
attitudesthatdiscriminateagainstpeoplefromcertainethnicgroups.
Aroundtheworld,people
whoarepoorand/orlive
2)Useofhealthgoodsandservices
inruralareastendto
Equityinhealthmeansthateveryonehastheopportunitytomakeequal havelessorlimited
use of health goods and services for equal needs. Many members of accesstohealthservices,
disadvantaged groups do not use services because of fear of being tomakelessuseof
treated badly or because they do not speak the same language as the servicesthatare
accessible,and
serviceproviders.
consequentlytoshow
3) Health status (such as life expectancy, mortality rates, nutritional worseoverallhealth
status,etc.)
statuscomparedto
peoplewhoarebetter
Equityinhealthmeansthatanydifferencesinhealthstatusarenotdue
offand/orliveinurban
to different use of health goods and services that stem from unequal
areas.
accesstothem.
INEQUALITY VS.
INEQUITY
We can see from Whiteheads definition that all inequities in health

involveinequalities,butnotallinequalitiesarenecessarilyinequities.
For an inequality to be considered an inequity, two conditions must be
met:
1. The inequality is between different population groups (e.g., poor vs.

notpoor;ruralvs.urban;etc.)andnotamongindividuals;and
2. The differences are both unnecessary and avoidable and unfair and
unjust.
WHEN IS
INEQUALITY AN
INEQUITY?
EXAMPLE 1
Let us take a look at some common health problems in developing

countriesandseeiftheymeetthecriteriaforinequity.
Webeginwithearlychildhoodmalnutritionandfindingsfromthe20089
KenyaDemographicandHealthSurvey(DHS).Nationwide,some30%of
all children under the age of three were chronically malnourished
(stunted)asmeasuredbyheightforage.
The graph on the left presents children of mothers with a secondary
education or higher. We can see that 6% were severely stunted and
another14%weremoderatelystunted.
PracticeQuestion
Dothesefindingsdemonstrateinequity,andwhyorwhynot?
Answer
The findings demonstrate differences (inequalities) among individual
children with similar backgrounds. They do not show differences
betweenpopulationgroupsandthereforearenotevidenceofinequity
WHEN IS
INEQUALITY AN
INEQUITY?
EXAMPLE 2
Now, let's look at all children under age three. The graph on the left
shows prevalence of moderatetosevere stunting by household wealth.
Wecanseethatmorethan1in3childrenfromthepooresthouseholds
were stunted, compared with approximately 1 in 5 children from the
leastpoorhouseholds.
PracticeQuestion
Dothesefindingsdemonstrateinequity,andwhyorwhynot?
Answer
The findings compare different population groups, so the differences
meetthefirstcriterionforinequity.Second,therootcausesofstunting
lieinpoorfoodintakeandpoorsanitation,whichareavoidable.Finally,it
isarguablyunjustthatthepooresthouseholdscannotaffordtofeedtheir
childrenorprovidecleanwaterandsanitation.Therefore,thedifferences
instuntingbyhouseholdwealtharelikelytobeaninequityinhealth.
WHEN IS
INEQUALITY AN
INEQUITY?
EXAMPLE 3
Inourlastexample,welookatfertilityandtheuseofcontraception,also
from the 20089 Kenya DHS. The graph above compares mean children
everborn among women ages 4049 to current use of contraception
amongmarriedwomen1549,byhouseholdwealth.Thepoorestwomen
havethelargestfamiliesandareleastlikelytobeusingfamilyplanning
infact,asfamilyplanningusegoesup,fertilitycomesdown.
The impact of family planning on fertility is well known. Clearly, the
higherfertilityamongthepoorestwomencouldbeavoidediftheyused
contraception. But are these differences unfair and unjust? In other

words,whatdowomenwant?
As it turns out, Kenyan women from the poorest households want on
averagetwiceasmanychildrenaswomenintheleastpoorhouseholds.
Therefore, one could argue that the higher fertility levels among the
poorest women in Kenya, while potentially avoidable, may not be
completelyunwanted.Totheextentthatthishigherfertilityiswanted,it
would not be unfair and unjust and therefore not meet the criteria for
inequity.
Atthesametime,thereasonsbehindthedesireformorechildrenlack
ofeducationalopportunitiesforwomen,higherchildmortalityrates,etc.
may represent social inequities, and higher fertility levels in and of
themselvesposepotentialhealthrisksforthepoorestwomenandtheir
children.
THE POOR HAVE

WORSE HEALTH
OUTCOMES THAN
THOSE BETTER-OFF
Didyouknow?
Throughouttheworld,a
childborntoapoor
familyismuchmore
likelytodiebefore
his/herfifthbirthday
thanachildborntoa
wealthierfamily.
Thisgraphshowsdifferencesinmalnutritionratesamongchildrenunder
5betweenthepoorest20percentofthepopulation(darkbluecolumn)
and the least poor 20 percent (light blue column) in eleven countries
aroundtheworld.
Note that the malnutrition rates among the poor are higher than rates
among the wealthiest population group in every country. This
demonstrateswithincountryinequities.
Note also the pronounced differences among countries: from Jordan,
where only 8% of all children under age 5 are malnourished, to East
Timor, where 58% of children under age 5 are malnourished. This
demonstratesbetweencountryinequities.
Whatotherwithinandbetweencountrydifferencesdoyousee?
(Hint:compareColombiaandPeru)
10
KNOWLEDGE RECAP
Answerthefollowingquestionstoseehowmuchyouknowaboutthistopic.Gotopage12to
seethecorrectanswers.
1. Eveninthebestsituations,itisinevitablethatsomeindividualswillhavepoorerhealththan
others.
[a]True
[b]False
2. Theconceptofhealthasahumanrightwasfirstarticulated
[a]BytheHealthCommitteeoftheLeagueofNationsinthe1930s
[b]Inthe1940s
[c]InWorldHealthOrganizationAlmaAtaDeclarationof1978
[d]Inthe2000UnitedNationalsMillenniumDeclaration
[e]Noneoftheabove
3. Theconceptofhealthequitydrawsparticularattentionto
[a]Measurementofhealthdisparities
[b]Healthinequalitiesthatareunnecessaryandavoidableandunfairandunjust
[c]Healthfinance
[d]bandc
[e]alloftheabove
4. Allinequalitiesinhealthcaneventuallybeshowntoderivefrominequity.
[a]True
[b]False
5. Equityinhealthcovers
[a]Accesstohealthgoodsandservices
[b]Useofhealthgoodsandservices
[c]Healthstatus
[d]aandb
[e]Alloftheabove
6. Highfertilityratesendangerwomenshealthandthehealthoftheirchildren.Womenin
ruralandpoorerhouseholdsusuallyhavemorechildrenthanwomeninurbanandwealthier
households.Thisevidenceissufficienttodemonstrateinequityinaccesstofamilyplanning.
[a]True
[b]False
11
KNOWLEDGE RECAP: ANSWERS
1. Eveninthebestsituations,itisinevitablethatsomeindividualswillhavepoorerhealththan
others.
[a]True
2. Theconceptofhealthasahumanrightwasfirstarticulated
[b]Inthe1940s
[b]False
5. Equityinhealthcovers
[e]Alloftheabove
ruralandpoorerhouseholdsusuallyhavemorechildrenthanwomeninurbanandwealthier
households.Thisevidenceissufficienttodemonstrateinequityinaccesstofamilyplanning.
[b]False
12
PolicyApproachtoEquity
Thereisgrowingconsensusthatovercominginequalitiesandinequitiesin
healthrequiresastrong,enablingpolicyenvironment.
For more than two decades, the United Nations, the World Bank and
othermultilateralandbilateraldonorshavesupportedstrategies,plans,
andprogramstoendpovertyandensureequitabledevelopment.Among
the most ambitious of these are the Millennium Development Goals
(MDGs), launched at a UN summit in 2000. Three of the eight MDGs
explicitlydealwithhealth.
Nevertheless,manyoftheseeffortsfailtomeaningfullyinvolvethepoor
andotherexcludedgroups.Thisleadstostrategiesthatmaybeillsuited
totherealityfacedbytheverygroupstheyaredesignedtobenefitordo
notadequatelyaccountforthebarrierstheyface.
ADDRESSING
INEQUITY WITH
POLICY
Didyouknow?
There are a growing
number of communities of
practice dedicated to
equity in health. For
example, see the Pan
American Health
Organization
TheEQUITYApproach,originallydevelopedbytheHealthPolicyInitiative
Project,addressesthiscriticalshortcoming.Itisapractical,stepbystep
process to actively engage the poor and other excluded groups in
policymaking and ensure that propoor strategies are incorporated in
policy design and implementation. It draws on project experiences and
internationalbestpractices.
The remainder of this course is adapted from the Equity Approach. The
approach has been modified to include a wider range of social factors
that may give rise to inequity in health and a section on performance
monitoring.
TheEQUITYApproachisdistinguishedbythreefundamentalprinciples:
1.Participation(beginningwithidentifyingandengagingthosewhohave
been excluded from mainstream health benefits and empowering them
toparticipatethroughouttheprocess)
THE EQUITY
APPROACH
OVERVIEW
13
2. Synthesis of quantitative and qualitative information (to quantify

inequalitiesandunderstandtherangeofbarrierstoaccessanduse),and
3. Feedback (throughout the cycle from analysis to advocacy and
dialoguetoaction).
WHAT DOES
EQUITY STAND
FOR?
Engageandempowertheexcluded
Quantifytheinequalitiesinhealthcareuseandhealthstatus
Understandthebarrierstoparticipation,access,anduse
Integrate equity goals, approaches, and indicators into policies,

plans,anddevelopmentagendas
Targetresourcesandeffortstoreachtheexcluded
ImplementYardsticksforperformancemonitoring
14
The EQUITY Framework Figure above illustrates the approach. The next
few pages will take you briefly through each of the six steps of the
EQUITYapproach.
The guiding principle of the EQUITY Approach is that policy, program,

and implementation decisions affecting the poor and other excluded
groupsshouldbemadewiththem,notjustforthem.
Empoweringexcludedgroupsistogivethemavoiceinthepolicyarena.
Empowerment means that the intended beneficiaries define their own
prioritiesandidentifythebarrierstheyfaceinaccessinghealthservices.
Itmeansthatpolicymakersandothersinpositionsofauthoritylistento
what they have to say, and that political leaders and healthcare
providers become more accountable for achieving results that benefit
theexcluded.
To learn more about working with the poor and other traditionally
excludedgroups,seethenextsessiononEngagingandEmpoweringthe
Excluded.
E: ENGAGE AND
EMPOWER THE
EXCLUDED
Highlights
Whenexcludedgroups
areinvolvedinpolicyand
programdesign,
solutionsarebetter
suitedtotheirneeds.
IdeasinAction
Thinkandactholistically
toengageexcluded
groups.Wheredothey
live(ruralareasorurban
slums)?Arethey
concentratedamong
ethnicminorities?Their
groupidentitymaybe
shapedmorebythese
characteristicsthanby
beingpoor.
15
Q: QUANTIFY THE
LEVEL OF
INEQUALITY IN
HEALTHCARE USE
AND HEALTH
STATUS
Advocates for health equity need quantitative information to convince

policymakers that inequalities in health are serious and deserve
attention.
Plannersneedquantitativeinformationtosettargets,proposebudgets,
andallocateresources.
Which health areas show inequalities? (only family planning?

