Reference no: EM132373437 , Length: word count:2500

General aims:

• To raise awareness of the approach of health equity and social determinants of health (SDH) among professionals in the health sector and in those employed in, sectors with the highest impact on the health of the population.

• To provide a tool that eases the integration of equity into health Strategies, programmes and Activities (SPAs).

ANALYSIS OF THE SPA'S EQUITY

1. What are the aims of the SPA?

List the aims of the SPA.

Is there any explicit aim relating to equity?

2. What is the target population?

Describe the socio-demographic, geographic, economic characteristics and other of the target population.

In your experience, which are the different social groups that need to be identified within the SPA in order to move forward in terms of health equity?

Answer the questions and complete the table.

Are there social groups not taken into account in the SPA's definition?

Does the SPA consider taking additional actions for some specific social groups?

Regarding the SPA's formulation, are there any social groups benefiting more than others?

Regarding the SPA's results, are there any social groups benefiting more than others? For example: are there groups with earlier access to new programmes or actions?

Do the SPA's interventions negatively affect any social group? For example, an excluded group or an action that will increase inequities.

3. Evaluation of the health needs of individuals

Does the SPA regularly analyse the health needs of the target population? Explain your answer.

There are several definitions of health needs. Which of the definitions of needs is more similar to the one employed by the SPA? Give a mark from 1 to 5 for each definition, (1 = very similar and 5 = very different).

4. Analysis of interventions

List all the SPA's interventions. In the case of a strategy, if there are not explicit interventions, detail the actions that are carried out in its development:
In the case of detailing interventions, indicate which ones come from individual approaches and which ones correspond to population approaches. In case of not detailing interventions, indicate what the global SPA's orientation is, in other words, indicate whether it is and individual or population strategy:

5. Implementation of interventions Describe the players that implement interventions within the SPA analysed.

What are the difficulties identified during the SPA's implementation?

What kind of supervision or coordination exists between the SPA and the players implementing the interventions?

What type of participation do these actors have in the formulation of the SPA?

Methodological Guide to integrate Equity into Health Strategies, Programmes and Activities

6. Intersectoral action

Answer the questions according to your experience with the SPA (in its formulation or implementation) up to now.

Does the SPA include any intersectoral action?
With what sectors?
If intersectoral action is included, what are the existing coordination mechanisms between the SPA and other sectors (permanent working group, joint scheduling, only joint evaluation or sporadic contact)?
Is there a specific budget and plan in place for intersectoral action?

7. Participation

As seen in the section about Social Participation in chapter 3, there are different types or mechanisms of participation (Wheel of Participation). Answer the following questions with reference to this section:

Questions No Yes Which one/ones?
Does the SPA include mechanisms of participation?
Is there a specific budget and plan in place for participation?
What groups and/or organisations are taken into account in the participation?
How do they participate?
Mechanisms and types of participation:
- Information
- Consultation
- Participation
- Collaboration
- Empowerment
For what purposes do they participate?
According to your experience, what are the main obstacles to participation?

8. What are the expected results of the SPA?

Explain what the expected results of the SPA are.

Explain the main achievements of the SPA.

What issues or aspects of the SPA do you think are still pending and are relevant? (What remains to be done?)

What indicators are relevant to the SPA?

Which was the most recent evaluation of the SPA?

Answer the following questions relating to the SPA's results:

Can you demonstrate that the SPA has contributed to improving the health of the target population?

Has the improvement been equitable for all social groups?

Has the SPA enabled better access to healthcare assistance and to actions for prevention or health promotion as defined in the SPA?

Has the improvement in access been equitable for all social groups?

9. Equity Challenges

Drawing on your experience and knowledge, what are the core equity challenges that need to be addressed by the SPA?

Taking into consideration the framework of the WHO Commission on Social Determinants of Health (chapter 3), think about which Determinants (intermediary and structural) may be linked to your SPA.

Review cycle: E-Q-U-I-T-Y

Aims
1. To analyse the general characteristics of the SPA, identifying its interventions and key stages.
2. To understand the SPA theory and to assess whether it includes an equity and SDH approach.
3. To identify and select the scope of the review.

