BACKGROUND PAPERS FOR THE MEETING OF COMMISSION ON SOCIAL DETERMINANTS OF HEALTH, HELD IN AHMEDABAD, SEP. 2005
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- BACKGROUND PAPERS FOR THE MEETING OF COMMISSION ON SOCIAL DETERMINANTS OF HEALTH, HELD IN AHMEDABAD, SEP. 2005
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RF_COM_H_88_SUDHA
Commission Country Work Strategy:
Supporting national policy action on the social determinants of health
Discussion paper for the Commission on Social Determinants of Health
DRAFT
COMMISSION ON
SOCIAL DETERMINANTS OF HEALTH
30 August 2005
l
his document has been prepared for the third Meeting of Commissioners taking place in India in
■
September 2005.
.osNH
Contents
Summary............................................................................................................................................................. 3
I. Introduction..................................................................................................................................................4
II. Why take action on social determinants?..............................................................................................4
III. Action at Country Level......................................................................................................................... 6
Goal.................................................................................................................................................................. 6
Why with governments? Strategic directions........................................................................................... 6
Objectives...... ................................................................................................................................................. 7
IV. How would governments benefit from being involved?................................................................... 8
V. Implementation.......................................................................................................................................... 8
Phases of work................................................................................................................................................ 8
Engagement opportunities........................................................................................................................... 8
Sharing between countries........................................................................................................................... 9
Support Model............................................................................................................................................. 10
WHO.................................................................................................................................................. IL
Dialogue in country work.................................................................................................................11
Successful engagements.............................................................................................................................. 12
Steps for Engagement................................................................................................................................. 13
Workplan...........................................................................................................................................13
Reviewing progress.................................................................... .......................................................... 14
Investing resources.......................................................................................................................... 14
Developing Capacities: guidelines and approaches.............................................................................. 14
VI. Regional networks and strategies....................................................................................................... 14
VII. Outputs from country work................................................................................................................ 15
VIII. Next Steps............................................................................................................................................. 15
Appendix 1: Developing the Country Work Strategy'.............................................................................. 16
Chile to Egypt............................................................................................................................................... 16
WHO Consultations..................................................................................................................................... 16
Appendix 2: Activities for Countries Participating in the Country Work Component..................... 17
Appendix 3: Information sent to Interested Countries............................................................................ 18
Appendix 4: Workplan Preparation Guide................................................................................................ 19
Endnotes............................................................................................................................................................ 20^
Summary
The Commission will work with countries to mainstream and strengthen actions to address the social
determinants of health inequities. The country work, as a key component of the Commission's
implementation strategy, will build understanding of how social determinants of health inequities can be
tackled in practice, drawing on experiences across countries, with a view to creating the conditions for
good health for future generations. A common objective across all country work will be to progress
governmental policies and social agendas towards having health as a "cross-government" or "whole-ofgovemment" priority.
The scope of country actions will range from: (a) strengthening interest in social determinants and
developing a common vision and understanding of priorities among stakeholders; to (b) adapting, scaling
up and mainstreaming existing circumscribed programmes, which have a proven positive impact on the
social determinants of health inequities; to (c) implementing comprehensive reforms to frame health as a
corporate priority in public policies and intersectoral action. The actions will aim for universal coverage
with the purpose of addressing the health gradient across the full spectrum of socioeconomic positions.
By engaging a cross-section of actors within countries, the country work will demonstrate how an
alliance across all levels of government, civil society, NGOs, technical institutions and global and
regional partners, can strengthen leadership, systems of governance and upstream policy action on health
inequities. The country work will organized around focal contact points or teams within countries. WHO
(regional, country and headquarters offices) will play a key role in supporting the country work.
Commissioners, the Secretariat, the Commission's knowledge networks, and experts from countries
championing health equity will be involved at key points of the process to assist in coordinating,
synchronizing, and catalyzing learning between countries, regionally and internationally.
Together, these mechanisms combined with other components of the Commission, will contribute to
building a network of actors and institutions with the capacity necessary for sustaining longer-term action
on social deter minants of health globally.
I.
Introduction
This document describes the latest thinking on the Commission's strategy for working with governments
to support action on social determinants of health inequities in countries, and discusses the operational
implications of the proposed approach. After initial discussion at the Meeting of Commissioners in Egypt,
earlier drafts of this document were circulated for discussion in three regional consultations held with
WHO and member states (Africa, America's and Eastern Mediterranean WHO regions). The current
document has incorporated adaptations to respond to concerns raised in these meetings, and also includes
the more recent comments “received from Commissioners and the Chair in the run-up to the Third
Meeting of Commissioners in India (see Appendix 1). It is intended as a stand alone piece as it is needed
for consultation purposes, and for this reason repeats some of the information related to the
Commission's overall strategy and conceptual and analytical framework, which are discussed in more
detail elsewhere1, "(http://www.who.int/social determinants/).
At the 2004 World Health Assembly, the Director-General announced the beginning of a process to act
upon the social causes of ill health and inequities by calling for a global Commission on Social
Determinants of Health (the Commission). The Commission over three years (2005-2008) will set the
foundation for sustained processes to profile and integrate the social determinants of health within public
policy and practice. The key insight underpinning the work of the Commission on Social Determinants ol
Health is that health care is only one of the influences on a population's health. Health is shaped by the
social conditions in which people live and work. During its 3-year mandate, the Commission will begin a
process of building the evidence, action, advocacy and leadership needed to sustain a global longer-term
commitment to addressing the social determinants of health inequities (Edmonton Social Planning
Council, 2005).
II.
Why take action on social determinants?
The estimated impact of social determinants of health on the health status (average and gaps) of the
population is large and yet inadequately addressed in contemporary policies and programmes. For
example, in Canada, typical of several post industrialized nations, the impact of social and economic
factors on health has been estimated at 50%, with health care systems responsible for 25%, the physical
environment for 10% and biology/genetic endowment for 15%. Despite this pattern of attribution, reports
from some provinces in Canada show that regional health authorities only spend 3% of their budgets on
promotion, prevention and protection initiatives (Edmonton Social Planning Council, 2005)3.
The diagram shown in Figure 1 identifies a number of potential points in the "social production" of
health where governments and other national actors can intervene to reduce social and health inequities4.
They may act upstr.eam to develop policies and institutions that affect or mitigate the stratification of
individuals in society (changing the social context); they may intervene on the structural determinants
of health which (shape where people live and work; they may intervene on pathways resulting in people's
differential exposure and vulnerability; or they may intervene through health systems to influence
differential access to health services and reduce the differential consequences of ill-health.
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Figure 1: Potential Policy Entry Points in the Social Production of Health
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Specific
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. Social
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condition, health
behaviours, life-
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Different!
al Health
and
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al access
to Health
System
In the context of this framework, the Commission understands that the health care sector is only one of
the sectors that impacts on health. Improving health equity is a concern across the whole sphere of
government and for all actors at country, regional and global level. Therefore, the Commission proposes
to work with interested countries to promote political leadership, knowledge and action at national and
sub-national government levels as well as with associated regional processes that strengthen country
agendas on social determinants of health. To be in line with its core values and mission, such
intersectoral actions would need to:
(a) Reflect shared values of health equity and a human centered orientation to development
(b) Support the notion of health as a social concern and an outcome of development
(c) Promote community and civil society involvement in decision-making
(d) Be effective and sustainable.
Furthermore, approaches to action and working with countries will need to be sensitive and responsive to
the country's socio-political context and history, as well as its developmental conditions. For example,
countries emerging from conflict will potentially require different modes of interaction and types of
support.
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III.
Action at Country Level
Goal
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As the ultimate purpose of establishing the Commission is for change, action at country level is key. One
strategy for change, discussed here in this strategy, is working with governments to support work:
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.. addresses health inequities as a mainstream, collective priority across
government and society and reorients actions for health towards tackling the
social determinants of health inequities.
Reaching this goal will require: (a) dialogues to strengthen interest in health related inequities, social
determinants and 'to develop a common vision and understanding of priorities among stakeholders; (b)
adapting, scaling up and mainstreaming existing circumscribed programmes, which have a proven
positive impact on the social determinants of health inequities; and (c) comprehensive strategic, planning
and budgeting reforms to frame health as a cross-government priority (see more details in Appendix 2). a
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Why with governments? Strategic directions.
There are several reasons for the proposed focus on working with governments to support action.
However, this will not be the exclusive engagement of the Commission at country-level. Other
engagements will take place through civil society, for example. At this level of engagement with
governments, several processes can be brought together to change .the health policies affecting people's
lives: government actions; civil society activism; knowledge institutions; public awareness and global
initiative and regional agreements and agendas.
From a strategic point of view, working with governments to promote leadership in this area is seen as an
opportunity for the Commission to start to help countries to take action on the social determinants of
health inequities; the purpose of the Commission is for action, and this component of work will help the
Commission to live up to this admirable aim from early on. In addition, involving countries in action
early on will ensure that the Commission will have several real-life examples of what is it talking about,
by the time of its presentation of its final report to WHO (May 2008). It will also enable the Commissio^
to ensure thatithe knowledge network experts and products get referred to real life situations in countries
to check their applicability.at country-level. Furthermore, it is an opportunity to raise international
political interest, at the smallest international unit, for acting on social determinants early on in the
process; the nation state engages in global and regional processes (e.g. G8, NEP AD, ECLAC, EU),
which can be used to amplify Commission messages.
Finally, and perhaps most importantly, the process of engaging governments is also an opportunity to
ensure sustainability of the work on social determinants of health after the Commission has formally
ended (August 2008) through:
-> the working mechanisms’ arid channels created within WHO in 2006-2007;
-> through the lessons-leamt on WHO work of this nature at country level, discussed with the WHO
Reference Group and WHO Technical Group;
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—> through the pressure from WHO's Member States to provide more country assistance and global
technical leadership in this sphere.
It is envisaged that a core of interested governments will be able to lead change in the future, and create
the demand for new ways of working at WHO, which is envisaged as the handover agency for the
Commission.
The strategic motivations outlined above for the Commission's country work can be summarized in short
hand. The suggested prioritization is as follows:
-> taking action on the determinants of health inequities
—> examples of good practice
-> developing pragmatic knowledge
—> WHO sustainability development
-> working through regional networks to scale up across countries.
Objectives
Taking the goal and the first four strategic considerations as key, the objectives below will be necessary
for the Commis'sion's country work. A more detailed review is needed to formulate a strategy for
amplifying the Commission's message and work through regional networks.
1)
facilitate direct assistance to countries, both technical and political, from: WHO, Commission
knowledge networks, Commissioners, and other experts
2)
facilitate between-country dialogue on the social determinants of health equity and the sharing
of related experiences and skills
3)
actively draw out learning gained from hands-on experiences of countries, nationally and subnationally, especially profiling and disseminating lessons for scaling up (within countries)
and the role of different levels of government and different governmental mechanisms
4)
support national and sub-national government leadership for promoting policies and actions
on social determinants of health across their region (including through regional institutions)
and share information on these experiences
5)
facilitate dialogue with civil society and local and regional knowledge institutions, and
develop a better understanding of the role of civil society and knowledge institutions in
supporting countries' policies on social determinants of health
6)
actively draw out the learning for WHO headquarter, regional and country offices in
particular, on how best to support Member States to address the social determinants of health
inequities in the future
7)
actively draw out lessons for WHO's relationships with other UN and international
Organizations' when working to address the social determinants of health in order to ensure
more efficient and sustained country performance in health policy-making in the future.
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IV.
How would governments benefit from being involved?
Taking action on the social determinants of health inequities will require determination and political
commitment. By being part of an initiative that involves partners with shared goals, actions can be taken
in the context of a larger global initiative and with the associated political and evidence-backed support
to be provided through the Commission's knowledge networks and WHO. At the same time, the
countries embarking on improving health equity as a cross-government goal will be supported in sharing
their experiences with one another in an area which has not been the traditional focus of government
activity. Many lessons will need to be discussed, shared and synthesized to gain a greater understanding
of what this means for policy development, planning and budgeting decision. Sharing technical know
how and leaming-by-doing will be and important part of building sustainable capacity in the future.
V.
Implementation
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Phases of work
The implementation of a stream of work to meet the abovementioned strategic objectives is complex and
the strategic directions present competing challenges that will need to be managed. The ideal phasing of
the work would seem to be to invest more time in several "exemplar" countries early on in the process, s^
that in-depth 'work can begin there, while at the same time expanding work and activities across countri™
as the resources and interests grow.
The challenge even this "ideal" approach presents is the issue of "selecting" countries whose processes
are more likely to succeed and getting behind these countries in a more proactive way. The second
challenge is to avoid creating a process that is perceived as too "exclusive", which may loose political
currency and goodwill. Discussions with regional representatives have indicated that inclusion is
important (indeed it is one of the determinants of health!). The third challenge is to manage with limited
resources and institutional capacities at the same time in which these capacities are being developed (e.g.
training materials, WHO technical assistance).
These challenges, necessitate an organic approach, guided by clear strategic directions, which is flexible
enough to take hold of new opportunities as they arise. The section below describes the envisaged phases
of country work and proposed models of engagement and support in view of the abovementioned
challenges.
Engagement opportunities
4
It is envisaged that engagement of countries can take place through different avenues. These include:
a)
Commissioners
a. personal and professional spheres of influence;
b. the body of Commissioners as a collective influence, imbued with a special mandate by
WHO, as they meet with governmental officials and discuss the Commission's work in
front of other audiences;
b)
WHO chaiinels
a. formal regional consultations
b. ' technical programmes, existing work
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c.
c)
i WHO country officer (WR) as a driving force [e.g. because of their own interest in the
■ subject; through new tools in the Country Cooperation Strategic frameworks; responding
to needs expressed for WHO to take health leadership in UN processes around the MDGs.]
Other streams of Commission work
a. Knowledge networks as they may come across good practices and developments
b. Civil society drivers as they map out opportunities
c. Global initiatives as they identify synergies between protocols and objectives for country
work.
I
Thus far, the use of personal spheres of influence, WHO World Health Assembly forums, WHO regional
consultations and to some extent, liaison with global initiatives, have been the main channels of
engagement tested so far. Each of these engagement platforms raises different issues with implication for
the organization of the work. The implementation process proposed here is intended to be responsive to
the different types of engagement.
Inclusiveness
The processes for engagement listed above are inclusive and should at least ensure that all countries have
appropriate opportunities to work on social determinants of health. Further to the engagement phase,
methods of support need to be developed to ensure that all countries are able to benefit from different
streams of work in the Commission, including the knowledge products generated by the knowledge
networks, documented and shared experiences of countries, and expert advice of Commissioners. These
methods include ensuring a good website and system of information sharing across the Commission
components, in particular between countries and with knowledge network products, and that WHO
begins to support all countries wanting to tackle social determinants of health inequities through its
technical programmes. For this to happen, clear signals would need to be sent from countries interested
in the work, as well as from mechanisms created internally to WHO for the Commission, including the
WHO Reference and Technical groups.
Sharing between countries
Sharing of experiences between countries is seen as key mechanism for spreading good practice and
supporting technical assistance. Mechanisms for sharing knowledge experiences include:
-> use of any other appropriate Internet-based technologies and the effective means of information
dissemination.
—> promotion of direct technical sharing between countries (through in-person visits)
-> focussed global inter-country meetings to discuss progress and themes of practical relevance across
multiple countries.
While, exchanges using technologies and good dissemination practice on the part of the Commission will
be most important for ensuring inclusiveness of a wide-range of countries, specific meetings of actors
engaged in country work can be used to grow interest in the work and to share experiences of countries
who have already started work or with a long track-record, with countries who are interested beginning
work.
The Commission will need to coordinate its various mechanisms for bringing together countries to ensure
the most effective pse of resources. For example, training programmes may be timed appropriately with
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respect to critical points in progress updates taking place in the country work5. Other meeting-related
strategies that can be used to promote interest and action across countries will be invite interested
countries to attend meetings or workshops that form part of national dialogues in a particular country
deeply engaged in the process.
i
Direct exchanges and technical assistance are the most limited type of sharing due to the financial
implications relative to the small exposures (i.e. 1 to 1 versus 1 to many). For this reason, specific
technical assistance exchanges overseen by the Commission process would need to be guided judiciously
to maximize progress in the strategic directions outlined above.
Other forums, for example, like different Regional Economic Communities (REC), as they are dealing
with proper implementation mechanisms of the overall NEP AD strategy and they can be instrumental in
linking properly country/regional level strategies on SDH.
Support Model
The support model described below is based on the notion of strong support from the Commission, and
WHO.
It is likely that the WHO will play an active role in coordinating support for the countries engaged earlj(
on in the Commission, and in particular for the countries the Commission wishes to show as examples of
change by the end of its term (2008).
WHO will also play a key role in ensuring the inclusiveness of the process. As increased requests for
technical assistance on social determinants work mount in a wide range of countries, WHO, through the
WHO Reference and Technical Group it will need to ensure that clear signals are sent to support scaling
up through headquarters and regional technical programmes, and country offices, thereby expanding the
effective and existing WHO workforce on social determinants while at the same time reorienting health
policy work to towards tackling social determinants of health inequities. The role that WHO plays in this
component of the, work, and the interaction between WHO and the Commission will ultimately work
towards the Commission goal of developing more sustainable models of support as the number of
countries demanding assistance in this area increases and in order to assist with the institutionalization of
the work in WHO. By the later phase, 2007-2008, much of the country support would be expected to be
mainstreamed into WHO's technical assistance to countries.
Commission Secretariat
With this in mind, the main functions of the WHO Commission Secretariat between 2005 and 2008 with
respect to the Commission's country work will be:
i) to actively coordinate support for the advancement of Commission-related work for those countries
identified by the Commission as having a high probability of providing "good examples" by 2008;
ii) to assist the WHO Reference Group and Technical Reference Group with the development of
institutional changes within WHO, through supporting inputs to Organizational workplans and
facilitating the Organization's technical assistance to countries for policies and programmes tackling the
social determinants of health.
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Assisting with the development of country implementation reports for countries involved in
demonstrating and documenting actions.
8. Facilitating exchange on social determinants evidence and know-ho between countries in the region.
9. Engaging formal WHO governing bodies and regional political forums through presentations,
discussions, and information sessions.
7.
Commissipners
As processes of change in countries related to tackling the social determinants of health will have as
much to do with evidence as with profiling the evidence and politics, the presence of Commissioners at
critical phases in the country work (e.g. national dialogues, presentations to health select committees)
will be an important part of their contribution to the Commission's country work. Further tools at their
disposal will be to use the location, communication opportunities and deliberations of their meetings in a
strategic way to consolidate or promote progress in countries. Furthermore, in their interactions with
global and regional bodies, Commissioners can create opportunities or incentives for countries to
progress in their work on tackling social determinants of health inequities. A small group of
Commissioners can support progress review and feedback for country work in 2006 and 2007.
Knowledge networks and civil society
Knowledge networks and civil society form an essential axis of support for advancing the work in
countries. Their assessments will be needed to ensure the quality and usefulness of:
—> inputs from the knowledge networks on the planned country work
—> evaluations of products from the country work
—> identification of experts to visit countries and attend global country meetings
-> support progress reviews and feedback to countries.
Dialogue in country work
The country level is a focal point of change where essential elements converge including knowledge
institutions, health workers and organized representatives, different levels of government, other UN and
other development institutions and civil society. Governments will be encouraged to involve these
different constituencies in its national dialogues, in programme reform and policy development.
I
Successful engagements
Deciding in which countries to work in an in-depth fashion requires will entail some risk on the part of
the Commission. The Commission cannot expect to hail successful change in all countries participating
in its country work stream. Even the investment of resources by the Commission is no guarantor of
success. For this reason, in addition to the strategic directions articulated above, it will be necessary to
caste a wide net, be flexible, and sometimes opportunistic, and also ensure that the necessary back-up to
the work is brought along in the process. Even in cases were success does not appear neatly after what is
effectively, 2.5 years, the work may still yield fruit with more persistent guidance and assistance.
The critical ingredient for success at country level will be the issue of country leadership of the process.
This means that steps should be put in place to ensure that the work is country-led, with the Commission
and its agents playing a facilitating and coordinating role. With this in mind, the Secretariat proposes a
set of steps for engaging with countries, that are framed by the recommendations for country leadership
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WHO
It is proposed that WHO plays a key role in brokering and providing support the country work
component of the Commission. WHO has a ready link to a pre-existing network of WHO and other UN
institutions, which in turn have strong relationships with Member States. This link provides several
opportunities, which can be used both to identify and to support countries in their work on tackling the
social determinants of health inequities, reduce duplication of efforts, and make space on global agenda's
to address social determinants of health. Also, the process of involving WHO in country work will help
to identify new, ways of working for WHO, with its counterparts at the country level and with its
technical programmes in the future. This will ensure sustainability and transferal of the Commission
recommendations into the practice of WHO country cooperation after the Commission formally ends in
2008.
