Monitoring health equity for social
marketing programs in Nepal
Rebecca Firestone, Nirali
Chakraborty, Mahesh Paudel,
Nicole Bellows
9th World Congress on Health
Economics
7-10 July 2013
Contact: rfirestone@psi.org
Background + Objectives
Nepal
Under-5 mortality 48/1,000
live births
Maternal mortality
170/100,000 live births
PSI implements
malaria prevention
and family planning in
Nepal using social
marketing strategies
Data sources: UNICEF, World Bank
How do we know that programs are
reaching target populations equitably?
Implementers need reliable and
actionable measures of equity in
program performance. We aim to:
1. Estimate socio-economic
distributions of health outcomes
from survey data using an SES
measure benchmarked against a
national reference population
2. Estimate socio-economic
distributions of programmatic
exposure
3. Disaggregate outcomes by
exposure level
Methods
 Data
– Population-representative 2011 survey of 1078 households on family planning in 23
districts where PSI operates, measuring
• Modern contraceptive use
• Exposure to any IUD messages, to PSI-branded communications on IUDs
– Population-representative 2010 survey of 3327 households on malaria prevention in
13 districts where PSI operates, measuring
• Any bednet and any LLIN use (children <5, pregnant women)
• Exposure to PSI-branded communications on LLINs, home visit on LLIN use
 Analysis
– Wealth index constructed using asset values – means, standard deviations, PCA
weights – from 2011 Nepal DHS
– Wealth quintiles and concentration indices calculated for all measures
– Significance testing
• Chi-square test for equality of proportions for quintile estimates
• 95% CI for each quintile
• Standard errors of concentration indices to test H0
• T-test differences in means to compare concentration indices exposed
and unexposed
Modern Contraceptive Use and Exposure to Communications by National Wealth
Distribution
1
0.9
CI PSI= 0.056*
CI DHS = 0.055*
0.8
0.7
0.6
Modern method (PSI) n=1036
Modern method (DHS)
0.5
0.4
0.3
0.2
0.1
0
Q1
Q2
Q3
Q4
Use of modern contraception by exposure to PSI-branded
IUD communication
Use of modern contraception by exposure to any IUD
messaging
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0
unexposed
exposed
Q1
Q2
Q3
Q4
Q5
CI Unexposed = 0.004
CI Exposed = 0.015
41% of women exposed, H0: CIexposed=CIunexposed p=0.686
* statistically significant at p<0.05; CI = concentration index
Q5
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0
unexposed
exposed
Q1
Q2
Q3
Q4
Q5
CI Unexposed = 0.071*
CI Exposed = 0.006
54% of women exposed, H0: CIexposed=CIunexposed p=0.026
Malaria Prevention Outcomes and Exposure to Communications for Children < 5
(n=1805)
by National Wealth Distribution
1
0.9
0.8
0.7
CI under LLIN= -0.035*
CI under any net= 0.012*
Slept under LLIN
0.6
0.5
Slept under any net
0.4
0.3
0.2
0.1
0
Q1
Q2
Q3
Q4
Children <5 under LLIN by exposure to PSI-branded
LLIN communication
Q5
Children <5 under LLIN by exposure to LLIN briefing
1.0
1.0
0.9
0.9
0.8
0.8
0.7
0.7
0.6
0.6
0.5
0.4
unexposed 0.5
0.4
exposed
0.3
0.3
0.2
0.2
0.1
0.1
0.0
unexposed
exposed
0.0
Q1
Q2
Q3
Q4
Q5
CI Unexposed = -0.0.129*
CI Exposed = -0.049*
67% of children exposed, H0: CIexposed=CIunexposed p<0.001
* statistically significant at p<0.05; CI = concentration index
Q1
Q2
Q3
Q4
Q5
CI Unexposed = -0.051*
CI Exposed = -0.022*
30% of children, H0: CIexposed=CIunexposedp=0.188
Findings and Recommendations
 Distribution of LLINs favored the poor among children <5. For
any bednet use and contraceptive use, the wealthy fared slightly
better
 Population in areas where PSIS operates had higher levels of
contraceptive use than DHS, but comparable level of equity
 All outcomes tended to be more equitably distributed among
those exposed compared to unexposed
 Social marketing programs can reach the poor and
contribute to equitable health outcomes
 Equity monitoring can be used to adjust
implementation strategies to ensure programs are
reaching target populations as intended
 Further reading at http://www.biomedcentral.com/14712458/13/S2/S6