Real-time wealth assessment to ensure results‑based financing systems reach the poor


Results-based financing (RBF) can improve the quality and safety of healthcare in low-and middle-income countries (LMICs) by linking funding to specific, verified results. RBF programs frequently focus on reaching the poorest and most vulnerable members of a population, but this cannot be achieved unless the program can ensure care is truly reaching the poor.

Monitoring equity in health system service delivery, therefore, is essential to successfully allocating health finance resources. Measuring equity, however, is typically time consuming and expensive, which creates challenges for LMICs and for individual ministries and programs.

Bluesquare is a global data company focused on digital health in LMICs. Bluesquare develops digital health platforms and tools, and works with local governments to make healthcare data collection and analysis effective for their needs – and the needs of health system clients.

This case study describes how Bluesquare incorporates real-time EquityTool wealth assessment into the health finance information systems it develops for LMICs who are using RBF.1 It also provides recommendations for scaling wealth assessment throughout digital health systems.


  • A simple way to assess if programs are reaching the poor.
  • Works with any data collection system, even paper-based systems, and is well-integrated with standard tools, such as DHIS2.
  • Results are reliably comparable to the country’s DHS.
  • Developed by a panel of experts* in the field of wealth measurement and relative wealth indices working together to create a validated method to simplify equity assessment.

*Experts represented UNICEF, USAID, UCSF, Population Services International (PSI), MSI Reproductive Choices, Results for Development, BroadBranch, and Metrics for Management.

Challenge: reaching the poor with pro-poor health programs

It is time consuming and expensive to collect community and household wealth information. This makes it difficult for programs whose work is focused on reaching the poor to be certain they are achieving their goals. Wealth measurement typically relies on infrequent, labor-intensive population-based surveys, such as the Demographic and Health Survey (DHS).

In addition to being cost-prohibitive, this type of survey is inherently unable to provide ongoing, real-time data. Programs and facilities that need equity information to make day-to-day decisions need a simple, inexpensive, reliable way to assess equity throughout the course of work.

Solution: make regular equity assessment standard practice

As LMICs increasingly adopt technology-based health information systems, they can leverage new opportunities for continuous monitoring by combining simplified metrics and digital tools. The EquityTool is a simple, easy-to-use, and free tool that makes ongoing wealth assessment and equity monitoring practical. It allows users to measure relative wealth by comparing the wealth of survey respondents to the national or urban-only population of a country.

The EquityTool is compatible with all data collection platforms – even paper-based systems. The tool measures household wealth using a short survey of country-specific questions, which can be completed in just a few minutes. Assessment requires only six to 18 questions (depending on the country) from the relevant DHS Wealth Index to reliably assess a respondent’s wealth quintile. This significantly reduces the number of variables needed for real-time, accurate wealth assessment.

EquityTool surveys can be incorporated into any survey platform. Each questionnaire identifies the percentage of respondents in each national or urban wealth quintile, and supplies the appropriate statistical code and assessment instructions for analysis. This facilitates easier and faster – and less expensive – data collection and analysis of wealth distribution and allows for fast and accurate comparisons across programs and populations.

The EquityTool empowers users to make near real-time adjustments in program delivery, in order to increase organizational effectiveness and strengthen program outcomes. It is available for over 60 countries, and survey questions are pre-translated into local languages.

Adding equity assessment to RBF monitoring: use case in Benin

An example of the EquityTool’s application to RBF comes from Bluesquare’s work with the Ministry of Health (MOH) in Benin. Benin introduced RBF in 2012 to increase the quality and reach of public health programs. Their RBF information system includes routinely collecting data from patient exit interviews and satisfaction surveys, and integrates the EquityTool into patient feedback questionnaires. This allows them to conduct real-time equity assessments.

The EquityTool survey for Benin uses eight questions to assess patient wealth. Bluesquare, the MOH’s health information system supplier, worked with the ministry to incorporate these questions into Benin’s RBF information system surveys. The EquityTool allowed the MOH to identify respondents’ socio-economic status, placing them into one of five wealth quintiles, based on DHS data for the country. This enables the MOH and individual programs to understand how many of the people they serve are in the wealth quintiles the program is targeted to reach.

Bluesquare has also worked with MOHs in the Democratic Republic of Congo, the Republic of the Congo, and Zimbabwe to incorporate the EquityTool into health information systems for similar applications.

Results: routine equity analysis supports health programs from planning through evaluation

Incorporating EquityTool surveys and analysis into RBF information systems enables MOHs and programs to automate equity assessment as part of ongoing data analysis. This facilitates monitoring to help ensure activities are reaching the intended audiences. The integration of equity data with existing patient data allows for more complex analysis and mapping of data, so MOH and program users better understand the wealth distribution in covered areas. EquityTool assessment in Benin, for example, showed that fewer people in the lowest quintile accessed services.

EquityTool analysis has also enabled Bluesquare and their clients to identify specific health concerns by wealth quintile, and understand how patients from different wealth quintiles make healthcare choices. In Benin’s analysis of reasons why individuals choose one health center over another, individuals in the lowest quintiles were far more likely to value the health center being “nearby.” Patients from higher quintiles – who were not eligible for free care – were more likely to be concerned about the cost of services.

Patients in the higher quintiles were also more likely to choose a health facility based on the competence of its personnel than those in the lowest quintiles. Even the reasons for seeking healthcare differed markedly by wealth quintile. Those in Benin’s lowest quintile primarily sought care only when medication was needed. Those in the highest quintile, however, were much more likely to seek medical consultation and prenatal care. These analyses improve campaign planning, allow facilities to address barriers for the most vulnerable populations, and can inform planning for future facility locations.

