Designing Projects for Equity

Session C: 1:30 – 2:45pm

Kathryn BrooksAmy ReidAbiyou Kiflie

Agenda

10 mins – Welcome

15 mins – Framing & Overview

30 mins – Ethiopia Case Study

15 mins – Discussion

2

Welcome

3

What is Health Equity?

When all people have “the

opportunity to attain their full health

potential and no one is

disadvantaged from achieving

this potential because of their

social position or other socially

determined circumstance”.

CDC

What is Health Equity?

“A particular type of health difference that is closely

linked with social, economic, and/or environmental

disadvantage. Health disparities adversely affect groups of

people who have systematically experienced greater

obstacles to health based on their racial or ethnic group;

religion; socioeconomic status; gender; age; mental health;

cognitive, sensory, or physical disability; sexual orientation

or gender identity; geographic location; or other

characteristics historically linked to discrimination or

exclusion.”

Healthy People 2020

A difference or disparity in health outcomes

that is systematic, avoidable, and unjust.

CDC

What is Health Equity?

______ Prejudice + Power

Norms, structures, policies, practices that advantage one group over another.

Differential access to goods, services, and opportunity of society by race.

People’s institute for survival and beyond

phyllis-jones, ajph

The -Isms

Equity & Quality Care

Equity is forgotten IOM aim

In order to reach any of our aims fully, equity is needed

We recognize that inequities are a product of our

systems

Improvement tools give us a way to make systems

better, but not without intentionality

Equity must be a priority and you must have

infrastructure to support that priority

What part of your culture helps and hinders equity?

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Co-design for equity

Listen. What matters to our community? How are

improvement projects selected?

Get the data. Where are the gaps?

But! don’t let imperfect data slow you down

Build a representative team. Whose voice is missing and

why?

Discuss power and equity in team processes

Understand the history of your organization as it relates

to your community

9

Key Improvement Design Elements

What are we trying to accomplish? Aims for equity

What changes can we make that will result in

improvement? Theory of change for equity

How will we know a change is an improvement?

Measurement for equity

How do we engage our colleagues in change that

advances equity? Organizing for equity

10

Improvement Aims

How much, by when, for whom, boundaries of system?

Does aim explicitly intend to narrow gaps between groups and/or support a marginalized group?

• Decrease maternal mortality by 50% by May 2019 and narrow the gap between X and Y by 50% in Region ABC.

• By December 2018, at least 90% of patients agree or strongly agree they have had an excellent experience in our facility and the gap is narrowed by 50% between A and B patients.

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Measurement

Assess your data capability and data quality to identify

and track equity.

Stratify your data by relevant sociodemographic factors.

Do not wait for perfect data to start improvements aimed

at narrowing equity gaps.

Design dashboard with equity data as part of regularly

tracked items so it is not a separate ‘add-on’.

12

Improvement Theory

Process of generating change ideas – who are you

getting these from? Missing voices?

Driver diagram & change ideas – Who do these work

for? Who do we miss?

Shift from individual/interpersonal to structural

13

How do we engage colleagues in change?

Challenges include fear, lack of buy-in and competing

priorities

Co-produce in authentic relationships

Clarify the ask

Tap in to motivations and values, co-design with those

most impacted, meet people where they are, start small,

Have courage to name issues

14

Lessons Learned15

Common Pitfalls

• Individuals v systems

• Not sharing decision

making power

• Not enough time to talk

about team dynamics

• Not enough

communication

Tips

• From whom do you need

buy in and support?

• Don’t wait for perfect

• Ask who benefits and

who is burdened in your

design decisions

• Be on your own personal

journey

Case Study: Ethiopian Health Care

Quality Initiative

Ethiopia Country Background

Total Population, 2017:94,228,000

GDP per capita, 2017: US $660

Health expenditure, 2013/2014: 2.6 billion ETB (4.3% GDP)

Neonatal Mortality, 2016: 29 per 1000 live births

Maternal Mortality, 2016: 412 per 100,000 live births

Facility delivery: 26%

Sources: World Population Review, WHO, EDHS 2016

NMR / MMR Compared to other countries in Africa

Rank Country MMR 2015

1 Sierra Leone 1,360

4 Nigeria 814

15 Cameroon 596

17 Nigeria 553

19 Kenya 510

27 Tanzania 398

29 Burkina Faso 371

30 Togo 368

31 Madagaskar 353

32 Ethiopia 353

33 Uganda 343

38 Sudan 311

40 Rwanda 290

43 Zambia 224

45 South Africa 138

Sources:

CIA World Factbook 2015

UN Inter-agency Group for Child Mortality Estimation ( UNICEF, WHO, World Bank, UN DESA Population Division ) at

childmortality.org.

