Monitoring Equity: An Active Approach

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Monitoring Equity An Active Approach
Presentation to International Community
Indicators Meeting Burlington, December 1st
2005 Supported by CDC, Atlanta

• Antoinette Ntuli,
• Chair, Global Equity Gauge Alliance

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This Presentation

• Patterns and dynamics of health inequity
• The GEGA approach
• An example of Equity Gauge community monitoring
  activities

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Health inequalities between countries life
expectancy, 2000
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Health inequalities countries maternal
mortality, 1991-1997
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Disparities by SES lower-income countries

• Venezuela (1994) poor municipalities in a city
  had infant mortality rates 3 times those of
  non-poor municipalities
• Immunization coverage correlates with
  wealthAfrica, Asia, Latin America (Gwatkin 99)
• Zambia (1996) infant mortality among the poorest
  nearly 2 times that among the least poor (124/ vs
  70/1000)

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Gender disparities

• India (Das Gupta 1987) girls twice as likely to
  die by age 2 as boys, probably due to family
  behavior
• India, Bangladesh, Pakistan (UN 1989) 1/6 girls
  died from neglect and discrimination
• Large differences in immunization and nutritional
  status of girls vs boys
• Chile (Vega 2001) Women pay more for private
  health insurance and more out-of-pocket for
  public services

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Living Conditions by Race, S. Africa
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HIV/AIDS in SA- 600 people dying every day from
an AIDS related illness

• HIV prevalence in 15-49 age group estimated to be
  18.4 for Africans and 6.2 for whites
• Estimated HIV prevalence among those with medical
  insurance, (largely the wealthiest section of
  society) is estimated to be around 5-6, well
  below the national average of around 30
  (Connelly).
• SA - households with a member with AIDS spend 34
  of their monthly income on health care. Non-AIDS
  households spent 4 (HDA).
• Age 15 - 49
• 28.4 among urban dwellers in makeshift housing
  as compared with 15.8 among the urban formal
  (Shisana et al).
• Poor African women most at risk - infection
  rate in men is 74 of that in women

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Global health changes in the last century
Source World Bank 2003
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Difference of income between the rich and the
developing countries 31(1820) and 7001(1999)
(Source Poverty, Health Development AIFO)
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SA Private/Public per capita spending ratios
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Percentage of Health care personnel in the
private and public sectors, 1999
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More health workers fewer deaths
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THE GLOBAL CONVEYOR BELT OF HEALTH PERSONNEL

500 million a year subsidy from poor to rich
countries
HEALTH SERVICES, HIGH INCOME COUNTRY
HEALTH SERVICES, MIDDLE INCOME COUNTRY
PRIVATE SECTOR LOW INCOME COUNTRY
URBAN CLINIC
URBAN HOSPITAL
RURAL CLINIC IN LOW INCOME COUNTRY

Padarath et al
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Global Economic and Trade Policies

• Rising Debt and outflow of resources (1980 60bn
  2000 206bn)
• Liberalisation, privatisation and escalating
  costs
• International agreements that limit governments
  ability to promote and safeguard public health
  (GATS)
• Trade barriers to cheaper drug access (TRIPS)

Source Seatini
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Does inequity matter?

• Practical and ethical considerations
• Human Rights WHO constitution - Right to
  health for all people
• Social, distributive justice
• Social Stability political and law and order
• Ethnic and racial prejudice
• Economic growth

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Definitions

• Inequities are differences in health that are
  unnecessary, avoidable, unfair and unjust and
  therefore Equity in health implies addressing
  differences in health status that are
  unnecessary, avoidable and unfair between groups
  of people
• Equity in health implies directing more
  resources for health to those with greater health
  need
• Equity in health means having the power to
  influence decisions over how resources for health
  are shared and allocated

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The Global Equity Gauge Alliance
Assessment and Monitoring
Community Empowerment
Advocacy
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The 3 Equity Gauge pillars interconnected actions
ADVOCACY
COMMUNITY EMPOWERMENT
ASSESSMENT MONITORING
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3 Pillars

