The Equity Gauge:
An Approach to Monitoring Equity in Health and Health Care in
Developing Countries
Report of a Meeting held in South Africa, August 17th
to 20th
Background
Global Health Equity Initiative (GHEI)
The Global Health Equity Initiative (GHEI), started by a
small group of researchers in 1996 has evolved into a network linking over 100
researchers from more than 15 countries who are unified by their concern over
growing inequities in health within countries. Funded by the Rockefeller
Foundation and the Swedish International Development Authority (Sida), the GHEI
took on the following goals:
- to articulate the concepts and values underlying equity in health;
- to develop measures and tools for health research and policy to help
analyze equity and inequity in health;
- to encourage empirical research on health inequities within countries in
the developing world;
- to establish a scientific foundation for proactive advocacy, policies and
programmes; and
- to stimulate action to reduce inequities in health at all levels of
society, by providing decision-makers with knowledge and concrete
suggestions for change.
The GHEI has evolved from a research-focused initiative to an
action-based programme (called Health Equity Frontiers) aimed at policy-oriented
monitoring and remediation of inequities in health. Under the auspices of this
programme a group of practitioners and technical experts met in Chile in
November 1999. The vision emanating from that meeting was that:
"By the year 2015 every country should have an
integrated system for monitoring health inequities that informs, monitors and
evaluates health and other socio-economic policies. The systems should be
responsive to the national or local contexts in terms of priority indicators to
be monitored and strengthened by access to a common global fund of knowledge and
technical expertise."
Following the Chile meeting the Health Systems Trust was
asked to host a meeting with the aim of establishing health equity monitoring
initiatives in other countries. A call for letters of intent was widely
circulated. 30 letters of intent were received from 28 countries. An
international advisory group, comprising technical experts in community action,
advocacy and health monitoring, reviewed submissions. A total of 13 countries
were asked to develop full proposals. These proposals were presented to the
meeting by a two or three person team comprising representation from the project
stakeholders. Individuals from a further 8 projects were invited to participate
in the meeting.
The objectives of the meeting were to:
- Exchange ideas and experiences amongst equity monitoring initiatives;
- Strengthen participants’ expertise in monitoring equity;
- Lay the foundations for country monitoring activities via three working
groups- technical, advocacy and policy;
- Identify rationale and logistics for longer-term collaboration between the
national initiatives.
Conceptual Underpinning of the Meeting
What is Equity?
Equity is essentially about fairness, and implies that the
most vulnerable and needy groups within a society require access to greater
resources than those communities that are more robust. In relation to health,
such an approach is intended to improve the health of the most vulnerable at a
faster rate than those whose health status is "better", thereby
reducing the gap.
What Constitutes an Equity Gauge?
An Equity Gauge is above all a means of tracking gaps in
health status at national or sub-national levels. A gauge is centered around a
component which is about measuring and monitoring a set of agreed upon
indicators. However for such a tool to be effective in promoting equity, a
number of other components are required to ensure that the information is used.
Five core elements of an equity gauge were identified. These include:
- Fair distribution as a fundamental organizing principle of the work
- Key health systems' stakeholders be involved in the development and
implementation of the project
- Community ownership is integral to the gauge
- The technical component, with regard to both the scope of the gauge and
its measures, is valid, reliable and sustainable
- The work informs decision-making in a way that is timely, user friendly,
and accessible, and takes cognisance of current levels of awareness and
demand within countries.
The South African Equity Gauge Project
The South African Equity Gauge Project (EGP) provided the
inspiration for the meeting. This on-going project, is a partnership between the
Health Systems Trust, (an NGO), and legislators from both national and
provincial levels. The project was developed during 1998 following a series of
meetings which brought together South African legislators and technical experts
from South African and internationally.. Funded by the Kaiser Family Foundation
and the Rockefeller Foundation, the project commenced in 1999. The EGP aims to
promote equity in health and health care through measuring and monitoring a
series of key equity indicators and disseminating this information. Data on
indicators is drawn from routine surveys and commissioned research. Activities
of the project to date have included publications, workshops, site visits, and
media launches. In keeping with the project’s aim of empowering legislators,
emphasis is placed upon ensuring that technical information is provided in a
usable and accessible format, and wherever possible linked to practical
experience, thereby encouraging maximum impact on policy development and
implementation.
The Gauges
The 14 Gauges which were presented at this meeting were
diverse in terms of focus and approach. There were several city-wide gauges, a
few which focused primarily on resource allocation, a number which were centered
around national survey-related data and a couple which planned for substantial
community involvement. The table below summarises the gauges presented to the
meeting with respect to the key focus, stakeholder involvement, indicators to be
monitored and project activities.