Rank Country NMR 2016

1 Central African Republic 42.3

6 Cote d'Ivoire 36.6

9 Nigeria 34.1

11 Sierra Leone 33.2

12 Djibouti 32.8

16 Sudan 29.4

19 Ethiopia 27.6

24 Niger 25.7

29 Cameroon 23.9

32 Zambia 22.9

32 Kenya 22.6

34 Tanzania 21.7

37 Uganda 21.4

45 Rwanda 16.5

48 South Africa 12.4

Ethiopia NMR / MMR on Global Scale

Sources:

CIA World Factbook 2015

UN Inter-agency Group for Child Mortality Estimation ( UNICEF, WHO, World Bank, UN DESA Population Division ) at

childmortality.org.

Rank Country MMR 2015

1 Sierra Leone 1,360

19 Kenya 510

35 Ethiopia 353

63 South Africa 138

96 Iraq 50

110 Egypt 33

123 Iran 25

138 United States 14

148 Singapore 10

153 United Kingdom 9

165 United Arab Emirates 6

171 Japan 5

177 Sweden 4

184 Greece 3

Rank Country NMR 2016

1 Pakistan 45.6

13 Sierra Leone 33.2

23 Ethiopia 27.6

45 Kenya 22.6

65 Iraq 18.2

83 Egypt, Arab Rep. 12.8

108 Iran, Islamic Rep. 9.6

156 United Arab Emirates 4.0

159 United States 3.7

172 United Kingdom 2.6

179 Greece 2.3

191 Sweden 1.6

201 Singapore 1.1

204 Japan 0.9

205 San Marino 0.6

Health Equity in Ethiopia

Inequities exist among many sub-populations within

Ethiopia for both service coverage and health outcomes:– Regional:

– Maternal mortality: 743 and 717 per 1,000 live births in Somali and Afar regions,

respectively, compared with 234/1,000 LB in Addis Ababa

– Urban/Rural:

– Skilled attendance at birth: 79% for urban population vs. 20% for rural (from DHS)

– Rates of ANC 1 visits 45.5% higher in urban settings than rural

– (add under 5 mortality, immunization coverage, diagnosis + treatment of common

diseases)

– Wealth Quintile:

– Children from richest quintile 2.44 times more likely to receive pentavalent

vaccine (diphtheria, tetanus, pertussis, hepatitis B and Haemophilus

influenza type b) compared to children in poorest quintile

Sources: DHS 2016; State of Inequality in Ethiopia report

Health Equity in Ethiopia

What are the root causes of these disparities?– Majority of population lives in “big 4” regions higher resource allocation

+ intervention activity

– Health system structure not designed for nomadic populations; need new

strategies to provide care in pastoralist areas

– Education strongly associated with accessing HC services; also with

income levels and urban/rural/pastoral archetypes

FMOH strategies to address inequities:– Inclusion of Equity as a pillar of quality in HSTP

– Establishment of a Special Supports directorate focused on pastoralist

regions

Ethiopian Health Care System

Ministry of Health

•Agencies

Regional Health Bureaus

Zonal Health Department

Woreda Health Office

HEW and HDA Structure

Over 38,000 Health Extension Workers (HEWs) trained

and deployed throughout the country to educate and

empower families to take control of their own health.

Families are mobilized by a Health Development Army

(HDA) to enhance community engagement– 1:5 network structure: one HDA representative to five women

– Groups of five form clusters of six groups with an HDA leader (thirty

women to one HDA leader).

Improvements in Maternal and Child Health

Ambitious initiatives of the FMoH led to a two-thirds decrease in child

mortality between 1990 and 2015, thus achieving Millennium

Development Goal 4

Critical progress in access and coverage

However, rates of neonatal and maternal mortality remain

unacceptably high, and disparities persist among sub-populations

Further progress will require more system-level change

Across health system levels

Across the MNH continuum of care

Move beyond coverage high quality, patient-centered, equitable care

Ethiopia Health Care Quality Initiative25

Program Design Guiding Questions

Where are the gaps?