Activity 1: Analysing the goal of the SPA

To start the review cycle, firstly, it is necessary to undertake a general analysis so as to understand what the SPA wants to achieve and the original context of its initial development. That is to say, the SPA's "why" and "what for".
Reviewing the objective of the SPA helps to specify the conceptualization of the problem or issue that it tackles. In many cases, a SPA comprises several objectives, what makes the review of the SPA a complex process.
Reviewing the aims section of the previously made checklist will assist in this process.

Activity 2: Identifying and classifying the interventions or actions included in the SPA

First of all, it is necessary to identify the interventions included within the SPA by considering the following question: What does the SPA do or recommend to be done to tackle the problem identified? (Describe the actions and interventions included in the SPA).
Once all interventions are identified, they will be classified as shown in the table. This will enable a more comprehensive view of the SPA.

Activity 3: Identifying and drawing a diagram of the SPA's key stages

It is necessary to identify the key stages? of the SPA. In other words, we need to sequence the process of the SPA's development, separating the different stages leading to the final objective. Once these key stages or phases are identified, it will be helpful to produce a diagram that presents the SPA in a simple manner and allows for subsequent activities.

It is important to bear in mind that this activity considers the SPA as it currently is (and not as we would like it to be).

The simplest way to present the SPA's key stages is to follow the diagram that comes next, though it may prove more useful when working with programmes and actions than with strategies:

Diagramming must be a flexible and dynamic process, taking into account there is no unique or true way of representing the key stages. The best option will be the one that best suits the specific situation of every SPA and the needs of the working team. In fact, it is possible that changes to the diagram will be introduced as we move forward in the review.

Activity 4: Defining the SPA's theory

The SPA's theory is the set of fundamentals, evidence and hypothesis which the SPA is based on. The SPA's theory will help us to find out more about the theoretical premises the SPA is built on and which justify the use of the SPA as a means to achieve the expected goals. Frequently, the SPA theory is not explicit, therefore it can be useful to analyse how the SPA is organised, the interventions involved as well as the goals and the attained results20.

Reflection and analysis regarding the SPA's theory is a must. The following questions can be used as a guide:
1. What is the general situation of the problem being tackled by the SPA?
2. In what way will the SPA's implementation moderate the problem?
3. What are the fundamentals, evidence and hypothesis that justify the SPA's implementation?
4. What are the expected results in each intervention of the SPA?

Activity 5: Assessing whether the SPA's theory incluyes an equity and SDH approach

In this activity, the working team must consider whether the equity and SDH approach is included in the SPA's theory, in other words: how does the SPA's theory conceptualise the problem of health inequities? In order to specify the answer, two aspects must be reviewed:

a. HETEROGENEITY: Does the SPA's design take into account in its interventions the heterogeneity of the target population?
This section invites reflection on how the SPA's design has taken into account the specific needs of the different segments of the population, either in terms of content or the intensity of actions; does the SPA recognise different needs and hence propose different interventions or actions? Is there a different method of working depending on social groups, territories or individuals within the SPA? What actions are proposed in order to tackle these differences?

b. HEALTH EQUITY: Has the impact of the SPA on health equity been explicitly defined in the design?
The working team should analyse whether the SPA design takes into consideration the way health inequities show up, their origin and what impact the SPA has on them. In this sense, the inclusion of equity-related indicators or aims in the SPA is not enough. We need to consider whether the mechanisms, actions and interventions lead to the reduction of inequities and whether they tackle SDH or not. If they do, we need to think about which ones they tackle and in what way.

Activity 6: Framing the review, if needed

In many cases the SPA is complex and comprises several sub-programmes. This can make it difficult to review the SPA in its entirety. Before taking the next step, the working team must decide whether a complete review of the SPA is applicable or whether it is preferable to prioritise one or several parts of it.

Step Q:

Activity 1: Identification of target groups/sub-groups of the SPA

The first activity in this step is to identify which groups or sub-groups of the target population must be considered for analysis of their differences with regard to the SPA.

Groups/sub-groups can be defined by:

• Income, education, occupation, social class or other socioeconomic indicator.
• Gender.
• Age group (adults, elderly, teenagers, etc.).
• Employment situation (employed-unemployed).
• Ethnic group.
• Disability.
• Location:
o Urban-rural.
o Autonomous Community, province, town, etc.
• Others.