The EquityTool is also an effective tool for monitoring and evaluating health programs. Bluesquare is currently integrating the EquityTool into innovative information systems and data analysis, such as an open source health insurance information system. Equity analysis provides valuable insights for linking premiums to socio- economic conditions such as wealth quintile. Bluesquare’s experience indicates that equity analysis also provides opportunities for deeper understanding of behaviors, needs, and potential service-seeking values of target populations.

Current equity measurement is conducted through surveys that are more expensive than adding a few additional questions to a routinely collected questionnaire. Implementing the EquityTool routinely can create substantial savings.

Nicolas de Borman, CEO, Bluesquare

Next steps: planning with equity analysis in mind

Bluesquare has found that it is most effective to include the EquityTool in the program design phase. This reduces learning curves and disruption of established routines compared to altering the system later. They recommend employing equity assessment from initial system design. This ensures that the information system consistently supports the goals of reaching the poor and targeting resources effectively.

The EquityTool is a reliable and cost-effective solution. “Current equity measurement is conducted through surveys that are more expensive than adding a few additional questions to a routinely collected questionnaire,” says Bluesquare CEO Nicolas de Borman. “Implementing the EquityTool routinely can create substantial savings.”

Lessons Learned

• Incorporate wealth analysis into health information systems from the initial design.

• Equity data can be used to improve strategic purchasing.

• EquityTool data alongside other health information helps identify specific health issues and services needed by people in different wealth quintiles.

• The EquityTool is a cost-effective solution for collecting data that can be used for programmatic decision-making, and for monitoring and evaluation program impacts.

M4M can help you use the EquityTool in your project. For more information contact .

What the story of the “Three Little Pigs” can teach us about hosting

As a software company, we often design tools for our clients in the scope of a specific project. And a key success factor in any of our projects is the transfer of ownership of these tools and services we’ve designed to our client, often situated in LMIC countries. We advocate for it with tooth and nails.

Yet, we also always advise that any tools we provide remain “hosted” with us, rather than at a local infrastructure. Hosting for us is a zero-sum game, it’s far from being our most profitable line of business and it requires constant maintenance. 

So why do we offer it, and even recommend it? And wait, first, what again is hosting exactly?

Building a house for your data that won’t be huffed and puffed and blown away

You’ve heard the nursery rhyme about the three little pigs, one who built his house with straw out of laziness and whose house got huffed and puffed and blown away by a wolf. One who built it with sticks and whose house, again, got huffed and puffed and blown away by a wolf.

The third one, however, took the long road to the brickworks and built a sturdy house that the wolf couldn’t huff and puff and blow away. 

Well, hosting is very much like having a house. And you can choose the straw one, the stick one or the brick one – at your own peril. Every tool we create needs to be hosted (housed) on what we call a server (the actual house) somewhere. Somewhere with doors that only specific people can enter (enhanced data security), that won’t be easily damaged, etc. 

In fact, losing, damaging or having no steady access to your service can lead to disastrous consequences, especially in the case of health information systems.

So what type of house can you choose from to house your project?

The straw and twigs house: under-the-desk hosting

No, this is not a joke; yes this happens frequently; no not just for unimportant projects.

This kind of  hosting is a laptop dependent server. While this may be fine for people who want their own server, to game or code personally when they want to, it obviously cannot be relied upon for projects impacting the health of thousands of people.

This server is at risk not only of being closed by a well-intentioned coworker, but also of being in an unsafe environment. From high temperatures, to a lack of proper fire safety (computers don’t like water nor fire), non-existent redundancy for electric power or a guaranteed internet connection, etc.

Aside from the risks inherent to the placement of this server, scaling up the infrastructure as the project grows will be really difficult. In any case, it will be definitely harder than a click to get a bigger server or more storage for a few extra bucks paid in an instant with your credit card.

The bricks house: cloud hosting

These have a decent place to store your data: physical access is verified, a cooling system is in place, ideally there’s an uninterruptible power supply, a broadband internet connection, etc.

In the case of international hosting specifically, such as AWS, Azure, Google, etc, they even have all the right certifications in place, give easy access to instant upgrades and promote best practices in terms of keeping your house up to industry standards. In fact, we at Bluesquare use AWS and host our client’s projects on it.

But in both cases, clients still need to build up their experience and skills, and set up some processes themselves in case of an unfortunate event. And, most importantly, the team in charge of the server usually has limited knowledge on health data in LMIC countries (mostly DHIS2 based). They will probably execute some tasks once a year, where our team executes them on dozens of servers per year.

So why do we bother with hosting when it’s more work than profit?

Bluesquare hosts dozens of servers and invests in automation of provisioning (creating “new servers” based on specific characteristics), monitoring, troubleshooting, and capacity planning. On top of offering all that cloud hosting provides, we have a monitoring team expert in the DHIS2 and health data stack dedicated to investigating problems before they occur. We also minimize interventions directly on your servers by automating most regular tasks via our slack channel and bots.

And this is just the tip of what we do to keep our client’s projects from being huffed and puffed.

We do it because we are committed to making our projects succeed in the long term. Because we believe in transferring ownership, while ensuring our clients can make the most out of the tools we created without worry. We are dedicated to our clients, to our work, and hosting tools critical to their health systems is an integral part of it.

View our DHIS2 hosting options →

Bluesquare is one of the 2 organisations officially recommended by the University of Oslo to host and manage DHIS2 instances.