UNICEF s equity approach: from the 2010 Narrowing the Gaps study via equity focused programming and monitoring to a Narrowing the Gaps+5 study & EQUIST
Narrowing the Gaps: Right in Principle, Right in Practice Conventional wisdom: equity is inefficient Reaching hard to reach: too costly, too difficult Reaching better off: easier, more cost effective Hypothesis tested: Greatest needs amongst the unreached New, innovative, efficient strategies & tools exist Benefits could outweigh additional costs of reaching them This suggests that a greater equity focus can: be more cost effective accelerate progress towards MDGs
Step 6: Compare costs and impacts of strategic shifts Results of Narrowing the Gaps to meet the MDGs # Child deaths & Stunting cases averted per $1 million invested 300 250 200 150 Equity focused approach Mainstream approach 244 300 250 200 150 Most deprived groups Least deprived groups 279 188 100 50 81 49 84 100 50 97 61 0 Reductions in child deaths Reductions in stunting cases 0 Reduction in child deaths Reduction in stunting cases
Monitoring Results for Equity Level 1: All Country Offices review the equity-focus of their situation analysis, the quality of causal and bottleneck analysis of child deprivations and the alignment of policies, strategies and plans Level 2: Where one or more specific child deprivation are prevalent and addressed by the country programme, the Country Office monitors UNICEF inputs and outputs Guide programmatic adjustments and management decisions Level 3: As countries show measurable progress in programme implementation, the Country Office, jointly with partners, assesses, analyses and addresses bottlenecks to estimate progress towards outcomes in representative areas or groups Enabling environment Supply side determinants Demand side determinants Level 4: As countries show good progress in reducing bottlenecks, the Country Office validates the achievement of outcomes and estimates progress towards reducing child deprivations
Decentralized Monitoring helps identify + remove bottlenecks 100% 80% General Food Distribution to targeted Supply deprived Bottlenecks districts 40% difference in food security 80% Community participation / dialogue; Strengthened partnerships btw community & services; Refresher training of CHW; performance Demand incentives bottlenecks for quality IPC / Utilisation limited by food availability counseling & additional on feeding continuity practices and quality bottlenecks to most deprived mothers and monitoring 72% 63% 59% 60% 54% 43% 40% 20% 0% COMMODITIES: % communities with food security HUMAN RES: % villages with sufficient CHWs Source Bangladesh, Nepal, Pakistan ACCESS: % Women with primary education or higher UTILISATION: % children 6-8 months receiving complementary foods CONTINUITY: % children 6-24 months receiving meals with minimum frequency EFFECTIVE COV: % children 6-24 months receiving the minimum acceptable diet
Decentralized Monitoring of equity bottlenecks UN(ICEF): - Programmatic adjustments -Operational/management decisions Conventional Monitoring Decentralized monitoring UN(ICEF) Institutional Reporting (internal & external) Monitoring for reporting Empower deprived populations Strengthen Capacities and systems for improved delivery of services Strengthen Decentralized Planning Enhance equity-focused policies, plans and budgets Evolving Role of Monitoring Increased equitable effective coverage of basic services and health/nutrition promotion MDGs with equity & beyond National Bottleneck analysis with partners (MAF, MBB) MAF
Narrowing the Gaps +5- The Sequel Are gaps narrowing? Have countries decreased mortality, malnutrition and morbidity in the most disadvantaged as compared to the best off children? To what extent was this done through improved equity of coverage of Health, Nutrition and WASH services? Which countries/regions have reduced most equity of coverage? How? Why? Which interventions have contributed most to narrowing the gap? which bottlenecks have reduced for these interventions? Which strategies have been put in place, that could be associated with these bottleneck reductions? Scope: over 50 high burden countries Timeline: May 2015-October 2015
Methods 1. Extraction and analysis of DHS and MICS data on coverage pre/ post 2010 2. Analysis of globally available information (DHS/ MICS, WHO WB, etc.) on coverage determinants and bottlenecks pre/post 2010 3. Attribution of excess deaths averted to changes in coverage and reductions in bottlenecks using EQUIST/ LiST 4. Qualitative analysis of strategies associated with equitable/ inequitable changes in coverage and bottlenecks (country by country, then aggregated for themes)
Early Childhood Years Sub Saharan Africa Young Child DALYs Lost per Quintile 0.80 0.70 0.60 0.50 0.40 0.30 0.20 0.10 0.00 Poorest Q2 Q3 Q4 Richest Development disability from under-nutrition Wasting Stunting Meningitis sequelae Malaria episodes + sequelae Diarrhea episodes Pneumonia episodes Child deaths Post-neonatal (infant) deaths Low birth weight Birth asphyxia sequelae Neonatal deaths
0.9 0.8 0.7 0.6 0.5 0.4 0.3 Actual changes in survival for disadvantaged populations compared to total survival gap, and equity gap benchmark for survival - Total Equity Gap SsAfrica EMONC IMNCI Delivery by skilled professional IMMUNIZATION PLUS ANTENATAL CARE FAMILY PLANNING NEONATAL & INFANT FEEDING & CARE ENVIRONMENTAL SAFETY WASH 0.2 0.1 - Total equity Gap in survival before 2010 Equity gap benchmark in survival Actual improvement in survival since 2010
Additional Years of child survival Actual changes in survival for disadvantaged populations compared to total survival gap, and equity gap benchmark for survival - SsAfrica Total Equity Gap 0.9000 Quality 0.8000 0.7000 0.6000 0.5000 0.4000 Continuity Sociocultural Acceptability Financial Affordability Geographical Accessibility Availability Commodities 0.3000 0.2000 0.1000 - Total equity Gap in survival before 2010 Equity gap benchmark in survival Actual improvement in survival since 2010
EQUIST A web-based platform to help policymakers reduce inequities in reproductive, maternal, newborn, child health and nutrition to narrow the gap between the most deprived and the least deprived. Focus on prioritization: EQUIST helps users to estimate and visualize the potential costs and benefits for young child health & nutrition of alternative strategies for equitable effective coverage of health, nutrition & WASH intervention packages A single platform for several tools: EQUIST merges several evidencebased tools into one visual and userfriendly platform