WHO mechanisms, for guiding budgets and country activities that will collaborate with the commission
country work include:
(a) Country Cooperation Strategies (CSS): these are the reference for the majority of WHO's Country
Office work in and with a particular country. The strategies combine assessments of country needs with
WHO country'and regional priorities, taking into account WHO's Corporate Strategy and Programme of
Work. These strategies are revised periodically, every two or more years, depending on the needs of th^
government. Strategies of cooperation between countries and the Commission will be coordinated in th"
future revisions of Country Cooperation Strategies. Easy-to-use tools for strengthening the application of
a social determinants lens when developing the CCS will also be developed with the CCS team and the
Venice Office for investment and Development Training Skills and Know-how development programme
on social determinants of health.
(b) Country office agreements with governments: country agreements or bilateral cooperation
agreements (BCAs) as they are known in the WHO EURO region, serve as the reference for WHO's
work in countries. WHO regional offices also work with countries not in receipt of financial support
from WHO. In these cases MOU's and Formal letters of technical support/cooperation are initiated.
Revisions of these agreements are opportunities to align WHO work on health systems and health
policies with the work on tackling social determinants of health inequities.
WHO Regional Offices, WHO Regional Committees
WHO regional and countries offices will play an important role in supporting the country work in their
regions. The WHO Commission Secretariat and the Regional Offices will work closely to ensure an
adequate support to the country work. Regional offices may take the lead in the following types ol^
activities (though not limited to):
1. Identifying countries with strong political interest in tackling social determinants to act as sites of
action in their region and supporting their work.
2. Supporting the development of country cooperation strategies and country office workplans.
3. Identifying .experts to support regional action on social determinants (a roster needs to use the skills
and professional mobility of the Diasporas where applicable).
4. Brokering mechanisms for sustainability and development of regional and country (WHO and in
country) capacities in addressing social determinants of health.
5. Coprdinatidn and advocacy with other regional agencies, inter-country regional organizations and
regional networks.
6. Liaising with the WHO Reference Group, knowledge networks and reviewing Commission-related
material to include regional perspectives.
11
of the work, discussed and developed by the Commissioners in Cairo. Countries participating in the
country work should ideally:
1.
Be self-selecting, in the knowledge that to act successfully on social determinants to reduce
healtn inequities will require political commitment from the highest levels of government and at
, the Highest level of other significant players in the country's political and health arena.
2.
Recognize health as an indispensable component of development.
3.
Have existing and future activities addressing the social determinants of health, and initiate and
enhance activities with special attention to those with potential for scaling-up.
4.
Become actively engaged in intersectoral cooperation and collaboration in health related issues,
and develop alliances and partnerships; and demonstrate an interest in putting in place the
necessary and management and institutional capacities needed to facilitate comprehensive
intersectoral policy .processes for health.
5.
Perform monitoring and evaluation and be willing to exchange information related to social
determinants of health.
6.
Facilitate community participation and ownership in all health programmes and activities.
7.
Designate the responsibility for the work at least to the ministerial level, which could be the
Minister of Health.
For purposes of ensuring the development of "pragmatic knowledge and recommendations", the final
group of participating countries should reflect the rainbow of realities facing countries around the world
when trying to tackle social determinants of health and probably include at least 1 country from each of
WHO's regions.
Steps for Engagement
To signal a serious intention to lead what will be a difficult process of change within a country, it is
proposed that countries be requested to address formal letters from senior officials in their governments,
expressing this interest. The exact nature of the country-level mechanism for taking forward the agenda
will differ from country-to-country, but at least for purposes of engagement, a letter should be sent
identifying a focal person(s) to work on developing a detailed workplan of activities. The workplan
would be prepared in consultation with different directors in the health department and across different
departments and inter-sectoral committees within government. Some prioritization of the different
components of work would also need to be indicated.
The second step of the preparation would involve an in-depth period of working on the workplan or
action plan with the Commission Secretariat, probably a period of 1 to 2 weeks, with a view to discussing
the viability of the different proposed activities in the workplan, and the nature of support to be expected
from the Commission. The finalized work/action plan would be presented back to Cabinet, the Planning
or Health Corrfrnittee for government approval. From the Commission's side, the process would be
coordinated by the Commission Secretariat, with input from the relevant Commission components of
work, including WHO. Appendix 3 and 4 outlines the steps and associated standardized documents to be
sent to an interested country.
Workplan
I
It is proposed, that WHO, support the initial development of the workplans and associated estimates of inkind and actual financial assistance. It proposed that the WHO Secretariat assess the feasibility of the
workplan activities using a small reference group that includes appointed knowledge network people, the
\\ HO Secretariat and a small group of Commissioners, with opportunities for input ensured for the civil
13
society stream and WHO health systems and policy experts. Once a guiding workplan is in placeprogressive seed funding and technical assistance to countries would be contingent on satisfactory
progress as reported in the progress review meetings planned for 2006 and 2007.
Re vie wing progress
Progress will be monitored using progress markers and tools developed by the Knowledge Network for
Measurement in collaboration with the Commission Secretariat and the countries concerned. It is
important that a meeting with the early-starter countries be held early on to discuss progress markers with
them with which they are comfortable. Some of these progress markers will be generic, others will be
specific to the country's context. In this context, at least 2 progress meetings are envisaged taking place:
1 in 2006 and 1 in 2007. These meetings will also be linked to other.objectives of the country work, such
as expanding interest by inviting interested countries and by focusing on topics of interest (for example
"the how to - for managing intersectoral processes in health"), with invited experts presenting.
Investing resources
Funds raised by the Commission will be used for working in countries. Assistance to countries will focus
on technical and political assistance, with limited financial seed funding made available during
implementatioh. Some donors have already earmarked spending for country work. Furthermore, it iS
expected that WHO will use its own resources to help strengthen its capacity to respond to the
anticipated requests from countries for technical assistance in developing health policies and
strengthening, health systems to tackle the social determinants of health inequities. Seed funding
decisions need to be made on the strength of the workplans (as approved by an agreed upon process in
the Commission, see above, workplans) and progress.
Developing Capacities: guidelines and approaches
The countries involved in the Commission's country work will be invited to make use of existing tools
and help to improve these tools based on their feedback and experiences of implementation. These tools
will relate to the different approaches in which they are engaged and include:
-> Guidelines for conducting situation analyses on policies or policy-mapping[Commission's social
determinants framework - to be adapted to a guideline by the Measurement Knowledge Network]
—> Approaches to analyzing and attributing inequities in health [Equity Team, WHO]
—> Guidelines for conducting historical case studies [Measurement Knowledge Network]
1
-» Guidelines for running national dialogues [existing, Venice Office]
Policy Process Evaluation guideline [existing, Venice Office] and Policy and Programme "Success"
Evaluations [Measurement Knowledge Network]
-> Approaches for including the social determinants approach in health programmes [WHO Knowledge
Network on Diseases of Public Importance]
-» Capacity Mapping for Social Investment [existing, Venice Office],
VI.
Regional networks and strategies
The development of regional strategies needs to be a key component of the activities country sign on to
in their workplans/plans of actions. The involvement of higher education institutions and academics in
the process of country work is also very important; building on existing “poles d’excellence”. Their
involvement will provide a motivating force for scaling up action on social determinants of health.
14
Furthermore the development of regional strategies headed by WHO regional offices, needs to be seen as
both a key component of capacity building within WHO for sustainability, as well as a mechanism tor
possibly engaging countries in action, providing demand from countries to WHO and for spreading the
messages of acting on social determinants of health. Further work needs to be placed on the development
of an understanding of the role of regional strategies within the Commission's strategic plan and how this
impacts on the other components of work and their relation to oneanother.
VII.
Outputs from country' work
At country level, the work will be expected to have:
• Contributed to knowledge on the relative weights of the different social determinants of health
inequities in the country, as well as any associated country-specific pathways.
° Identified policies and actions to most effectively address social determinants of health
» Improved the coherence and performance of mechanisms for policy integration & partnership
within government (national through to local) and with other sectors in society, including
community and civil society.
» Developed'specific (multi-sectoral) health policies & strategies that address the most-important
social determinants of health.
° Directed resources and capacities to address social determinants of health.
0 Contributed to wider knowledge on policies and practice for addressing, monitoring and
evaluating the social determinants of health.
° Profiled and supported political leadership on the social determinants of health.
All participating countries will be expected to document their experiences related to tackling social
determinants of health from a governmental perspective, and make these documents available to the
Commission withili the 3 year time-frame.
Across countries, the work will be expected to contribute to learning and leadership processes that will
re-enforce actions taken to address social determinants of health in practice. In addition to changing
practices within countries, it is expected that country work will:
• generate two types of knowledge: the more traditional kind in the form of case studies and policy
reviews; and the less traditional kind related to know-how. Through these processes, the
transferability of lessons learnt and appropriate means and technologies for transferability will be
better understood. This type of knowledge will assist with developing strategies for sustainability
and catalysing processes in other countries.
• the country work will provide an opportunity to test guidelines and approaches.
• the country work will contribute to scaling up interest in the work on social determinants of
health through regional networks.
VIII.
Next Steps
This current version of the Commission Country Work Strategy will be discussed at the India meeting of
Commissioners alongside a report-back on progress in advancing some components of the country work.
A useful target for the finalization of this strategy would be to have the broad strategic issues and
parameters for implementation as well as the role of Commissioners finalized shortly after the India
meeting.
15
Appendix 1: Developing the Country Work Strategy
The document is the result of an iterative process coordinated by the Commission Secretariat,
incorporating input from the Chair (through the general strategic meetings), Commissioners and WHO.
This process is described in more detail below.
Chile to Egypt
In the first meeting of Commissioners in Santiago Chile (15-16 March 2005), the Commissioners
identified the promotion of "country leadership" for tackling the social determinants of health as an
important component of the Commission's work. In response, the Secretariat, with input from a WHO
task force, prepared a first draft of this document for discussion at the 2nd meeting of Commissioner
(Egypt, May 2005). The meeting objectives identified the following aspects of country work for
discussion with the Commissioners: a) selection criteria, b) next steps for setting up the country work, c)
WHO linkages, and d) Commission linkages with respect to country work. The Commissioners'
discussions focused on the selection criteria and the broad mandate of the work. It was agreed that the
broad focus of the work would be:
i.
Towards developing a national strategy for action on social determinants
ii.
Explicit focus on countries in the south that are interested in/ able to implement practicA
programmes and policies, i.e.: real change - not just another report.
iii.
Specific actions, which may include testing and learning from processes and mechanisms for
social determinants of health policy and interventions; scaling-up or multiplying existing
programs and positive deviants; introducing good practice initiatives in different country contexts.
Further to this; ;the Commissioner's developed an internal note, entitled "Guidelines for Country
Involvement". The spirit of these guidelines was to ensure that the country work of the Commission
could deliver several examples of action and change for the better by 2008. These guidelines were
incorporated into subsequent revisions of the strategy document and used to shape the strategy.
WHO Consultations
i
Subsequent to the Egypt Meeting of Commissioners, a revised version of the document was circulated in
three regional meetings of WHO technical staff and governmental representatives in the Eastern
Mediterranean Region (May 2005), the Region of the Americas (July 2005) and the African Region (July
2005). In a parallel process, the document was also circulated to WHO headquarters, who advise
countries on hjealth policy. Formal comments were received from 3 WHO staff.
•
16
Appendix 2: Activities for Countries Participating in the Country Work Component
Commission on
Social Determinants of health
This note outlines the specific activities countries may wish to engage in as part of their involvement in the Country
Work component of the Commission. It will be updated periodically to reflect new developments.
ACTIONS
Implementing national health strategies and plans
for addressing social determinants of health equity
affecting policy making, planning and budgeting processes and
covering:
National dialogues
Implementing or Scaling up
circumscribec Programmes
Using the knowledge gathered in the exercises^;®
described below, run national dialogues
\"
involving different health sector and inter■' ii'i!ihaluilai JiukulmiueiAimlailuilaiaimsub
*
national levels of government, with civil society,
health professionals, NGOs and other actors.
This activity refers to the mplementation of a new
programme or scaling-uf of an existing one. This
activity may hApsilhn mponent of a broader
national strategy. A list of current recommended
programmes will be compiled by the knowledge
networks and regularly updated, e.g. School
feeding programmes [partnered with the World
Food Programme]; Access to ART
SUPPORTED BY EVIDENCE ON THE SITUATION
AND AN UNDERSTANDING OF CONTEXT AND HISTORY
Historical Case Studies
On political, social and economic processes,
including the impact of international and
regional processes/expectations, influencing:
• national health agendas for tackling health
inequities and investing in the social
determinants of health
• public,
government and
perceptions of "health" ,
health" /"public health".
professional
"populations
Situation Analysis and
Appraisals
Policy Process Evaluations
• Identify issues, build commitment
• Diagnose problems and
opportunities, including evidence
on determinants of health, health
inequities, and current policies
• Generate and test options
Documenting the origins, context and
process of specific strategies, initiatives
and programmes aimed at tackling health
inequities using a social determinants
approach.
Demonstrating an understanding of the
management and institutional capacities
needed to manage comprehensive
intersectoral policy processes for health.
• Agree on priority actions
SCALED UP AND SUPPORTED THROUGH:
• SHARING EXPERIENCES ACROSS COUNTRIES
. COMMISSION AND THE WORLD HEALTH ORGANIZATION, WITH
17
Appendix 3: Information sent to Interested Countries
Wtjmm
WW?
---- .
..
—
-
• -
Commission on
Social Determinants of health
Description of Documents
J6 August 2005, version 1
Ai .<■
WIpOO
----
Document title
Description
Planning steps.doc
Describes the steps involved in developing the country action or work plan
Example Letter 1 (English or French) - announcing intention.doc
Letter announcing the country's desire to be involved in the CSDH country work
Example Letter 2 (English or French) - final workplan.doc
Letter affirming agreement on the workplan activities
The Commission and its work.ppt
Presentation for the briefing of health departments and other ministries
(requested from CSDH or WHO regional office)
Commission Country Work.ppt
Same as above (requested from CSDH or WHO regional office)
>
18
Appendix 4: Workplan Preparation Guide
16 August 2005, version 1
This note outlines the broad steps countries will embark on in preparing their workplan of activities.
1.
The focal person for liaison with the Commission's country work is appointed and their appointment is approved by the
Cabinet, or some other high level decision-making governmental authority.
2.
Focal persons contact the Commission Secretariat and WHO regional counterparts to' inform them that they are
proceeding with Phase 1 of the workplan development; obtain any further information, and discuss possible assistance in
elaborating the Phase 1 process.
3.
Phase 1: during this phase, the following needs to take place:
-> a briefing with heads of department within the health ministry, describing the relationship between social
determinants and health, and the Commission's goals
—> briefing of other government ministries [Presentations provided by Secretariat,
http://www.who.int/social_determinants/en/]
-> heads of departments in tire health and other ministry (ies) are approached to discuss their potential involvement
and topics of mutual interest to pursue with the Commission's work on social determinants of health.
—> this information is compiled into a preliminary draft workplan (see example in Box 1). sent to the WHO
Secretariat, and the dates of the Phase II working visit is arranged with WHO.
Box 1: Example from Chile (first participating country)
Topics of Mutual Interest
No.
Project
Description
itrengthen the social
leterminants approach
1’ithin the national public
ealth objectives
1
Matrix to follow-up on
priority goals of the
National Health Objectives
for the Decade 2000 - 2010
2
Mid-point Evaluation
Achievement of National
H ealth O bjectlves for the
Decade 2000 - 2010
Identify interventions introduced since
the year 2000 to achieve the priority
goals, in particular those incorporating
a health determinants approach. The
matrix will provide an overview of
action taken and areas that need to be
reinforced.
Analysis of action taken and
measurement of health indicators to
determine progress toward national
health goals.
3
Strengthen Capacities of
Regional H ealth
Authorities to Analyze
Interventions In Public
Health
PAHO - M O H project to design and
execute a program of e-training for
professionals of the Regional Ministry
Secretaries (SEREMIs).
Fernando Mufioz,
Undersecretary of
Public Health
4
Development of National
and Regional Public Health
Plans
During 2005 the Regional Health
Authorities will formulate Public
Health Plans with interventions in core
areas; lifestyle and environmental risk
factors, considering priorities identified
in Regional health diagnosis, including
local health equity indicators.
Ximena Aguilera,
Head, Division of
Health Planning
ntegration of social
leterminants of health into
ational and regional public
ealth work plans
Contact
Cabinet,
Undersecretary of
Public Health
Ximena Aguilcra,
Head, Divisi6n of
Health Planning
Possible Commission
Support
Provide evidence with respect
to effective interventions,
especially those that
contribute to the reduction of
health inequities.
Provide evidence with respect
to effective interventions,
especially those that
contribute to the reduction of
health inequities.
Provide information on
successful experiences and
technology transfer to develop
e-learning modules to build
capacity to address social
determinants.
M ethodological support to
formulate interventions to
improve health status of
vulnerable groups.
4.
Phase 2: the person appointed by the country will spend 1 -2 weeks revising the preliminary draft workplan with WHO,
supported by the different components of the Commission.
5.
Phase 3: Once the revision of the workplan is completed, it will be presented to the government. Any requested
modifications will be included and discussed with WHO and the Commission. Also at this stage it will be useful for the
country to develop a clearer idea of the appropriate institutional mechanism for taking forward the work in the country.
Finally, a letter should then be sent to WHO indicating broad agreement on the proposed set plan of activities and the
institutional mechanisms overseeing operations at country level;
19
Endnotes
The strategic goals of the Commi-tsion will be operationalized through several components of the Commission, of which 11
country component is one of these. For details on the other components, please refer to the document "Imperatives and
Opportunities for Change" on the Commission website (http.7/www.who.int/social detenninants,').
' WHO 2005. Towards a Conceptual Framework for Analysis and Action. Geneva: WHO. In process of publication. See
ww. who. i n t/socia l_determinan is.
' O'Hara P 2005. Creating Social and Health Equity: adopting an Alberta Social Determinants of Health Framework.
Discussion Paper. Edmonton Social Planning Council. Web-based: www.edinspc.coin.
WHO 2005. Towards a Conceptual Framework for Analysis and Action. Geneva: WHO. In process of publication. Sec
www.whe.int social deicnninants.
5 One example of this is the work of the European Office of WHO (Venice)
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Meeting Report
iThe First Meeting of CSDH
Regional Civil Society Facilitators
i
WHO Geneva
8-10 August 2005
C-S IVl
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Reporfof the First Meeting of CSDH Regional Civil Society Facilitators
WHO Geneva, 8-10 August 2005
INTRODUCTION
The Commission on Social Determinants of Health (CSDH) aims to address the
gross inequalities in health between countries and among social groups within
countries through action on social determinants of health. The engagement of
civil society is vital to this process. Civil society engagement with the
Commission will: provide a global platform for civil society voice; advance civil
society agendas relative to social determinants; strengthen capacities among
participating civil society organizations; enhance learning from community level;
promote country action shaped by civil society knowledge and concerns; broaden
the political uptake of the Commission's messages; and improve the chances of
sustainable impact for the CSDH.
Civil society engagement with the Commission must be guided by a
comprehensive strategy that draws on the knowledge and experience present in
civil society organizations and communities. This strategy must involve civil
society in all major components of the Commission, including action in partner
countries, Commission Knowledge Networks and the activities of the
Commissioners. The strategy must reflect the diversity of civil society actors and
the specificities of global regions. Most importantly, the strategy must be
designed and led by civil society groups themselves.
To meet these requirements, the CSDH secretariat will work with civil society
organizations from four global regions (Africa, Asia, the Eastern Mediterranean
and Latin America) acting as CSDH Regional Civil Society Facilitators. The term
Facilitator underscores that the role of these groups is to coordinate a
consultative process. They will elicit inputs from a broad range of civil society
actors in their respective regions and synthesize these inputs into a regional civil
society strategy that reflects collective ownership. On 8-10 August 2005,
delegates from the Regional Civil Society Facilitator organizations met for the
first time to clarify principles, goals and methods for their work with the CSDH.
Topic of the meeting:
i
Civil society participation in the Commission on Social Determinants of Health
and the role of Regional Civil Society Facilitators (CSFs)
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Meeting objectives:
1.
Ensure that CSFs are fully informed about all aspects of the Commission,
including overall goals, deliverables, components and process
2.
Achieve clear shared understanding on the purposes of civil society
engagement with the CSDH
3.
Identify entry points for civil society participation in key components of the
CSDH, including Commissioner activities, Country Work and Knowledge
Networks
4.
Clarify criteria and methods to be used in regional civil society mapping
exercises and in the creation of regional civil society data bases
5.
