Identifying and addressing inequities in child and maternal health provision Gian Gandhi Health Section, UNICEF NYHQ 1
On average, global burden has fallen steadily As measured by number of under-five deaths globally since 1990 Millions of under-five deaths 14 12.0 12 10.8 10 9.6 8.2 8 6.9 6 4 2 0 1990 1995 2000 2005 2011 Source: Adapted from UN Inter-agency Group for Child Mortality Estimation, 2012
But global and national averages hide inequities Under-five deaths per 1,000 live births 146 121 114 101 90 91 114 62 51 67 by wealth quintile by mother's education by residence Source: UNICEF analysis (Aggregate of countries with DHS surveys conducted after 2005)
But global and national averages hide inequities Under-five deaths per 1,000 live births 146 121 114 101 90 91 114 62 51 67 by wealth quintile by mother's education by residence Source: UNICEF analysis (Aggregate of countries with DHS surveys conducted after 2005)
But global and national averages hide inequities Under-five deaths per 1,000 live births 146 121 114 101 90 91 114 62 51 67 by wealth quintile by mother's education by residence Source: UNICEF analysis (Aggregate of countries with DHS surveys conducted after 2005)
Multiple causes of deprivation (inequity) E.g. Wealth, education, geographic location, and gender inequity in Nigeria 14 Ukraine Average number of years of schooling 12 10 8 6 4 2 Nigeria 6.7 years Cuba Education poverty Bolivia Indonesia Honduras Cameroon Bangladesh Chad Extreme education poverty 9.7 years Richest 20% Poorest 20% 3.5 years 10 years Rural Urban Urban 6.4 years Rural 3.3 years 10.3 years Rich, rural boys Rich, urban boys Rich, rural girls Poor, urban boys Poor, rural girls 2.6 years Boys Girls Source: SOWC 2012 0 C. A. R. Rural Hausa 0.5 years Poor, rural Hausa girls 0.3 years
Specifying mortality impacts of inequity... and hence key interventions for scale up 250 Under Five Mortality Rate (per 1000 Live Births) in Nigeria 200 150 100 50 0 37 56 50 41 Poorest Nigeria: wealth Nigeria quintile Q1 14 22 11 27 Nigeria: Richest Nigeria wealth Q5 quintile (richest) Others Injuries AIDS Pneumonia Measles Malaria Diarrhea Neonatal Source: Carrera, C. et al (2012). "The comparative cost-effectiveness of an equity-focused approach to child survival, health, and nutrition: a modelling approach." The Lancet 380 (9850): 1341-1351.
Identifying location of deprived populations Can use district level coverage and outcome tracers to identify key districts Childhood immunization and nutritional status (%), Uganda 100 90 80 70 88 79 79 73 69 68 60 50 56 54 50 % Full Immunization Coverage (12-23 months) 40 30 20 10 13 20 11 11 16 25 34 16 24 % Underweight Children (6-59 months) 0 Source: Uganda Demographic and Health Survey (UDHS) 2011 Preliminary results, Uganda Bureau of Statistics
The Tanahashi Model to assess system bottlenecks Nigeria application 2006 100% GAP 90% 80% Target Population 70% 60% 50% 40% 30% 20% 10% 9 0% % District with LLITN's or nets + insecticide in stock % villages with HR providing LLITNs % villages selling or distribution LLITN or nets + insecticide % households having at least one bed net % pregnant women using MN last night % pregnant women using ITMN Adapted by T. O Connell from Tanahashi T. Bulletin of the World Health Organization, 1978, 56 (2) http://whqlibdoc.who.int/bulletin/1978/vol56-no2/bulletin_1978_56(2)_295-303.pdf toconnell@unicef.org
Using bottlenecks framework at district level Example: Bottlenecks to Full Immunization coverage in Uganda districts Buikwe district Mukono district 100% 80% 60% 40% 20% 0% 100% Wakiso district 100% 80% 60% 40% 20% 0% 80% 60% 40% 100% 80% 60% 40% 20% 0% Masaka district 20% 0% 100% 80% 60% 40% 20% 0% Bukomansimbi district 10 Source: LQAS Analysis for CODES project (District Strengthening project), 2012 data
Example: Madagascar Wealth and literacy are important descriptors of inequity in immunization Poorest - Richest All vaccines Measles (1) DTP3 DTP1 0 10 20 30 40 50 60 70 80 90 100 Illiterate- Educated All vaccines Measles (1) DTP3 DTP1 0 10 20 30 40 50 60 70 80 90 100 Source: DHS survey, 2009 Inequities in immunization coverage by socioeconomic group and maternal literacy (from no formal education to secondary school and above)
Example: Madagascar Location and overarching drivers of inequities in immunization 30,000 Unvaccinated and under-vaccinated by region in Madagascar EPI Coverage Survey 2011 Absolute number of children 25,000 20,000 15,000 10,000 5,000 Loss for Follow-up # No Vaccine # - NB: Loss to Follow-up = Children having received DTP1 but not DTP3
Example: Madagascar bottlenecks assessment COMMODITIES: Vaccines not available (up to 150 days) Stock out at district level due to poor supply chain management Refrigerator is stopped due to lack of kerosene Delays in fund allocation for kerosene No transport fund to collect and deliver kerosene to facilities HR AVAILIBILITY: Session delays and absenteeism Delay and uncertainty in fund allocation for outreach In many CSBs, the only health worker is often absent PHYSICAL ACCESS: Lack of transportation and poor planning No public transport options between CSB and distant villages Only 18% of CSBs have rational microplan for vaccination Health worker does not respect agreed date/time of session Absence of community member during planning