Family planning and maternal health? All areas of maternal and
childhealth,includingchildhoodvaccination,etc.)
How widespread are the inequalities? (only the poorest of the

poor?Theentireruralpopulation,etc.)
Howdeeparetheinequalities?(arethemostdisadvantaged25%
less likely to use the needed services than the betteroff
population?Halfaslikely?Onetenthaslikely?)
Didyouknow?
Acountrythatshows
highinequalitiesonone
healthindicatorislikely
toshowhighinequality
onotherhealth
indicators.However,
differenthealth
outcomesmayshow
markedlydifferentlevels
ofinequality.For
example,childhood
vaccinationcoverage
generallyshowsless
disparitybetweenthe
poorestandleastpoor
segmentsofthe
populationthan
childbirthinahealth
facility.
16
Whatarethereasonsthatsociallyexcludedgroupstendtoshowlowuse
ofhealthcareservices?Wecannotremovebarrierstoaccessuntilthese
reasons are fully analyzed and understood. Potential barriers to access
andusemayarisefrombothsupplysideanddemandsideissues.
Supplyside:
Aretheresufficienthealthfacilitiesandserviceprovidersnearto
where people live, work, or shop? Traveling more than a few
kilometers can be a barrier, especially if transport is limited or
expensive.
How much do facilities and service providers charge? Can the

pooraffordtopaytheseprices?Sometimespublicfacilitiesoffer
freeservices,butthemedicineorcommoditymustbepurchased.
Do the facilities and service providers that the socially excluded

tendtouse,offertheservicesthattheyneed?
Areoperatinghoursconvenient?Areservicesofferedeverydayor
onlyonceaweek?
Are there interpersonal barriers between providers and clients?

Do providers speak the same language as the clients; are there
differences in social class? Are female providers available for
women who may be reluctant to accept physical examinations
frommaledoctors?
U: UNDERSTAND
ALL THE BARRIERS
TO
PARTICIPATION,
ACCESS, AND USE
Demandside:
Do consumers even want the services? Do they see the

inequalitiesasaproblem?
Are there negative attitudes or beliefs that the services are

harmfulorthattheyviolateculturalorreligiousvalues?
Are there others in the household (spouse, parents, parentsin

law)opposedtotheservice?
Do women have a say in how household resources are used for

theirhealthandthehealthoftheirchildren?
17
I: INTEGRATE EQUITY
GOALS AND
APPROACHES IN
POLICIES, PLANS,
AND AGENDAS
Governmentsaroundtheworldhavesetambitiousgoalstoimprovethe
health and welfare of their people. For example, in 2000 the United
Nations General Assembly, representing 189 countries, unanimously
adoptedtheMillenniumDeclaration.Thisresultedin8goals,18targets
and48indicatorsknownastheMillenniumDevelopmentGoals(MDGs).
Amongthehealthtargetsare:
Halve the proportion of people who suffer from hunger
(malnutrition)between1990and2015
Reducebytwothirdstheunderfivemortalityratebetween1990
and2015
Achieveuniversalaccesstoreproductivehealth
Achieving the Millennium Development Goals means improving the

health of the poor. As governments set and revise policiesand plans to
improve their health programs, povertyrelated inequalities and equity
goalsshouldbeexplicitlyincludedindialogueanddocuments.
Governmentsneedto:
18
Setfirmgoalsforimprovedcoverageandhealthoutcomesamong
thepoorandotherexcludedgroups
Designstrategiestoachieveequitygoals
Ensureequitybasedmonitoring
Ensure that poor and traditionallyexcluded clients know their

healthrightsandchoicesascitizens
T: TARGET
RESOURCES AND
EFFORTS TO THE
POOR AND OTHER
EXCLUDED GROUPS
There are two basic approaches to designing health policies and

implementingprograms:
Mainstreamorgeneralpopulationapproachesseektobenefitall
segments of the population. These would include efforts to
provide universal access to priority services, such as childhood
vaccinationandfamilyplanning.
19
Targeted approaches seek to selectively enhance provision of

neededbutunderutilizedservicesoraccesstoservicesbyspecific
groups.
Targetingforequitymeansdirectingresourcesandoutreachactivitiesto
thosemostinneed,toimprovetheirserviceutilizationandhealthstatus
and to achieve greater equity. Strategies targeting the poor are also
knownaspropoor.
Effectivetargetingforequityrequirespoliciesthat:
Focusonreachingandservingexcludedorunderservedsegments
ofthepopulation
Takeintoaccountbothpovertyandothersocialfactorsassociated
withpoverty,suchasplaceofresidence,ethnicity,gender,etc.
Mobilize additional resources for excluded and underserved

groupseitherby
o
redistributingexistingpublicresourcesfromthosewhoare
betteroffand/or
adding new resources to specifically reach the excluded

andunderserved.
IdeasinAction
Dependingonthe
countrysituation,target
groupsmayinclude
urbanpoor,ruralpoor,
theentirerural
population,indigenous
populationsand
refugees,aswellasother
disadvantagedor
excludedgroups.
Resource mobilization adding new resources for health is a major

component of effective targeting. It can take many forms, including
generaltaxrevenues,selectivelychargingfeesforservices,publicprivate
partnerships, etc. Each of these strategies faces challenges, which are
discussedinmoredetailinthesessionTargetingforEquity.
Once a program has identified inequities in health and designed and

implemented strategic interventions to address them, it will want to
monitorprogressandevaluateresults.Monitoringandevaluationanswer
twodistinctbutrelatedquestions:
Y: IMPLEMENT
YARDSTICKS TO
MEASURE PROGRESS
(1)Areourinterventionsreachingtherightpeople(monitoring)?
20
Regardless of the specific targeting strategy, the basic objective of

targetingforequityistoincreaseserviceuptakebypreviouslyexcluded
groups.Thiscanbeestimatedbymeasuringwhatproportionofprogram
clientsbelongtothetargetgroup.Whilethisdoesnottranslatedirectly
intoprogramcoverage(i.e.,theproportionofthetargetpopulationthat
uses services), increasing the numbers of people served is a necessary
firststepinreducingoverallinequity.
(2)Havetheybeensufficienttomakeadifference(evaluation)?
Highlights
Tolearnmoreabout
PerformanceMonitoring
andEvaluation,including
selectingperformance
indicators,collectingdata
andinterpretingfindings,
seethesession
ImplementingYardsticks
toMeasurePerformance.
Soonerorlater,policymakersandprogrammanagerswillwanttoknow
iftheirinterventionsmadeadifferenceinimprovingthehealthstatusof
the targeted group. This will require populationlevel data similar to
thoseusedtoquantifytheinequalitiesearlier.
21
KNOWLEDGE RECAP
1. TheEQUITYapproachrestsonwhichofthefollowingprinciples:
[a]Buildingcorecompetenciesofaprofessionalcadreofanalysts
[b]Emphasisonnationallyrepresentativesurveystoquantifyinequalities
[c]Feedbackthroughoutthecyclefromanalysistoadvocacyanddialoguetoaction
[d]Alloftheabove
[e]Noneoftheabove
2. Empoweringtraditionallyexcludedgroupsmeansthatpolicymakersandotherauthorities
listentowhattheexcludedgroupssayandbecomemoreaccountableforachievingresults
thatbenefitequity.
[a]True
[b]False
3. Islackofconsumerknowledgeabouttheimportanceofchildhoodvaccinationusuallyan
issueofsupplyorofdemand?
[a]Supply
[b]Demand
[c]Bothsupplyanddemand
[d]Neithersupplynordemand
4. Tofurtherprogresstowardshealthequity,nationalhealthpoliciesandstrategicplans
shouldinclude
[a]Targetsforpoorandexcludedgroups
[b]Equitybasedmonitoringindicators
[c]Outreachtoensureexcludedgroupsknowtheirhealthrights
[d]AandB
[d]Alloftheabove
5. Singlingoutsociallyexcludedgroupsforspecialattention
[a]Perpetuatesdiscriminationagainstthosegroups
[b]Tailorsnewand/oradditionalresourcestotheneediestareas
[c]Isabasicprincipleofuniversalhealthcoverage
[d]BandC
[d]Alloftheabove
22
[c] Feedbackthroughoutthecyclefromanalysistoadvocacyanddialoguetoaction
2. Empoweringtraditionallyexcludedgroupsmeansthatpolicymakersandotherauthorities
listentowhattheexcludedgroupssayandbecomemoreaccountableforachievingresults
thatbenefitequity.
[a] True
3. Islackofconsumerknowledgeabouttheimportanceofchildhoodvaccinationusuallyan
issueofsupplyorofdemand?
[b] Demand
4. Tofurtherprogresstowardshealthequity,nationalhealthpoliciesandstrategicplans
shouldinclude
[d] Alloftheabove
5. Singlingoutsociallyexcludedgroupsforspecialattention
[b] Tailorsnewand/oradditionalresourcestotheneediestareas
23
TheBasis:EngagingandEmpoweringthe
Excluded
Povertyisakeyfactorcontributingtosocialexclusion.
POVERTY, SOCIAL
EXCLUSION, AND
Depending on the country context, other factors may include rural

residence, gender (women and girls), ethnic group or caste, sexual
IdeasinAction
LACK
OF VOICE
identityandothercharacteristicsoutsidethemainstream.
Whenexcludedgroups
definetheirown
Socialexclusionisaviciouscyclewherebymembersofexcludedgroups
priorities,identify
arepreventedfromparticipatinginthesocialandpoliticaldecisionsthat
barrierstoaccessing
healthservices,andhelp
affect their lives, leading to low educational achievement, poor health,
designsolutions,theycan
lack of employment, and continuing poverty, and that perpetuate
becometruepartnersin
exclusioninthenextgeneration.
theresultingprograms.
Theprogramswillalsobe
Tocombattheseeffects,thefirstcomponentoftheEQUITYFrameworkis
moresustainableand
toengageandempowertheexcluded.
bettertailoredtomeet
theirneeds.
Engaging and empowering groups which have been traditionally
excluded both improves the quality and effectiveness of strategies to
address poverty and other inequities in health, and builds social
capacityandleadershipinthosecommunities.
WHERE TO FIND THE