Clarify CSF deliverables and participation in third meeting of CSDH
Commissioners in India (Sept 05)
Meeting products:
1. CSF representatives informed about all aspects of the Commission
2. Entry points for CS participation in all components of CSDH identified
3. Criteria and methods for regional civil society mapping exercises defined
and agreed
4. Civil society participation in CSDH India meeting specified
Mechanisms used for the identification of Regional Civil Society
Facilitators:
Severaj convergent strategies were employed by the CSDH secretariat to identify
organizations appropriate to act as CSDH regional CSFs. The mechanisms and
criteria ■ applied included: (1) identification of relevant groups through WHO
Regional Consultations on the CSDH; (2) identification based on
recommendations and contacts from CSDH Commissioners; (3) prioritization of
organizations that have a network structure, to maximize outreach potential and
convening capacity; (4) concern to include networks that bring together different
types of civil society organizations within their respective regions; (5) concern to
include groups that have strong connections with grassroots communities and
the social "base".
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EXECUTIVE SUMMARY:
KEY OUTCOMES AND LEARNING FROM THE FIRST MEETING OF CSFs
1.
i What do we mean by "civil society"?
1.1,. Definition: General acceptance of WHO definition of civil society as "a
social sphere separate from both the state and market" made up of "non
state, not-for-profit, voluntary organizations, ranging from formal
organizations registered with authorities to informal social movements
coming together around a common cause".
1.2.
The need to reduce fragmentation and the problem of representation.
The Commission should build on and strengthen existing regional civil
society processes, rather than seeking to create new structures. Civil
society actors from beyond the health sector need to be included (for
example agriculture, labour movements). The media are crucial vectors of
power, and Commissioners should make use of their celebrity status and
capacity to intervene in media. Special channels of participation must be
created for the traditionally voiceless, so they can express their realities
and not just be spoken for by others.
The relationship of civil society with governments: participation
versus institutionalization. The CSDH was called to promote social and
political action that can improve the health chances of vulnerable people.
While the primary responsibility for promoting health equity and human
rights lies with governments, participation in decision-making processes
by civil society groups and movements is "vital in ensuring people's power
and control in policy development'". Participation implies, most basically,
people's being present (or adequately represented) and able to exert
power or influence where policies affecting their health opportunities are
. weighed and decisions taken. Beyond simple presence and the
opportunity to have their voices heard, genuine participation implies that
people have the ability to effectively advocate for, guide, and have a
1 discernable impact on processes in defense of their social interests. This
is the perspective in which civil society participation in the CSDH is
understood. CS partners are invited not simply to endorse programmes
defined by others, but to contribute substantially to the processes through
which the Commission's knowledge generation, action and leadership will
be shaped. This means the opportunity to exercise real influence within
key components of the Commission.
1.3.
i
i
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Communication and media as a space for civil society. People
themselves must be informed participants in defining concrete objectives
for the CSDH process, identifying feasible and appropriate strategies to
’achieve the objectives and implementing those strategies on the ground.
This principle implies a particular effort to include groups and
^communities that have tended to suffer acute forms of marginalization,
disempowerment and social exclusion.
1.4.
2.
What does civil society expect from the CSDH? (some key emerging
messages)
2.1.
3.
Make the political nature and aims of the Commission more explicit.
2.2.
Emphasize the hierarchical structure of health determinants (they are not
all on the same level).
2.3.
Affirm health as a human right. This assigns central responsibility for
health to the State.
2.4.
The CSDH process should strengthen civil society at country and regional
levels, while placing SDH intervention on government agendas.
2.5.
The CSDH can itself consitute a tool for positive change in civil society
organizations, for example by enabling alliances among organizations
and helping health-focused groups link with partners beyond the health
sector.
Guiding principles for civil society " participation" in the Commission.
3.1
Autonomy of civil society with respect to the CSDH.
3.2 Participation must be real, not symbolic or tokenistic. That is, civil society
must, participate in decision-making. Participants in the Geneva CSFs
mee.ting referred to "the collective construction of public policies".
3.3 Transparency in the processes and implementation of the CSDH, need for
a code of ethics that will address conflicts of interest, resolution mechanisms
and intellectual property issues regarding knowledge, among other matters.
Participants argued that this can only be achieved by maintaining with civil
society and other partners "a direct, fluid and steady communication, not
necessarily free of differences".
I
i
5
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4.
3.4
Recover the spirit Alma Ata, and the political commitment that this implies.
3.5
Efficient and timely communication and sharing of information. Stress was
placed on the need to "put the CSDH into concrete political action, so that
it doesn't stay closed-in in itself".
Entry points and critical themes around CSDH
4.2. Entry points and critical themes around Commissioners: Mechanisms
should be created for disclosure of possible Commissioner conflicts of
interest. CSFs should carry out a critical political "audit" of the
Commissioners, as well as of the other Commission components. Some
Commissioners have shown a strong interest in engaging with
civil
society, CSFs should nurture these connections. Commissioners should
participate in regional civil society forums in order to link with relevant
groups. With their experience and high profile, Commissioners will be
able to play a significant leadership role in political and advocacy
processes in regions and countries, as well as at the global level.
4.3.
Entry points and critical themes for KN process: criticism of the Northern
.bias which is apparent in the selection of KN hubs. All North-based hubs
should work with South-based institutions as equal partners. Explicit
criteria should be developed for the selection of KN members to ensure
North-South balance. Intellectual property rights issues need to be
clarified. Who owns and controls the knowledge the networks generate?
Meeting participants stressed the importance of community-based
surveillance and community-based research on determinants, the results
of which would be owned by communities themselves. Danger of
"verticalization"-or silo thinking in the respective KNs; need to focus on
how to connect them, how to keep recommendations from adopting a silo
structure. Criteria for the selection of KN members should be discussed
and agreed with civil society, in order to ensure broad participation and
the inclusion of diverse experiences and to guarantee that KN work
translates into knowledge that can really be applied in developing country
contexts.
4.4.
Entry points on Country Work: During the Geneva meeting, the
Anglophone group emphasized the need for the CSDH to develop explicit
methods and strategies for engaging with countries where the
government is not receptive to an equity-oriented SDH approach, but civil
society is. The CSDH can take advantage of its independent status to
reach out directly to civil society organizations and people’s movements
6
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in such countries. CSFs can help identify opportunities, catalyze and
implement strategies in these contexts. It is crucial that civil society be
involved in the learning processes in countries to identify the key health
determinants, then use
their networks to drive implementation of
interventions. Links with countries should not only happen through the
national central government, but should also operate in provincial and
local spaces. It may be possible to achieve a better initial reception in
these spaces and, from there, to catalyze processes for national scale-up.
5.
Main obstacles to civil society participation in the CSDH
5.1 Limited confidence and credibility regarding the spaces of real
participation for civil society within the CSDH. This is reflected in the
genera! weakness of channels of communication with civil society until
now and in the absence of explicit mechanisms for civil society
participation in decision-making within the CSDH.
5.2 There is a concern that the work of the CSDH could be perceived as
limited to the activities of Commissioners, whereas the CSDH in fact
comprises numerous actors. The Commission must not be allowed to turn
inward on itself; Commissioners should build real and permanent
connections with regions, countries and civil society. To achieve this,
WHO's involvement in the orientation and implementation of Commission
processes is fundamental, given the Organization's role of global health
leadership.
5.3 The possibility that the Knowledge Networks may assume a primarily
academic orientation is a source of concern for CSFs. If this occurs, the
concrete experiences of civil society and communities in relation to the
specific themes may be excluded. At the same time, CSF colleagues
expressed worries about the powerful dominance of Northern countries
among the KN Hubs; in this light, it is all the more vital to ensure strong
representation of developing countries among the membership of the KNs
and among the KN Chairs. Meanwhile, mechanisms must also be sought
to avoid a vertical or compartmentalized mode of working in the KNs.
Criteria for inclusion of KN members should be drawn up in collaboration
and consensus with civil society.
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5.4 CSDH Country Work requires a sophisticated contextualization of the
relationship between government and civil society. Mechanisms must be
put in place to ensure the participation of all sectors of civil society in each
partner country in the elaboration of the country work plan and its
implementation. The CSDH must play an active role in the meetings and
discussions around these issues at national level. The Commission cannot
have a neutral position.
5.5 The global process of the CSDH is above all a political process, and
this challenge should be assumed as such. This implies that the
Commission and in particular the Commissioners will take on tasks of
advocacy and negotiation.
6.
How do the CSFs define themselves, and what will they do?
6.1 The goal of the Facilitators is to develop and strengthen civil society
participation in the CSDH. The CSFs do not "represent" civil society.
6.2 The work should call upon and strengthen relationships with civil
society beyond the health sector, involving organizations and movements
from sectors including education, environment, labour and others.
6.3 The Facilitators act as a link between the CSDH and civil society and
community groups.
i
7.
Civil society requirements from CSDH (in particular Commissioners)
7.1 Should express publicly the vision of the centrality of health and the
importance of SDH in achieving it.
7.2 Should help to open space in countries for dialogue between State
and civil society, with Commissioners using their political influence to
■ facilitate this dialogue.
7.3 Commissioners should play a concrete role in CSDH Country Work,
supporting countries and civil society to advance "powerful ideas" in
relevant levels and settings.
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7.4 The independence of the CSDH from WHO is favorable, but only up to
a point. From the standpoint of civil society, the involvement and guidance
of WHO in the process are seen as central, so that the Organization
genuinely commits itself to an SDH agenda and assumes the global
leadership role that should belong to it in this area. The WHO should be
deeply involved and have clear responsibilities in the operational
processes and leadership of the CSDH.
7.5 Should incorporate into their analysis the complex challenge of the
representation of the voiceless and powerless. What is Commissioners'
responsibility towards these excluded and vulnerable groups?
7.6 Mechanisms for decision-making within the CSDH need to be made
explicit.
7.7 Commissioners need to have a direct and permanent relationship with
civil society, for example via specific Commissioners responsible for each
region, for particular countries, and/or for specific themes.
7.8 Civil society and CSDH should establish jointly a working agenda of
advocacy visits by Commissioners to regions and countries. During these
visits, Commissioners will act in already existing spaces and forums
created by civil society, for example the upcoming
Continental Health
Forum in Caracas, Venezuela.
7.9 Capacity building and training on SDH for social leaders, along with
tools to increase their capacity for political influence on relevant
topics.
In addition, CSDH training strategies should include capacity building for
appropriate decision-making at intermediate government levels.
7.|10 Communications aspects: It is vital that civil society partners
participate in the development of the CSDH communications strategy, and
that this strategy should make use of the particular spaces of civil society.
Some communications messages strongly expressed during the first CSF
meeting included: health is a human right; health is not limited to health
care, but is about improving people's quality of life in a full sense; tackling
the "causes of the causes".
9
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8.
'Proposed work plan
From the point of view of civil society, the most relevant concern in the first phase
of work with the CSDH is to identify the actors and sociopolitical contexts of
countries and regions. To achieve this, an important tool will be the mapping of
various areas: identification of government agendas that include SDH; typology
of countries in terms of participation and democracy and of the relationship of
government with civil society; identification of relevant actors and the roles they
play (profiling/characterizing the various actors); identification of State
organizations and other institutions of power in countries; inventory of key donor
agencies working in the region; identification of civil society properly speaking;
identification of regional or continental civil society organizations; mapping of the
virtual networks that exist in every region; identification of relevant
communications media, such as community radio stations and others; and the
identification and characterization of spaces and events in which the CSDH can
act in countries and regions.
A second process, parallel to the one just described, is to establish through
consensus a joint working agenda for civil society and the CSDH, which will
include visits and participation by the CSDH (especially Commissioners) in civil
society meetings and spaces, as well as the monitoring of progress on agreed
objectives, in line with the guiding principles presented above.
A third process is the social construction of public policies around SDH, from
regional spaces and specifically at the level of CSDH Country Work. Civil society
will also; participate actively (as members) within the CSDH Knowledge Networks.
The strategies used will be based on regional specificities and participation. One
of the immediate tasks for each CSF will be to hold a regional civil society
meeting to discuss this aspect and to analyze, design and agree upon a regional
work plan for civil society participation in the CSDH during 2006-2008. Following
this, a second meeting of CSFs will take place.
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MEETING NOTES
Attending:
CSF Delegates;
Fernando Borgia, Foro Social, Uruguay
Prem John, Asian Community Health Action Network, India
Bridget Lloyd, Health Civil Society Network, Southern and Eastern Africa
Mwajuma Masaiganah, Equinet / People's Health Movement, Tanzania
Alicia Munoz, Confederation Latinoamericana de Organizaciones del
Campo, Asocracion National de Mujeres Rurales e Indigenas, Chile
Louis Reynolds, People Health Movement, South Africa
An'iit Sen Gupta, People's Health Movement, India
Alaa Shukralla, Association for Health and Environmental Development,
Egypt
Mauricio Torres, Asociacion Latinoamericana de Medicina Social,
Colombia
Walter Varillas, Red Salud y trabajo, Peru
CSDH Commissioner.
Professor Ndioro Ndiaye
CSDH Secretariat
Alexandra Bambas Nolen
Hilary Brown (teleconference)
Tim Evans
Alec Irwin
Orielle Solar
Nicole Valentine
Jeanette Vega
WHO:
Eugenio Villar
Gerry Eijkemans
Gabrielle Ross
Facilitators: Alec Irwin and Orielle Solar
1
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HEAL III
Organization and methodology:
The meeting took place over 2 1Z> days and consisted of presentations by CSF
delegates and members of the CSDH secretariat, plenary discussions and 4
small group sessions. For the small group sessions, participants divided into two
working groups based on language facility (Spanish and English). Designated
rapporteurs summarized the results of working group sessions for the plenary.
Location :
I
WHO Headquarters, Geneva (Salle B)
Day 1 (8 August):
1.
Meeting introductions and presentations by CSF groups
The meeting was opened by Tim Evans on behalf of WHO. Alec Irwin
summarized the structure and goals of the event. CSF groups presented their
respective organizations and work. [For detailed content see meeting CD.]
2.
The CSDH process
Jeanette Vega presented the overall structure of the CSDH and its milestones so
far. Nicole Valentine presented the CSDH Knowledge Networks and Country
Work.
Discussion'. The political context (national, global) should itself be considered a
social determinant of health. Politics seem strangely muted in the CSDH
discourse. On the other hand, political battles do not all need to be fought
frontally. Several participants stressed their desire to see the CSDH give clear
emphasis to health as a human right. The core of the human rights approach is
that it assigns central responsibility for health to the State. Jeanette Vega
proposed that, instead of ostentatiously deploying human rights rhetoric, the
CSDH will aim to be pragmatic in identifying policies that can actually help
operationalize the right to health for marginalized groups.
Some participants objected that, as presented for example in the KN slides, the
determinants lacked a clear, hierarchical order. Need to understand the causal
connections: among SDH, to see which are the "determinants of the
determinants". Poverty should not be left out. The configuration of key SDH will
I
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be regionally specific. Meanwhile, regional networks such as Mercosur could be
important political spaces for the Commission.
The CSDH places much emphasis on positive country examples, but how do we
identify what is "positive"? What criteria will be used? The absence of poverty
from the KN themes was criticized. Participants criticized a lack of adequate
transparency in certain CSDH processes thus far and warned against a merely
tokenistic inclusion of civil society.
3.
Civil society involvement in the CSDH: initial proposals
Orielle Solar presented initial ideas on civil society involvement in the
Commission process and the roles and products of regional CSFs.
Discussion: Participants agreed that the timelines originally proposed by the
CSDH secretariat (with regional mapping exercises to be completed by
September Commissioners meeting) are unrealistic. More time will be required
for a genuinely
i
consultative process. CSFs must in no way be seen as "representing" civil
society in their regions. Their role is to facilitate a participatory process and to
create linkages. The Commission should be prepared to come to and support
civil society forums and processes that are ongoing in the various regions , e.g.,
upcoming social forums in Venezuela and Pakistan in January 2006. The CSDH
should be ready in some cases to adapt to civil society calendars, rather than
always the other way around. The proposal was made that, instead of a finished
regional mapping exercise, the CSFs could bring to the India meetings the first
draft of a document setting out the broad principles of civil society participation in
the Commission along with some key entry points.
4.
Results of Group Work session 1
General acceptance of WHO definition of civil society as "a social sphere
separate from both the state and market" made up of "non-state, not-for-profit,
voluntary organizations, ranging from formal organizations registered with
authorities to informal social movements coming together around a common
cause". In the Anglophone group, it was proposed that trade unions be explicitly
included- but political parties actively contesting elections excluded. Discussion
unresolved on the status of political parties.
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Entry points and critical themes around Commissioners: Mechanisms should be
created for disclosure of possible Commissioner conflicts of interest. CSFs
should carry out a critical political "audit" of the Commissioners, as well as of the
other Commission components. Some Commissioners have shown a strong
interest in engaging with civil society, CSFs should nurture these connections.
Commissioners should participate in regional civil society forums in order to link
with relevant groups.
i
Entry .points and critical themes for KN process: criticism of Northern bias
apparent in selection of KN hubs. All North-based hubs should work with South
based institutions as equal partners. Explicit criteria should be developed for the
selection of KN members to ensure North-South balance. Intellectual property
rights issues need to be clarified. Who owns and controls the knowledge the
networks generate? Importance of community-based surveillance, community
based research on determinants, the results of which would be owned by
communities themselves. Danger of "verticalization" or silo thinking in the
respective' KNs; need to focus on how to connect them, how to keep
recommendations from adopting a silo structure.
i
Entry points on Country Work: Anglophone group emphasized the need for the
CSDH to develop explicit methods and strategies for engaging with countries
where the government is not receptive to an equity-oriented SDH approach, but
civil society is. The CSDH can take advantage of its independent status to reach
out directly to civil society organizations and people's movements in such
countries. CSFs can help identify opportunities, catalyze and implement
strategies in these contexts. It is crucial that civil
society be involved in the learning processes in countries to identify the key
health determinants, then use their networks to drive implementation of
interventions.
Day 2 (9 August):
5.
Plenary discussion with CSDH Commissioner Professor Ndioro Ndiaye
Representatives of the two Working Groups presented their main results in
plenary. Professor Ndiaye responded.
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Discussion; The previous WHO Commission (Commission on Macroeconomics
and Health) made some valuable contributions, but was limited. Relationship of
CSDH to CMH needs to be clarified. The CSDH is an essentially political process,
not just producing technical documents but attempting to influence public policy.
This political focus should be made more explicit. The CSDH should have
national visits, visit countries to exert political pressure and advocacy. Civil
society groups, particularly in developing countries, need a direct relationship
with Commissioners. On the other hand, catalysing appropriate contacts is
difficult because much of the population is outside organized civil society.
Professor Ndiaye acknowledged the political character of the Commission's work
and stressed the need to build concrete mechanisms for connecting government,
civil society and Commissioners. She proposed the possibility of periodic
thematic consultations among stakeholders and urged that the CSFs develop a
concrete programme for this collaboration. A matrix of the key SDH in each
region could be drawn up, then community-based, action-oriented research
focused on the issues. The Commission should build on and strengthen existing
regional: civil society processes, rather than seeking to create new structures.
Civil society actors from beyond the health sector need to be included (for
example agriculture, labour movements). The media are crucial vectors of power,
and Commissioners should make use of their celebrity status and capacity to
intervene in media. Professor Ndiaye stressed the importance of tapping the
resources of diaspora communities for the work of the CSDH and its interface
with civil society.
6.
Results of Group Work sessions 2 and 3
Discussions focused on: conceptual aspects of the proposed regional civil
society mapping exercise; "social control" of CSDH processes and outputs; and
potential barriers and facilitators for civil society in using the entry points
identified within the Commission's components.
The mapping would not be simply a list of CS organizations, but instead a
political mapping, a "power mapping" of actors, forces and processes in each
region that can facilitate action on SDH or hamper progress. Suggestion that the
mapping involve two parts:
1. First, a "situation analysis" of civil society and other actors in the region,
including a list of key categories of relevant actors; need to identify
facilitating and "blocking" actors, including State and for-profit private
sector actors as appropriate to provide orientation for action;
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2. Second part of mapping would enumerate organizations and actors
related to possibilities for involvement in specific collaborative processes
with the CSDH; initial inventory would be updated and expanded over time;
image of concentric circles expanding outward as more and more groups
are connected into the process, which should continue beyond the lifetime
of the Commission.
The mapping must be crafted from the start as a strategic exercise. It should be
seen as an open-ended process. A key part of CSFs' initial situation analysis
would be identifying their own weaknesses and "blind spots", i.e., areas
(geographical, social, political) where they will be especially challenged in
gathering relevant information and contacts.
Training and capacity building around SDH for civil society should be oriented
towards political influence and impact. Training modules oriented to political
action could be developed for: government leaders and mid-level managers, also
for civil society organizations and communities.
Areas of disagreement with the CSDH process thus far: process not transparent
and genuinely inclusive; poverty neglected; insufficient emphasis on health as a
human right; political context not seen as a major determinant.