City-wide Gauges
| |
Stakeholders |
Indicators |
Project Activities |
|
Cape Town |
Academics, "Unicity" and provincial DoH,
NGOs, CBOs and CHCs |
Health need, health resources, quality of care |
HIV used as a tracer condition to identify
discrepancies between health needs and distribution of health care
resources as well as access to health care |
|
Ecuador |
ALDES, Academics, Municipality, Indigenous
organisations |
Social macro-determinants, social participation, health
status |
Creating a new municipality-based monitoring system for
monitoring social and health inequalities particularly gender and ethnic
disparities. |
|
Kenya |
APHRC/PC, NCPD, Nairobi City Council |
Health status, quality of care |
Analysis of DHS and Nairobi cross sectional survey,
production of pamphlets, wall charts etc, workshops for parliamentarians,
consensus building seminar and donor consultative meeting |
Gauges Focussing on Resource Allocation
|
Thailand |
Academics, Health System Research Institute, Provincial
DoH, Health Care Reform Project |
Health status indicators, service utilization
indicators. Resource allocation indicators |
Analysis of secondary national data sets; commissioning
of primary research via small grants scheme; comparison with benchmarks of
fairness; dissemination via a national workshop and the media |
|
Zimbabwe |
TARSC, M o H and F, Parliamentary Budget and Health
Committees, LA Associations, health providers and civic groups |
Distribution of resources (finance, personnel, drugs),
health status, health infrastructure |
Stakeholder steering committee; review and analysis of
budget data involving public participation, benchmark setting, capacity
building, networking, dissemination via reports, advocacy meetings,
workshops and site visits |
Gauges Focussing on Community Involvement
|
Malawi |
MoH, Christian Health Assoc. NGOs, Human Rights
Organisations |
Access to and utilization of health services,
Distribution of personnel, quality assurance |
Community participation in needs assessment including
story-telling at community level to elucidate needs and concerns |
|
Philippines |
Social Weather Stations, NGOs, Bureau of Health, DoH |
Traditional/Administrative health data, non-traditional
indicators to be designed by SWS |
Gathering secondary data on health inequities;
undertake primary national research; sample province wide surveys; PRA and
focus groups to obtain local level data; develop health policy
recommendations |
National /Survey Related Gauges
|
Bangladesh |
ICDDR,B: Centre for Health and Population Research,
BRAC, Bangladesh Inst of Dev Studies and Bureau of Stats |
Health status, access to healthcare, health seeking
behaviour, expenditure on healthcare, socioeconomic status |
Incorporation of equity into existing surveys;
establishment of a new equity monitoring system; dissemination of
findings; capacity development to carry out equity research |
|
Chile |
National Cttee for a Better Health, M of Planning, Nat
Inst of Stats, Academics |
Comparison of relative and absolute differences in
health status, proximate and health system determinants by income and
educational level quintile |
Enhancement of existing national survey, analysis of
routine data, inventory of policy levers, dissemination via discussions
and workshops government and NGOs. |
|
China |
MoH, Centre for Health Stats and Information, Academics |
Socioeconomic status, health status, access to, and
perceived quality and distribution of healthcare, social capital |
Creation of an equity monitoring Newsletter
Development of a National Survey capacity for
monitoring equity in health and health care |
|
Cuba |
Academics, MoH, Provincial and municipal DoH, community
orgs |
Disparities in distribution of health and health
determinants |
Routine data analysis; municipality level monitoring;
quarterly dissemination through workshops and mass media |
|
South Africa |
National and Provincial Legislators, NGO, Academics |
Private versus public sector; health status; financing;
access; quality of care; race-inequalities; rural/urban inequity |
Routine data analysis; commissioned surveys; site
visits; workshops; publications; mass media; informal liaison and support
of parliamentary committees |
|
Uganda |
Ministries of H, F, Loc Gov, Gender, Water, NGOs |
Health status, quality of care, health financing,
access to care |
District and national level monitoring; workshops with
community involvement; site visits to assess compliance with guidelines
and standards |
|
Zambia |
Parliament, House of Chiefs, NGOs, Churches, Medical
Council of Zambia, Women for Change, |
Health Status, Health Financing, in the Public Sector,
Access, Quality of care, Socio-economic status, gender inequity |
Routine data analysis, commissioned research,
publications, workshops |
All the proposed gauges presented at the meeting anticipated
a combination of activities including gathering of technical data accompanied by
information dissemination. Depending on their specific needs some proposals
placed greater emphasis upon the technical data, while others gave more weight
to stakeholder participation and effective information dissemination.
Issues and challenges
Discussions on technical, advocacy, and community
participation aspects of the proposals led to the identification of a number of
common issues and potential guidelines for equity gauge development.
Technical Methodology
The gauges need to have a well defined purpose with a focus on a small
number of clearly identified indicators arrived at by a consultative process
involving all stakeholders
Wherever possible gauges should utilize simpler measures that are
methodologically valid, by making creative use of existing data-sets,
experience and expertise rather than using more sophisticated constructs or
collecting new data.
Attention needs to be given to the use of participative methodologies and
the challenge of using non-traditional indicators
In order to better inform policy, information from the gauges needs to be of
high quality with particular attention given to methodological concerns
regarding causal inferences, confounding and bias in drawing valid conclusions
at international, national and local levels.