Example: Madagascar bottlenecks assessment INITIAL UTILIZATION: Demand a small problem Vaccination not a priority for 30% mothers of unvaccinated CONTINUED UTILIZATION: Lack of data to maintain utilization Mobilizer ineffective in detection of loss to follow up Absence of child health card (replaced by note pads) No vaccination register, no newborn register at village level Motivation? Training? EFFECTIVE COVERAGE: interventions of sufficient quality, and timeliness to achieve impact. i.e. fully immunized child by 12 months, with potent, safe vaccines, from sterile needles.
Citizen-led accountability through A Promise Renewed (APR) We need to raise awareness of the commitments that governments make on behalf of women and children, particularly the most disadvantaged Only when communities/individuals understand that these commitments have been made can we create vocal demand for improved health outcomes CSOs can raise awareness about the commitments that governments have made, starting in those communities that have the worst health outcomes CSOs can facilitate use of tools like ureport, to track government progress in meeting those commitments to ask: o Are the resources being invested according to plan? o Do health facilities have essential supplies? o Are communities being told about public performance in meeting targets that have been set?
Identifying inequities: Summary Addressing inequities requires data (administrative, survey) and analysis to identify marginalized and under-served groups to identify impacts of inequity and key interventions to address these to identify districts where marginalized and under-served reside to identify drivers of inequity (barriers to coverage and effective utilization) to ensure accountability Framework exists to identify what determines bottlenecks to equitable quality coverage Tools now available to monitor, report and hold stakeholders more accountable
Towards equitable universal health coverage Compared to simply scaling up current practices (which may worsen inequities) an equity-focused approach can avert many more child and maternal deaths UNICEF in partnership with WHO, is supporting efforts towards equitable UHC; e.g. supporting monitoring, assessment of pathways to achieve results, CSO networks for accountability Civil Society Organization networks are an essential step towards citizen-led accountability for equitable UHC Reasons for optimism Proven interventions, renewed commitments by governments, improved data and tools for measurement Yet, in the majority of countries we could accelerate progress through greater use of explicitly pro-equity UHC strategies and policies
Thank you!
Back up slides 26
Key Messages Globally, we are making progress However for too many women and children and some conditions progress is too slow The ambition of A Promise Renewed The immediate challenges for accelerating progress
Why do we need to renew our promise to children? Significant progress toward MDG 4, but we re fast approaching 2015: opportunity to accelerate progress towards MDG 4 and sustain the momentum beyond 2015 Despite significant progress, challenges remain variable progress across regions, populations, and specific causes of mortality requires targeted, highimpact interventions New data insights, effective technologies, and country innovations enable a sharper, more strategic focus on the countries, diseases, and populations with the highest burden of under-five mortality Accelerating now, based on data and science, can inform planning and investment, saving millions of lives each year
Analysis of District Health Management Performance and its determinants Bottlenecks Manag. shortcomings Determinants Causes Commodities Human Resources Access Utilization & demand Technical & organizational quality Procurement and supply management Decision space District level coverage and outcome tracers Human Resources Resources Management Governance Financial Management Information Management Service organization Capacity & skills Incentives Why? Immediate cause Why? Direct cause Why? Indirect cause Why? Systemic cause Why? Ultimate cause
Rationale for a determinant framework A causal framework tends to take a negative view of things: what has caused problems A determinant framework is more focused on what determines good coverage, what is working now, and what needs to be built up so results are achieved. The focus is on what determines effective coverage, i.e. what gets impact. This is embedded in a clear theory of change This also helps drive the discussion towards setting priorities that are results focused instead of process focused. 31