Areas of agreement and approval: shift from biomedical to social model in health;
health as a social value, not an economic input; efforts to address root causes
rather than symptoms.
7.
CSDH communications tools
Hilary Brown of the- Commission secretariat and XX of PAHO explained by
teleconference the uses of the CSDH Sharepoint communications tools and their
relevance for CSFs.
Day 3 (10 August):
8.
Results of Group Work session 4 and final plenary
Participants broke into working groups for a last session on expectations for the
upcoming India meeting of the Commission, then joined in a closing plenary.
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Discussion: Theme of potential Commissioner conflicts of interest must be put on
the table explicitly during the CSDH meetings in India, as the Terms of Reference
for Commissioners are debated. Hubs and members of KNs should also operate
transparently and declare any conflicts of interest. Issue of intellectual property
rights were again highlighted with respect to Knowledge Networks and other
CSDH "products": who "owns" the knowledge of the KNs? Explicit criteria need to
be defined for selecting membership of KNs, so as to ensure North-South and
other forms of balance. More broadly, a "code of ethics" should be formulated for
the CSDH and all its components -- including Commissioners and also CSFs.
Health as a human right should be explicitly included in the Terms of Reference
for all KNs. The Gujarat State government has a highly problematic civil rights
record, and the failure to grasp the implications in time points to weaknesses in
the Commission's strategic planning.
Participants stressed that contractual arrangements need to be finalized rapidly
so that CSFs can get to work. Resources must be adequate to the effort
demanded. Civil society relations with the Commission must be based on clear
principles: collaboration but also autonomy. CSFs need to do a more thorough
"profiling" of Commissioners in order to identify those who will be most useful
partners. It was emphasized once more that CSFs are not "representatives" of
civil society but engaged in supporting a process. A key challenge is to bring the
Commission into relationship with "flesh and blood people”, especially workers
and marginalized communities. Special outreach and facilitation mechanisms will
have to be put in place to secure the participation of grassroots organizations in
the various regions.
Action points:
Secretariat
• Secure full participation for CSFs in the India meeting of Knowledge
Network hubs, including dedicated time for presentation of civil society
concerns with KN process and content.
• Secure maximum participation for CSFs in India Commissioners meeting,
including dedicated time for CSF presentations and dialogue with
Commissioners.
• Develop Terms of Reference for CSF participation in September CSDH
meetings and circulate to CSFs for approval.
• Fqrmulate revised Terms of Reference for CSF roles, timeframes and
deliverables, reflecting input from first meeting of regional CSFs.
I
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•
®
Complete draft contracts (Agreement for Performance of Work) based on
revised TOR and circulate in time for discussion and correction with CSFs
in India.
Prepare and circulate draft report of first meeting of regional CSFs.
CSFs
» Identify a delegate and confirm participation in India meetings of KN hubs
and Commissioners, 9-14 September.
» Examine draft TOR for CSF participation in India meetings and approve or
modify.
• Each CSF to develop a 10-minute presentation for Commissioners
meeting in Ahmedebad; form and content to be defined and agreed with
other CSFs.
» 'Proceed with draft regional civil society "political mapping'Vsituation
analysis, along lines discussed in first meeting of CSFs.
« Begin political and ethical "audit" of the Commissioners and other
components of the CSDH -- leading towards an eventual "code of ethics"
for the Commission.
o Begin to identify dates on which to hold regional civil society meetings this
fall.,
® Iden tify possible regional civil society forums or events on which a second
meeting of CSFs could "piggyback" in late October or November.
' People’s Health Charter
18
Health Development Agency
Economic appraisal of
■
■
■ ■
nterventions
Authors: Michael P. Kelly
*,
David McDaid1,
Anne Ludbrook
*
and Jane Powell^
‘Director of Evidence and Guidance, HDA
^Research Fellow, LSE Health and Social Care and European
Observatory on Health Care Systems, London School of
Economics
^Health Economics Research Unit, Institute of Applied Health
Sciences, University of Aberdeen
IlSenior Lecturer in Health Economics, University of the West of
England, Bristol
Introduction
Relationship between upstream and
downstream interventions
The economic appraisal of public health interventions is
both underdeveloped and intrinsically difficult. This paper
Downstream interventions aim to change adverse health
considers some of the problems, and points towards
behaviours; upstream interventions target the circumstances
potential solutions
that produce adverse health behaviours. The best evidence
that exists lends io be about downstream rather than
Problems to be solved
upstream interventions. While these interventions are
The problems of applying economic evaluation to public
this presents a second important difficulty. For example, an
important in themselves, from an evaluation point of view
health interventions are considerable. The most important
approach that relies on specific downstream interventions,
are outlined here.
such as individual counselling to assist smoking cessation,
Determinants of health and of inequalities
in health ’
will be mediated by broader social structural factors such as
poverty, unemployment and social conditions. The analytical
and evaluation problem is that upstream interventions to
Oyer a long period, there has been an overall improvement
improve the circumstances in which people live may not be
in the aggregate health of the population. However, at
the heart of public health is a conundrum - as the overall
a sufficient condition to produce health improvements, but
health of the population has improved, in the most recent
interventions to be effective. The importance of the socio
may be a necessary precondition for other downstream
past, inequalities in health have worsened. Despite a vast
economic context has implications for flow interventions are
literature on the determinants of health, specific analysis of
designed and evaluated. Evaluating single initiatives may fail
tie determinants of inequalities in health is underdeveloped
to capture effects that rely on multiple interventions.
And there is relatively little evidence of what interventions
will work to reduce inequalities in health. Consequently the
Mediating role of behaviour change
baseline for analysis of effectiveness limited. The most
To be effective - and therefore cost effective - public health
comprehensive analysis is in the HDA’s Evidence Briefings
interventions (unlike many clinical interventions) often
(Kelly, 2004; www.hda-online.org.uk/evidence).
require a change in individual or population behaviour
patterns to ensure uptake of the intervention. The behaviour
The variability in effectiveness and the likelihood of success
change is an intermediate or process event, necessary to
of interventions are crucially filtered through two sets of
achieve the desired final outcome. The behaviour change
mediating factors which are, to some extent, independent
itself must be modelled into the economic analysis, but
of the mechanics of the intervention itself. These are the
the modelling needs to account for the behaviour as more
enthusiasm, expertise and engagement of the staff carrying
than the operation of; a’ simple rational economic calculus
out the intervention; and the local delivery infrastructure.
in the mind of the individual. The traditional approach to
For example, sex education is much more effective when
economic evaluation has been to synthesise costs and final
delivered by enthusiastic and motivated staff. In the
outcomes, such as life years gained, so intermediate process
absence of much in the form of intention to treat analysis
variables have often been ignored or dismissed as irrelevant.
in public health, the effects of the real world have to be
Yet understanding this behavioural process is crucial to
disentangled when assessing study results. Statistical analysis
determining why public health and health promotion
of confounders can help here, but the confounders add a
programmes and interventions work (or fail), and at what
layer of complexity to the understanding of effectiveness
cost. It can help in understanding the barriers to individual
and cost effectiveness. The most rigorous analysis of these
ihange, and how different approaches might be used to
confounders is to be found within the HDA's evidence into
overcome such barriers. 'This will require some awareness
practice work (Kelly eta/., 2004).
of different socio-economic factors including income,
employment, crimd rates and educational attainment
Biological and social variation
- especially important if the objective is not just to improve
Clinical treatments take place in the context of a relatively
population health, put also to reduce inequalities in hea.th,
narrow, well defined span of biological variation in individual
where the impact on specific subgroups is also required.
Separating cause and effect
which is not itself well defined (beyond usually blunt
Unlike drug-based or technological interventions, public
measures of socio-economic difference), and the variability
health initiatives often use multi-faceted approaches, making
in the population is not well mapped. Unsurprisingly,
it more difficult to identify which elements of a programme
individuals respond in widely different ways to different
may lead to change. Some public health interventions occur
public health interventions, so different interventions
outside the health domain, in transport; education, local
may work better than others with some individuals - the
authorities or the workplace Even where interventions are
stubborn class differences in smoking rates are a testimony
well defined and tightly circumscribed within an obvious
to this. There has been some limited attention to this effect
health domain, as in the delivery of smoking cessation via
in the literature. Better information is needed on tailoring
nicotine replacement therapy (NRT) in primary care, attributing
interventions, and it may be efficient to have a range
cause to this intervention is difficult. Secular trends, and other
of interventions available. The HDA Evidence Base has
anti-smoking activities to which the population is exposed,
consistently pointed to the need for tailored and targeted
will also have effects, and interactive or synergistic effects
interventions, and the argument has repeatedly been made
between interventions need to be considered.
by the HDA for a much better understanding of the social
Study designs to help solve the problem of cause and effect
may bring problems of their own. Randomised controlled
trials, which are intended to eliminate bias, are often the
preferred solution. However, it is important that these
are pragmatic trials, carried out in real-world settings, in
differences in the population. Economic appraisal needs to
embrace the diversity in the population and consequent
variations in potential responses (Graham and Kelly, 2004).
Absence of 'D' in public health R&D
have implications for the scale and feasibility of the studies
In contrast to drug trials, public health interventions are
often implemented without much pretrial development
required. While theirandomised controlled trial is the best
Thus public health interventions can change during their
wjv or eliminating bias and linking cause and effect, it is not
implementation, complicating interpretation of the results.
order to test effectiveness and not just efficacy. This may
witrout limitations.^ther study designs have the potential
2
responses. Public health interventions take place within a
very wide spectrum of social difference in the population
to provide good quality evidence if they are rigorous in
When should effectiveness be measured?
dealing with sources of bias. It should be noted that, in
The impact of public health programmes is not short term.
terms of reducing health inequalities, the potential sources
At what point is an intervention judged to have succeeded?
of bias need to be identified and studied. The mediating
- at some point immediately after the intervention has been
or confounding factors at the point of implementation in
completed; at three or six months, or a year, or longer?
real-world settings need to be considered from the point of
And what is the capacity for effects to atrophy or decay
view of effectiveness and cost effectiveness, and inequalities.
with time? In real time, the final outcomes of public health
interventions may take many years to be realised, and thus
differently with different groups Where appropriate, this
may be difficult to attribute directly to any one intervention
type of analysis needs to be integrated into the design of
Retrospective analysis may be possible, but only if steps
evaluation studies and may have implications for the size and
were taken originally to ensure the appropriate data were
cost of studies
' oiler led llir je may be polerill.il loi using set ondaly data Io
model longer-term impacts.
1
The solution: an analytical
framework
How should effectiveness be measured?
I he problems noted previously are not reasons not
There are no standard methods to give common currency
to the impact of public health interventions, other than
die monetary valuation appioaches used within CBA. I he
use of common currency outcome measures - estimates
to undertake an economic analysis. They have to be
acknowledged and then incorporated into the analysis try
considering the existing information, building assumptions
into the analysis, and making them explicit.
of cost per quality-adjusted life year (QALY) to evaluate
public health interventions - needs careful assessment
There are a number ol different potential methods ol
Cost per QALY estimates'already exist tn the more clinical
evaluation available to the economist, although the emphasis
areas of public health evaluation, and there is much
in most thus far is on the evaluation of individual interventions
work in progress in terms of smoking cessation services.
rather than the complex programmes found in public health.
Many of the estimates produced to date show that public
Several types of economic evaluation are outlined briefly here,
health interventions compare favourably with treatment
each of which has a different scope and suitability.
interventions.
The simplest economic studies are concerned only with costs
However, the QALY measure may not be sufficient to
- not (usually) because they see outcomes as irrelevant, but
capture the complex impact and context of psychosocial
because, in relation to the services under study, the health
treatments in public health and the wider range of
and quality-of-life outcomes have already been established
relevant non-health outcomes. Past experience has shown
from other research, or are currently not measurable because
that QALY outcome measures may not reflect sufficient
of conceptual difficulties or research funding limitations.
differences between effects of interventions to decide
One of these cost-only methods is the cost-offset study,
priorities for public health practice. Attempts to draw
which compares costs incurred with (other) costs saved
comparisons of interventions across public health and
For instance, a new public health intervention might have
healthcare interventions should be made in full knowledge
higher start-up costs, but may reduce the need for in-patient
of the limitations of the one-size-fits-all approach. Intense
admissions and thus lead to cost savings downstream. The
interventions of long duration cost more than their shorter,
limitation of such an approach, though, is that it does not
less intense counterparts, and there may be a non-linear
look at alternative use of the resources elsewhere. Cost
association between intensity and duration of intervention
minimisation analysis extends economic analysis further
and cumulative outcomes. This needs to be borne in mind
by considering alternative uses of resources, and proceeds in
when making cost per QALY comparisons of clinical and
the knowledge that previous research has shown outcomes
psychosocial public health interventions from the limited
to be identical in the intervention or policy alternatives being
cost-effectiveness evidence.
evaluated Well conducted cost-minimisation analysis can be
thought of as a special type of cost-effectiveness analysis,
Individual versus population measures
Should success be measured at an individual level or at a
but in most instances such evidence will not be available and
more complex evaluation will be required.
population level? Economists usually argue that the costs and
Cost-effectiveness analysis is the most common
benefits to individuals should be an integral part of economic
approach used in economic evaluation, and synthesises
evaluation. However, for pragmatic reasons appraisals of
single outcomes and costs (eg increase in life years gained)
public health are frequently conducted from the viewpoint of
to health promotion intervention. An obvious weakness
the NHS and other public sector agencies. It can be argued
with the strict cost-effectiveness methodology is the
ir at either costs and benefits are unlikely to vary significantly .
enforced focus on a single outcome dimension (in order to
O' systematically between individuals; or that individual
compute ratios), when public health programmes can have
costs and benefits are unlikely to vary significantly between
multiple outcomes. Carrying multiple outcomes forward is
treatments Neither argument is necessarily sustainable in
less tractable analytically, but three options are available,
the area of health improvement. A better understanding
associated with three other modes of economic evaluation.
of individual costs and benefits, and how these relate to
One option, cost-consequence analysis (CCA), is to retain
individual outcomes, may help in understanding why certain
all or most outcome dimensions using whatever appropriate
interventions work better than others, and why they work
measures are available. The other two options weight the
outcomes, either in terms of money (cost-benefit) or in
Cost-consequence analysis is similar to cost-effectiveness
terms of utility (cost-utility).
analysis in terms of the questions addressed, but is applied to
evaluate interventions with more than one multi-dimensional
Cost-utility analysis measures, then values, the impact
of an intervention in terms of improvements in preferenceweighted, health-related quality of life such as the QALY.
Cost-utility analyses allow comparisons to be made across
all areas of health intervention, aiding resource allocation
decision making. But they do not capture the broader non
health consequences and opportunity costs of programmes.
outcome. In CCA, for each alternative the evaluation would
compute total (and component) costs, and measure change
along every one of the relevant outcome dimensions. The
cost and outcome results would need to be reviewed by
decision makers, and the different outcomes weighed up
(informally and subjectively) and compared with costs
While this approach has theoretical problems, as it does
Cost-benefit analysis (CBA) values all costs and benefits
not synthesise benefits and costs, it can be used to look at
in the same (monetary) units If benefits exceed costs, the
issues of changing behaviour that are so crucial to public
evaluation would recommend investing in the programme,
health interventions. CCA does not attempt to combine
and vice versa. CBAs are thus intrinsically attractive, and
measures of benefit into a single measure of effectiveness,
theoretically an ideal approach, but conducting them can
so it cannot be used to rank interventions. Nevertheless it is
be problematic because of the difficulties associated with
a systematic technique that allows decision makers to weight
valuing outcomes in monetary terms (including public
and prioritise the outcomes of an evaluation. It is possible to
acceptability).
Given the nature of public health interventions and their
impact across many o'her public sectors, there is a strong
produce cost-effectiveness comparisons for single outcomes
within the CCA framework. The analysis involves focusing
on a particular problem, for example teenage pregnancy,
case, in this area in particular, for more attention to be
then considers two or more possibilities: to do something
placed on CBA. NICE guidance currently recommends only
(one or more interventions); or to do nothing, then, using
a health and personal social services perspective (although
either existing available data post hoc, or deriving new
costs to patients and families may also be reported). CBA
data, an appropriate method is established for an analysis
would theoretically adopt a complete societal perspective,
of costs and outcomes in a common currency. The evidence
but pragmatically, as a minimum from the policy-making
collected needs to relate to four questions: what works to
perspective, the analysis could at least then be conducted
improve health; what works to reduce inequalities in health,
from the perspective of the total public budget, which makes
what works in changing behaviour; and what works in
intuitive sense given the broad impact of these interventions.
promoting uptake of behaviour change interventions? The
Valuation methods used by health economists in CBA studies
sources of evidence for these questions will be different.
have concentrated on direct valuations by either asking
Outcomes can be measured in terms of QALYs, healthy year
individuals to state the amount they vvould be prepared to
equivalents or disability-adjusted life years. Other outcomes
pay (hypothetically) to achieve a given health state or health
might be in terms of teenage pregnancies or conceptions
gain, or observing actual behaviour and imputing implicit
averted, awareness and take-up of contraception or avoiding
values.
adverse circumstances of teenage pregnancy, such as missed
education and training opportunities. Comparisons between
More recently, an approach first developed in marketing
has been used to value health interventions. Commonly
known as discrete choice experiments, this approach
allows individuals to rank different real-world scenarios,
which may consist of several dimensions. Although its use
in health promotion and public health has been limited so
far, this approach has the scope to explore some of the
individual characteristics, and environmental factors that
may influence the uptake of interventions and changes in
behaviour. By including cost as one of these dimensions, a
monetary value can also be elicited. Although complex, in
interventions would require capturing the wide range of
consequences (good and bad) and the potential costs (to
the initial provider, partner organisations and other services).
A cost-effectiveness ratio for every intervention would
compare cost (minus the saving in resources) with a unit of
outcome such as a QALY, but the analysis can also show the
trade-off between different outcomes across the alternative
interventions.
Conclusions
that the scenarios need to be devised carefully, this approach
In the longer run, the development of properly conducted,
has the advantage pf not specifically asking individuals to
comprehensive CBA across all the interventions identified
p_t a monetary value on health states or health gain, which
as capturing the broad, cross-sectoral impact of public
can make the technique easier to administer than traditional
health interventions should be a priority. CBA and CCA
willingness-to-pay studies, and also promote its acceptability
to decision makers. ■'
should be linked to data and evidence about effectiveness.
Additionally, the links between measurable outcomes from
policies, programmes and interventions and long-term
• At the societal level, the ideal method in the long run
health outcomes need to be modelled. There is a need for
is cost-benefit analysis (CBA), which would integrate
sophisticated economic and effectiveness models that can
outcomes into a single measure, allowing comparisons
be used to evaluate the wider implications and impacts of
lo be made between inleivenlions. I his would permit
different prevention strategies, and to encompass impacts on
the resource trade-offs within and between government
departments to be exposed.
inequalities.
Approaches to economic assessment undertaken by
economists, traditionally not considered to be 'economic
evaluation’, could also be conducted. For instance,
econometric studies on the impact of taxation changes on
consumption of alcohol and cigarettes are promising lines of
investigation.
• Given the practical difficulties in applying CBA, the use
of cost-consequence analysis (CCA) within a pragmatic
framework is suggested to capture the layered outcomes
of public health interventions at the local level.
• CCA is similar to cost-effectiveness analysis in terms
of the questions addressed, but is applied to evaluate
interventions with more than one outcome, and where
It is important to understand the context in which a public
combining these outcomes in a full CBA is not feasible.
health intervention operates, and thus move beyond the
• CCA does nobattempt to combine measures of benefit
'black box' within which much traditional health economic
into a single measure of effectiveness, so it cannot be
evaluation sits. In particular there is a need to gather
used to rank interventions.
information on process outcomes and factors influencing
• The full range of research methods should be used as
changes in the behaviour of individuals and populations, as
an adjunct to CCA. This would include randomised
well as the institutional arrangements that may influence
controlled trials, quasi-experimental designs and
both the costs and effectiveness of interventions. Such
qualitative methods.
information can help decision makers identify whether a
successful (or unsuccessful) initiative undertaken in one
locality might be generalisable to other settings
There is presently insufficient economic evaluation evidence
to knowledgeably inform public health policy making locally
or nationally. This state of affairs can be changed, but will
require strong direction to ensure the priorities for economic
evaluation evidence become organised and coordinated
at local, regional and national levels. Teams of economists
working in isolation from the interventions and service-users
they evaluate will not help to deliver the true scenario.
Further reading and ongoing work
Standard texts that may usefully be consulted are Drummond
etal. (1997) and Sefton etal. (2002). Recently several
initiatives have been undertaken, both in the UK and
elsewhere, to explore some of the issues in the economic
evaluation of complex interventions (Hale et al., 2005).
