Make Every Day “Health Equity Day”
By: Jay Gribble
As a kid, after celebrating Mother’s Day and Father’s Day, I asked my mom about kid’s day, to which she responded, every day is kid’s day. When I went looking for a global day of health equity and didn’t find one, I thought similarly. Every day should be health equity day! The Health Policy Plus (HP+) project is dedicated to advancing policies that improve access, quality, financing, and governance that allow health equity to become a reality. Yet health equity remains elusive, with definitions that are difficult to understand and even more difficult to measure. If we think of health equity as existing when everyone has a fair and just opportunity to be as healthy as possible, then achieving health equity must extend beyond the health sector. Broad policy areas that include poverty reduction and efforts to end discrimination must be part of the solution to tackle big structural issues that stand in the way of anyone being as healthy as possible. Efforts to address employment, education, housing, and the environment all come into play as we think about the barriers that stand in the way of achieving health equity.
Ultimately, achieving health equity will require both a multisectoral and systematic approach; one that links to labor, education, and gender, and that follows a stepwise process. Within the health sector, there are a variety of ways that we can achieve incremental progress on health equity. One potential model to follow is the four-step policy process: (1) identifying disparity and its underlying causes, (2) advocating for and achieving policy changes, followed by implementing those new policies, (3) monitoring the policy to ensure it is achieving desired improvement, and (4) continuing to look for ways to reduce disparity through revised strategies and policies.
Step 1: Identifying Disparity
A critical first step is to identify disparity and its underlying causes. One example is an approach that HP+ developed for diagnosing inequity in family planning programs. This approach uniquely identifies inequalities for a diverse range of disadvantaged subgroups — based on age, marital status, education, residence, ethnicity, and religion, not just wealth quintile. In addition, the approach identifies inequalities across various domains of family planning — looking beyond use of family planning to accessibility, availability, and quality of family planning — at both national and subnational levels. By applying the methodology to Uganda, previously unmeasured disparities have been identified that can help program managers use scarce resources to improve health equity. Similarly, HP+ collaborated with Indonesia’s national health insurance scheme (JKN) to determine if it is improving equity in healthcare access. When considering geography and socioeconomic status, the analysis found that expenditures had been inequitable — and are becoming increasingly inequitable. The analysis led to practical recommendations related to facility location, human resources for health, and reaching beneficiaries with additional information. These examples illustrate the key role that data and information can play in identifying and quantifying the extent to which inequities exist — and among which groups — so that a policy solution can be developed and implemented to improve health equity.
Step 2: Advocate, Achieve, Implement
A second step to improving health equity is to develop new policies, advocate for their approval, and support their implementation. Our work in Madagascar provides an example. Since the 1920s, Madagascar’s family planning efforts were governed by a French colonial legal framework that prohibited distribution of contraception to youth or married women without spousal consent. Recognizing the need for a new law that reflects current thinking about reproductive empowerment and autonomy, HP+ provided technical and financial support to stakeholders to develop a new law and advocate to decisionmakers at each step of the approval process. In December 2017, the Senate of Madagascar passed a landmark reproductive health and family planning law that marked the final step in the law’s adoption. The president’s promulgation of the new law is a tremendous step forward toward rights-based reproductive health services in the country.
Similarly, in Malawi the government identified the need for a policy that addressed the reproductive health needs of young people — especially the most vulnerable populations — given that youth under the age of 24 represent almost two-thirds of the country’s population and experience high rates of HIV infection and unintended pregnancy. With support from HP+ and input from a range of ministries and stakeholders, the Government of Malawi developed the Youth Friendly Health Services Strategy 2015–2020, which focuses on family planning, HIV, teen pregnancy, comprehensive sexuality education, and access to services. The strategy is built around five objectives that include enhancing the enabling environment; comprehensive and age appropriate information and services; strengthening ownership, coordination, and collaboration among implementing stakeholders; community engagement; and resource mobilization. HP+ has supported the strategy’s rollout to help providers understand their roles in achieving the strategy’s objectives and to help young people understand what they are entitled to receive under the policy.
Step 3: Monitor Progress
Many assume that the approval of a law or policy resolves health inequities, but monitoring key indicators that track progress is essential to determining how effective the new policy is in closing the equity gap. HP+ has supported the development of costed implementation plans (CIPs) in many countries that serve as a roadmap to help achieve family planning goals. And while the CIP is designed to improve access and achieve goals, performance monitoring is a key element to determine if a country is on the way to achieving its goals. HP+ adapted Palladium’s strategy execution approach in developing a CIP performance monitoring approach that tracks improvements in a set of key indicators. While CIP tools help stakeholders monitor progress, added structured review meetings foster accountability for progress and inform priority-setting for the next reporting period.
As another example, in Guatemala, HP+ supported the National Contraceptive Security Commission to develop a monitoring system that allows the commission and other stakeholders to track how the strategy is being implemented, as well as its impact on family planning in the country. The automated system monitors and facilitates collecting, processing, analyzing, and submitting information on financing and family planning services. With this data, the commission can ensure the availability of contraceptive supplies in all parts of the country — helping close gaps in health equity. These systematic approaches to policy monitoring guide decisionmakers in determining how well policies are being implemented and the extent to which resources need to be redirected, program areas emphasized, and policies revised for better alignment with health equity goals.
Step 4: Revise as Needed
If a policy revision is needed, stakeholders need to make the case with evidence, as well as clear recommendations as to how the current policy should be revised to address equity and other goals. Burkina Faso’s task-sharing policy provides an example. For several years, the policy was not sufficiently inclusive of different cadres of providers, contraceptive methods, or self-care. In 2020, the Burkinabe Ministry of Health, with support from HP+ and other stakeholders, revised the policy to include new task distributions including dispensing of DMPA-SC by private pharmacists, self-injection of DMPA-SC, and the HIV self-test. This revision provides a framework that describes how task-sharing will be scaled up in a structured way across all levels of the health system. This type of revision recognizes that new technologies and products become available and aims to ensure all people have access to them, thereby reducing health inequities.
Closing Health Equity Gaps
Eliminating health inequities is a broad goal and a tall order because it requires working within the health system, as well as outside it. HP+ focuses on how to close health equity gaps by promoting evidence-based laws, policies, and guidelines, and working within the four-step policy cycle to keep a vigilant eye on the underlying causes of inequities and how proposed policy solutions are closing existing equity gaps. While we celebrate the achievements presented here, these are just a few of the examples of how promoting health equity takes place. If we “make everyday health equity day,” addressing these gaps become second nature and we focus on not only the great leaps forward but on the intermediate steps we need to take to get there.
Jay Gribble is a senior director in Palladium’s health practice leadership team and deputy director for family planning and reproductive health on the USAID-funded Health Policy Plus project.