• Assessing and Monitoring to provide evidence of
  the current dimensions of health inequity, as
  well as changes over time
• Actively supporting community empowerment in
  developing projects, advocacy campaigns, and
  interventions
• Advocating for health equity through
• Influencing decision makers through an expert
  role
• raising public awareness and shaping public
  discourse
• Influencing decision makers through a campaign
  or by social action

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Country Equity Gauges
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An Equity Gauge as an Agent of Change

• An Equity Gauge functions as a catalyst for
  equity, strengthening the work of existing groups
  by building partnerships to
• Provide evidence of inequities
• Strengthen community voices
• Strengthen the link between community groups and
  decision makers
• Directly support the role of decision makers
  through the above

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Partnerships

• Equity Gauges comprise COUNTRY LEVEL PARTNERS
• Government offices, ministries (health, planning,
  finance), parliamentarians, other policy makers
• NGOs at the community, local, national, and
  international levels
• Research and policy institutions, and universities

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Case Study SA Equity Gauge

• Partnership with Parliamentarians, communities,
  NGOs
• Providing evidence through monitoring inequities
  access to social determinants including
  employment, housing, healthcare, access to basic
  services
• Technical support for Parliamentarians, including
  workshops, site visits, budget analysis
• Partnership with multi-media project
• Indicators database (www.hst.org.za)

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Community Partnership - HIV Monitoring Tool

• Conceptualised as a mini Equity Gauge all three
  pillars( monitoring and assessment, advocacy and
  community empowerment) incorporated into the
  project.
• Intention empower communities through
  development of a community based HIV monitoring
  tool t
• Equity focus one urban and one rural area
• Results/findings from monitoring tool used to
  highlight inequities and advocate for improvement
  in services
• Local champions/drivers of the process clinic
  committees together with communities both
  supported by the Equity Gauge 

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The Process

• Embarked on series of PRA exercises to understand
  the communities and their needs
• Information sheets on ARVs and Govts Operational
  Plan produced and widely distributed
• Community meetings, meetings with Dept of Health
  staff and local stakeholders to introduce project
  and to get feedback on proposed processes
• Tool developed, tested and piloted
• Clinic Committee together with the community
  complete tool

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Findings

• In Sterkspruit (rural site) community have
  identified following areas for attention
• Lack of information on HIV and ARVs, Stigma and
  Discrimination
• Getting to the clinic is difficult there is no
  reliable and affordable transport system (hiring
  a private car to get to the clinic can cost R300
  (42USD)
• There is no ambulance to transport people to the
  hospital.
• Clinic often runs out of food supplements for
  people on ARVS, is not open on weekends, lacks a
  telephone, and there are frequent drug stock
  outs
• Lack of home based carers

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Lessons to date

• Working with communities time consuming, and
  especially in developing jointly identified
  priorities
• Power imbalances within the community can
  contaminate initiatives
• Sustainability is important. Therefore critical
  to involve and capacitate members of the
  community to be drivers of the work
• Buy-in from health authorities equally important
  initiative must not be seen as being
  antagonistic or threatening to them

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GEGA Challenges

• Number and level of public priorities, especially
  in the poorest countries
• Poor quality of data
• Translating information and evidence into
  persuasive and effective public arguments
• Sustaining partnerships - Different levels of
  information needs and advocacy attention, windows
  of opportunity
• Swimming against tides of privatisation, global
  forces, and deregulation

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GEGA Successes

• Assembling a constituency of diverse stakeholders
  
• Context mapping to direct goals and strategies
• Institutionalization of equity-sensitive
  indicators and targets in on-going monitoring -
  Chile
• Policy effects achieved by many Gauges Zambia
• Marked differences in the positioning of equity
  in public discussion and debate
• Improved processes for public and political
  decision-making El Tambo
• Publications in peer reviewed journals

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