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ADITI RAO: The monitoring
results for equity systems

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is a planning, programming,
and monitoring approach

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conceptualized by
UNICEF in 2011,

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and further developed
and evaluated in 2014.

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This framework builds on the
existing human rights-based

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approach to programming, and is
intended to enhance and sharpen

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country programs for
accelerated results

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for the most
disadvantaged populations.

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In particular, it is based
on a determinant framework

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to identify barriers,
bottlenecks,

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and enabling factors which
either constrain or advance

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the achievement of
desired outcomes

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for disadvantaged population.

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The framework emphasizes
strengthening the capacity

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of government and partners
to regularly monitor

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intermediate outcomes to
enable more effective program

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implementation and timely
course correction in plans

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and strategies at all levels.

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The framework was
originally depicted

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as a cup with four levels,
as shown in the image.

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More recently, it has
focused more on the functions

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of the levels and
operationalizing them,

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and less on the visuals.

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But let's go with this.

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The levels here closely
follow the main components

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of a theory of change or
logic model, which many of you

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might be familiar with.

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Level one of the
framework focuses

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on situational analysis,
strategic planning,

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and program development.

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This level looks at
the quality of analysis

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of child deprivation within
country situation analyses,

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as well as how well aligned
are policy strategies

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and plans developed to the
results of the analysis.

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Specific attention is given
to understanding causes

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of deprivation, and barriers and
bottlenecks to their removal.

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Level two focuses on the inputs
and outputs of specific program

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activities or
advocacy initiatives,

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while level three focuses
on early indications

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of the removal of
barriers and bottlenecks

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identified and progress
towards equitable outcomes.

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Data from this
level is often used

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to iterate and adjust decisions
made at levels one and two.

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Finally, level four looks
at intervention coverage

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and its impact on equity.

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Once you feel you have
an adequate understanding

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of the framework,
we will explore

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how it can be used
to analyze a given

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scenario, such as
challenges arising

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from hard-to-reach populations
for the Global Polio

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Eradication Initiative in the
Pakistan and Afghanistan border

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region.

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Taking this example,
consider the GPEI

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is struggling to reach
specific populations

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in the Pakistan-Afghanistan
border region

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where routine immunization,
including polio vaccine

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coverage, is low.

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The objective will be
to identify bottlenecks

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in program delivery
and think through how

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the four major levels
of the framework that

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are inputs and
situation analysis,

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process or activities, outputs
or outcomes, and impact levels

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will shed light on
the problem outlined.

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To complete this
exercise, one can

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use the template shown here.

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Can you think of what you might
say for each of these boxes?

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In thinking about the first box,
inputs and situation analysis,

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you may consider what
is a key deprivation,

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ie poor vaccination coverage,
among which groups does

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this deprivation persist,
and how does risk exposure

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interact with equity.

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Thereafter, you may
think of activities

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to alleviate the bottleneck.

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What kinds of outputs
might we look out

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for which will indicate whether
the ultimate outcome has then

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been achieved?

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And finally, what has been the
intended or unintended impact

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of the effort?

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To make this more
interesting and challenging,

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in thinking about
hard-to-reach populations,

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try going through this exercise
separately for geographically

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hard to reach,
socially hard to reach,

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and populations
in conflict areas.

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How might the bottlenecks,
activities, outputs,

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and outcomes differ?

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Also important to consider
are the assumptions

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we are making at each step.

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When implementing
program activities,

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it is immensely
helpful to come back

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to assumptions made at each
step to better understand

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what may have worked or not and
how we might iterate processes.

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Finally, when considering
bottlenecks and barriers,

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and thereafter
outlining activities,

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keep in mind the concepts
of intersectionality.

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Communities can be hard
to reach in multiple ways.

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Often, we rush to adjust
one aspect, while entirely

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ignoring others.

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This makes finding effective
and appropriate solutions

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challenging, but
also more accurate.

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The next step to filling
out the template we just saw

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would be to identify strategies
to overcome inequity problems,

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both at the proximal program
lover and, more distally,

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at the policy level.

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Strategies can be
organized across domains.

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And here are some suggestions.

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Service delivery,
capacity-building, advocacy,

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behavior change and
communication, policy analysis

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or development.

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In thinking through
strategies, you

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may use this template to
list out the strategies

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that were used or that you
think could be used to address

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inequities in the GPEI in
Pakistan and Afghanistan border

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regions.

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I would encourage you all to
take a pause at this point

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and think through this exercise.

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In this lecture, we have
looked through challenges

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of reaching the last
1% of polio cases,

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specifically how it
relates to health equity

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and social justice, what
aspects of the program

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have caused and
perpetuated inequity,

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and what are some actions
that have been taken

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or can be taken to
adjust the gaps.

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We have also looked through some
theoretical frameworks which

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allow us to better understand
complexities around issues

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of equity in program
design and implementation,

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as well as highlight key
concepts to keep in mind as we

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progress.

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Now let's come back
to the questions

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posed for consideration at
the beginning of the lecture.

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There is obviously more
than a single right answer

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to each of these
questions, but let's think

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through some of them.

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What are the underlying
factors which

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have led the last 1% of
children with polio cases

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to be consistently
underserved, and how

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do eradication activities
confront and address

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those forces?

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Here, we can think about
political priorities

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and motivations,
systemic structures

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which favor those in higher
socioeconomic positions,

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living in wealthier
circumstances with access

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to education and
basic health services,

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whereas more vulnerable
communities are often afflicted

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with more than just
one disease or burden

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plunging them in a
vicious cycle of poverty.

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We also discussed how
eradication programs by design

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are required to reach
every last individual.

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However, the fact that this
program has experienced

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sustained difficulties
in reaching the last 1%

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reveals a weak health
system in service delivery,

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and perhaps the lack of
a holistic understanding

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of the problem.

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The program is tasked with
vaccinating every last child.

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However, whether the service
is adequately and equitably

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delivered is another
question still.

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What are long-term effects
of eradication programs?

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Are communities fatigued
with prolonged activities,

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or are they also relieved to
be receiving health services?

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Are programs fatigued
with intensive activities,

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or do they continue
to be motivated,

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having reached the last mile?

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How about can tools for
reaching the 1% developed

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for eradication be transformed
for health systems?

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A popular argument made to
support eradication efforts

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is that the immense
global investment

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in developing
infrastructural capacity,

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training human
resources, creating

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detailed maps of every
corner of the world

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can and must be transitioned
to some other health programs

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initiatives, as well as
strengthen existing tools

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and capacity.

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Or, on the other hand, we can
argue the tools and processes

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for a single disease-focused
approach cannot adjust or add

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to more holistic and
integrated programs.

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Other questions
one might consider

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in implementing
programs is how are

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global goals and local
priorities balanced,

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and how do we reimagine
and reorganize our systems

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and programs so that they are
responsive to the needs of all,

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and especially the
most vulnerable,

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perhaps towards more
just and durable future.

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So I hope I've left
you all with topics

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to consider when thinking
about achieving health equity

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and social justice when
implementing and designing

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programs.

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Thank you all so
much for your time.

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