| How Exemplars demonstrated a focus on equity | Detailed strategies | Country examples and links to more detail |
|---|---|---|
| Prioritize high-need areas and communities for rollout of interventions | Piloting in areas of highest need (e.g. areas with highest burden of disease, poorest areas, or geographically hard-to-reach areas) supports testing of feasibility, to ensure the implementation approach is appropriate to that area | Bangladesh’s phased introduction of FB-IMCI in areas of highest U5MR. (Bangladesh narrative) |
| Integrate equity considerations into the demographics served within a certain community (e.g. age, gender) | In Bangladesh, local groups that oversaw community clinics had to have female or adolescent male representation of at least 1/3 of the overall group, to ensure adequate representation of the elements of the population that used community-level services the most. For the same reason, the local groups needed to have a female as either its president or vice-president. (Bangladesh narrative) | |
| Use CHWs to reach hard-to reach and underserved areas |
CHWs can be responsible for 1) basic prevention and treatment measures, 2) health promotion and education, and 3) referring complicated cases to health facilities | In Ethiopia, the Health Extension Program sought to expand health services in Ethiopia’s rural and pastoralist communities. (Ethiopia narrative) |
| Improve access to family planning, to empower women and help reduce neonatal mortality |
Integrate family planning into national priorities | In Bangladesh, family welfare assistants visited couples to distribute contraceptives and provide guidance on family planning. (Bangladesh narrative) |
| Use community health workers to promote family planning measures |
In Nepal, the Female Community Health Volunteers promote family planning and distribute contraceptives, again helping to improve reproductive rights for women. (Nepal narrative) In Bangladesh, different cadres of CHWs over time have been responsible for providing family planning services, starting in 1976 with the family welfare assistants, who were a female-only cadre under the Directorate General of Family Planning. More recently, starting in 2011, the Directorate General of Health Services introduced a cadre of community health care providers, whose responsibilities included providing family planning services. (Bangladesh narrative) In Senegal, the bajenou gokh cadre of CHWs focus on maternal, neonatal, and child health promotion at the community level, including family planning consultations. (Senegal narrative) |
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| Narrow the equity gap between women and men, as a critical contextual factor that influences U5M. Ways to do this include policy change, community education, and incentives | Narrow gap in school enrollment among girls and boys. Track key indicators of gender parity, including school enrollment, literacy rates, and proportion of women in the workforce | Bangladesh's Female Secondary School Stipend Project; provided girls with stipends for attending school at least 75% of the time and maintaining passing grades. (Bangladesh narrative) |
| Provide health insurance to populations most in need | Identify the families most in need, e.g. by classifying the population / families into socioeconomic categories |
To determine level of financial support for health insurance, Rwanda used a system called ubudehe, to classify families in a village into socioeconomic categories. While health insurance coverage was still universal, this system created a pay scale for how much different individuals had to pay. |
| Identify the percentage of people covered under private health insurance, or under other government insurance (e.g. as civil servants, military, and law enforcement). Identify the level of funding available, and from here, set a target for percentage of the population to cover |
Rwanda’s community-based health insurance, Mutuelle de Santé. |
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| Track out-of-pocket health expenditure per capita over time, to see progress | Senegal tracking OOP health expenditure as part of the mutuelles de sante (voluntary community-based insurance plans) 1 | |
| Develop financial incentives to motivate uptake | Motivate uptake of interventions, e.g. through building them into community education and/or financial incentive structures (such as conditional cash transfers) | In Peru, 6 antenatal care visits were a condition for the Juntos cash transfer program. (Peru narrative) |
| If using financial incentive structures, create accountability structure to make sure the criteria for incentives are met | In Peru, compliance with Juntos requirements was directly verified by healthcare providers and monitored by the program’s field staff at bimonthly health center visits. Households who did not meet their specific requirements for cash transfer, including attending ANC as applicable, were considered ineligible to receive the transfer for three months.2 (Peru narrative) |
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| Remove other barriers to access | Minimize other financial barriers beyond health insurance, e.g. by waiving access fees for key populations |
In 2005, Senegal introduced the free delivery and cesarean policy (FDCP), which exempted health care users from fees for normal deliveries at health posts and health centers. (Senegal narrative) Nepal promoted facility-based delivery through the Maternity Incentive Scheme, which offered women a cash payment to help offset the costs of facility-based delivery (especially transportation costs). This was later folded into the Safe Delivery Incentive Program, which added free delivery services in the 25 poorest districts and other incentives for antenatal care. (Nepal narrative) |
| Ensure that facilities adhere to the fee structures implemented by the national government | In Ethiopia, FMOH made maternity and family care services (including antenatal care) free of charge at health posts, health centers, and primary hospitals.(Ethiopia narrative) | |
| Consider cultural beliefs and preferences in the areas of the intervention rollout, to improve uptake and sustainability | In Peru, vertical birth position and maternal waiting homes for families. (Peru narrative) | |
| Use local research organizations to study contextual factors that are barriers to access (See recommendation 4) | ||
| Even while prioritizing equity and improved access, ensure that quality is improved in tandem | In Peru, a 2006 study found that Proyecto 2000 likely improved quality of care at health facilities. (Peru narrative) |
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1
University of Global Health Equity. Exemplars in Under-5 Mortality: Senegal Case Study. Kigali, Rwanda; 2019.
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2
University of Global Health Equity. Exemplars in Under-5 Mortality: Peru Case Study. Kigali, Rwanda; 2019.
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3
USAID. African Strategies for Health - Health Insurance Profile: Rwanda. United States Agency for International Development (USAID). http://www.africanstrategies4health.org/uploads/1/3/5/3/13538666/country_profile_-_rwanda_-_us_letter.pdf. Accessed Apr 23, 2020.
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4
Lu C, Chin B, Lewandowski JL, et al. Towards Universal Health Coverage: An Evaluation of Rwanda Mutuelles in Its First Eight Years. PLoS One. 2012;7(6):1-16. https://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0039282&type=printable. Accessed Apr 23, 2020.