Where can IHI help in closing those gaps?

Who are the stakeholders and what are their

priorities?

Who is being left out of the current system?

How will this work be sustained in the long term?

Program Components

Creation of Ethiopian National Health Care

Quality Strategy with the Ethiopian FMOH

Activate a culture of continuous improvement

at all levels of the healthcare system

Launch and test large-scale results-focused

collaboratives in maternal and neonatal health

Overall Project Driver Diagram

Improved Healthcare

Outcomes and Improved Quality of

Health Services

Institutionalized Culture of Quality

Development and Implementation of Unified

Quality Strategy

Government Ownership

QI Capability Building

MNH-focused CollaborativesAll Other Drivers of

Quality Services

(WHO Building Blocks)

Elements of design incorporated

specifically to advance equity

Geography: inclusion of pastoralist collaborative

Integration of Compassionate and Respectful Care work stream

Inclusion of HEWs (community health workers) in collaboratives to create link with communities and groups often left out of system

Learning Collaborative Design

Learning

Session 3

Learning

Session 2

Intensive coaching to support teams to improve system and skills gaps

(visits, phone calls, engagement of program and supervisory

managers, data collation & interpretation)

12-18 months

Learning

Session 1

Address

gaps in

clinical

and QI

skills and

supplies

(training

and

procure-

ment of

essential

supplies)

Finalize

change

package,

publicize

& spread

Learning

Session 4

Action

Period 2

Action

Period 3

Action

Period 1Identify

focus area

and core

indicators

Conduct

Baseline

Assess-

ment

MNH Collaborative Learning Session

Phased Design

Prototype:• One collaborative in each of five regions (Amhara, Oromia, SNNP,

Tigray, and Afar) to test the collaborative design and develop

regional change packages of successful change ideas to catalyze

MNH improvement.

Test of Scale:• Fully integrate the design into existing public system and

structures and test to scalability of the approach in 19 additional

woredas.

Prototype Phase (18 months)

= Agrarian

= Urban

= Pastoral

Key

Test-of-scale Phase (18 months)

= Agrarian

= Urban

= Pastoral

Key

IHI MNH Initiative Regions

IHI MNH Initiative Regions

= Prototype Phase Woreda

Fogera Woreda, Amhara

(pop. 264,512)

Launched April 2017

Progress to Date: Learning Collaboratives

Limu Bilbilu/Bekoji Woreda,

Oromia (pop. 237,820)

Launched April 2016

Tanqua Abergele Woreda,

Tigray (pop. 107,081)

Launched August 2016

Duguna Fango Woreda,

SNNPR (pop. 118,051)

Launched October 2016

Amibara, Afar

(pop. 94,718)

Launching January 2018

Collaborative Aim

Reduce maternal and neonatal mortality

across Ethiopia by 30% over a period of 5

years

Equity lens: For whom?

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Theory of Change

Reduce maternal and

neonatal facility-based mortality in

participating sites by 30% over a period of 30 months

Increased Health Seeking Behavior

Optimize the ability of the HEW to educate the community

Community Engagement for awareness creation and positive influence

Utilize the Health Development Army structure to reach the house hold

Use culturally acceptable strategies to improve dissemination and uptake of key

health messages

Use schools as a dissemination mechanism

Use multimedia for Health education activities

Create positive experiences through every health encounter

Use each facility visit to educate/counsel mothers towards raising their health seeking behavior

Improved experience at care

Improved mechanisms to reach appropriate level of health care facility

Improved referral network

Improving transportation mechanisms (ambulance and others) for immediate

response

Maximizing the potential of nearby health facilities to avoid unnecessary referral

Improved quality of care at health

institutions (safe, effective, patient-centered, timely,

efficient, equitable)

Create a culture of QI and leadership

Create structure (QI teams, committees, plan) to facilitate and execute work

Improve data quality through DQA’s

Create a learning platform for collaboration and routine use of data for improvement

Increase the skills of health professionals and health managers to use QI methods and tools

Organize learning collaborative among health facilities serving the same geographic areas (full Woreda

Coverage)

Availability of skilled and respectful health personnel

Training in key MNH national protocols

Onsite mentorship to maintain skills and address skills gaps

Maximize efficiency of existing facility staff

Professionals get regular updates on the management and prevention of key causes of mortality

