National and sub-national governments are routinely required to develop health policies, strategies and plans. These include comprehensive national health plans as well as more focused plans, such as post-disaster recovery plans, community health plans, and reproductive health plans. All too frequently, these plans are not based on a thorough assessment of how the health system is functioning, particularly with regards to producing equitable results for various sub-populations. A country can have several plans at once, each covering separate programs, with no clear framework guiding how they fit together and how they jointly contribute to the overall health system. Furthermore, health plans often resemble “wish lists” with too many objectives and activities to achieve with realistic expectations about human and financial resources. Finally, sub-national governments sometimes struggle to adapt or customize national policies and plans to their particular context, and then to implement them effectively.
These challenges are the main contributors to the “implementation gap,” or the difference between what policymakers plan to do and what target populations actually experience. The implementation gap tends to be particularly severe in disadvantaged and hard-to-reach areas and contribute to health inequities, which have improved slightly in many countries over the past decade, but far too slowly (Victora et al 2012).[i] The implementation gap, coupled with the growing demands for accountability for domestic and foreign resources, have led development partners and civil society to demand greater rigor and transparency in planning processes, and more objective and detailed monitoring and evaluation practices.
In response to these challenges, donors and researchers have produced numerous manuals, guidelines and tools to support improved planning, implementation and monitoring. In the early 2000s, UNICEF and the World Bank developed a tool called “Marginal Budgeting for Bottlenecks,” which was the first tool that allowed users to systematically assess deficiencies in the overall health system, develop strategies to overcome these deficiencies, and then project the costs and impacts of alternative scenarios.[ii] The MBB was applied in dozens of countries around the world and led to enhanced prioritization of maternal, newborn and child health and nutrition programs under a holistic “health system strengthening” approach. The MBB, however, faces certain challenges such as its substantial data requirements, complicated interface, and lack of a systematic approach to analyse and address health inequities. The Johns Hopkins Bloomberg School of Public Health simultaneously developed the Lives Saved Tool (LiST)[iii], which allows users to project the impacts of changes in coverage of health and nutrition interventions on child mortality using rigorous data and validated assumptions; this tool has quickly become one of the more popular and trusted resources for projecting the impacts associated with changed coverage of MNCH interventions.
In 2012, WHO and the UN Inter-Agency Working Group on Costing (IAWG-Costing) developed the OneHealth tool, which attempts to link strategic objectives and targets of disease control and prevention programmes to specific investments in health systems. The tool provides planners with a single framework for scenario analysis, costing, health impact analysis, budgeting and financing of strategies for all major diseases and health system components.
The EQUitable Impact Sensitive Tool (EQUIST) was developed in this context, as a strategic planning, modelling and monitoring platform that links other tools: for example marrying the conceptual framework of the MBB with LiST’s impact projection function through a substantially easier and more visual user interface. The tool was designed to help governments and the global health community think about issues of equity in maternal, newborn and child health in a more systematic and evidence-based way, and to design health strategies that will lead to stronger, more resilient health systems. Applications of EQUIST at sub- national or national levels can serve as a solid background or follow-up analysis to support OneHealth Applications, which in turn are primarily intended to inform sector- wide national strategic health plans and policies.
EQUIST was conceived of and designed by health specialists working at the United Nations Children’s Fund (UNICEF). It was built by Community Systems Foundation (DevInfo). Funding was provided by the Bill and Melinda Gates Foundation. EQUIST is linked to the Lives Saved Tool (LiST), developed by the Johns Hopkins Bloomberg School of Public Health, estimate cost using World Bank costing module in the Marginal Budgeting for Bottleneck tool (MBB), and uses data globally available (MICS, DHS).