EXCLUDED
People tend to selfidentify and associate with others on the basis of

religion,ethnicity,occupation,and/orsharedconcerns.
Thepoorarenotusuallyaffiliatedwithorganizationsledbynationaland
regionalpolicymakingelites.However,theymaybefoundincivilsociety
organizationsandassociationsoutsidetheformalsector.
Urban workers in the informal sector often organize in associations of
market vendors, hawkers, peddlers, and other trades. For example, in
Ghana, market porters known as kayeye are organized by tribal
membership, pay monthly dues, and receive assistance in housing and
transport back to their villages. Rural subsistence farmers may belong to
cooperatives, community selfhelp organizations or insurance pools.
Ideas in Action The

Nyanza and Coast
provinces of Kenya have
the highest rates of
poverty and poor landless
farmers. Female-headed
households are especially
likely to be poor. Civil
society organizations that
represent landless
farmers and femaleheaded households may
provide effective entry
points to engaging the
excluded.
24
Churchgroupsandtraditionalstructuressuchascouncilsofvillageelders
ortriballeadersmayalsorepresenttheinterestsofthepoorandother
excludedgroups.However,theseorganizationsoftendonotspeakforall
ofthedisenfranchised,especiallywomen.
Most excluded groups lack the technical, interpersonal, and

organizationalskillsneededtoadvocateeffectivelyontheirownbehalf.
Longtermtraining,mentoring,andothertypesofassistanceareneeded
tobringthemtogetherandimparttheknowledgeandspeakingskillsto
participateeffectivelyinthepolicyarena.
For example, the USAIDfunded Health Policy and Education Project in
Guatemala has provided technical assistance to build capacity of
indigenouswomentoorganizenetworks,strengthenknowledgeofsexual
andreproductivehealthissues,andanalyzehealthinequities.Asaresult,
indigenous women at the national and local levels have engaged in
dialogueandadvocacytotransformpolicies,increasefinancialresources
for FP/RH programs, and encourage culturally appropriate services for
indigenouswomen.
Women have come together to form the National Alliance of
Organizations for Reproductive Health of Indigenous Women of
Guatemala,ALIANMISAR, and departmental (provincial) networks in the
predominantlyMayanhighlands,includingAltaVerapaz,Chimaltenango,
Quetzaltenango, Quich, San Marcos, and Solol. The national alliance
now consists of more than 90 organizations and actively participates in
citizen monitoring, advocacy, and policy dialogue to promote better,
more culturallyappropriate health services that are accessible to the
indigenous populations, especially those living in rural areas and in
poverty.
EMPOWERING THE
EXCLUDED
IdeasinAction
Empoweringthe
excludedgoesbeyond
healthservices.In
Nigeria,theWomens
RightsAdvancement
ProtectionAlternative
(WRAPA)advocatesand
mobilizescommunitiesto
promotewomens
humanrights,eliminate
discriminatorypractices
andviolenceagainst
women,andenhance
womensliving
standards.
25
ENGAGING THE
EXCLUDED IS A
CONTINUING
PROCESS
It is important to engage and empower the excluded in every stage of

policyformulation,implementation,andevaluation.
Thisframeworkdisplaysthestepsofdevelopingandimplementing
strategiestoaddressinequitiesinhealthandshowshowpoorand
excludedgroupscanparticipateineachstep.
26
PROBLEM
IDENTIFICATION
Whiledatafromsurveys,expenditurestudies,etc.canquantifytypesand
levelsofinequalities,understandingbarrierstoequitableaccessanduse
ofservicesrequiresqualitativeinformation.
This qualitative information must come directly from those who are
affected bysocial exclusion. They alone can give insights into their day
today worries, factors that affect their ability to access services, and
culturalnormsthatconstrainthem.
InSierraLeone,theHealthPolicyInitiativeexploredoperationalbarriers
tofamilyplanninguseamongpeopleaffectedbyconflict(Sonneveldtet
al.2008).
Interviews and focus group discussions with refugees and internally
displaced persons revealed both demand and supplyside factors.
Interest in family planning varied at different phases of the conflict,
depending on whether people were preoccupied with basic survival,
fleeing from danger, displaced from their home, settled in refugee
camps,ortraumatizedandfeelinginsecure.
Highlights
Thepoorcanprovide
uniqueinsightsto
understandthedynamics
behindpovertyratesand
trends,socialand
economiccharacteristics
ofunderservedgroups,
inequalitiesinservice
access,andotherfactors
thatcontributeto
inequitablehealth
outcomes.
Didyouknow?
Formoreinformation
aboutquantifyingthe
levelofinequalitiesand
understandingbarriersto
access,seethenext
session.
Womenstatedthattheywereunabletousefamilyplanningduetotheir
inability to locate services, lack of funds to pay for services, provider
biases regarding specific contraceptive methods, disruption of health
services,andfrequentcommoditystockouts.
The insights provided by potential users themselves are essential to
provideFP/RHservicestopeopleaffectedbyconflict.
27
POLICY FORMATION
Highlights
Tolearnmoreabout
policyimplementation,
seetheIntegratingEquity
Goalssession.
Intendedbeneficiariescanadviseontheappropriatenessandfeasibility
of various policy options and advocate for adoption of needed policy
changesandallocationofthenecessaryresources.
Theycanalsobeengagedinthedesignofpoliciesandactionplansfor
example, by participating in public policy dialogue, providing
testimoniestopolicydraftingcommittees,andreviewingdraftpolicies
andlegislation.
The Health Policy Initiative project assisted national stakeholders to
engage the poor in the formulation of Kenyas new National
Reproductive Health Strategy. The project conducted focus group
discussions with poor women and men in Nyanza Province to assess
barrierstoFP/RHserviceuse.
Findings were disseminated through provincial and communitylevel
meetingswithlocalhealthauthorities,programimplementers,service
providers,andcommunitymembersthemselves.
These sessions provided a forum for the poor to engage service
providers and decisionmakers directly to discuss the challenges they
faceinaccessingFP/RHservicesandtoproposepotentialsolutions.The
government then convened a national policy dialogue session, which
28
brought feedback from community and provincial deliberations to

nationaldecisionmakers.
Informed by this feedback and additional analyses, the National
Reproductive Health Strategy includes clear, timebound equity
indicatorsandspecificstrategiestotargetresourcesandeffortstothe
poor.
POLICY FORMATION
Highlights
Tolearnmoreaboutthe
processofpolicy
implementation,seethe
TargetResourcesand
ImplementYardsticks
session.
Service beneficiaries can be actively engaged in implementation as

experts on operational barriers and community educators and
organizers.Theycanencouragecommunityparticipationandserveas
trustedsourcesofinformationandsupplies.
For example, the HIV epidemic in Vietnam is concentrated among
alreadymarginalized key populations at higher risk of HIV people
who inject drugs, men who have sex with men and female sex
workers. Stigma and discrimination keep those most in need from
accessing prevention services, care, treatment and support (UNAIDS
2012).
29
USAIDsupportedprojects,includingthePOLICYProjectandtheHealth
Policy Initiative, engaged people living with HIV (PLHIV) and Mostat
RiskPopulations(MARPs)toreformVietnamsHIVpolicyenvironment
toadoptinternationalstandardsandbestpracticesandhumanrights
approaches.
To ensure that PLHIV and MARPs are aware of their rights and have
the means to redress grievances, the Health Policy Initiative and in
country partners launched five HIV legal clinics and a national HIV
hotline.
PLHIVserveontheclinicsadvisoryboardsandaspeercounselorsin
the clinics and hotline. They provide counseling and legal
representation to people who visit the clinics and assist in legal
outreach and community awarenessraising through PLHIV support
groups.
Formoreinformation,see:
http://www.globalhealthlearning.org/sites/default/files/page
files/802_1_Vietnam_Making_Policies_Work_for_People_FINAL_acc.pdf
POLICY
MONITORING
30
Users must know their rights and have appropriate channels to