Activity 2: Initial assessment of groups/sub-groups in each key stage of the SPA

Once the groups or sub-groups of interest have been identified for the analysis, the working team must examine-using its experience-the key stages of the SPA and describe the groups they think are accessing and benefiting in each stage.

Activity 3: Analysis of groups/sub-groups in each key stage of the SPA

Once the preliminary assessment is made of which groups and sub-groups access and benefit from the SPA according to the experience of the working team, it is important to undertake an analysis of this assessment using the sources of information which are available -quantitative and qualitative- that will enable the analysis undertaken in activity 2 to be completed and adapted.
In order to do that, the following activities will be implemented:

A. Identification of the information available.
B. Data extraction and analysis.
C. Interpretation of data.

Activity 4: Identification and prioritisation of group(s) or sub­ group(s) in a situation of inequity

Results from the previous analysis must be reviewed and a reflection has to be made regarding:
• Which groups have less probability of accessing each stage or benefiting from it? If working with territories, identify those with the greater differences and interpret the implications for the target social groups.
• At which stages are the differences greater?

• Is there any other group harmed by the intervention (negative externalities)?

• Are there any consequences for other sectors?

Potential consequences of the actions or interventions of the SPA for other sectors must be analysed. For example, a recommendation for the restriction of the tuna consumption could have a negative economic impact on the fishermen and the tuna­ related industry. This is how a preventive health action can have a relevant social impact on other sectors, especially regarding those groups or territories that are more vulnerable. Once the groups have been characterised, they can be classified by priority according to their inequity situation. If the revision is considered as not feasible for all groups identified, one or several groups will be chosen to focus the review and redesign of the SPA according to the prioritisation employed. It is important to justify the prioritization cristeria used. In order to ease the process, a brief summary of the main criteria used in different methods of Public Health prioritisation has been provided in Annexe III.

UNDERSTANDING barriers and facilitating factors in each key stage

Activity 1: Analysing the main difficulties and support that the prioritised sub-group finds in each key stage of the SPA

Having prioritised the group(s) without access to the SPA or which have not obtained the expected results from the SPA (last activity of step Q), the aim in this step is to identify the main difficulties the prioritised group(s) have to face and the main forms of support they have in each key stage. Using the Tanahashi model of effective coverage (see Figure 16)22, the question must be asked as to whether the problems related to lack of access or benefits that the prioritised group confronts are linked to the presence of barriers or the absence of facilitators, and their relative weight which these have.

INTERRELATING the SPA with the Social Determinants of Health

Activity 1: Interrelating barriers and facilitators to intermediary determinants (Social Determinants of Health)

Analysing which intermediary determinants are linked to the different barriers and facilitators.
Using the following table, interrelate the identified barriers and facilitators with the intermediary determinants. Mark with an X the one(s) which is/are linked.

Activity 2: Interrelating the SPA analysis to structural determinants (Social Determinants of health inequities)

Within the structural determinants, we need to analyse socioeconomic position on one hand and context on the other. As such, this activity is comprised of two parts:
a) Characterisation of the prioritised social group(s) in relation to their socioeconomic position
The prioritised group(s) in step "Q" is placed in a specific stratum of society. In this activity, the goal is to characterise the groups regarding its socioeconomic position.
Taking into account the conceptual framework of SDH of the WHO Commission on Social Determinants of Health, the following actions will be required:

Description of the prioritised social group from the perspective of resources and prestige.
Summarise in one paragraph how you would characterise the social group prioritised from the perspective of resources, prestige, impact of belonging to a specific group throughout life-cycle, especially in the first years, etc.
Analysis of the existence of barriers within the social group prioritised.

The team must discuss and reflect on the hypothesis about why barriers are present and why they are greater in this group; summarise it in one paragraph. The following questions may serve as a guide for the discussion:
• How would you link the socio-economic position of the prioritised social group with the identified barriers and facilitators?
• Why are they present in these groups and not in others?

• Why barriers are greater in the social group prioritised by the working team?
b) Analysis of the SPA's context

The context analysis can be structured in the following way:

Analysis of micro-context: Micro-context where the SPA is developed can be assessed as the positive or negative influence of other programmes and interventions during the development of the SPA, as shown in the following diagram.