The UK Health Promotion and Health Economics Forum
has published a manual providing guidance on economic
evaluation in the area of health promotion. Similar work
has been undertaken on behalf of the Joseph Rowntree
Keypoints
i
Foundation (www.jrf.org.uk) to look at how economic
evaluation techniques traditionally used in the health
• The mechanisms of economic appraisal may, can and
arena can be applied to other areas of social welfare, and
should be applied to public health interventions.
what can be learned by looking at how other branches
• Economic appraisal should be linked to the appraisal of
effectiveness.
• Economic evaluations should be a routine and consistent
part of all public health interventions.
• Economic evaluation should use a common, economic
framework. A common framework would facilitate and
of economics, and other disciplines, have approached
evaluation. In the USA, the Centers for Disease Control and
Prevention (www.cdc.gov) continues to build up an evidence
base on the cost effectiveness of health promotion and
public health interventions, and has developed a checklist
and guidance to help improve the comparability of studies.
enhance a consistent and transparent basis for decision
Recognition is growing among health economists and
making.
others of the importance of qualitative approaches and the
• Such analysis should retain the shape and feel of a
general challenges of evaluating complex multi-sectoral
traditional economic framework, but will need enough
interventions. One positive step is the imminent creation
flexibility to capture the multi-dimensional, complex
of a joint Cochrane/Campbell Collaboration Economics
and layered outcomes of public health policies and
Methods Group (www.med.uea.ac.uk/research/research_
interventions.
econ/cochrane/cochrane_home.htm) that will look at these
• The economic analysis must be able to inform evaluations
of the effectiveness of interventions that reduce
inequalities in health.
issues in the fields of health, social welfare, education and
crime.
Annex: Examples of economic evaluation
Introduction
interventions. A range of health promotion interventions
were considered, in( hiding inloini.ition raiiipaigns,
In most potential priority areas for public health interventions,
requirements to declare the salt content in food, and taxes
economic evidence cap be identified in the literature. The
on salty food or subsidies for foodstuffs with less salt.
US Centers for Disease Control has been building up a
Intermediate outcomes in terms of blood pressure reduction,
database of cost-effectiveness evidence, while a recent
and their subsequent impact on myocardial infarction
overview of evidence on the cost effectiveness of a wide
and stroke rates, were estimated for an entire population.
range of policy and individual interventions to prevent/reduce
Overall, the model indicated that health promotion would
smoking is available from the WHO Health Evidence Network
be a cost-saving intervention as the direct costs associated
(www.euro.who.int/HEN; www.euro.who.int/document/
with the programme, including the impact of taxation,
e82993.pdf).
would be less than future medical care costs avoided and
There are areas where evaluation is more limited, perhaps
lost productivity due to morbidity and premature mortality.
due to their complexity, or to a lack of demand and thus
By using a model it was possible to extrapolate the data to
resources for such evaluations. For instance, recent reviews
consider the consequences for the whole population and
of the effectiveness of breastfeeding and of falls prevention
test for uncertainty in variable parameters, and to build a
by the NHS Centre for Reviews and Dissemination noted that
greater case for investment in this form of health promotion.
only very limited evidence was available in these areas.
A contextual analysis of the target subgroups might have
helped inform decision makers as to which approach was
Where economic evaluations have been conducted, they
have concentrated on individual interventions, similar to
most appropriate to those target groups of highest priority
(Selmer eta/., 2000).
drug and technology evaluations, rather than those aimed
at improving population health. The challenge in many
Another modelling study focused on estimating the costs
respects is not about identifying studies providing evidence
and health consequences (reduced incidence of cancer)
for the cost effectiveness of public health interventions, but
arising from increasing the dietary intake of fruit and
rather about the difficulties in trying to compare the results
vegetables to recommended levels. Demographic, health and
of studies because of significant methodological differences
healthcare cost data from 20% of the Danish population
and limitations, as well as poor reporting.
over a four-year period were included in the model. The
model found that the strategy would be dominant over
Few have looked beyond final outcomes to also consider the
process by which those outcomes are achieved. Many public
health/health promotion interventions will be successful only if
individual and cbmmunity behaviours can be altered. Without
understanding these factors, it is difficult to determine the
transferability of the results of any one successful intervention
to a different setting. This is of particular importance given
that much of the available literature derives from the USA,
where the context can be very different. Rather than trying
to come up with firm conclusions about the strength of
cost-effective evidence, this'section provides information'
from some examples of economic evaluations in this area,
emphasising the types of intervention examined and
methods used, as well as the public health issues addressed.
An example is also provided of ongoing work seeking to
incorporate contextual information into economic evaluation.
Example 1: Modification of diet through
health promotion
the current situation as daily life expectancy might be
increased by between 0 8 and 1.3 years, and between
19 and 32% of all cancers might be prevented. Overall
healthcare costs would remain unchanged - resources
saved in cancer treatment would be required for additional
lifetime healthcare costs for a longer-living population. This
study, while useful, also demonstrates some of the limits of
current economic evaluation in this area, as it does not take
into account the costs and different mechanisms needed to
promote behaviour change. Such models would also benefit
from considering uptake rates, perhaps generating some of
this information from additional qualitative and quantitative
research (Gundgaard etal., 2003).
Example 2: Evaluating the impact of
financial incentives as a way of modifying
behaviour
Although not fitting directly within the traditional mode
of economic evaluation, econometric analyses have been
The complexity of such studies can be seen by looking at a
health promotion programme to modify the population's
intake of salt. A simulation model was constructed
that synthesised data on the effectiveness of various
used to estimate the impact of taxes (and subsidies) on
the consumption of goods such as cigarettes, alcohol and
healthy food options. An area less well explored has been
the evaluation of direct financial incentives at an individual
level as a way of. modifying behaviour. One example is a
how; one review of effective measures to reduce alcohol
Quit and Win campaign (www.quitandwin.net) that involved
misuse in Scotland reported that the evidence for mass
rewarding individuals with prizes as part of a mass media
media interventions working was weak, and that they may
strategy. Hie intervention was found to be very much at
influence knowledge and awareness rather than behaviour
the low end of the coit-effectiveness thresholds considered
perse. It is also important to examine the impact of mass
acceptable by NICE. Financial incentives in the form of
media and community public health campaigns on specific
lottery prizes being awarded have also been evaluated as a
target groups. For instance, one recent study in London
mechanism to help improve vaccination uptake rates, and
looking at the cost effectiveness of a smoking cessation
again these appear to have an acceptable cost-effectiveness
campaign targeted at the Turkish community reported a
level compared with other funded interventions.
favourable cost-effectiveness ratio of £105 per life-year
An additional example of the impact of modest financial
incentives is a pilot study undertaken in Denmark comparing
three different approaches intended to increase influenza
vaccination rates in target population groups. The study
saved (Stevens et al., 2002).
Example 4: Brief interventions
Short-term interventions to promote public health have
compared several different interventions: personal invitations
been subject to much evaluation, but only limited economic
to family doctors; a lettei from local authorities with user
evaluation. Three economic studies have shown brief
fees waived for vaccinations; personal invitations from
interventions to prevent alcohol misuse to be relatively cost
family doctors; and user fees being waived. The latter
effective due to fairly high levels of effectiveness and low
method increased the uptake rate from 40 to 70%. More
costs. Modelling the results using UK cost data suggests
generally, there is a small but growing body of literature
that the cost per life saved is in the range £1,446-£2,628
on the role of financial incentives paid to health and other
if no savings in resource use are taken into account. If
sector professionals to promote screening and vaccination
resource savings are considered, then the benefits exceed
initiatives. Although ethically open to question, there may also
the costs of the intervention (www.scotland.gov.uk/health/
be a case for looking at the use of direct financial incentives
alcoholproblems/docs/lire-OO.asp). Brief interventions for
for populations to use healthy interventions - eg paying
smoking cessation have been estimated to cost around
individuals a small fee to be vaccinated (Nexoe ef al, 1997).
£73 per QALY (www hta nhsweb.nhs.uk/fullmono/
mono616.pdf). However, this result should not be applied
Example 3: Evaluating the cost
effectiveness of mass media campaigns
on behaviour
Although there has been much written about the
effectiveness of mass media campaigns in changing health
behaviour, including a Cochrane review, much less has been
done to evaluate their cost effectiveness, although some
too simphstically. More intensive interventions for smoking
cessation which have higher costs per QALY, such as
buproprion, NRT and counselling at £487 per QALY, still
represent good value for money and have a higher impact in
terms of quit rates.
Example 5: Workplace health promotion
studies can be found. One study, for instance, evaluated a
One area where a growing body of economic evidence
four-year television and radio campaign to deter teenagers
exists is for workplace health promotion, in part because
from beginning smoking in four communities in the USA.
there have been greater demand and resources available
Markov modelling was used to estimate the impact on life
to look at interventions seen to have a direct impact on
expectancy as a result of individuals not taking up smoking,
productivity. There is good evidence, for instance, of the cost
and students were purveyed immediately at the end of
effectiveness of systematic, organisation-wide approaches
the four-year campaign, then again two years later. The
to promote positive mental health at work and reduce
intervention was found to be cost effective, with a low cost
work-related stress. These have recommended including
per life year gained compared with many other interventions.
staff support, two-way communication structures, enhanced
Again, the difficulty with this analysis is that further
job control, increased staff involvement, and an improved
information on the context is needed to determine whether
working environment in programmes (www.nelh.nhs.uk/
the results are generalisable to other settings (Seeker-Walker
nsf/mentalhealth/whatworks/knowhow/workplace-
eta/., 1997).
cfa.htm). In the USA, employee assistance programmes
Studies of mass media campaigns emphasising the dangers
providing counselling services for employees and their
of alcohol and driving in the USA and Australia have also
families for a range of issues have been evaluated. These
been reported to be cost-saving overall, with benefits far
programmes have been found to be highly cost-saving, with
outweighing costs. Again, though, evaluation requires
improvements in productivity and reduction in absenteeism
greater depth to determine what is actually working and
more than outweighing the direct costs. The analyses can
generally also be considered to be conservative, as they do
some of this contextual information, a variety of research
not take into account additional health and community
methods are being used. These include.
benefits associated with maintaining employment
• Event logs documenting actions and impacts in each of
(Alexander, 1990).
the intervention communities
Example 6: Incorporating context into
ongoing economic evaluation of a
community health promotion programme
In addition to strengthening the quality and transparency of
economic evaluations, there is much scope for augmenting
• Dianes kept by, and interviews with, community
development officers on how the programme is evolving
• Interviews with other key stakeholders
• Documentation of resource costs and impact of changes
in health outcomes on resource use
• Focus groups in non-study areas to ascertain what value
other community groups place on changes in health
the essential elements of economic evaluation with
status due to the intervention
additional qualitative data to inform the context. This can
• Community-based postal survey to elicit community
be illustrated by looking at an ongoing randomised trial
values for project-related social outcomes
of an integrated programme of community-based and
primary care strategies deigned to improve the emotional
• Organisational survey before and after the PRISM
and physical health of women after childbirth. The scheme
intervention to document inter-organisational
includes educational programmes for primary healthcare
collaboration and the impact this has on the
professionals; distribution of mothers' information kits;
collaborations over time.
provision of befriending servicestand coordination of services
by a community development centre. The evaluation of the
programme includes an 'ecological' economic evaluation.
The aim is not only to help with interpretation of the
success of the programme as it evolves, but also to build
additional factors into models that might be used to consider
This incorporates all the standard elements of an economic
evaluation, but also recognises that the programme itself is
a dynamic entity that interacts with the local context, with
important non-health-related outcomes. In order to capture
the programme's transferability to other settings. Such
approaches may increase the costs of studies considerably,
and may not be appropriate for all public health
interventions (Hawe etal., 2004).
Drummond, M.F., O’Brien, B., Stoddart, G.L. and Torrance, G.W. (1997) Methods for the economic evaluation of health care
programmes, 2nd edn. Oxford: Oxford Medical Publications.
Graham, H. and Kelly, M.P. (2004) Health inequalities: concepts, frameworks and policy. London: Health Development Agency.
www.hda-online.org.uk/Documents/health_inequalities_concepts.pdf
Gundgaard, J., Nielsen, J.N., Olsen, J. and Sorensen, J. (2003) Increased intake of fruit and vegetables: estimation of impact in
terms of life expectancy and healthcare costs. Public Health Nutn'tion 6: 25-30.
Hale, J., Cohen,, D., Ludbrook, A., Phillips, C„ Duffy, M. and Parry-Langdon, N. (2005) Moving from evaluation into economic
evaluation: a health economics manual for programmes to improve health and well-being. Cardiff: National Assembly for Wales.
Hawe, P„ Shiell, A., Riiey, T. and Gold, L. (2004) Methods for exploring implementation variation and local context within a cluster
randomised community intervention trial. Journal of Epidemiology and Community Health 58: 788-93.
Kelly, M.P., Speller, V. and Meyrick, J. (2004) Getting evidence into practice in public health. London: Health Development Agency.
www.hda-online.org. jk/documents/getting_eip_pubhealth.pdf
Nexoe, J., Kragstrup, J. and Ronne, T. (1997) Impact of postal invitations and user fee on influenza vaccination rates among the
elderly: a randomized controlled trial in general practice. Scandinavian Journal of Primary Health Care 15: 109-12.
Seeker-Walker, R.H., Worden, J.K., Holland, R.R., Flynn, B.S. and Detsky, A.S. (1997) A mass media programme to prevent
smoking among adolescents: costsand cost-effectiveness. Tobacco Control6: 207-12.
Sefton, I, Byford, S... McDaid, D., Hills, J. and Knapp, M. (2002) Making the most of it: economic evaluation in the social welfare
field. York: York Publ,shing Services (for the Joseph Rowntree Foundation).
Selmer, R.M., Kristiansen, I.S., Haglerod, A., Graff-Iversen, $., Larsen, H.K., Meyer, H.E., Bonaa, K.H. and Thelle, D.S. (2000) Cost
and health consequences of reducing the population intake of salt. Journal of Epidemiology and Community Health 54: 697-702.
Stevens, W„ Thorogood, M. and Kayikki, S. (2002) Cost-effectiveness of a community anti-smoking campaign targeted at a high
risk group in London. Health Promotion International 17: 43-50.
Acknowledgements: An evaluation version of this paper was prepared for the Wanless Team, HM Treasury in December
2003. Thanks to Professor Christine Godfrey, University of York for comments.
'■
8
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ISBN 1-84279-431-0
•
© Health Development Agency 2005
email, commumcations@hda-online.org.uk
Kelly, M.P. (2004) The evidence of effectiveness of public health interventions - and the implications. London: Health
Development Agency. www.hda-online.org.uk/Documents/evidence_effective_briefing_paper.pdf
Contact - website: www.hcW hs.uk
References
Alexander, A.C.G. (1990) McDonnell Douglas Corporation employee assistance program financial offset study 1985-1989.
Westport. CT, USA: Alexander Consulting Group.
International perspectives on Early Childhood Development
Prepared by the Knowledge Hub on Early Child Development for the WHO
Commission of the Social Determinants of Health
August 2005
Executive Summary
The present work builds on the affirmed desire of the Commission on Social Determinants of
Health (CSDH) to be judged on both its scientific rigor and the policy implications that the
Commission’s work will generate. In addition, we contribute to the general discussion on the
social determinants of health by complementing the work of the Commission’s other
Knowledge Networks and by focusing on the fundamental conceptual issues relating to Early
Childhood Development and Education (hereafter ECD). The scope of this review is to
provide an international and global perspective on the determinants and life course
implications of early child development.
There are important reasons for conducting this work. With advent of technologies that
facilitate communication, connections among researchers and policy makers across the globe
is increasingly taking place. This is occurring because of the recognized value of
international collaborations in reciprocal learning and policy development. The importance
of international co-operation to protect the fundamental rights of children is also
acknowledged in the UN Convention of the Rights of Children that encourages State Parties
to undertake measures at the legislative and administrative levels to implement the rights of
children recognised in the Convention “within the framework of international co-operation”
(Article 4).
While international co-operation is critically important, there are several challenges that limit
the extent to which experiences, programs and research findings related to early childhood
from one country can be applied to other countries and cultural realities. This includes
cultural and language differences while others may be related to differences in the extent to
which some countries have the adequate resources to ensure that children’s rights are
protected and appropriate policies implemented. Thus, there are a number of different issues
about early childhood development that require a discussion at the global level so that not
only knowledge-based principles can be applied universally across cultures and contexts but
also implementation strategies can be readily adopted internationally to promote healthy
child development.
The critical importance of the first years of life is well acknowledged. Three broad domains
of early child development contribute to health, and have a role to play in health equity,
across the life course: physical, social/emotional, and language/cognitive. The outcomes of
early child development become life long determinants of health, but are, in turn, influenced
by early life factors that are underlying social determinants of health. At the most intimate
level the ‘within family’ environmental attributes of stimulation, support, and nurturance
influence all three key domains of ECD mentioned above. There arc a wealth of studies
involving first world, immigrant, and developing country populations showing that nurturing
qualities of family environments influence development and can be improved through
intervention programs involving improved parenting skills, nutritional supplementation, and
quality childcare arrangements. Although long-term follow-up has occurred on only a subset
of these studies, the results are very promising when the initial ECD programme was of high
quality.
At the next level of social aggregation, neighbourhcods/communities influence ECD. The
key aspects here are safety, cohesion, and the avoidance of ghettoization of poor and
marginalized families. The Bernard van Leer and Aga Khan Foundations have both
demonstrated that community development approaches to improving child development are
feasible and effective in developing country contexts. The challenges here are greater in
urban environments than they are in village contexts, because city environments tend to
create spatial separation among people from different walks of life and, thus, large
differences in the qualities of the neighbourhood environments for children. Nonetheless,
ECD is an important perspective to take when considering the urban aspects of SDH and
their relationship to ‘sustainable cities’.
At the broadest level of social aggregation, socioeconomic and programme delivery factors
make a difference for ECD. Here, the programme delivery factors arc much easier to modify
than the socioeconomic context. The ‘gold standard’ for service delivery around the world
would be the local neighbourhood ‘hub’ for ECD, through which families could access
quality child cate (emphasizing stimulation, nutrition, and quality play spaces); infant and
family support programs; a conduit to pre and post-natal, primary, developmental health care
services; family literacy programs; and a borrowing library of resources (books and toys) for
young children. Examples of such hubs exist in many wealthy countries; in immigrant
neighbourhoods; and among Aboriginal communities. Elements of the hub model also exist
in many' of the best developing country programs. In principle, if a supportive community in
a developing country has a well functioning hub, children should be able to reach school age
at the same level, of development as their counterparts in the wealthy world. Thus, compared
with many/ of the social determinants of health that are deeply embedded in economic
processes, most of the social determinants of ECD are relatively easily modifiable.
The scope of this document is to integrate knowledge about the different levels of
aggiegation described above from an international perspective and to discuss the
determinants and life course implications of early child development (ECD) at the global
level. This review identifies general principles that can guide wealthy' and developing
countries in improving their children’s developmental outcomes during the early' years of life.
It presents to the Commission a series of strategic considerations to assist it in planning a
successful approach to early child development as a Social Determinant of Health. Over the
course of the Commission’s life, it is hoped that guidelines and recommendations will be
promulgated that will apply in any place and cultural context to improve, globally, early child
developmental outcomes.
2
The Social Determinants of Early Childhood Development
The social environment influences early child development (ECD) first. Later, as the
life course unfolds, ECD emerges as the determinant of health most responsible lor the fact
that inequalities in health cut .across virtually all causes of disease and disability. Inequalities
in health appear at the beginning of the life course as ‘social gradients’ in ECD. Sensitive
periods in brain and biological development start prenatally and continue into post-natal life,
during which time the social environment plays a key role in determining outcomes. In
particular, the extent to which early developmental processes lead to ‘healthy’ outcomes
depends upon the qualities of stimulation, support, and nurturance in the environments where
children grow up, live and learn. Early physical, social-emotional, and language-cognitive
development, in turn, influence a wide range of subsequent health outcomes, as well as well
being and learning skills, across the balance of the life course. Thus, ECD is a social
determinant of health in a special sense: at first, the early social environment is a determinant
of ECD, but then ECD becomes a determinant of health across the balance of the life course.
By school age, development has been influenced by factors at three levels of society:
family, neighbourhood/village, and the broader societal level.
Family-level Characteristics
Families are the first environments with which children interact from birth. They are
critically important in providing children with stimulation, support and nurturance. These
qualities, in turn, are influenced by the resources that families have to devote to child-raising
(strongly influenced by income); to their style of parenting; and to their tendency to provide a
rich and responsive language environment (strongly influenced by parental levels of
education). Thus, family-level characteristics may influence children’s development in both
a positive and a negative manner, as risk and protective factors (Bronfenbrenner, 1986).