communicatewithauthoritiestofullyexercisethoserights.
Traditionally excluded groups can provide important feedback on policy
initiatives.Theycanbeengagedthroughcitizensmonitoring,civilsociety
watchdog and local health oversight committees, collect information
throughclientinterviews,andcompilecommunityscorecards.
Involving traditionally excluded groups is essential for providing first
hand accounts of implementation issues on the ground. For example in
Peru, the USAIDfunded POLICY Project provided technical and financial
assistance to establish five Centers for the Resolution of Conflicts in
Health. The centers are managed by local NGOs and employ
multidisciplinary teams. To foster widespread community support, the
BoardsofDirectorsincludeleadersfromvarioussectors.
In three years, the five centers took up some 750 cases dealing with
mistreatment, lack of information, difficulties using the social insurance
system, lack of informed consent, and violations of privacy. In addition,
bycompilingandanalyzinginformationfromindividualcases,thecenters
successfully promoted policy decisions to improve local public health
systemsandservices.
Formoreonusingalternativedisputeresolution(ADR)mechanismsto
increaseaccesstohealthcare,particularlyforpoorandvulnerable
populations,goto:
http://www.globalhealthlearning.org/sites/default/files/page
files/296_1_Guidelines_CEPRECS_Final.pdf.
31
KNOWLEDGE RECAP
1. Intendedbeneficiariesshouldnotbeengagedinmonitoringandevaluationbecausethey
lacktechnicalexpertiseandincludingtheminevaluationcreatesconflictofinterest.
[a]True
[b]False
2. Thepoorareoftennotaffiliatedwithnationalorregionalcivilsocietyorganizations.
[a]True
[b]False
3. Mostexcludedgroupslackthetechnical,interpersonalandorganizationalskillstoadvocate
effectivelyontheirownbehalf.
[a]True
[b]False
4. Themostusefulinformationonbarriersthatlimitaccesstoanduseofhealthservices
comesfromthosewhoaredirectlyaffectedbysocialexclusion.
[a]True
[b]False
5. TheEQUITYapproachencouragesengagingtraditionallyexcludedgroupsin
[a]Identificationofproblemsinaccesstoanduseofhealthservices
[b]Formulationofpolicyreform
[c]Resourceallocation
[d]Programimplementationandmonitoring
[e]Alloftheabove
32
KNOWLEDGE RECAP:
ANSWERS
[b]False
2. Thepoorareoftennotaffiliatedwithnationalorregionalcivilsocietyorganizations.
[a]True
3. Mostexcludedgroupslackthetechnical,interpersonalandorganizationalskillstoadvocate
effectivelyontheirownbehalf.
[a]True
4. Themostusefulinformationonbarriersthatlimitaccesstoanduseofhealthservices
comesfromthosewhoaredirectlyaffectedbysocialexclusion.
[a]True
5. TheEQUITYapproachencouragesengagingtraditionallyexcludedgroupsin
[e]Alloftheabove
33
Analysis:QuantifyingandUnderstanding
Barriers
IDENTIFICATION
AND ANALYSIS OF
EXISTING
INEQUALITIES
ThesecondphaseoftheEQUITYFrameworkdealswiththeidentification
and analysis of inequalities inherent in existing strategies. This session
will cover analysis of existing data as well as collection and analysis of
newdatatobetterpinpointproblemareasandidentifybarriersthatmay
hindertheachievementofmoreequitablehealthoutcomes.
Therearemanydimensionstoinequalitiesinhealth:
Whoisdisadvantaged?
Howmanyareaffected?
Wherearetheylocated?
Whichhealthindicatorsshowinequalities?
Howmuchisthedisparity?
34
Letsstartwithpoverty:whoispoor?Weoftenseetwobasicdefinitions
ofpoverty:
Absolute poverty: A person is considered to be poor if his/her income
and/orexpendituresarebelowanestablishedpovertyline.TheWorld
Bank considers the international poverty line to be $1.25/day. Most
countriesdefinetheirownpovertylinesusinglocalcurrencies,andsome
governments establish different poverty lines for different parts of the
countrybasedoncostofliving.
Relativepoverty:Insteadofconsideringasinglepovertyline,itispossible
torankpeoplefromthepooresttothewealthiest(orleastpoor)and
divide them into categories. For example, the Demographic and Health
Surveys(DHS)includeequalsizedwealthquintiles:Quintile1consistsof
the poorest 20% of the population, Quintile 2consists of the next 20%,
on up to Quintile 5, which consists of the wealthiest 20% of the
population.
QUANTIFYING
INEQUALITIES
IdeasinAction
Quantifyinginequalities
willhelpdecidewhomto
engageandwhatto
discuss.Similarly,
discussionswithexcluded
groupswillsuggestissues
thatneedfurther
quantitativeanalysis.
Didyouknow?
Howmanypeopleare
consideredtobepoor
dependsonthe
definitionofpoverty
used.
Howdowemeasurepovertywhatdatacanweuse?
There is no one best way to measure poverty. Many economists,
including the World Bank and national statistical institutes, measure
poverty directly through expenditures surveys that ask households how
muchtheyspendondifferentthingsand/orhowmuchmoneyhousehold
membersearn.
However, national expenditures surveys rely on lengthy questionnaires
and do not leave time to ask detailed questions about health. Health
surveys, such as the DHS, often rely on indirect measures of poverty,
using durable assets (such as household appliances) and housing
characteristics (such as electricity, composition of the roof and floor,
etc.).
MEASURING
POVERTY
Highlights
TheWorldBankLiving
StandardsMeasurement
Studyhasprovided
nationalexpenditures
datasince1980.
Forthelast10years,the
DemographicandHealth
Surveyshaveincluded
relativemeasuresof
householdwealthbased
onassets data.
Assetscanbeusedasaproxyforexpendituresiftheyareincludedinor
can be linked to an expenditures survey (absolute poverty). If
expendituresdataarenotavailable,assetsdatacanbeusedtoestimate
relativepoverty.
35
While expendituresbased and assetsbased measures of poverty

generally show the same trends, they do not always identify the same
individualsasbeingextremelypoor.
FACTORS TO
CONSIDER
Inapreviousmodule,wesawthatpovertyisonlyonefactorcontributing
to social exclusion. Quantifying inequalities should also consider other
factorsassociatedwithhealthinequalitiesandthedegreetowhichthey
gotogether.
Weshouldaskbroadly,Whoislikelytoshowlowerhealthstatus?
Povertyisoftenassociatedwithotherfactorsthatcontributetoinequity
inhealth.Separatewealthquintilesshouldbeconstructedforurbanand
ruralpopulationstobetterunderstandthecontributionsofpovertyand
placeofresidence.
Formoreinformation,seeAddressingPoverty:aguideforconsidering
povertyrelatedandotherinequitiesinhealth
(http://www.globalhealthlearning.org/sites/default/files/pagefiles/ms
0827.pdf).
36
FACTORS TO
CONSIDER: PLACE
OF RESIDENCE
Placeofresidenceishighlycorrelatedwithpoverty:insubSaharanAfrica,
thewealthiestquintileisoftenalmostexclusivelyurbanwhilethelowest
quintilesarealmostexclusivelyruralpopulationisdistributedamongthe
lower quintiles. Therefore, any comparison of the poorest quintile with
theleastpoorquintileisalsocomparingthepoorestoftheruralpoorwith
theurbanpopulation.
Toillustratetheproblem,letuslookatthe2008KenyaDHS.Thatsurvey
foundmuchloweruseofmodernfamilyplanningmethodsinthepoorest
quintilethanintheleastpoorquintiles,4and5.
What was responsible? Poverty? Place of residence? Both?
37
FACTORS TO
CONSIDER: URBAN
VS. RURAL
Agoodwaytovisualizetheseparatecontributionsofplaceofresidence
and poverty is first to divide the population into urban and rural
residents.
Then, divide each residence group into its own wealth quintiles. This
allowsustocomparethepoorestruralresidentswiththeleastpoorrural
residents, and the poorest urban residents with the least poor urban
residents.
In the figure on this page, we construct separate wealth quintiles for
urban and rural women in Kenya and compare them with the national
trend.
Doesourunderstandingoftherelationshipbetweenwealthanduseof
familyplanningchange?
Noticethattheuseofmodernfamilyplanningbyurbanwomen,shown
intheblueline,isessentiallythesameacrossallwealthquintiles,while
modern method use among rural women increases steadily with
increasingwealth.
This suggests that the difference between the lowest and the highest
national quintiles is due almost entirely to the very low rates of use
amongthepoorestruralwomenandthatpovertyplaysalmostnorolein
familyplanninguseinurbanareas.
38
Insomecountries,ethnicityplaysanimportantroleinsocialexclusion.In
Guatemala,theMayanpopulation,whichisconcentratedinthecountrys
highlands,isespeciallydisadvantaged.
FACTORS TO
CONSIDER:
ETHNICITY
The figure on this page presents modern family use in Huehuetenango

Departmentin2008,brokendownbyplaceofresidenceandethnicity.
Whatdothesedatatellus?
The textured blue bars in the middle of the graph represent all urban
women(ontheleft)andallruralwomen(ontheright).
Noticethattheurbanbarishigherthantheruralbar.Thisshowsaclear
urbanadvantage,similartowhatwewouldseeinAfrica.
Wealsoseepronouncedethnicdifferencesinbothurbanandruralareas.
Note that the urban advantage almost disappears for Mayan women,
suggesting that they face similar barriers to family planning use in both
urbanandruralareas.
39
FACTORS TO
CONSIDER:
DIFFERENT HEALTH
INDICATORS
Afinalconsiderationisthatdifferenthealthindicatorsmayshowdifferent
patternsofinequality.
The figure on this page presents results from the 2011 Uganda DHS for
threecriticalchildsurvivalindicators:antenatalcarebyaskilledprovider,
delivery in a health facility and timely completion of childhood
vaccinations.
Levels of skilled antenatal care are high and uniform across wealth
quintiles, indicating no inequities; in contrast, women in the top wealth
quintile are more than twice as likely to deliver in a health facility than
womeninthepoorestquintile.Doesthissuggestinequity?
Theinternationalcommunityrecommendsthatatleast80%ofchildrenbe
vaccinatedagainstchildhooddiseases.
PracticeQuestion
HasUgandareachedthattarget?Arethereinequitiesinthelevelsof
childhoodvaccination?
40
Answer
Vaccinationlevelsdonotvaryappreciablyacrossincomegroups.
Therefore,therearenoinequitiesinthisindicatoreventhoughnational
coveragefallsshortofthe80%target.
Whatisaccesstohealthcare?
Analysts have identified the following five critical dimensions to access
(Pechansky&Thomas1981):
Availability. Do providers have trained staff, equipment and

suppliestomeetclientsneeds?
Accessibility.Howeasilycanclientsphysicallyreachtheproviders
location?
Accommodation. Is the service organized to meet clients

preferencesforexample,hoursofoperation?
Affordability. Are clients able and willing to pay the providers