Advocacy
Great importance is attached to understanding the "political
space" in which the equity gauge is to be created and used, as well as
understanding the socio-political context.
A stakeholder analysis needs to be undertaken with early involvement of all
stakeholders at all stages of the planning, implementation and evaluation
process. In understanding and organising stakeholders, financial conflict of
interest between stakeholders should be avoided. There is also a need to
explore different models, viewing stakeholders as convenors, and appreciating
top down and bottom up approaches as complementary rather than as
alternatives.
The difficulty of engaging the disadvantaged from the beginning is
acknowledged. Given the importance of having a proactive community, capacity
building for action is likely to be an important part of a gauge
Sustaining partnerships is essential and ensuring an effective participation
process is likely to involve building alliances, institution building, and
capacity building. All different kinds of networks can be used, not only
formal meetings.
The identification and compilation of the various policy levers, as well as
a clear articulation of the corresponding actionable elements of information
gained under the auspices of the gauge, will assist projects in achieving
their goals.
Findings need to be returned to the community via briefings and
intersectoral meetings, as well as by providing access to data in a format
that is easily understood There is need for a careful socio-political calculus
around the release of sensitive findings. Creative forms of dissemination are
to be encouraged, for example using drama, puppets, or scripts to convey
messages as a means of advocacy.
The tension in advocacy was acknowledged. It can benefit the already rich
and powerful, mirroring the operation of an ‘inverse advocacy law’. The
real challenge is to engage and involve the ‘haves’ in advocacy on behalf
of the ‘have-nots’, and in highlighting the importance that reducing
inequity benefits the whole of society:
"If you come here to help me then you are wasting your
time, but if you come here because your liberation is bound up in mine, then let
us begin." Lily Walkers, Australian Aboriginal Leader
Community involvement
The link between the scope of a gauge and the extent of community
participation that is possible was highlighted. The local and national
political spaces will affect the possibilities for community involvement. It
was recognised that Local level gauges have greater potential for community
involvement, and can be combined with a community development approach to
become community-led rather than just community-based.
The need for resources to allow for community participation and development
was recognized. The challenge of mobilising resources for community-led gauges
includes exploring possibilities involving both donor and locally solicited
funds. A further challenge lies in achieving sustainability and replicability.
It was also recognised that communities can be place-based or
interest-based, and that not all communities are geographically bounded and
self-contained. Different communities can overlap and co-exist in the same
geographical space.
The challenge of collecting and presenting ‘elite’ information can
support the achievement of equity if the process is inclusive. The easy
accessibility, use and presentation of information to communities and the
development of adequate community capacity to mobilise around this requires
more attention.
The Way Forward – An Equity Gauge Network
A number of equity gauges were presented at the meeting, each
of which had specific plans for moving forward. To strengthen the impact and
capacity of individual country gauges the need for an equity gauge network was
muted. Participants brainstormed a variety of issues that were critical for the
development of a network. It was also recommended that the network needs to be
organised to encompass specific focus areas or hubs which will serve to anchor
the various gauges and to promote more focussed action directed at promoting
equity. Further conceptualization is needed on these focus areas to incorporate
the spectrum of gauge activities envisioned. The network is likely to be
supported by a team of technical advisory experts focussing on the three areas
of need identified at this meeting viz., technical methods, advocacy and
community participation.
In order to refine the concept of an equity gauge network,
consultants will be asked to develop a clear brief for the network. The
activities to be included in the remit of the network, come out of suggestions
from the meeting. These suggestions are grouped into four categories below.
Funding and Resource Mobilization,
Stimulating debate on, and marketing the concept of, an Equity Gauge and
assisting gauges in accessing resources F&R
Technical Considerations
Information sharing including information generated from GHEI
Developing and strengthening technical expertise in areas required by equity
gauges, eg around linking household databases as well as facilitate sharing of
information on lessons learnt
Instituting of an award to countries for progress in achieving Health
Equity, and a good practice award towards Equity Gauge development
Stimulating improved skills and resources to assist (eg publications) for
engaging communities
Mapping of advocacy groups
Assisting with political mapping – developing a typology of
"political space" for Equity Gauges in countries
Exploring the potential of standardising indicators internationally
Communications
Facilitating exchanges among gauges in geographic areas as well as
internationally
Creation of a web site
Accessing Key Partners
Mobilising international NGO’s to engage community groups local NGO’s in
terms of Equity Gauges
Explore mechanisms for linking the network to other networks and involving
others in the work
Extending WHO monitoring work
Facilitating links with other relevant groups/movements eg. Amnesty
International, Health for All
Over the next year HST with support from the Henry J Kaiser Family Foundation
and the Rockefeller Foundation will work towards the further development of the
Equity Gauge Network.
For further information please contact Pat Naidoo, email: rpillay@imul.com
or Antoinette Ntuli, email: ant@healthlink.org.za or contact the Health
Systems Trust: Tel 27-31-307-2954; Fax:27-31-304-0775; Website:
www.hst.org.za
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