Over three decades ago North American researchers began observing that children
who lived in families with very low income did not acquire the same level of verbal and
cognitive skills as children who did not live in poor families (e.g., Birch, 1970). It was
argued that poverty put children at risk because of the deficiencies in resources associated
with poverty such as poor nutrition, including calcium, vitamins, and protein deficiencies,
which are all essential elements for healthy physical development and cognitive growth.
Recent studies have also documented that children from disadvantaged families tend to do
worse in academic achievement, social skills and cognitive functioning than children who are
not from economically disadvantaged families (Conger et al., 1992, 1994; Duncan, BrooksGunn, & Klebanov, 1994; Liaw, & Brooks-Gunn, 1994; McLoyd, 1990; Smith, BrooksGunn, & Klebanov, 1997). These same studies have identified other important social aspects
of a child’s environment that are associated with a healthy early childhood development.
Factors such as adequate maternal nutrition, maternal mental and physical health, parental
stress and depression, parenting styles, unemployment, limited or no income, housing
conditions, and neighbourhood quality are some of the most important determinants of ECD
identified in recent research—these family-level characteristics have important implications
for optimal child health outcomes.
Living in family poverty has long been implicated in children’s health and
development (Engle. Castle, & Menon, 1996; Gissler, Rahkonen, & Hemminki, 1998;
Wadswoith, 1997) and has also been linked to poor health in adulthood (Lundberg, 1993;
Rahkonen, Lahelma, & Huuka, 1997; Wadsworth, 1997; West, 1997). Family poverty can
affect the extent to which children’s basic needs are met: needs such as safe housing,
nutritious meals, and high-quality childcare (Brooks-Gunn, 1995). Brooks-Gunn studied the
effects of family income on behaviour and IQ, and found that psychological resources such
as family networks of support, high maternal education, and positive maternal mental health
mediated children’s scores. In addition, Brooks-Gunn, Berlin, and Fuligni (2000) have
demonstrated that the home environment can either buffer or exacerbate the effect of low
family income on children’s cognitive ability.
Famiiy-level factors, such as low maternal education, poor maternal mental health,
and lack of family networks, have been demonstrated to pose risks to ECD (Brooks-Gunn,
1995; Hertzman, 2000). In the case of poor parental mental health, in situations of extreme
poverty, or high levels of family stress (which could be associated with either of the
preceding factors), important parent-child interactions may be impaired, resulting in fewer
opportunities for learning experiences in the home (Bornstein, 1995; Willms, 2002). Single
parenthood has also been shown to be more highly associated with depression, three times
the level found in co-parenting individuals. When socioeconomic factors arc considered, the
rate of single-parent depression drops to only twice that of co-parenting individuals (Somers
& Willms, 2002). As stated earlier, depression and adverse child outcomes are linked. For
instance, the severity and chronicity of maternal depression are predictive of disturbances in
child development (National Institute of Child Health and Human Development [NICHD]
Early Child Care Research Network, 2004).
Parenting style is a fundamental influence on child development. Infancy/early childhood is
the period during which interactions with parents provide the foundations for development of
trust that is ar-, essential element for children to ‘know’ that they can safely explore
environments and learn from those explorations (Ainsworth, Blehar, Waters, & Wall, 1978;
Bornstein & Tamis-LeMonda, 1989; Bruner, 1975). A ‘responsive’ parenting style is what
allows children to safely explore environments and that responsive parenting consistently
provided in the early years puts children on a positive developmental trajectory throughout
childhood and adolescence (Landry et al.. 1997). In turn, children who have successfully
explored environments and have had positive learning experiences during their infancy and
early childhood are more likely to develop cognitive abilities that arc needed to assimilate
information from one learning experience and apply it to other similar contexts (RoveeCollier, 1995). Parental behaviours such as positive reinforcement, displays of warmth and
affection, and consistent disciplinary strategies (known as authoritative parenting) result in
fewer child behaviour problems and relate positively to academic competence and positive
peer relations that, in turn, enhance a child’s health (Brody & Flor, 1998; Conger, Elder.
Lorenz, Simmons, & Whitbeck, 1994). The benefits of positive and responsive parenting
have been widely documented and relate to the socio-emotional domain (Bornstein, 1995:
Ainsworth et al., 1978; Sroufe, 1988) as well as to the development of cognitive abilities
(Olson, Bates, & Bayles, 1984). While some literature associates negative parenting
4
strategies with low income, Chao and Willms’s (2002) study, using data from the Canadian
National Longitudinal Survey of Children and Youth (NLSCY), demonstrated that both
positive and negative parenting practices were found at all levels of socioeconomic status.
Positive parenting strategies have also been shown to provide a buffer for poor child
outcomes in families experiencing adverse circumstances. For instance, positive parenting
has been found to buffer the expected effects of factors such as financial strain and parental
divorce, through building children’s coping resources (Annistead, Forehand, Brody, &
Maguen, 2002; Hertzman, 2000).
The ability of parents to provide positive parenting can be hindered by socio
economic or personal circumstances such as unemployment, stress, and/or depression.
Several studies have documented that women who live in poverty with young children are
more likely to be depressed than non low-income women (Liaw & Brooks-Gunn, 1994;
Kaplan, Roberts, Camacho, & Coyne, 1987; Radloff, 1975; Hall, Williams, & Greenberg,
1985). In tum maternal depression is associated with language and cognitive problems, poor
social skills and behavioural problems in infancy and early childhood (Murray, Hipwell, &
Hooper, 1996; Abrams, Field, & Scafidi, 1995; Murray, 1992; Cogill, Caplan, Alexandra,
Robson, & Kumar, 1986). The effect of parental depression on the ability of children to
engage in social interactions and object recognition are observable as early as two months of
age (Campell and Cohn, 1991). In addition, infants of depressed mothers show a greater
degree of‘stress’ response as indicated by higher heart rate and cortisol levels than infants of
non-depressed mothers (Field, 1995). Furthermore, mothers with depression have been found
to have difficulties in providing their children with positive and responsive parenting, which
is instead characterized as hostile, disengaged or intrusive, disorganised, and generally less
competent (Gelfand & Teti, 1990; Goodman, 1992; Murray, 1997; Murray & Cooper, 1997;
Webster-Stratton & Hammond, 1988; Burbach & Borduin, 1986).
Research on family and parental influences on ECD has produced some lessons that
should apply world-wide. However, such research has also been primarily produced in
developed western societies, limiting the extent to which our current knowledge applies to
other cultures, especially those in developing countries. Yet, it is reasonable to conclude that
fostering family environments that are stimulating, supportive, and nurturant will benefit all
children regardless of geography, ethnicity, language or societal circumstances.
Neighbourhood-level Characteristics
At the level of the ‘neighbourhood’ (by which, we mean neighbourhood, village, or
local community), children growing up in a safe area that is ‘cohesive’ in relation to children
- where it mobilizes resources formally (creates programs) and informally (treats its children
like they belong there) - are less likely to be vulnerable in their development than children
from similar family backgrounds living in unsafe and non-cohesive neighbourhoods.
Neighbourhood characteristics influence children’s development in a variety of ways
(Beauvais and Jenson, 2003): through stresses (exposure to toxins, and social and
psychological conditions such as high crime rates), through social organization (role models,
5
collective efficacy, and shared values), through institutions (function of schools, police,
neighbourhood services, etc.), and through ‘epidemic’ forces (power of peer influences).
Neighbourhood safety, cohesion, and crowding are a few of the factors that may influence
family practices, family psychological well-being, and thus children’s development (Dunn &
Hayes, 2000; Hertzman, 2000: Hertzman & Kohen, 2003; Kohen, Hertzman, & BrooksGunn, 1998; Sampson, 1991; Sampson, Raudenbush, & Earls, 1997: Shonkoff & Phillips,
2000; Wilson, 1987). For example, concerns regardingsafety, for children as well as parents,
might affect a child’s opportunity to participate in physical activity in venues such as
neighbourhood playgrounds; such limitations have a domino effect, inhibiting a child’s social
experiences. Research also shows that neighbourhood cohesion may act to diminish the
effects brought on by safety issues, as social networks ' may provide supportive enclaves
where families and children feel safe (Sampson et al., 1997).
Neighbourhood-level factors influence different child developmental outcomes to
different degrees. Two recent reviews (Duncan & Raudenbush, 1999; Leventhal & BrooksGunn, 2003) have reported that the socioeconomic status of the neighbourhood demonstrates
the most consistently powerful effects on children’s health, but that research with school-age
children provides the most consistent evidence of neighbourhood-level effects. Once children
enter school, they have an immediate increase in their social networks and potential
resources from which they can draw, as the influence of teachers and other professional, as
well as school dynamics (positive or negative), shape children’s lives at this age (Engle et al..
1996). School-aged children’s1 interaction with their environments increases at a time when
they may not have the resources for dealing with challenging neighbourhood conditions such
as liigh ciirne, lack of cohesion, dangerous roadways and more. These reviews showed that
neighbourhood effects are stronger for cognitive and academic indicators than for
behavioural and mental health measures (Duncan & Raudenbush, 1999; Leventhal & BrooksGunn, 2003).
Socio-political Context
Finally, at the level of society, access to ‘quality’ programs matters. This includes the
full range of childcare, family support, and family strengthening programs; public health
programs for high risk children; vision, hearing, and dental screening, etc.; and broader
arrangements such as parental leave and housing programs. ECD is also influenced by
broader societal conditions and policies that are far outside the traditional realm of child
policy: the level of wealth of society, the political environment (e.g., rationalization of
services and downsizing of health care), health and social services policy (e.g., welfare
policy), and community and environmental programming (e.g., upkeep and presence of
playgrounds and green space, presence of neighbourhood policing office, placement of
public libraries), international studies comparing success in the acquisition of basic
competencies (that is, reading and mathematics skills) by teenage and young adulthood
For instance, Hertzman, Brooks-Gunn, and Kohen (1999) found that family characteristics buffered the
neighbourhood effects of schcol-readiness more for toddlers than for older children. These findings suggest that
neighbourhood effects for school readiness measures may be stronger for children who have more interaction
with their neighbourhoods.
6
demonstrate that societies that address all these areas achieve the best outcomes for children
(OECD, 2001).
Societies have a crucial role to play in supporting initiatives that bring young children in
contact with environments that have the following characteristics: exploration of all sorts
(physical, auditory, tactile, musical, artistic) is encouraged; mentoring and development of
new skills is provided; the child’s developmental advances are celebrated; there is protection
from inappropriate disapproval, teasing, or punishment; and the language environment is rich
and responsive (Ramey and Ramey, 1998). These characteristics are important both within
early learning and care settings, and also in family and neighbourhood environments. The
fact that infants and young children are particularly receptive to responsive and interactive
environments frames a very important challenge for ECD policy and programs. Influencing
ECD globally requires that we take initiatives that are supported by the international
community, but that must nonetheless penetrate to the most intimate realms of early life.
Few other social determinants of health are of this character.
Society and ECD Programming -- ECD programs that provide children with high
quality care, which incorporate some principles of responsiveness and positive learning
experiences, may be able to compensate for the lack of such environments at home and better
prepare children for entry into formal school programs. To be effective, however, these
programs must start as young as possible; be of relatively long duration; and provide
opportunities for care on a full-time basis (Hertzman & Wiens, 1996; Doherty, 2001).
A notable example of an ECD program that promotes development through interactions with
a responsive and positive environment is the Reggio Emilia approach in the Emilia Romagna
region of Italy. It is based on the principle that early consistent responsiveness which
‘exploits’ the children’s natural curiosity to learn more about their environments, supports
long term cognitive and socio-emotional development. What has made the Reggio Emilia
approach appealing to early childhood educators worldwide is the dynamic nature of the
pedagogical tools whereby the educator needs to quickly adapt their ‘teaching’ strategics to
provide children with learning experiences that are relevant to the their fast changing
abilities. What has made it appealing to the policy community is that it is widely understood
to be a central, not a peripheral, element in the regional strategy for social and economic
development. There is compelling evidence of the relationship that exists between the types
and amounts of activities that young children engage with (e.g., family activities involving
the child, books and toys for learning, opportunities for parent-child interactions) and
performance on cognitive assessments in infancy and childhood (e.g., Aylward, 1997; Bee et
al, 1982; Bradley et al, 1993; Longstreth et al, 1981; V. Molfese, DiLalla, & Bunce, 1997)
The more they are offered opportunities for stimulating interactions with objects, physical
environments, and responsive adults, the more likely children are to develop adequate
physical, cognitive, language, and social skills.
7
Overview of International ECD Programs and Lessons Learned
While for the most part the studies reported above have been conducted in western societies.
especially in North America, Australia and the UK, the review of the studies presented below
would indicate that there are principles of effective ECD programs that may in fact apply to
many different cultures, languages and contexts. The following section summarizes current
knowledge of the fundamental principles associated with ECD. In order to review this
knowledge from a global perspective several sources were consulted, especially reports from
non-govemmental sources including the European Commission Childcare Network; OECD
PISA; UNESCO; the Consultative Group on Early Childhood Care and Development:
UNICEF; World Bank; WHO; Bernard van Leer Foundation; Aga Khan Foundation.
As indicated in the previous section, the most important influences on early child
development originate from within the family environment, the neighbourhood/village where
children live, and the type of ECD programs that children are exposed to during their early
years. One of the challenges in providing a global perspective of ECD is that, unlike the
processes of brain, physical, and sccio-emotional development which are common to all
human beings, there is great variability across cultures in the specific ways in which family
environments, the neighbourhoods/villages and ECD programs may influence child
development. At the same time, studies conducted in developed as well as developing
countries have been identifying a set of fundamental environmental conditions that are
associated with healthy child development in different countries, and among different
cultures, languages, and ethic backgrounds. For example, a wealth of studies involving first
world, immigrant, and developing country populations show that the nurturing qualities of
family environments that influence development can be ameliorated through intervention
programs involving improved parenting skills, nutritional supplementation, and quality
childcare arrangements. At the next level of social aggregation, neighbourhoods/communities
influence ECD some key aspects are safety, neighbourhood/community cohesion, and the
avoidance of ghettoization of poor and marginalized families. The Bernard van Leer and
Aga Khan Foundations have both demonstrated that community development approaches to
improving child development are feasible and effective in developing country contexts.
In order to ‘measure" program effectiveness, specific criteria and procedures need to be put in
place. In fact, programme evaluation is a discipline in and of itself that many wealthy
societies rely upon to provide evidence of the extent to which programs arc effective at the
community level. However, for many countries struggling with a lack of resources, these
forms of program evaluation may be neither feasible or affordable. Traditional programme
evaluation can be expensive and often times inflexible. While there may be limited
‘scientific’ evidence of the effectiveness of ECD programs implemented in many developing
countries there has been ample documentation of the effectiveness of these programs
gathered according to different standards of evidence than those put forward by the western
academic research community. Given the relevance of their findings these studies cannot be
ignored and have to be included in the discussion of a global perspective such as that taken
on by this Commission on the Social Determinant of Health.
8
In the words of Ruth N. Cohen of the Bernard van Leer Foundation: “...academic research is
valuable but it is also expensive and, by its very nature, often long term and inflexible. We
were looking for another form of research, one that would be more immediate, achievable by
smaller programs that did not have access to vast resources, and adaptable to local needs and
capacities. The point was to gain useful insights about actual impact - or the lack of it - on
children, people, families and communities, and how this looked when considered in relation
to the aspirations of the project. We recognized early on that these insights would often be
personal and subjective rather than objective; would be hard to substantiate by, for example,
statistical measures; and would need sympathetic sifting and consideration. In addition, we
soon saw that some if the emerging data could be linked to something that is often underrated:
intuition about what is happening. That doesn’t mean that the data necessarily confirmed
intuitions or feelings, rather that they helped us to see how accurate these were” (Early
Childhood Matters, December, 2002 - No. 100).
The Effectiveness Initiative (El) of the Bernard van Leer Foundation was created to conduct
systematic evaluations of the effectiveness of community based programs promoting ECD.
Ten projects were evaluated as part of this initiative each of these having at least a ten year
track record, representing geographic diversity and illustrating a variety of different
approaches. These ten projects are summarized in the Appendix.
The El objective was not to examine whether a programme was effective or to measure to
what extent it was effective by assembling evidence on the basis of ‘quantitative’ indicators
but rather to learn why a program was effective. Below are reported some of the general
lessons that were learned from this El. Each of these lessons learned have important global
and international implications for ECD programming and policy development.
The historical moment in which the program is implemented, and the receptivity (at the local
and government level) of the environment are critical in determining the success of a
program. The consciousness within the community of its problems and needs and an ability
to recognise the long-term potential benefits of the program are also critical factors. The
relationship between a program and whoever finances it should be properly defined at the
outset. Such relationship should be characterised by a friendly spirit of collaboration. It
should be based on a common view of desired outcomes and the donation of funds should not
imply or legitimize authoritarian management practices.
One major component of program effectiveness is the consistency of contribution of those
implementing the program in the community; those working in it; and those supporting the
program with funds and other assistance. The commitment of the personnel can be more
significant for program success than the programs’ design was a theme that emerged
repeatedly in the El evaluations. “People who are intensely involved in the program, who are
willing to work long hours and who confront barriers and the needs of a target community
with vigour, enthusiasm and selfless dedication can be the difference between failure and
success even of a poorly planned and poorly organised project. Being an effective
community worker or organiser also means being reliable and lending a he'ping hand in good
times and bad. Such sentiments, as well as a spirit of unity, hard work and community
9
service, should be reinforced as much as possible among the personnel, but also among the
other stakeholders” (Zimmermann, 2004; pg. 177).
Understanding the social conditions of the target community that could help refine a program
was also found to be an important factor contributing to program success. The direction of
the program should be shaped by the priorities and needs of the community. The program
staff should be considerate of problems raised by stakeholders and beneficiaries, particularly
if this occurs repeatedly, as signals that there may be unmet demands that require attention.
Community workshops or discussion groups among parents, or other stakeholders can be
reliable sources of information on community needs and priorities. These can also provide
stakeholder with the opportunity to provide input and release tensions. The notion that the
people constituting the target of the program may precisely understand what they need for
self-actualization and advocacy cannot be overlooked.
The traditions and the culture of the community where the program is going to be
implemented should not be ignored. Culture and tradition regulate several aspects of the
relationship between parents and children, including feeding and eating routines, the
behaviours that are tolerated and those that are punished, and the household economic
arrangements. For programs promoting changes in the community, program approaches
should be applied incorporating cultural and traditional practices as much as possible.
in several cases the implementation of the programs required that community ‘insiders’ as
well as ‘outsiders’ be involved. This approach had the advantage of overcoming some of the
limitations that are implicit in having only insiders or outsiders involved in the program.
Some stakeholders have argued that insiders ‘understand’ the traditions and the needs of the
target population better than outsiders and thus they could act as important mediators
between the community and the programs. In addition, insiders may be more successful in
communicating with, other local stakeholders. Thus, the success of a program may as well
depend to a great extent on the positive attitude among insiders towards that specific
program. On the other hand, outsiders may be people who bring with them greater expertise
thus addressing a lack in the community of qualified members, in addition, outsiders may be
able to bring to the community a less biased perspective and they tend to be less motivated
by personal interests. “If mothers find warmth and a caring attitude among the insiders who
are their points of contact with a programs, or if they find competence and professionalism
among the outsiders, then their relationship with the program is more likely to be positive
even if their perceptions about the insiders and outsiders are due to bias. A model for the use
of insiders and outsiders suggests itself. If the outsiders are resented by a community, then
insiders should be encouraged to join the staff in some capacity. If the insiders are criticised
because they are considered less skilled, then they should be offered more training, and
outsiders might be brought in to supervise the technical aspects of their work” (Zimmerman,
2004)
For example, in Israel an Ethiopian paraprofessional (an ‘insider’ to the Beta Israel
immigrant community) was paired with a local non-Ethiopian Israeli professional social
worker (an ‘outsider’) to run some components of early childhood programs of Ahnaya. In
this ‘dyad’ of insider-outsider, the Israeli professional was responsible for the technical
10
aspects providing support to the Ethiopian insider that in turn provided the Israeli
professional with expertise ’ with respect to the culture and the values of the target
community. The technical abilities that the outsider brought to the community combined with
the insider’s knowledge of the community culture and values enhanced to the benefit of the
community and contributed to a more positive outcome of the program.
Community empowerment through training for local people is another critical element
involved in the success of a program. People within the community can be trained to perform
key functions in programs interventions which can have a pivotal role in enhancing the
commitment of the target population to support and sustain the program. It also fulfills an
added purpose which is that .of increasing the human resources involved in the program
delivery. By promoting capacity building through training, a given program will assign
responsibility to community members and encourage their commitment in the solution of
community problems. Assigning a more active role to community members can lead to a
more proactive approach to problem solving and to greater continuity of the program after
the outsiders leave.