Activity 3: Intersectoral action and social participation in the SPA's development

Intersectoral action and social participation are two key strategic axes for addressing SDH and health inequities. In order to analyse how the SPA integrates these strategic aspects, we will develop the following activities:
a) Identification of the role that intersectoral action plays in addressing the barriers found in the SPA:
Identify, where appropriate, which are the other sectors-apart from health- involved in the creation of barriers, or that are necessary for addressing them or giving a solution. Complete the following table:

b) Identification of social participation aspects in addressing the barriers found in the SPA:
Identify which aspects of social participation would be important to integrate in the SPA to reduce or remove barriers. Complete the following table:

Step T: THINKING of the redesign plan

Activity 1: Identification of aims and priorities for the redesign

For this activity, the following aspects will be developed:

a) Defining a new theory for the SPA including the equity and SDH approach:

The working team will need to review the materials of the four steps prior to the review, and reach a consensus of the new SPA theory: based on the SPA's theory made by the team at the outset, assess what modifications will need to be made for the integration of the health inequities theory approach.

b) Reviewing the SPA's key stages and interventions and proposing the inclusion of new stages and interventions for addressing the SDH:
Within the team, discuss the following questions:

• Which are the most important access barriers? In which of the SPA's key stages?
• Which are the most important access facilitators? In which of the SPA's key stages?
• Are all necessary interventions envisaged? Are there interventions addressing the barriers identified in the review process? If there are not, propose interventions to act upon the barriers.
• Are there interventions to boost the facilitators identified? If there are none, propose interventions to boost facilitators.
• Are there interventions addressing the aspects included in the new SPA theory to reach equity and social determinants approach? If there are not, point out which would be feasible or advisable.

Activity 2: Identification of areas and levels of action in the redesign

The working team will have to identify the areas and levels of action needed to accomplish the aims and recommendations of the redesign. The area of the actions necessary for the redesign must be taken into consideration and those actions to be implemented in the SPA must be specified (changes or recommendations). For example, the redesign areas could include:
• Modification of the SPA's contents: incorporation of a new service or adjustment of an existing service.
• Structural and organisational changes.

• Improvement of management and implementation at local, regional and national levels: Training, supervision and management control.
• Actions at a core level to improve the implementation: Regulations, guides, follow-up and monitoring systems (indicators).
• Improvement of knowledge, abilities and implication of the prioritised social group with regard to the programme.
Once the actions which are to be carried out and their corresponding areas have been established, the level or levels of implementation of the proposed action must be defined: national, regional or local.

Activity 3: Integration of intersectoral action and social participation into the SPA

For the results to be effective and sustainable, it is important to integrate social participation and intersectoral action in the redesign of the SPA.

In the same way that inequities are the result of a complex accumulation of disadvantages, interventions must normally be tackled through a network of multiple sectors and levels. The sequence and coordination of other sectors' implication and the level and type of social participation must be part of the redesign.

From this perspective, intersectoral action becomes an essential requirement for addressing inequities and SDH.

In this step, to approach the issue of intersectoral action, the working team needs to analyse the interrelated sectors that have previously been identified (Page 98: Step I, activity 3).

The team must answer the question: What actions or interventions are needed from other sectors to address the identified barriers and the health inequities and to attain the aims of the redesign?

In relation to social participation, spaces and conditions for participation allowing vulnerable communities to reach a greater control on material, social and political determinants of their own welfare must be created. Empowerment, as conceived from the Health Promotion perspective, is inseparably connected with the achievement of effective control by communities of the political and economic processes that affect their welfare. Participation on its own cannot be considered a real empowerment without paying attention to the results of the political processes, that is to say, the redistribution of resources and power. It is necessary to go beyond participation in the decision-making process, emphasising control and transparency. The growing capacity of communities to control key processes affecting their lives and the quality information is the basis for empowerment.

The type of participation predominant in the SPA and the keys stages of the SPA in which it was present or absent has already been discussed in the previous steps. Moreover, based on the identified barriers, an analysis of the role played by social participation in overcoming these barriers has already been analysed. In this step, the type of participation that the team will foster in the SPA's redesign and the actions and spaces needed for its development will be defined.

For this purpose, the team will answer the following question: Which mechanisms, actions or recommendations could the SPA establish to redistribute power from the participatory spaces (giving more participation to the SPA's target individuals and to other civil organisations)?

Attachment:- Methodological Guide Equity.rar