charges?
Acceptability. Are clients and providers comfortable with one

anotherforexample,intermsofethnicity,gender,socialclass,
etc.?
UNDERSTANDING
BARRIERS
Highlights
Financialconcernsmay
notbethegreatest
barrierstoaccessto
healthcarefacedbythe
poor.
Supplysidebarriers
Inability to pay providers prices is not always the greatest barrier to
service use by the poor and other excluded groups. Remote rural areas
often lack appropriate facilities, making it necessary for residents to
travel to other locations to obtain services. Operating hours may not
match clients schedules; health providers may be unresponsive to or
discriminate against women and/or certain ethnic groups. Even when
services are supposed to be provided free of charge, under the table
feesandothercostssuchassuppliesandmedicinesnotprovidedbythe
facility,maypreventpoorfamiliesfromobtainingthehealthservicesand
goodstheyneed.
41
Demandsidebarriers
Members of socially excluded groups may not be aware of service
locationsorfacesocial,culturaland/orfamilyoppositiontousingservices
andgoodsthatwouldbenefittheirhealth.Forexample,in2003,political
andreligiousleadersinnorthernNigeriaurgedparentsnottovaccinate
their children against polio, charging that the vaccine might contain
contraceptives,HIV,andcanceroussubstances.
WhilenationalsurveyssuchastheDHSareusuallyexcellentdatasources
to quantify inequalities in use of health services and health outcomes,
theyseldomaresufficienttoidentifybarrierstouse.
IDENTIFYING
BARRIERS
Once the priority groups and health indicators have been quantified,
groupmembersshouldbeengagedindialogueandqualitativeresearch.
Qualitativeresearchmethods,suchfocusgroupdiscussionsandindepth
interviews, are excellent ways to identify the problems that prevent
excludedgroupsfromobtainingservices.
Didyouknow?
InKenya,theHealth
PolicyInitiativeheld
focusgroupswithpoor
urbanandruralresidents
toidentifybarriersto
accessingandusing
familyplanning.
Manywomenfeared
pain,infertility,orbirth
defects.
Otherbarriersincluded
costs,familyopposition,
preferenceforlarge
families,andlimitations
ofhealthproviders.
Thisqualitative
informationhelpedthe
governmentdevise
solutionstoimprove
equitableaccessandFP
use.
To obtain the most useful information and to ensure that appropriate

ethics procedures are in place to protect participants privacy and
confidentiality, we recommend that programs work closely with
professionalresearchers.Anumberoftrainingcoursesinresearchethics
online; for example, the free CITI Program for researchers involved in
internationalresearch.
Geographicinformationsystems(GIS)areanothersourceofinformation
on physical access. Many countries have computerized files of the
locations of health facilities, which can be combined with maps of
transportation corridors and physical obstacles, such as rivers and
mountainranges,todeterminewhetherserviceavailabilityisasignificant
barriertouse.
This information can form the basis of discussion and subsequent
identification of strategies to eliminate or reduce barriers. Suggestions
forpossiblestrategiesmayemergefromopendiscussionoftheanalysis
findingswithcommunities,policymakers,andotherstakeholders.
42
In each scenario, can you identify whether the apparent barriers to

equityarerelatedtoissueswithsupplyordemand?
EXAMPLES OF
SUPPLY- AND
DEMAND-SIDE
BARRIERS
A health clinic serves over 15,000 people in a rural district. The clinic is
locatedinasecludedareathatisahalfday'swalkforthemajorityofthe
district's population. It receives regular deliveries from the central
hospital, but does not have adequate staff to maintain normal hours.
Most days, the clinic is only open for 34 hours in the morning, which
usuallycoincideswithschooldaysandmorningfarmschedules.
PracticeQuestion
Whatistheprimarybarrierpreventingaccesstohealthservicesandis
itrelatedtosupplyordemand?
Answer
The primary barrier to access is related to the supply of manhours (in
thiscase,qualifiedstaff)thatareneededtokeepthehealthpostopenso
thatcustomersareabletoreceiveservices.Asecondarybarriertoaccess
couldbethelimitednumberofhealthfacilitiesintheregion,creatinga
demandforservicesthatistoogreatforthehealthproviderstosatisfy.
Aschoolhasanunofficialpolicyofnotallowingpregnantstudentstobe
enrolled in class. This rule is enforced by the director and despite
complaints to the district education office, no alternative arrangements
aremadetoeducatepregnantstudents.
PracticeQuestion
Whatistheprimarybarrierpreventingaccesstoeducationalservices
andisitrelatedtosupplyordemand?
Answer
Theprimarybarriertoaccessofeducationalservicesforpregnant
womenisthesocioculturalviewsofpregnantwomen.
43
KNOWLEDGE RECAP
1. Placeofresidenceishighlycorrelatedwithpoverty
[a]True
[b]False
2. Measuresofwealthbasedonpossessionofdurableassetsandhousingcharacteristicsare
sufficienttoidentifywhichindividualsandhouseholdslivebelowthenationalpovertyline
[a]True
[b]False
3. Theimpactofpovertyonuseofhealthservicesoftendifferssubstantiallybetweenurban
andruralareas.
[a]True
[b]False
4. Ifacountryshowsuniformlyhighperformanceononekeyindicatorforchildsurvival,other
childsurvivalindicatorsusuallyalsoshowuniformlyhighresults.
[a]True
[b]False
5. Allofthefollowingaregoodpotentialsourcesofdatatounderstandbarrierstohealth
serviceuseexcept:
[a]Geographicinformationsystems(GIS)
[b]Focusgroupdiscussions
[c]Nationallyrepresentativehealthsurveys
[d]Indepthinterviews
[e]Alloftheabovearegooddatasourcestounderstandbarrierstouseofhealth
services
6. Whichofthefollowingmayposesubstantialbarrierstousinghealthgoodsandservices
[a]Operatinghoursofhealthfacilities
[b]Unofficialpracticesoflocalauthorities
[c]Transportationcorridors
[d]Language
[e]Alloftheabove
44
1. Placeofresidenceishighlycorrelatedwithpoverty
[a]True
2. Measuresofwealthbasedonpossessionofdurableassetsandhousingcharacteristicsare
sufficienttoidentifywhichindividualsandhouseholdslivebelowthenationalpovertyline
[b]False
3. Theimpactofpovertyonuseofhealthservicesoftendifferssubstantiallybetweenurban
andruralareas.
[a]True
4. Ifacountryshowsuniformlyhighperformanceononekeyindicatorforchildsurvival,other
childsurvivalindicatorsusuallyalsoshowuniformlyhighresults.
[b]False
serviceuseexcept:
6. Whichofthefollowingmayposesubstantialbarrierstousinghealthgoodsandservices
[e]Alloftheabove
45
AdvocacyandDialogue:IntegratingEquityGoals
More than 40 years ago, policy planners coined the term wicked to
describe social problems such as inequity. By their nature, wicked
problemsmustbeconsideredintheircontext,havemultiplecausesand
mustbeaddressedbymultipleinterventions.
INTEGRATING
EQUITY GOALS AND
APPROACHES
Whatdoesthismeanforequityinhealth?Itmeansthatthehealthsector
alone is incapable of eliminating health inequities. In the words of the
1973 seminal paper, Every wicked problem can be considered to be a
symptomofanotherproblem"(RittelandWeber1973).
Thefailuretoachievetheloftygoalsofthe1970s,suchashealthforall
by the year 2000 of the 1978 Alma Ata Declaration, and the growing
focus on the social determinants of health has given rise to a new
approach,HealthinallPolicies(HiAP).ThecentraltenetofHiAPisthatall
sectorsmustshareinthegoalofimprovinghealth.
Integratingequitygoalsintohealthplanningandbeyondrequiresthatwe
recognize that different sectors and stakeholders are usually competing
forthesameandoftenlimitedresources.Whatisinitforthemfor
the nonhealth sector to advocate for more attention to health, or for
betteroff groups to advocate for increased resources for the poor and
sociallyexcluded?
There is ample evidence that better health contributes to economic
growth.Effortstointegratehealthequityintothenationalagendashould
look for opportunities to bring together groups that often have little
formalcontactwithoneanother:
Whole of government (e.g. health, finance, education, industry

andagriculture,etc.)
Privatesector,bothforprofitandnotforprofit
Civilsociety,especiallytraditionallyexcludedgroups
WHAT DOES
INTEGRATION
REQUIRE?
Didyouknow?
Thegreatestimpetusfor
integrationtodatehas
comefromregionswith
arguablythelowest
levelsofhealth
inequities,
suchasEuropeand
Australia.
46
While the greatest impetus to integrating health and health equity has
come from the industrialized world, the importance of the work
supersedesnationalboundaries.InthewordsoftheAdelaideStatement
of2010:
we are clearly reaching an untenable, unsustainable situation within
health systems worldwide. The problems facing health are wicked.
Solutions must be innovative and revolutionary. That is Health in All
Policies.
Equityinhealthcannotbeachievedwithoutfinancialresources(seenext
module on Targeting). Therefore, some of the best opportunities for
integration may lie in policies and planning being led by the finance
sector,especiallyaroundpovertyreduction.Belowaretwoexamples.
WHERE ARE THE

OPPORTUNITIES FOR
INTEGRATION?
PovertyReductionStrategyPaper
In1999,theInternationalMonetaryFund(IMF)andWorldBankinitiated
the Poverty Reduction Strategy Paper (PRSP) process to focus greater
attention on poverty reduction and to explicitly link loans and debt
forgivenesstoachievingtheUNMillenniumGoals(MDGs).
IncorporatingequityintoPRSPsdoesfacechallenges.
Most developing countries already have or have submitted final

plansforapproval.Onceapproved,thePRSPisgoodfor3years.
ChangescanbemadeonthebasisofanAnnualProgressreport.
While health figures prominently in all PRSPs, health equity is

seldommentioned.Forexample,theBurundiPRSPfor20122015
mentions equity in health once in passing, and none of the
healthindicatorsincludeinequalities.
Highlights
Countriesprepare
PovertyReduction
Strategiestoqualifyfor
multilateralloansand
debtrelief.Theymust
describethe
policiestheywill
strengthenand/oradopt
toalleviatepovertyand
meettheMillennium
DevelopmentGoals.
TheHPIguide,Making
FamilyPlanningPartof
thePRSPProcess,canbe
adaptedtopromote
healthequity.
Cashtransferprograms
They have been gaining in popularity, first in Latin America and more
recently in Asia. In many programs, recipients must meet certain
conditions to continue receiving their grants, such as keeping their
47
childreninschoolandobtainingpreventivehealthcareforchildrenand
pregnantwomen.
For cash transfer programs to be successful in improving health equity,
neededservicesmustbeavailable.Thisisnotalwaysthecase,ascanbe
seeninthefollowingexamplefromPeru.
While modern contraception is widely used in Peru, use lags behind in

ruralareas,intheSierraregionhometolargenumbersofindigenous
womenandamongthepoorestquintile.
In2005,PerulaunchedtheJUNTOSprogram.Itprovidesamonthlycash
transferof100soles(US$31)topoorhouseholdswithpregnantwomen
and/orchildrenunderage14providedthatrecipientsmeetrequirements
suchasenrollingchildreninschoolandobtainingprenatalcare.
Participation in Family Planning (FP)/Reproductive Health (RH)
orientation at a health facility was included in the menu of program
conditions,butwasslowtobefullyimplemented.Discussionswithclients
and providers revealed a lack of culturally appropriate and adequate
FP/RH information for poor, indigenous women, and that providers
neededtraininginhighquality,culturallyappropriatecounseling.
Through policy dialogue and advocacy, Health Policy Initiative worked
with health authorities to integrate cultural beliefs of indigenous
populations into program FP/RH counseling guidelines and to design
guides for healthcare providers. The project trained 19 trainers who
trained physicians, nurses, midwives, and paramedical personnel in
culturally appropriate counseling, and made field visits to rural health
facilitiesforpracticalskillsdevelopment.Healthpersonnelalsoprepared
actionplansandmonitoringindicatorsfortheirfacilities.
EXAMPLE FROM THE