Community mobilization is also an important factor that contributes specifically to the
sustainability of programs. When assistance for program implementation arrives in a
community in the form of external expertise community members become knowledgeable of
the specific program and may take initiative to either create more programs or expand the
program offered. Community mobilization is in fact another means of building local capacity
and promotes program sustainability.
It has been documented that open communication is an important ingredient of program
effectiveness. Such communication has to be open and there need to be different channels of
dialogue between the program providers and the target community. Open communication
promotes understanding and consensus between different members of the community and it
helps linking community members socially; it encourages the recognition of
accomplishments that in turn consolidates individual and collective achievement. When
people have a chance to exchange experiences and to share experiences that worked or didn’t
work for them, motivation to continue participate in the program is enhanced as a result.
Venues for open communication may include frequent and regular meetings within and
across groups of mothers, ECD educators, and other members involved in the program.
These opportunities for communication can take many different forms depending on each
specific context and program.
It is important to have an appropriate management plan that allows quality control and
assessment of the program progress. A program could promote a positive sense of
competition among component activities which could act as an incentive to achievement but
that also functions as a system of checks and balances. “Mutual support and accountability
create a sense of responsibility towards the success of a program. Problems and progress
should be discussed openly at frequent meetings among stakeholders. This would also help
ensure that experiences and innovations are shared. Likewise, simple but comprehensive
structures for research and for monitoring and evaluation should be put in place. These
structures should take into consideration all the beneficiaries and stakeholders and provide
11
pathways to receive stakeholder feedback. The capacity of staff to receive and properly
assess this feedback must be built up. One measure of effectiveness may be the extent to
which a program can make adjustments to take advantage of positive openings or turn crisis
into opportunity.” (Zimmerman, 2004)
The Early Childhood Development portfolio of the Aga Khan Foundation provides additional
examples of successful ECD programs. In 2004 Syria began implementing a national
programme of ECD that involves the participation of the Ministry of Education, other
ministries, national and international agencies, and academic institutions. This extensive
network of collaboration has lead to the design of a pilot community based early childhood
programme implemented in existing nurseries and kindergartens. These nurseries and
kindergartens function as ‘hubs’ or base for further outreach and services. At the local level,
professionals and volunteers are trained in the areas of childhood care and education and
participate in organizing six-week summer camps for children under 12 years of age. The
pilot conducted in the village of Taitout has been completed successfully and will be
implemented in other villages and communities.
The Consultative Group on Early Child Care and Development is another important hub
where several ECD programs conducted around the world are documented, especially those
implemented in developing countries. Within this consultative group a number of successful
ECD programs and strategies have been identified.
The following are examples of the type of programs that have been found to be most
associated with positive outcomes:
Programs that involve parent participation including parent education, parent support
groups, and home visiting programs. One example is a mother-education project in Turkey
that has shown that helping mothers develop greater parenting skills has long-term effects on
children’s development. This programme has also demonstrated effective use of an adult
education network to house and disseminate the mother education model on a broad scale
throughout the country, adding in elements of mother literacy and retraining of unoccupied
adult educators to provide the services.
Programs that add an early childhood care and stimulation component to already existing
health or community development efforts. For example, adding health and nutrition to a child
care setting creates an integrated programme that meets the holistic needs of the child.
Research has shown that care and nutrition enhance the potential for physical, mental, and
emotional development. Experience in feeding programs in Guatemala have demonstrated
that programs that emphasise the interaction between children and adults in feeding situations
are more effective than just providing children with additional food. This type of programme
is an example of the importance of holistic approaches that may be more appropriate for a
wide range of cultures.
Programs that integrate traditional caregivers in the delivery of quality child care practices.
Supporting traditional caregivers in their training and personal development involves
building on care giving situations that are already provided in the community. An example
12
comes from a programme in Mali where older women in the community serve as caregivers
supported by the community youth. This group of caregivers receives additional training to
enhance their role and their ability to respond to young children’s needs.
Programs that use media such as the radio have been used to reach parents and caregivers
and disseminate information about ECD and the needs ofyoung children and their families.
Radio is being used effectively as part of a parent education programme in the Philippines to
provide hard-to-reach families with child development information.
Programs involving an active participation of older siblings who are often the primary
caregivers in the households of many countries. These child-to-child programs aim at
engaging both older and younger children in new behaviours and informational activities. For
example, in Botswana, school children help younger children in the community make the
transition into the primary school by bringing the younger children to the primary school and
socialize them into school activities.
Programs that focus on facilitating the transition from ECD programs to primary school.
These programs build on the concept of ‘readiness for school’ and envision training to
primary teachers in exposing children to developmentally-appropriate learning experiences.
In Kenya, preschool teachers and primary school teachers are provided joint training sessions
aimed at enhancing understanding of child growth and development and appropriate
methodologies to be used in teaching young children.
Programs that address the children’s needs in conjunction with women’s programs. An
example of these programs is a family day care home programme developed in Vietnam and
provides quality child while women are engaged in income-generating activities.
Programs that build on existing resources or networks. For example, in Nepal literacy
programs have been in place for many years but new topics and materials for newly literate
women were needed. A series on child development and parenting was thus created to meet
women’s need for more relevant reading material, while at the same time it provided them
with useful information in their role as parents.
13
The Basis for Policy and Programs at the Regional, Country, and Global Level
Below are 10 strategic considerations for the Commission to consider when promoting ECD
globally as a Social Determinant of Health.
1.
Early Child Development should be promoted as something occupying a policy/program
space that complements current agendas for the 'rights of the child, ’ ‘child survival, ’ and
‘access to education ’ — At present, the principal foci of international development
assistance are in these three areas. Although each of them either influences, or is
influenced by, ECD, none of them lead directly to a global agenda to create
environments/programs for young children that promote healthy child development
across the three key developmental domains described in this report. Thus, a potential
‘early win’ for the Commission would be to achieve international agency agreement on
the positioning and complementarity of ECD in relation to existing global child agendas.
2.
The long-term goal of a strategy for ECD should be to create global access to the
conditions that support healthy child development, with the objective of ‘raising and
levelling the (developmental) bar’ — ECD is influenced both by programs/services and
by the nuiturant qualities of the families, neighbourhoods/villages, and societies where
children grow up, live and learn. This implies that we need a two-pronged strategy; one
that deals with the quality of programs designed to provide early learning and care, and
another that addresses families, neighbourhoods/villages, and societies from an
environmental perspective. The overall criterion for success would be ‘raising and
levelling the developmental bar’; in other words, both improving child developmental
outcomes, overall, within societies and at the same time reducing social inequalities such
that developmental gradients become ‘flatter’.
3.
The domain ofsocial/emotional development must be given equal priority to physical and
language/cognitive development
— Until now, the principal domains of child
development that have been addressed through global agencies have been the physical
and the language/cognitive. This is because these domains are passively (though very
partially) addressed through existing initiatives in child survival and schooling. The
social-emotional domain ha been largely neglected until now. There are many reasons
for claiming that this should be remedied. Just one will be stated here. A knowledge of
brain and biological development leads to the conclusion that the social-emotional
domain is a principal ‘gate-keeper’ for other domains. In other words, poor early socialemotional development undermines language/cognitive development (in extremis even
physical growth is affected) and, as the life course unfolds, limits the development of
empathy necessary for global citizenship.
4.
The Commission should build upon the work already done by the small family of
international agencies that are currently in the ECD field, and on the lessons from their
work that have been summarized in the previous section of this report — Positioning
ECD as an internationally recognized ‘Social Determinant of Health’ has obvious
potential advantages for advancing a successful agenda. Without ‘health’ the ECD
14
agenda tends to be an institutional orphan, in that there is no network of ministerial
responsibility through which it can operate. By bringing in health, the global network of
national Ministries of Health creates for ECD an institutional home. Although this is an
opportunity, it also brings potential challenges. Until now, international ECD has largely
operated as a series of community-based projects and ad hoc initiatives. Although these
are low profile on the international stage, they have been very efficient in the sense that a
high proportion of energy and resources have gone directly to communities and front-line
training, rather than politicking and other high-level interchange. Bringing strong
institutional partners, such as Ministries of Health, into ECD must be done in a way that
expands upon this cun-ent strength and does not undermine it through bureaucratization.
In this regard, building on the leadership of the small family of international agencies
already doing ECD is essential.
5.
Countries should be encouraged to develop comprehensive intersectoral strategies for
ECD; and to do so in ways that create a broad base of support — The determinants of
healthy child development, and the opportunities for improvement, cut across many
government ministries and exist at all levels of society, from the most intimate of family
processes to the broadest realms of social policy. To date, those societies that have
achieved the most in ECD are those that have developed and implemented a coherent
intersectoral, multi-level policy that is broadly understood and supported. Although it
may be too much to ask of a weak state, struggling to fulfill traditional government
functions, to match countries like Sweden in this regard, it is not unrealistic to promote
the idea that every society strives to create a credible framework of understanding and
action around which national and international initiatives can be aligned. The action
corollary to this is not a single new program initiative in a given society, but rather a
basket of initiatives with a common rationale.
6.
The international lending and granting agencies should be encouraged to use an
investment framework, rather than a welfare framework, in evaluating ECD program
proposals — There is now a body of evidence, endorsed by internationally credible
economists (such as van der Gaag and Heckman) showing that ECD programs that are
effective in improving developmental trajectories are better seen as ‘investments’ than as
‘expenditures’. There are two reasons for this. First, successful ECD programs pay for
themselves many times over in reduced remedial education, juvenile delinquency,
incarceration, and teen pregnancy expenses. Second, as adults,’ those who benefited from
ECD programs as children have higher levels of successful participation in the economy
than those who did not. In other words, the Commission is in a position to argue to the
international lending agencies that ECD is literally, not just rhetorically, about
investment, and proposals should be evaluated that way.
7.
There is need for an international program of monitoring progress in ECD at the
population level - At present, there are no internationally agreed-upon outcome
indicators for ECD. Yet, without population level indicators that can parallel infant
mortality and life expectancy, it will be impossible to monitor progress over time. At
present, an opportunity comes from the fact that there are several indicators being
implemented on an ad hoc basis in developing and wealthy societies. The danger is that,
15
like multi-attribute health status indicators, so many different instruments will proliferate
globally that we will never achieve an international benchmark. An unambiguous
success of the Commission process would be achieving consensus on a single indicator
that stood for ECD the way life expectancy, GDP, and carbon dioxide emissions stand for
mortality, economy, and sustainability, respectively.
S.
Despite many holes in our knowledge base, we know enough about the characteristics of
social environments and interventions that support healthy child development to'make
intelligent choices about the sorts of initiatives that the international community should
support - Because ECD is about environments as well as programs, and because it is
inherently inter-sectoral and multi-level in character, an ECD agenda is fundamentally
one of social change. Thus it is difficult to apply, in a straightforward way, the rules of
evidence that were developed for discrete health interventions unmediated by broader
social processes. Put simply, a new basket of ECD initiatives (see point 5 above) should
be implemented and evaluated according to three criteria: is the basket of proposed
initiatives based upon principles that have succeeded in other societies with healthier
child development? are the programs within the basket ‘as evidence-based as possible
under the circumstances’, fully implementable, broadly supported, and sustainable in
their new context? and, are the population-level indicators of ECD moving in a positive
direction over time with the implementation of the new basket of initiatives?
9.
Modern communications technology should be exploited to create a global platform for
local groups to share successes; learn from one another; and make progress even if/when
senior governments are not supporting ECD — Although the Commission has a key role
to play in raising the profile of ECD and institutionalizing it internationally, it also can
and should play a leading role in creating a horizontal network of local and regional
leaders in ECD through internet platforms. Unimaginable even 10 years ago, this
technology can now allow individuals and groups working with children throughout the
world to learn from one another, and receive support and encouragement in contexts that
would otherwise be isolated. A lot of work is needed to make this happen, but it is
relatively uncomplicated and feasible within the ambit of the Commission.
10.
Although the global trend for mothers to enter the formal economy is exacerbating the
challenge of work-life/home-life conflict, it should also be seen as an opportunity to bring
ECD out of the realm of exclusively private life, into the social sphere — The trend
towards increased female participation in the formal economy has been gradual in many
societies. Moreover, since the care of children is often seen as a mother’s responsibility,
systems are rarely put in place to ensure that quality child care is available for the
children of working mothers. In some settlements around the world, this problem has
led to a crisis where young children are swaddled to control them during working hours,
or they are brought into dangerous working environments and cared for there. In
neighbourhoods and villages where collective arrangements are worked out, there is the
prospect of providing early learning and care programs of equal quality to the best in the
wealthy world. The international community has shown that the training, housing,
health/safety and equipment needs in this regard are feasible to address in receptive
communities around the world. Championing a linkage between maternal labour force
16
participation and quality early learning and care is something that the Commission should
closely consider.
17
Proposed Work Plan for the Knowledge Hub in ECD
A proposed work plan was described in two previous submissions. What follows below is a
re-statement of that work plan, modified in light of Commission activities over the past
several months.
1. Negotiating the priorities of the Knowledge Hub with the Commission - Although the
proposed priorities of the Hub have been stated before, the focus of activities will depend
upon the Commission’s reaction to the ten strategic considerations presented above. Each
consideration, if adopted, implies a program of work that would logically involve the Hub,
the Secretariat, and the Commissioners themselves. Moreover, there is scope for the ECD
Hub to work productively with other Hubs, especially those concerned with urban and gender
issues. Thus, what follows below is preliminary to the Commission’s deliberations.
2. Creating a global network of ECD researchers, policy makers, agencies that connect the
developed and developing worlds — The first activity of the Hub will be to work with the
Commission to select the members of the Network. Membership will be on two tiers. The
first tier, comprising not more than 20 people, will be the ‘direct contact’ group. This group
will be asked to participate in conference calls and face-to-face meetings, as well as to
respond in a timely fashion to written materials. The second, broader class of individuals
will be ‘corresponding members’. Their primary responsibility will be to respond to
documents that the Network hopes will become subject of an international consensus. To
date, a broad global list has been drawn up, but no decisions have been made as to
membership composition.
Building a consensus that an international 'child survival’ agenda and an ECD agenda
are not in conflict — The first product of the Network will be a short statement on why child
survival and ECD are not in conflict as international priorities. The basic argument can be
made in less than 2 pages. Thus, getting a disparate group of individuals around the world to
concentrate on something like this should help us figure out what individuals’ engagement
styles are like and whether or not their level of commitment is adequate for the Network.
Moreover, getting a ‘quick win’ in the form of a consensus statement will create a sense that
this Network is not just another committee, but is actually going to make a difference.
j.
4. Building an international consensus on the scope of early child development — In practice
this means expanding the concept of physical development beyond basic growth and
nutrition; expanding beyond IQ in the language-cognitive domain; and bringing the socialemotional in as a domain of equal significance to the others. A second aspect of this work is
to address the perceived dichotomy between ‘rights talk’ and ‘development talk’ to
demonstrate that a broad notion of ECD is fully consonant with the International Convention
on the Rights of the Child. Consensus statements need to be agreed to early in the process, in
order to frame the balance of the work of the Network.
4. Review of literature appropriate to an international perspective on ECD - A thorough
review of the subject would cover the following topics:
18
• social influences on early developmental biology;
»the influences of family, community, care arrangements and the state;
• how early development influences later health and well-being (why physical, socialemotional, and language/cognitive are all important);
• the economics of investment in early child development;
• the relationship between nutrition and stimulation in early development;
• the internationalization of work-life/home-life conflicts on family function;
• the development of ‘resilience’ in children from very difficult early environments.
This present document touches on each of these themes but, in order to stand as an
independent review, would need to go into more detail in each area. We await the
deliberations of the Commission as to whether or not it is a priority to pursue this.
5. Creating a single modifiable standard for assessing ECD around the world — One of the
most useful things that the Knowledge Network can do is to promulgate a method of
assessing the state of early child development on a population basis and create a climate of
receptivity to an understanding of why having a comparable approach throughout the world
will be an advance on basic statistics like infant mortality and low birth weight. The method
should be non-hierarchical, in that it should put the expectations of children from developing
and wealthy countries on the same plane. It should be feasible to administer in countries
with modest infrastructure; should tap the domains of development of interest to us; and be
sensitive to change over time. Finally, it should modifiable in ways that allow for long and
short versions; cultural modification; and refinement without losing its basic comparability
over place and time.
6. Highlighting successes in the wealthy and developing worlds - Some of the world’s
successful ECD models have been described in this document, but this needs to be expanded
to illustrate to a health-oriented global audience how the right mixture of social policies and
inter-sectoral collaboration can work to support child development and health. This will
involve highlighting both national successes and community success stories. The regional
childcare model in Emilia Romagna, Italy, is thought to be the best in the wealthy world. The
regional infrastructure established by the Aga Khan Foundation in the Gilgit region of
northern Pakistan is a success story in the developing world. Success stories like these have
been written up before, but primarily to highlight the work of a single agency; not to fonn
part of a global consensus.
7. How to approach special global challenges in ECD — The generic approach to ECD
proposed here needs to be complemented by an emphasis on the unique ways that
determinants of ECD play out in different societies. For instance, in many societies basic
child survival, AIDS orphanage, child slavery, and/or warfare are the dominant challenges
for ECD. In others it is something prosaic like work-life, home-life conflicts. The
Knowledge Hub will articulate a strategy for maintaining a global unity of focus on ECD
while emphasizing different major challenges in different places.
8. Sustaining global knowledge exchange — One of the most useful potential outputs of this
Network will be to advance the notion of a simple web-based system of access to the global
knowledgebase on ‘what works’ to improve ECD. Because most ECD activity is carried out
19
at the local level and the knowledge base is diffused across many disciplines, there is a
singular lack of connectedness between the evidence as to what works and the people who
are trying to make a difference for young children. Because of the relative ease of access to
the Internet in this day and age it is expected that such a system might disproportionately
benefit developing countries. The Network is the obvious forum for taking this idea from the
talking stages to the point where a feasible plan is in place.
20
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APPENDIX A
Inventory of Relevant Initiatives
Effectiveness Initiatives
The El project was started in 1999 when the Bernard van Leer Foundation partnered with the
Consultative Group on Early Childhood Care and Development. This investigative project
lasted three years. The goals of this project were to identify and examine the crucial aspects
of an effective ECD program, and to create avenues for communication between nations to
increase understanding of how to create effective ECD programs.
El Columbia:
Partner Organisation: Centro International de Education y Desarrollo Humana (CINDE)
This community development project started in 1978 in the isolated villages of the Pacific
coast of Colombia. This project is funded by CINDE (Centro Intemacional de Education y
Desarrollo Humano or in English, “International Center for Education and Human
Development”) and carried out under PROMESA (Proyecto de Mejoramiento Educativo, de
Salud y del Ambiente or in English “Program for the healthy physical, emotional and
intellectual development of young children”). ECD and other activities are conducted by a
community organisation. Local committees meet regularly and carry out activities. Local
Promesa groups carry out systematic planning to design projects and are often asked by
others outside the community to help design projects. A number of the programs that began
as part of Promesa have been taken over by other institutions. Contributions and services to
communities by Promesa include: operation of a conununity pharmacy, involvement in
obtaining local land titles, management of a rotating loan fund, and a community library
functioning in Nuqui. Also, many new habits have been incorporated into the culture
through the work of Promesa; positive results achieved include the reduction of malaria
through modification of local beliefs, attitudes and practices. In addition to these changes,
most homes have sanitary facilities, there is a garbage collection system, nutrition has
improved, children are less likely to be abused, conversation with children is more frequent,
and continuing in school is accepted/encouraged.
El Honduras
Partner Organisation: Madres Guias-Guide Mothers
This is an ECD program with family, community and centre strategies. This project is funded
by the Christian Children’s Fund Honduras (CCFH) and run by the Madres Guias
program. They effectively provide assistance and networking to conununities affected by
hurricane. The program was implemented in Honduras because of high poverty and low
school enrolment. The CCFH seeks to improve child health and education through different
venues, including: raising basic literacy, increasing access to clean water, providing medical
care, implementing vocational training for youngsters and other training initiatives, and
providing a training module for personnel. There are 55 local programs servicing 220
communities. CCFH ensure community responsibility for child welfare by requiring the local
programs be run by a committee consisting of mothers and fathers in the area. Women who
27
show leadership are chosen to be “Madres Guias” (guide mothers), trained in proper child
health care, nutrition, early childhood stimulation and educational practices and then put in
charge of small groups of families. The results of this program have included: improved
health care, controlled common childhood illnesses, reduced malnutrition among children,
successful preparation for primary school, systematic responses to other childhood problems,
favourable change in behaviours/ attitudes regarding child health/development, and
noticeably enhanced self-esteem and confidence of mothers.
