Global Equity Gauge Alliance Sub-national Health Systems Performance Assessment April 24-26, 2002 Lexi Bambas & Hilary Brown.

Global Equity Gauge Alliance Sub-national Health Systems Performance Assessment April 24-26, 2002 Lexi Bambas & Hilary Brown

What do we mean by health equity? A world without systematic differences in health status across socially, demographically, or geographically defined populations or population subgroups (Starfield, 2001).

What are the dimensions of inequity in health? Distributions of: Health status: inequalities, harms, risks Health-affecting resources: health system resources (access, quality, cost of treatment) and PROGRESS-related factors Dimensions may also include social consequences of illness

Social Strata across which Inequities Exist PROGRESS: Place of Residence Religion Occupation/income Gender Race/ethnicity Education SES (including income) Social Networks/capital

Key Principle in Redressing Inequities in Health Where inequities exist, intervene to: correct the injustice, directly reduce the harm, and/or minimize the consequences of the harm Implications often include: Ensuring that marginalized pops have access to basic material and non-material resources Compensating for disadvantaged population subgroups Better distributing health care resources according to need (rather than privilege)

The Equity Gauge Model Purpose: Monitor health outcomes and processes with the goal of shaping more just policy 3 Pillars of an Equity Gauge: Measurement Advocacy/action Community participation

Vision of the Global Equity Gauge Alliance By the year 2015 every country should have an integrated system for monitoring health system inequities that informs, monitors and evaluates health and other socioeconomic policies Puyuhuapi Conference position statement

What is an equity gauge? Action-oriented project aimed at bridging research to policy: Monitoring the current dimensions of health inequity as well as changes over time, especially in response to policies and programs, using rigorous methodologies; Advocating for health equity through evidence-based policy recommendations and through raising public awareness; and Actively supporting public and community participation in developing projects, advocacy campaigns, and interventions.

Why is there an Equity Gauge initiative? Routine data on gaps are generally not available or inadequate, and data is particularly scarce in lower-income countries Special studies reveal wide & often widening gaps in health & its determinants between better- and worse-off groups

Inverse Care Laws Health care resources: the rich consume more hospital and public health care than the poor, though they have less need (Hart 1971) Public health and preventive care: immunization coverage strongly correlated with socioeconomic status (Gwatkin et al. 1999) Financial risk: poorer populations that access services risk medical impoverishment (Liu and Hsiao, 1997; WB, Voices of the Poor) The gradient of health along PROGRESS variables correlates poor health to various forms of disadvantage

Counties by Level of Marginality, Mexico 1990-96

Distribution of Health Resources, Mxico 1990-96 by level of county marginality Very lowLowMediumHighVery high 0 5 10 15 20 0 40 60 80 100 %

Global Equity Gauge Alliance Secretariat held by Health Systems Trust in S.A. Functions: Promotion of the 2015 goal Technical assistance to support each of the three pillars Cross-fertilization of lessons learned Resource mobilization Global networking to encourage monitoring and generally promote health equity endeavors

The Gauges exist in Asia: Bangladesh, China, Thailand Africa: Kenya, South Africa (2), Uganda, Zambia, Zimbabwe, Burkina Faso Latin America: Chile, Ecuador

A few examples Chile: focus on monitoring, capacity development Bangladesh: focus on monitoring and advocacy Kenya: focus on primary data collection, community participation

Chilean Equity Gauge Re-designing national household survey on SES to enable an equity analysis of: health status, household composition, housing quality and education Participating in first LSMS with national and regional representation Piloting training health equity module Identifying policy levers to improve equity

Partnership Catholic University: Department of Public Health and other social science faculties MINSAL (Ministry of Health) Health Reform Committee MIDEPLAN (Ministry of Planning) Ministry of Education FOSIS (National Fund for Social Development and Interventions)

Infant Mortality Rates by County 2.62 7.69 14.59 28.34 42.25 0 5 10 15 20 25 30 35 40 45 VitacuraProvidenciaIndependPurranque P. Saavedra M Infantil Per 10,000 live births

Chilean Gauge Challenges Community Participation increasing community involvement through empowerment is a complex process requiring a long-term strategy Advocacy capacity development for the Gauges multisectoral team in media strategies is needed

Bangladesh Equity Gauge Monitoring Incorporating questions along PROGRESS lines into existing data collection systems & conducting equity analyses Building national capacity to implement equity enhancing research & policy Advocacy Use of newsletter & mass media to inform policy makers and civil society of results

Partnership ICDDR,B International Center for Diarrhoeal Disease Research, Bangladesh BRAC BBS- Bangladesh Bureau of Statistics BIDS- Bangladesh Institute of Development Studies

Gender gap in child mortality (by education), Matlab, Bangladesh 1982 and 1996 Source: Bhuiya et al. 2001

Inequity in health status: Infant and under- five mortality

Inequity in the utilization of health services Children brought to a health facility for acute respiratory infection (1996-97)

-- Source: Bhuiya et al., 2001 --Poor members --Poor Non-members --Rich

Bangladeshi Gauge Challenges Monitoring Introducing equity-oriented questions into new data collection methods begins with multisectoral support for redressing inequities Advocacy Difficulty in engaging key constituents to endorse the utility of equity analysis Mounting a successful advocacy campaign requires a long-term strategy Resistance by policy makers to disseminating politically sensitive results

Nairobi Equity Gauge Monitoring Secondary analysis to unveil differences in morbidity and mortality among slum vs. non-slum areas Community Participation Develop IEC materials on existing health inequities & holding community meetings to raise awareness Advocacy Newsletter and workshops to disseminate results among key decision makers from NGOs, government and funders

Partnerships African Population and Health Research Center National Council for Population and Development Urban Slums Development Project, Nairobi City Council

% distribution of births in Kenya (by type of assistance received during delivery)

% distribution of births in Kenya (by place of delivery)

Nairobi Gauge Challenges Community Participation & Advocacy Moving forward is contingent upon results from monitoring activities The year 2002 is an election year in Kenya New actors New priorities

Range of Approaches Geographic level of analysis: county/municipality based regional national data collection systems Indicators measured: health status access, utilization, & cost of health care resources and services other health-affecting resources (PROGRESS variables) Monitoring/research strategies: use of primary and secondary data development of new systems, integration into existing systems

(cont.) Participants and stakeholders: government offices, ministries, legislators, policymakers and planners NGOs private and public research institutions academia indigenous groups Communities and community leaders Advocacy strategies: various media outlets dissemination of information to both government and civil society stakeholders wide and pro-active partnerships

Global Equity Gauge Alliance Sub-national Health Systems Performance Assessment April 24-26, 2002 Lexi Bambas & Hilary Brown.

Documents

health equity

poor health

health status

risks health

gradient of health

public health care

health system resources

monitor health outcomes