FIELD: PERU
Highlights
Achievingpolicychange
forequityrequiresdata
analysisandstakeholder
engagement.
Affectedgroupsarebest
abletospeaktothe
challengesandbarriers
theyfaceandsuggest
interventionsappropriate
fortheirneeds.Theycan
alsoassistwith
implementation,for
example,asoutreach
workersfortheirpeers.
Toreadmoreabout
healthpolicyreformin
Peru,clickhere.
In less than a year, the number of monthly FP/RH information sessions

tripledandattendancenearlydoubled.TheMOHallocatedfundsthrough
JUNTOSfornewinformationalmaterialsandapprovedtheguidelineson
culturallyappropriatecounselingforuseinhealthfacilitiesinareaswith
substantialindigenouspopulations.
48
KNOWLEDGE RECAP
1. Someofthegreatestopportunitiesforeliminatinghealthinequitiesmaylieoutsidethe
healthsector
[a]True
[b]False
2. Financialconcernsarealmostalwaysthegreatestbarrierfacedbythepoorinaccessing
andusinghealthgoodsandservices
[a]True
[b]False
3. Wickedsocialproblems
[a]Areevilinnature
[b]Usuallyarisefromothersocialproblems
[c]Requiremultipleinterventionstosolve
[d]BandC
[e]Alloftheabove
49
healthsector
[a]True
[b]False
3. Wickedsocialproblems
[d]BandC
50
Action:TargetResources&Implement
YardstickstoMeasureProgress
THE DEVELOPMENT
PARADOX
Didyouknow?
thereislittlereasonto
expectthatworkingto
reachuniversalcoverage
willleadto
improvementsinhealth
equity.Infact,thequest
foruniversalcoverage
couldhavetheopposite
effect
(Source:Gwatkin&Ergo
2011)
In2010,UNICEFreportedastartlingstatistic:twothirdsofthecountries
making progress in reducing child mortality showed increasing
inequalities. In other words, as national under5 mortality rates were
decreasing, the gap between the poorest and the best off groups was
growing. In this figure, each red dot is a country where inequities have
growndespiteprogresstowardsmeetingMDG4.
Thiswasnotthefirsttimesuchafindinghadbeenreported.Itwasfirst
described in 1955 by the economist, Simon Kuznets. Kuznets
hypothesized that inequality will first increase while a country is
undergoingdevelopmentandthenbegintodecrease.
51
RELATIONSHIP
BETWEEN
DEVELOPMENT
AND INEQUALITY
Therelationshipbetweendevelopment(onthexaxis)andinequality(on
theyaxis)followsaninvertedUshapedcurve.
Didyouknow?
For more details on the
Kuznets curve, click here.
Sinceitspublication,theKuznetscurvehasbeenfoundinawiderange
ofdisciplinesfromeconomicstohealthtoenvironmentalsciences.
TherearevaryinginterpretationsoftheKuznetscurveanddebateasto
whether or not all countries must undergo a period of high inequality
beforedifferencesbetweenwealthgroupsdecrease.
For example, diffusionofinnovation theory would suggest that the rise
and fall in inequality is inevitable, because the first individuals to adopt
aninnovationtendtobeofhighersocialclass,wealthier,andwithhigher
formaleducationthanthosewhoadoptlater.
Otherswouldarguethatinequalitiescouldbeeliminatedorreducedby
focusing efforts on the poor rather than by expecting general
developmenttotrickledown.Infact,experiencehasshownthathealth
interventions will not reach the neediest groups without appropriate
planning and oversight. In this module we discuss targeting, a
mechanism to direct resources to those most in need in a planned
mannertoachievegreaterequity.
52
WHAT IS
TARGETING?
Targeting means focusing efforts directly on the poor and/or other

excluded groups so that the benefits reach all the excluded groups and
onlythem.
Arguably, targeting should be considered only when health gaps have
opened up between the least and most welloff segments of the
population.
If everyone shows equally bad health indicators, a more universal
approachtoexpandinghealthcoveragemaybemoreappropriate.
Didyouknow?
Targetingisnotnew.
SouthKoreabegan
includingfamilyplanning
innationaldevelopment
plansin1962and
directed
governmentresourcesto
ruralandpoorurban
families.Duetothisearly
historycoupledwiththe
introductionofsocial
healthinsurancein1977,
Koreaconsistentlyshows
amongtheleasthealth
inequalitiesintheworld.
(Source:Yang1979)
Highlights
Withoutwellplanned
andeffectivetargeting
strategies,public
resourcesoftengoto
peoplewhoneedthem
least,whilethepoorest
donotbenefit.
53
WHAT DOES
TARGETING
REQUIRE?
Developing and implementing a targeting strategy is a major policy

undertaking.
Someimportantaspectstoconsiderinclude:
Political will. Policy dialogue and advocacy will be needed to convince
policymakers, program planners, and managers that targeting for the
poor and/or underserved is essential to meeting the countrys health
needs.Iftargetingisperceivedastakingservicesawayfromsomegroups,
it may generate political opposition. Wealthier and more politically
powerful groups may oppose any effort they see as reducing their
benefits.
Resources.Underservedgroupsareusuallymoreexpensivetoreachthan
the rest of the population. Extending services to reach the underserved
willrequirededicatedresources,eitherfromraisingnewfundingforthe
targetedeffortsand/orbyredirectingresourcesfrombetteroffareas.
Infrastructure.Oftentimespoorandotherexcludedgroupsliveinareas
thathaveneitherpublicnorprivatehealthcareproviders.Reachingthem
will require investments in building, equipping and staffing new health
facilities or establishing outreach channels such as mobile services. The
figureaboveillustratesthekindofplanningthatshouldbeconductedas
partofthetargetingprocess.
54
IDENTIFYING
INTENDED
BENEFICIARIES
The operational goal of targeting is to provide government benefits to

everyone who needs them while ensuring that benefits do not go to
thosewhodonotneedthem.
Thefirststepinanytargetingschemeistoidentifythepeoplewhowill
beeligibleforthetargetedservices.
Noidentificationsystemcanbe100%accurateindiscriminatingbetween
thosewhoneedtargetedassistanceandthosewhodonot.
The more difficult or onerous the system classifying individuals needing
assistance,thelesslikelyitistobeimplementedandthemorevulnerable
itistomisuseormanipulation.
Ascanbeseenintheflowchartonthispage,therearetwobasicoptions
toidentifytargetbeneficiaries:
geographictargeting(i.e.,everyoneresidentinareasclassifiedas
pooriseligiblefortargetedassistance)
individualized targeting through the application of specially

designed data collection and certification procedures or self
identification
IdeasinAction
TheexamplefromIndia,
onthefollowingpage,
illustratestargeting
approachestodistribute
voucherstoincrease
abilitytopayforprivate
providers.Twomethods
wereadoptedtoidentify
beneficiaries:
individualized
targetingforrural
households
participatingina
largergovernment
fundedpoverty
alleviationeffort
geographictargeting
forurbanslums
If there are geographic areas with high concentrations of poverty, the

entireareacanbetargetedandallresidentseligibleforassistance.
55
Ifthepoorarescattered,anindividualizedapproachmaybeappropriate.
Whatever approach is adopted should consider the costs of
administrationrelativetothecostsofthebenefitstobeconferred.
TheGovernmentofIndiaiscommittedtoreducingfertilityandinfantand
maternal mortality. Improving access to FP and RH is necessary to
achievethesegoals.Indiawillnotmeetitsgoalsunlessthehealthofthe
poorimproves.
India enjoys a vibrant private health sector that provides FP and RH
services to those who can afford to pay. Using public subsidies to help
poor clients use private facilities might be more a more costeffective
waytoincreaseFP/RHusebythepoorthaninvestinginexpandedpublic
services.
VOUCHERS FOR
REPRODUCTIVE
HEALTH SERVICES
IN INDIA
Therefore, USAID/India asked the Family Planning Services Technical

AssistanceProject(ITAP)tohelpplanandtestthefeasibilityofproviding
voucherstopoorfamiliestoenablethemtoreceiveFP/RHservicesfrom
privateproviders.
Theproject,Sambhav(itispossible),wasimplementedbetween2006
2012 in four districts in the northern states of Uttar Pradesh,
Uttarakhand,andJharkhand.
Toensurethattheprogramdesignwasappropriateforlocalconditions,
ITAP carried out baseline surveys and discussions to understand health
status,serviceuse,andbarrierstoseekingandreceivingcare.
They found higher fertility rates and maternal, neonatal, and child
mortality and morbidity among both the urban and rural poor due to
loweruseofmaternalhealthservicesandhigherunmetneedforFPthan
women from the higher income groups. Further, poor women incurred
substantial out ofpocket expenses for FP/RH services, including
medicinesandtransportation.
QUANTIFYING
INEQUALITIES AND
UNDERSTANDING
BARRIERS
56
Theprojectalsoidentifiedprivatenursinghomesandhospitalsthatwere
willing to offer services at reduced rates in return for increased client
volumes.
ITAP continued to actively consult with government, state health
societies,NGOs,communityleaders,andtheprivateproviderstodesign,
implement,andlatermonitorthevouchersystem.
Everyonehadconcerns:wouldgovernmentbureaucracydelaypayments
to private providers? Would private providers comply with government
standardsandguidelines?
ITAP helped to bridge the sectors and encourage participation in the
pilot.
TARGETING
STRATEGY AND
MEASURING
PROGRESS
Highlights
FormoreontheSambhav
experience,gohere:
Thevoucherschemestargetedthosemostinneed.
Differentproceduresweredesignedtoidentifybeneficiariesindifferent
areas.
http://www.globalhealthlea
rning.org/sites/default/files
/page
files/SAMBHAV%20report.p
df
In rural areas, households with Below Poverty Line (BPL) certificates