Improve the reliability of the supply chain management system to deliver essential

commodities all the timeAddress gaps in essential commodities as defined in

baseline assessment

Availability of national guidelines, clinical protocols and job aids

Dissemination of existing protocols and support for local development when necessary

Timely identification, prevention and management of life threatening conditions

to mothers and newborns

Fast tracking/triaging/follow-up mechanism

Reliable implementation of labor and delivery bundle

Reliable implementation of the "MNH" checklists/relevant guidelines

Support for a care delivery system that ensures respectful care for patients

Incorporation of compassionate and respectful care (CRC) change ideas and training in learning sessions

Clean, safe, comfortable spaces for patients and staff

Theory of Change

Reduce maternal and neonatal facility-based

mortality in participating sites by 30% over a period of

30 months

Increased Health Seeking Behavior

Improved mechanisms to reach appropriate level of

health care facility

Improved quality of care at health institutions (safe,

effective, patient-centered, timely, efficient, equitable)

Adaptable design

Review of collaborative design with RHB and

partners with extensive experience in Afar region

Additional emphasis on addressing 1st and 2nd

delays through community engagement-linked

change ideas and improving referral systems.

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Successful change ideas

Increasing patient centeredness of care:

• Restructuring of pregnant women’s conferences to be more

participatory and responsive to their needs

• Incorporation of cultural elements into maternity waiting homes

Strengthening referral systems

• Back-referrals

• Reducing financial barriers to referrals

• Community-level resource mobilization for local ambulances

QI methods as advocacy tool

• Facilities using data to more strongly advocate for increased

resource allocation from their Region or zonal leadership

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Learning Collaborative Core IndicatorsProcess

Measure

Data

Source*

ANC

(coverage) Antenatal care coverage – four visits

HMIS

ANC

(quality) Percentage of pregnant women tested for syphilis during ANC1

HMIS

Delivery Management

(coverage) Proportion of births attended by skilled health personnel

HMIS

Delivery Management

(quality)* Proportion of deliveries with 100% compliance to ‘on admission’ bundle

Chart review

with checklist

Delivery Management

(quality)* Proportion of deliveries with 100% compliance to ‘before pushing’ bundle

Chart review

with checklist

Delivery Management

(quality)* Proportion of deliveries with 100% compliance to ‘soon after birth’ bundle

Chart review

with checklist

Delivery Management

(quality-sick

newborns) Proportion of neonates treated for birth asphyxia

HMIS or

Delivery

register

PNC (coverage)Percentage of women who attended postnatal care 48 hrs after delivery

HMIS

PNC

(quality-sick

newborns) Proportion of neonates treated for sepsis

HMIS or

Delivery

register

PNC

(quality-

preterm/LBW) Percentage of preterm or low birth weight infants put on KMC

Delivery

register

Clinical Outcome/Impact Measures

Institutional and community level (when available)

measures of:Maternal Mortality

Neonatal Mortality

Stillbirths

Perinatal Mortality

Measurement for Equity

Quantitative: Core collaborative indicators to be

stratified by region and by geographic archetype (urban,

agrarian, pastoralist)

Qualitative: • Assessment to better understand the mechanism of how QI

leads to change, including effect on health worker motivation as

it relates to quality of care

• Qualitative assessment of maternal perception of care and

utilization of services

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New frontiers/opportunities

3 opportunities identified through current work:

1. Increased quality of care at facilities opportunity to attract

more women to facility care (pull factor for increased

demand seeking)

2. Greater demand for facility services need to strengthen

the newly pressured referral system

3. Empowering communities to participate in their health also

provides the opportunity for greater patient involvement and

direction of facility-based QI efforts to ensure that teams are

prioritizing the ‘right’ issues that matter most to people

44

New frontiers/opportunities

Hoping to expand focus on 1st and 2nd delays

through additional community-focused activities.

• Study to explore demand creation

• Test new change ideas to address 1st and 2nd

delays

• Participatory Women’s Groups

• Testing additonal change ideas from collaboratives

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Acknowledgements

The Ethiopia

Federal Ministry of

Health

Regional Health

Bureaus, woreda

and facility

leadership, health

care workers

Bill and Melinda

Gates Foundation

Margaret A. Cargill

Philanthropies

What is one next step you can take to advance equity in your improvement projects?

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