wereeligible.
57
KanpurCityadoptedgeographictargeting:allresidentsoftheselected
slumswereeligible,andindividualscouldusetheirrationcardsasproof
ofresidence.
Both of these strategies illustrate Integration with other programs: BPL
and food rations are Government of India programs designed to assist
poor families. Click here for a detailed figure as to how the system
worked.
Bythetimethepilotwascompleted,Sambhavcovered11ruralblocksin
threedistrictsand368urbanslumsinonecity,withimplementationtime
periodsrangingfromabout12years.
Results
Thevouchers:
Enablednearly12,500babiestobeborninprivatehealthfacilities
Supportedapproximately47,600antenataland10,300postnatal
visits
Providedtreatmentfor6,750RTIs/STIs
Paidfor2,000sterilizationsandmorethan1,700IUDsand3,000
injectables
In Hardiwar, the voucher program reversed the inequalities in
modern family planning use between BPL recipients and women
innonBPLhouseholds,ascanbeseenintheabovefigure.
Targetingmayrequiremajorchangesinthewayservicesaredeliveredin
boththeprivateandthepublicsectors.
Privatesector.Iftargetingisintendedtoshiftwealthierusersoutofthe
public sector and into the private sector, there must be private sector
capacity to absorb these new clients. Private providers may face policy
constraintsthatwillneedtobemodifiedforthesectortoexpand,such
as:
Import restrictions on commodities needed by the commercial

sector;
Pricecontrolsthatrestrictpricesprivateproviderscancharge;
CHALLENGES TO
THE HEALTH
SECTOR
Highlights
Communicationbetween
thepublicandprivate
sectorsisintegralto
overcomingthese
challenges.
58
Licensingrequirementsthatrestricttheservicesprivateproviders
canoffer;
Lackoftrainingopportunitiesforprivateproviders.
Public sector. Reaching remote rural areas and/or urban slums through
thepublicsectorbringsitsownchallenges:
Publicsectorstaffareusuallyprotectedbycivilserviceregulations
andmaybeunwillingtomovetoruralareasorworkindangerous
urbanslums
Recurrentcosts(logistics,supervision,etc.)tokeepruralfacilities
functioning may be higher than for comparable facilities located
inurbanareas.
Highlights
Generatingdemandfor
andeducatingthe
communityabout
availableresourcesisjust
asimportantasproviding
theresources
themselves.
Finally, where the poor face nonfinancial barriers to using services

(language,culture,etc.),effectivetargetingmayinvolvedevelopingnew
educationalmaterials,retrainingproviderstoaddressthespecificneeds
oftargetgroups,orevenhiringnewcadresofhealthworkers.
PERFORMANCE
MONITORING
Allequitybasedprogramssharetwointerrelatedgoals:
(1)toimprovethehealthstatusofpreviouslyexcludedgroups,andinso
doing,
59
(2) to reduce the inequalities between the worstoff and betteroff

segmentsofthepopulation.
Performanceyardsticksallowustoseehowclosetheprogramcomesto
reaching these goals and provide information needed for programmatic
decisionmaking.
Two cardinal principles should be kept in mind when designing and
implementingperformanceyardsticks:
1.Collectingdatausesprogramresources;and
2.Collectingdataforreportingthatarenotusedformanagementwastes
programresources.
Therearenohardandfastrulesfordesigningmonitoringandevaluation
(M&E) systems that would apply to all programs, or even to the same
programatallstagesofitslifespan.
Afewkeyquestionstoconsider:
Whatshortandmediumtermdecisionswillneedinformation?
What kind of evidence will policymakers, managers, and

communitymembersfindmostconvincing?
Whathumanandfinancialresourcescanbemobilizedtocarryout
monitoringandevaluation?
Can the program make use of data collected for other purposes
and/or by other organizations, for example population censuses,
nationallivingstandardssurveys,etc.?
Highlights
Thistabledescribesthe
stagesofprogram
development,thekinds
ofdecisionsthatare
involvedateachstage,
theinformationneeded
tomakethedecisions
andtheprimary
stakeholdersinvolved.
GoingbacktotheEQUITY
framework,wesee
Engagementofthe
excludedinevery
stakeholdergroup,
Quantificationof
inequalitiesand
Understandingbarriersin
thefirststage,and
IntegrationandTargeting
inthesecondstage.
Yardstickstomeasure
progresscometothe
forefrontinstages3and
4.
Ideally, four sets of indicator yardsticks would be selected, covering

programdesign,implementation,serviceuptake,andequityimpacts:
CHOOSING
INDICATORS
Design:Theseyardsticksareprincipallyqualitativeandcanbeanswered
yes/notothefollowingquestions:
60
Are equity goals explicitly stated in the policy and program

documents?
Are priority beneficiaries clearly designated and do they match
thegroupsidentifiedinstepQ?
Are desired health outcomes (e.g. maternity care, child
vaccinations, family planning, etc.) clearly specified and do they
match the outcomes showing the greatest inequalities identified
instepQ?
Do the program strategies (demand creation, supply
strengthening)matchthebarriersidentifiedinstepI?
Implementation: Have resources been spent on or directed to priority

areas/beneficiaries? Equitybased disaggregation can be introduced into
avarietyofmonitoringindicators,forexample:
Number of policies or guidelines that focus resources or other

attentiononpoorand/orotherunderservedareasorgroups
Increaseinresourcesallocatedtounderservedareas
Number of health facilities rehabilitated in designated priority

areas
Numberofpeopletrainedfrompriorityareasandwhoremainin
theirassignedareas
Highlights
Policiescandemonstrate
agovernmentspriorities
andcommitmentto
improvingthelivesofits
people.Whenhealth
inequalitiesare
recognizedasapriority
thatrequiresaction,
policiesandstrategies
shouldoutlineclear,
timebound
equitygoals.
Highlights
Formoredetailson
equityfocused
monitoring,clickhere.
Number of service delivery points in priority areas experiencing

stockoutsofessentialdrugsandsupplies
Service uptake: These indicators monitor client characteristics to assess
whether users belong to the intended target group. If geographic
targetingisused,servicestatisticscanbedisaggregatedgeographically:
Number of antenatal care (ANC) visits by skilled providers from
facilitiesinpriorityregions
Number of deliveries with a skilled birth attendant in priority
regions
Number of children reached by nutrition programs in priority
regions
Coupleyearsofprotection(CYP)inpriorityregions
61
If individualized targeting is used, routine service statistics may need to

beaugmentedwithperiodicclientinterviewstomeasurepovertystatus,
ethnicityorothercharacteristicsassociatedwithlowhealthstatus.
Number and percentage of vouchers redeemed by users under
thepovertyline
Impact: Populationlevel surveys are needed to measure impact
yardsticks. They should be assessed against baseline measures taken
duringtheQstage.
Changeinhealthoutcome(s)amongpreviouslyexcludedgroups.
Reduction in inequality/inequalities between worst and bestoff
segmentsofthepopulation.
Reduction and elimination of povertyrelated and other inequalities in

health is a longterm goal. In the short and mediumterm, programs
shouldfocusonimprovingthestatusoftheexcludedgroups.
MORE ON IMPACT
INDICATORS
For example, the 2011 Ethiopia DHS showed enormous povertyrelated

disparitiesinsafemotherhoodpractices,butonlyhalf(49%)ofthebirths
tothewealthiestwomentookplaceinahealthfacility.
Economic development may mask the equity impacts of targeted
interventions.Ifhealthoutcomesforthebestoffgroupsimprovedueto
general development, while the poor benefit from targeted
interventions,bothgroupsmayshowimprovementsovertimewhilethe
gapbetweenthemremainsconstant.Thegraphonthispageillustrates
thetwoinfluencesonstuntinginchildren.
62
KNOWLEDGE RECAP
Answerthefollowingquestionstoseehowmuchyouknowaboutthistopic.Gotopage65toseethe
correctanswers.
1. Byandlarge,thecountriesthathavemadethemostprogresstowardsreachingtheMillennium
DevelopmentGoalsforchildmortalityhavedonesobyreducingdisparitiesbetweenthepoorest
andbestoffsegmentsoftheirpopulation
[a]True
[b]False
2. Astheirhealthindicatorsimprove,mostcountrieswillgothroughaperiodofincreasinginequality
beforedifferencesbetweenwealthgroupsdisappear
[a]True
[b]False
3. Directingspecialeffortstowardsthepoorand/orotherexcludedgroups
[a]Isacoreelementofuniversalhealthcoverage
[b]Tendstoincreasestigmaanddiscriminationtowardsthetargetedgroups
[c]Isespeciallyimportantwherehealthstatusisuniformlylow
[d]aandc
[e]Noneoftheabove
4. Extendingcoveragetotraditionallyunderservedgroupswill
[a]Increasehealthsystemcosts
[b]Usuallyrequirededicatedresources
[c]Oftenbeopposedbypoliticallypowerfulgroups
[d]Alloftheabove
[e]Noneoftheabove
5. Meanstestingthatis,identifyingindividualswhocannotaffordtopayforhealthgoodsand
servicesisusuallythesimplestwaytoensurethatgovernmentbenefitsdonotgotothosewhodo
notneedthem.
[a]True
[b]False
6. Performancemonitoringbecomesapriorityactivityonlyafterprogramsareimplemented.
[a]True
[b]False
7. Failuretoreduceinequalitiesbetweentheworstoffandbestoffsegmentsofthepopulationmeans
thateffortstoimprovehealthequityhavehadlittleornoimpact.
[a]True
[b]False
63
1. Byandlarge,thecountriesthathavemadethemostprogresstowardsreachingtheMillennium
DevelopmentGoalsforchildmortalityhavedonesobyreducingdisparitiesbetweenthepoorest
andbestoffsegmentsoftheirpopulation
[b]False
2. Astheirhealthindicatorsimprove,mostcountrieswillgothroughaperiodofincreasing
inequalitybeforedifferencesbetweenwealthgroupsdisappear
[a]True
[e]Noneoftheabove
[d]Alloftheabove
5. Meanstestingthatis,identifyingindividualswhocannotaffordtopayforhealthgoodsand
servicesisusuallythesimplestwaytoensurethatgovernmentbenefitsdonotgotothosewho
donotneedthem.
[b]False
6. Performancemonitoringbecomesapriorityactivityonlyafterprogramsareimplemented.
[b]False
7. Failuretoreduceinequalitiesbetweentheworstoffandbestoffsegmentsofthepopulation
meansthateffortstoimprovehealthequityhavehadlittleornoimpact.
[b]False
64
Recap
By harnessing the arguments of human rights and justice, the equity
approach expands the case for public health beyond the traditional
healthsectorandbringsinnewadvocatesandchampionsforincreasing
resourcesforthepoorandotherexcludedgroups.
7
SUMMARY
Designing and implementing effective health solutions begins with the

active participation of those who have been excluded from the policy
debate and are most affected by deeprooted health disparities the
poor,isolatedruralpopulations,ethnicminorities,women,and/orother
disadvantagedgroups.
Healthinequalitiesandinequitiesarefluidandmayvarymarkedlyfrom
country to country, within countries and across health outcomes.
Solutionsmustrestonasolidfoundationofunderstandingthedepthand
breadthofexistinginequalitiesandthebarriersfacedbyexcludedgroups
toaccessanduseofhealthcare.
The health sector alone cannot achieve equity in health. Mobilizing
politicalwillandresourcestoreachthemostdisadvantagedwillrequire
newadvocatesandchampionsandintegrationwithlargerdevelopment
initiatives.
Continuous performance monitoring completes the equity approach,
ensuring transparency and accountability as well guiding changing
strategiesforchangingsituations.
New publications on equity in health appear daily and make any

bibliography instantly obsolete. The websites below add new resources
astheybecomeavailable.
WorldHealthOrganization,ActionontheSocialDeterminantsof
Health
WorldHealthOrganization,Gender,WomenandHealth
PanAmericanHealthOrganization
ADDITIONAL
RESOURCES
65
Unnatural Causes, sponsored by the National Association of

CountyandCityHealthOfficials(UnitedStates)
National Collaborating Centre for Determinants of Health

(Canada)
HealthEquityInitiative
Didyouknow?
Useyourfavorite
internetsearchengineto
findmorefreecourses.
Typeinhealthequity+
course+online.
Other free online training courses also proliferate. Two of the many
possibilitiesarelistedbelow.
Michigan Public Health Training Center, Measuring health

disparities(onlinecourse)
EmpireStatePublicHealthTrainingInstitute(NewYork)
66
FinalExam
Congratulationsyouhavenearlycompletedthiscourse!
The final exam will test your understanding of the material presented.
AnswerthefollowingquestionstoseehowmuchyouknowaboutM&E
fundamentals.Gotopage71toseetheanswers.
[a]Measurementofhealthdisparities
[c]Healthfinance
[d]bandc
[e]alloftheabove
[a]True
[b]False
ruralandpoorerhouseholdsusuallyhavemorechildrenthanwomeninurbanand
wealthierhouseholds.Thisevidenceissufficienttodemonstrateinequityinaccessto
familyplanning.
[a]True
[b]False
[a]Buildingcorecompetenciesofaprofessionalcadreofanalysts
[b]Emphasisonnationallyrepresentativesurveystoquantifyinequalities
[d]Alloftheabove
[e]Noneoftheabove
67
5. Empoweringtraditionallyexcludedgroupsmeansthatpolicymakersandother
authoritieslistentowhattheexcludedgroupssayandbecomemoreaccountablefor
achievingresultsthatbenefitequity.
[a]True
[b]False
6. Intendedbeneficiariesshouldnotbeengagedinmonitoringandevaluationbecause
theylacktechnicalexpertiseandincludingtheminevaluationcreatesconflictof
interest.
[a]True
[b]False
7. Ifacountryshowsuniformlyhighperformanceononekeyindicatorforchildsurvival,
otherchildsurvivalindicatorsusuallyalsoshowuniformlyhighresults.
[a]True
[b]False
serviceuseexcept:
[a]Geographicinformationsystems(GIS)
[b]Focusgroupdiscussions
[d]Indepthinterviews
[e]Alloftheabovearegooddatasourcestounderstandbarrierstouseofhealth
services
healthsector
[a]True
[b]False
[a]True
[b]False
68
[a]Isacoreelementofuniversalhealthcoverage
[b]Tendstoincreasestigmaanddiscriminationtowardsthetargetedgroups
[c]Isespeciallyimportantwherehealthstatusisuniformlylow
[d]aandc
[e]Noneoftheabove
[a]Increasehealthsystemcosts
[b]Usuallyrequirededicatedresources
[c]Oftenbeopposedbypoliticallypowerfulgroups
[d]Alloftheabove
[e]Noneoftheabove
13. Meanstestingthatis,identifyingindividualswhocannotaffordtopayforhealth
goodsandservicesisusuallythesimplestwaytoensurethatgovernmentbenefitsdo
notgotothosewhodonotneedthem.
[a]True
[b]False
14. Eveninthebestsituations,itisinevitablethatsomeindividualswillhavepoorerhealth
thanothers.
[a]True
[b]False
69
FinalExamAnswers
[b]False
ruralandpoorerhouseholdsusuallyhavemorechildrenthanwomeninurbanand
wealthierhouseholds.Thisevidenceissufficienttodemonstrateinequityinaccessto
familyplanning.
[b]False
5. Empoweringtraditionallyexcludedgroupsmeansthatpolicymakersandother
authoritieslistentowhattheexcludedgroupssayandbecomemoreaccountablefor
achievingresultsthatbenefitequity.
[a]True
[b]False
7. Ifacountryshowsuniformlyhighperformanceononekeyindicatorforchildsurvival,
otherchildsurvivalindicatorsusuallyalsoshowuniformlyhighresults.
[b]False
serviceuseexcept:
70
healthsector
[a]True

10. Financialconcernsarealmostalwaysthegreatestbarrierfacedbythepoorin
accessingandusinghealthgoodsandservices
[b]False
[e]Noneoftheabove
[d]Alloftheabove
13. Meanstestingthatis,identifyingindividualswhocannotaffordtopayforhealth
goodsandservicesisusuallythesimplestwaytoensurethatgovernmentbenefitsdo
notgotothosewhodonotneedthem.
[b]False
14. Eveninthebestsituations,itisinevitablethatsomeindividualswillhavepoorerhealth
thanothers.
[a]True
71
MEASUREEvaluation
CarolinaPopulationCenter
UniversityofNorthCarolinaatChapelHill
400MeadowmontCircle,3rdFloor
ChapelHillNC27517
Tel.:9194459350
www.measureevaluation.org
MEASURE Evaluation
University of North Carolina at Chapel Hill
400 Meadowmont Village Circle, 3rd Floor
Chapel Hill NC 27517 USA
P: +1 919-445-9350
F: +1 919-445-9353
E: measure@unc.edu
www.measureevaluation.org
eCourse available for download:
http://www.measureevaluation.org/resources/
publications/ms-15-105
MEASURE Evaluation is funded by the U.S. Agency for

International Development (USAID) through Cooperative Agreement
GHA-A-00-08-00003-00 and is implemented by the Carolina
Population Center at the University of North Carolina at Chapel Hill,
in partnership with ICF International, John Snow, Inc., Management
Sciences for Health, Palladium, and Tulane University. The views
expressed in this publication do not necessarily reflect the views of
USAID or the United States government. MS-15-105

Addressing Equity in Public Health

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Addressing Equity in Public Health

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2014

We can see from Whiteheads definition that all inequities in health

1. The inequality is between different population groups (e.g., poor vs.

Let us take a look at some common health problems in developing

contraception. But are these differences unfair and unjust? In other

THE POOR HAVE

KNOWLEDGE RECAP: ANSWERS

2. Synthesis of quantitative and qualitative information (to quantify

Integrate equity goals, approaches, and indicators into policies,

The guiding principle of the EQUITY Approach is that policy, program,

Advocates for health equity need quantitative information to convince

Which health areas show inequalities? (only family planning?

How widespread are the inequalities? (only the poorest of the

How much do facilities and service providers charge? Can the

Do the facilities and service providers that the socially excluded

Are there interpersonal barriers between providers and clients?

Do consumers even want the services? Do they see the

Are there negative attitudes or beliefs that the services are

Are there others in the household (spouse, parents, parentsin

Do women have a say in how household resources are used for

Achieving the Millennium Development Goals means improving the

Ensure that poor and traditionallyexcluded clients know their

There are two basic approaches to designing health policies and

Targeted approaches seek to selectively enhance provision of

Mobilize additional resources for excluded and underserved

adding new resources to specifically reach the excluded

Resource mobilization adding new resources for health is a major

Once a program has identified inequities in health and designed and

Regardless of the specific targeting strategy, the basic objective of

KNOWLEDGE RECAP: ANSWERS

Depending on the country context, other factors may include rural

WHERE TO FIND THE

People tend to selfidentify and associate with others on the basis of

Ideas in Action The

Most excluded groups lack the technical, interpersonal, and

It is important to engage and empower the excluded in every stage of

brought feedback from community and provincial deliberations to

Service beneficiaries can be actively engaged in implementation as

Users must know their rights and have appropriate channels to

While expendituresbased and assetsbased measures of poverty

The figure on this page presents modern family use in Huehuetenango

Availability. Do providers have trained staff, equipment and

Accommodation. Is the service organized to meet clients

Affordability. Are clients able and willing to pay the providers

Acceptability. Are clients and providers comfortable with one

To obtain the most useful information and to ensure that appropriate

In each scenario, can you identify whether the apparent barriers to

KNOWLEDGE RECAP: ANSWERS

Whole of government (e.g. health, finance, education, industry

WHERE ARE THE

Most developing countries already have or have submitted final

While health figures prominently in all PRSPs, health equity is

While modern contraception is widely used in Peru, use lags behind in

EXAMPLE FROM THE

In less than a year, the number of monthly FP/RH information sessions

KNOWLEDGE RECAP: ANSWERS

Targeting means focusing efforts directly on the poor and/or other

Developing and implementing a targeting strategy is a major policy

The operational goal of targeting is to provide government benefits to

individualized targeting through the application of specially

If there are geographic areas with high concentrations of poverty, the

Therefore, USAID/India asked the Family Planning Services Technical

In rural areas, households with Below Poverty Line (BPL) certificates

Import restrictions on commodities needed by the commercial