El India
Partner Organisation: SelfEmployed Women’s Association (SEWA)
The Self-Employed Women Association, SEWA, was founded to provide support to working
women in India. Early childhood daily care was needed and consequently created as a social
service for women. These care centres increased child health and development in multiple
ways: mothers were able to make more money resulting in better nutrition for children, care
centres provided immunizations for children, older siblings (most female) were freed of
childcare responsibilities and therefore able to attend school, children with special needs
were identified and referred to the appropriate services, and children in care centres were
provided with a stimulating and enriched learning environment. SEWA ran several
informational programs covering topics such as nutrition, child education, and disease
prevention/control. Between 1998 and 2002 India experienced cyclones, drought, flooding,
earthquakes, and communal violence. SEWA and childcare teams worked together to
provide shelter, clothing, food, and medical supplies to affected communities in affected
areas.
El Israel
Partner Organisation: The Association for the Advancement of the Ethiopian Family and
Child in Israel (ALMAYA)
This program, established in 1985, works with Ethiopian families that have migrated to
Israel. It provides children with experiences that honour their traditional culture and prepares
them to enter primary school. It is funded and run through ALMAYA (The Association for
the Advancement of the Ethiopian Family and Child in Israel). Community based
programs are run by Ethiopian madrichot (para-professionals), paired with a local Israeli
professional educator or social worker. Madricha’s arc given training in various areas,
including leadership, nutrition, and education. Almaya runs pre-school and after-school
enrichment programs. Almaya also organizes for children a toy-lending library, a “big
brother” program, and choral groups. The children who took part in the ECD program
showed: increase in self-awareness, independent behaviour and decisiveness; a better
developed capacity to express their feelings and their needs and to apply their talents;
increase in communication skills; a greater tendency to show leadership; smaller tendency
to be embarrassed by their Ethiopian heritage. These children also showed better organisation
of activities and ideas, more initiative, positive perception of the importance of school, home
and family, and the tendency to embrace positive social interactions. Parents of these
children were more likely to be involved in school activities and see themselves as
responsible for their children’s future.
El Kenya
28
Partner Organisation: Madrasa Resource Centre (MRC)
This program, funded by the Aga Khan Foundation (AKF), the Bernard van Leer Foundation
and UNICEF, provides preschool services to Muslim families in Kenya through Madrasa
(Qur’anic schools). These, preschools were implemented in response to a cycle of poor
education leading to poor jobs, leading to poor education, as well as widespread malnutrition
and disease. Teacher training/mentoring and conununity development are carried out at the
Madrasa Resource Centre (MRC). The MRC is committed to encouraging and supporting
communities in creating sustainable pre-schools, continuing teacher training and mentorship,
implementing accepted pre-school curricula, creating a database for monitoring and
evaluating clients, and exploring the long-term impacts of its own activities on its clients.
The Madrasa program has been quite successful: in the last 5 years 150 new preschools have
been constructed, hundreds of community members have received training in finance and
organisation, over 1000 women have been trained as teachers, and almost 10,000 children
have been exposed to early childhood education.
El Mozambique
Partner Organisation: Assofiafdo da Crianfa Familia e Desenvolvimento (CDF)
There is currently an El in partnership with Assoqiaqao da Crianqa Familia e
Desenvolvimento (CDF). This program evolved from an effort during the war to reunite
children with their families. It now focuses on a variety of conununity based activities, one of
which is ECD.
El Netherlands
Partner Organisation: Stichting Samenspel Op Maat.
In 1999 the Stichting Samenspel Op Maat organization joined the Bernard van Leer El. The
Samenspel program provides a preschool/playgroup setting that helps integrate migrant
(primarily Turkish and Moroccan) women and children into the Dutch culture.
El Peru
Partner Organisation: Servicios Urbanos y Mtjeres de Bajos Ingresos (SUMBI)
This program began in 1968 and then consisted of a nutrition education project and a nonformal preschool program among poor ethnic minorities in Puno state. The low-cost program
was funded by Caritas Peru, Ministry of Education and UNICEF. The program was named
Programas no Escolarizados de Educacion Inicial (Non-Formal Early Education Programs),
or ‘PRONOEI’ in the Spanish acronym. Teachers were trained in Piagetian theories to
provide early education and paraprofessionals were trained to provide health, nutrition and
early education activities. Currently there are over 17,000 PRONOEI preschools in Peru,
providing education, nutrition, and health care to children. In 1999 PRONOEI was chosen
to become part of the El. Children who had the advantage of attending PRONOEI
preschools were advanced cognitively and socially as compared to children who had not
attended the preschools.
El Philippines
Partner Organisation: Community ofLearners Foundation
The Pinatubo Family Education Program in the Philippines came into being in 1992, shortly
after Mt Pinatubo erupted in 1991 and almost 1,000,000 indigenous Aeta people were
29
displaced. The volcanic eruption resulted in ruination of farm lands, destruction of homes,
death of livestock, and a plummet in health conditions. The German Agro Action, which was
funding much of the disaster relief partnered with COLF (Community of Learners
Foundation) to provide early childhood education to the disaster victims which gave rise to
the Pinatubo Family Education Program. This program attended to many of the needs of
these communities, including ECD, and focused on rebuilding cultural values, adaptation to
new living environments, and increasing parent education about early childhood education.
The program implemented preschool services and a Parent Education Program (PEP). As the
years went on the program expanded to encompass the whole family, including activities for
children ages 7-15 and adult literacy classes. The program has resulted in success
academically and socially for children who participated. The program also resulted in
improved parental attitudes towards play, education and health.
El Portugal
Partner Organization: Agenda Movement
In 1999 an El was established in Portugal through the Agueda Movement (started in 1981),
and funded by the Bernard van Leer Foundation. The El allowed the Agueda Movement to
analyze and reflect upon its role in the lives of Portuguese children and families. When the
Agueda Movement was first started it provided resources and education for children with
special needs. The program has grown to cover health education and services, identification
of families at risk for having children with special needs, formation of community
development groups, and training seminars for parents, teachers and community members.
Tracer Studies
The tracer studies were conducted under the Following Footsteps program. The goal of the
tracer studies was to trace former participants of selected El and other ECD programs and
determine any lasting impacts these programs had on their lives.
Botswana
The challenges of change: a tracer study of San preschool children in Botswana
This study was carried out between 1993 and 1995. It traced children who had attended the
Bokamoso Preschool Program. The San people were traditionally hunter-gatherers, but no
longer have access to the natural resources they once relied upon. As a group,
unemployment and alcoholism rates are high. San children have difficulty in the formal
education system adapting to a different culture and language. A preschool program was
implemented with goals of reducing the San drop-out rate, involving parents in their
children’s education, and exposing children to other languages. A lunch program was
implemented to encourage students to attend. Most students who attended the preschool are
still in school. These preschools are successful in exposing children to other languages while
still using the native San language, a strategy the formal education system does not use.
There is a chance however that the positive experiences San children have in preschools
adapted especially for them will cause them to dislike even more the elementary schools they
must later attend. The report stated that the main reasons San children leave the school
system early are: the language gap, excessive use of corporal punishment, comparison of the
school system to the preschool program, and lack of cultural understanding.
30
Colombia
Twenty years on: a report of the PROMESA programme, Colombia
This study was earned out in 2004. The purpose was to describe the activities and
achievement of the program FROMESA. As a result of PROMESA (implemented in 1978),
children tended to stay in school longer; on average their parents had 3.5 years of schooling,
while the children had an average of 10 years of schooling. Children also had improved
scores in math, language and critical thinking. Health and nutrition had improved; children
were taller and heavier than their parents, and 95% had had vaccinations. Infant mortality
rates dropped. State of the environment, community economics and use of technology had
all improved which in turn improved health conditions. Adult literacy and self-concept of
women had also improved which in turn helped the communities and families. Some
important factors in the implementation of PROMESA include: utilization of community
leaders, training of local peoples to run programs, and encouragement of cooperation
between
organizations.
Honduras
The future will be better: a tracer study of CCF's Early Stimulation Programme, Honduras
This study was carried out in 2004. It examined the effects of the Early Stimulation Program
(ESP) run by the CCFH (Christian Children’s Fund Honduras). The CCFH’s preschool
program resulted in beneficial emotional and social development, improved performance in
difficult school subjects, and increased hygiene and health in children. The program also
increased parental awareness of the importance of their children’s wellbeing and what factors
contributed to their child’s wellbeing (e.g., love, respect, etc.). Parents involved in the ESP
showed more respect towards their children and were less likely to use beatings as a way of
training children. Children who participated in the ESP were more likely to form mixedgender groups of playmates.
Ireland
Still going strong: a tracer study of the Community Mothers Programme, Dublin, Ireland
This study was earned out in 2002. The purpose of the study was to report on the progress of
mothers and children who took part in a home visiting program during the child’s first year
of life. The Community Mothers Program (CMP, established in 1988) delivers this program.
The goals of the program are to assist and sustain parenting skills to improve parent
empowerment. Children who participated in this program were more likely to be up to date
with immunizations and dental care. These children also were more likely to read to or be
read to by their mothers, and more likely to enjoy school and achieve school success.
Mothers who took part in the program were more likely to place value on playing games with
their children and less likely to use physical punishment with their children. Mothers who
took part in the program also reported more positive attitudes both towards themselves and
towards motherhood.
Israel
A sense of belonging: A tracer study ofALMAYA's Parents Cooperative Kindergarten, Israel
This study was carried out in 2003. It assessed the impacts of the Parents’ Cooperative
Kindergarten program implemented by the Almaya Association. The purpose of this study
was to determine whether this program was effective. Children who participated in the
31
Colombia
Twenty years on: a report of the PROMESA programme, Colombia
This study was earned out in 2004. The purpose was to describe the activities and
achievement of the program I-ROMESA. As a result of PROMESA (implemented in 1978),
children tended to stay in school longer; on average their parents had 3.5 years of schooling,
while the children had an average of 10 years of schooling. Children also had improved
scores in math, language and critical thinking. Health and nutrition had improved; children
were taller and heavier than their parents, and 95% had had vaccinations. Infant mortality
rates dropped. State of the environment, community economics and use of technology had
all improved which in turn improved health conditions. Adult literacy and self-concept of
women had also improved which in turn helped the communities and families. Some
important factors in the implementation of PROMESA include: utilization of community
leaders, training of local peoples to run programs, and encouragement of cooperation
between
organizations.
Honduras
The future will be better: a tracer study of CCF's Early Stimulation Programme, Honduras
This study was earned out in 2004. It examined the effects of the Early Stimulation Program
(ESP) run by the CCFH (Christian Children’s Fund Honduras). The CCFH’s preschool
program resulted in beneficial emotional and social development, improved performance in
difficult school subjects, and increased hygiene and health in children. The program also
increased parental awareness of the importance of their children’s wellbeing and what factors
contributed to their child’s wellbeing (e.g., love, respect, etc.). Parents involved in the ESP
showed more respect towards their children and were less likely to use beatings as a way of
training children. Children who participated in the ESP were more likely to form mixedgender groups of playmates.
Ireland
Still going strong: a tracer study of the Community Mothers Programme, Dublin, Ireland
This study was carried out in 2002. The purpose of the study was to report on the progress of
mothers and children who took part in a home visiting program during the child’s first year
of life. The Community Mothers Program (CMP, established in 1988) delivers this program.
The goals of the program are to assist and sustain parenting skills to improve parent
empowerment. Children who participated in this program were more likely to be up to date
with immunizations and dental care. These children also were more likely to read to or be
read to by their mothers, and more likely to enjoy school and achieve school success.
Mothers who took part in the program were more likely to place value on playing games with
their children and less likely to use physical punishment with their children. Mothers who
took part in the program also reported more positive attitudes both towards themselves and
towards motherhood.
Israel
.4 sense of belonging: A tracer study ofALMAYA's Parents Cooperative Kindergarten, Israel
This study was carried out in 2003. It assessed the impacts of the Parents’ Cooperative
Kindergarten program implemented by the Almaya Association. The purpose of this study
was to determine whether this program was effective. Children who participated in the
31
intervention showed more organized thinking and better communication skills. As well,
these children saw homework as a way to learn and understand while children who did not
participate in the program saw homework as something that must be done to keep the teacher
happy. Participant children also had a greater sense of connection to community and family.
These children also had a greater tendency to express feelings and emotions.
Jamaica
A new door opened: A tracer study of the Teenage Mothers Project, Jamaica
This study was carried out in 2001. It assessed the impacts of the Teenage Mothers Project
(TMP) which operated between 1986 and 1996. This program had three main objectives: to
decrease to rate of teenage pregnancy in the area, to facilitate training of teenage mothers,
and to reduce the number of repeat teenage pregnancies. Participants of the program had
higher employment rates and had pursued further education. The program was effective in
decreasing the number of repeat teenage pregnancies. Mothers who took part in the program
also had a greater sense of control over themselves and their situation and were more
assertive. On average, children who had taken part in the program showed a greater success
in school, including superior language and leadership abilities. The report suggests that
should a project like the TMP be repeated, some important characteristics of this program
successful program would include: involving fathers in the program, putting emphasis on
bonding of the mother and child, the importance of nutrition, supportive/concemed/sensitive
staff, and small group counselling.
Kenya
In the web ofcultural transition: A tracer study of children in Embu District, Kenya
This study was carried out in 2001. It assessed the impacts of training the teachers who are
employed by the preschool and the effect of that training on the children who attended.
These training programs included information about the following: child development, the
importance of play, child centered learning, community management and community
organization. This training affected participating children in the following ways: better
academic performance in the formal school system, children had a better learning
environment (better learning tools, child-teacher relationships, etc.), and children were found
to be more helpful, kind, and honest.
Trinidad
To handle life's challenges: a tracer study of Servol’s Adolescent Development Programme
in Trinidad
This study was d arried out in 2002. It assessed the impacts of the Adolescent Development
Program (ADP). Females who had taken part in the program showed a tendency to postpone
having children (average age of first pregnancy in Trinidad is 16/17). Males did not show
this tendency. Parents who had taken part in the training reported increased patience and
attentiveness with their children as a direct result of the training. They also reported
increased self esteem. The training equipped participants with the ability to express their
feelings and emotions.
32
USA
Supporting families with young children, the Fligh/Scope Parent-to-Parent dissemination
project.
This study was carried out in 2002. The purpose of the study was to examine the Parent-toParent program that was active between the years of 1978 and 1984. The locally controlled
program was originally designed to provide low-income parents with in-home visits by
health professionals. These visits included information sessions for parents regarding child
development and developmentally appropriate practices while utilizing pre-existing family
strengths. Some deficits in the original program to be addressed in futures programs include:
recognizing and dealing with hopelessness and dispair, providing easily accessible yet
affordable health care, keeping the welfare of children in the forefront, establishing good
relationships with parents, securing a stable source of funding, and increasing the emphasis
on providing parenting skills.
33
APPENDIX B
Inventory of Institutions and Organizations Potentially Contributory to International
Initiatives in Early Child Development
Governmental Organizations and Affiliates in Receiving Nations
Aga Khan Development Network
Geneva, Switzerland
The Aga Khan Development Network (AKDN) focuses on health, education, culture, rural
development, institution-building and the promotion of economic development. It is
dedicated to improving living conditions and opportunities for the poor in developing nations,
without regard to their faith, origin or gender. (See also the Consultative Group).
Association for the Development of Education in Africa: ECD Working Group
Paris, France
The Working Group on Early Childhood Development was created in 1997 with UNICEF as
the lead agency. In 1998 the leadership of the Group was moved to the Netherlands Ministry
of Foreign Affairs. WGECD is guided by a consultative group composed of representatives
of African countries who have demonstrated interest in ECD and international agencies and
sub-regional organizations with strong commitment to ECD. The goal of WGECD is to
encourage and support national governments in Africa that commit to and invest in ECD.
The Working Group’s activities cover areas of research, information dissemination, advocacy,
networking and capacity building in order to enhance the capacity of policy makers to make
informed decisions where it concerns the rights and development of children under eight
years of age.
The Working Group initiated a policy-studies project aimed at getting a better insight in what
would be required to enhance governments’ commitment and involvement in ECD. Three
countries, Ghana, Mauritius and Namibia, which have made steps toward a distinct and
cross-sectoral ECD policy and which acknowledge the importance of holistic child
development, carried out case studies analyzing the processes involved in the formulation
and implementation of their ECD policies. WGECD and UNICEF provided financial and
technical support. Concurrent with the case studies, the Working Group carried out a survey
of ECD provision and policy in all African countries, through a questionnaire sent to
ministers of education. On completion of the case studies and the survey, WGECD, together
with the teams from each of the three countries, carried out a meta-analysis of the findings
and produced a report that provides guidelines for African countries interested in developing
their own ECD policies.
34
Bernard Van Leer Foundation
The Hague, Netherlands
This foundation is dedicated to funding research and related activities focused on early child
development. Grants are provided for initiatives that are based in a variety of nations around
the world. In particular, the interest of the foundation is to fund projects that meet the
following criteria; 1) a holistic approach to early childhood development; 2) the enhancement
of parents’ capacity to support their children’s development; 3) a development strategy that is
rooted in the local context and is culturally, socially and economically appropriate; 4) the
building of capacity, local ownership and working in partnership.
Caribbean Commission for Health and Development
Contact; George A.O. Alleyne
The goal of the CCHD is to give substance to the 2001 Nassau Declaration "The Health of
the Region is the Wealth of the Region." In this regard, the Commission is responsible for
providing the guidelines for action to increase investment in health in the Caribbean
Community.
Consultative Group on Early Childhood Care and Development
This organization is co-directed by Kathy Bartlett of the Aga Khan Foundation, and Louise
Zimanyi of Ryerson University (Canada). It is composed of a consortium of agencies,
donors, NGOs and foundations that links with regional-based Early Childhood Care and
Development networks comprising individuals and organizations involved in programming,
research, policy-advocacy, monitoring and evaluation for young children (0-8) at risk in the
Majority World. The term Majority World refers to those countries that are often referred to
as South countries, developing or third world countries and serves to remind us that the
majority of the world’s children are at risk of delayed or debilitated development. One major
goal of the organization is to strengthen regional networking, capacity-building, outreach and
activities, as well as improving and/or establish more effective links with others working in
health, social welfare, community development, adult literacy and basic education. In the
next 5 years, key priorities of the organization include: development and use of indicators
related to ECCD, HIV/AIDS and the impact on children, families, other caregivers, early
literacy and family literacy efforts, conflict and post-conflict situations and the impact on
young children and families, 0-3 year olds: their care and development, child rearing
practices, early brain development, the Convention on the Rights of the Child: issues and
follow-up for young children, training and Capacity Building of ECCD practitioners,
programmers, researchers, organizations and policy makers, quality delivery in ECCD and
sustainability (of programs, local ECCD organizations).
Early Childhood Development Virtual University
School of Child and Youth Care
University of Victoria
Victoria, Canada
35
The Early Childhood Development Virtual University (ECDVU) is a capacity building
initiative designed to help meet the need for more leaders in early childhood development in
Sub-Saharan Africa. It is an innovative and multi-faceted approach to addressing ECD
leadership needs in Africa. It is a unique training and capacity building program using faceto-face and distance learning methods including seminars; computer assisted learning (CAL),
the Internet, and video-conferencing. A key feature of the Program is those student cohorts
continue to live and work in their own country while they study. The cohort will be able to
apply what they are learning directly to their daily work; this will contribute to developing
the Early Childhood capacity of their country on an ongoing basis. The ECDVU is based on
a paitnership model, which encourages partnerships among institutions, governments, NGOs,
and learners and teachers. Some of the partners participate in advisory groups, which provide
technological and pedagogical expertise to the program. Others are members of the 'Friends
of the ECDVU1 who are committed to the objectives of the capacity building initiative and
are prepared to offer advice and support as needed. Organizations associated with the
ECDVU include the World Bank, UNICEF, UNESCO, USAID, Bernard van Leer
Foundation, Aga Khan Foundation, Save the Children Fund, Banyan Tree Foundation, The
ECCD Consultative Group, ECDNA and others.
The Early Child Development Team/Human Development
World Bank
Washington, D.C.
The ECD team at the World Bank is administratively located in the Bank’s Human
Development Network (HDN) within the Children and Youth Group. The team’s primary
mission is to improve the Bank’s staff and client’s knowledge of ECD programming and to
improve the quality of the Bank’s lending for ECD. The team is lead by Mary Eming Young,
a pediatrician and public health/child development specialist. As well, Marcelo Bortman is a
Senior Public Health Specialist for Latin America and the Caribbean, in the Human
Development section at the World Bank.
UNICEF Innocenti Research Centre
Florence, Italy
This centre works to strengthen the capacity of UNICEF and its cooperating institutions to
respond to the evolving needs of children and to develop a new global ethic for children. It
promotes the effective implementation of the Convention on the Rights of the Child, in both
developing and industrialized countries, thereby reaffirming the universality of children’s
rights and of UNICEF’s mandate. In particular, the centre works to ensure that its research
supports the five priorities of the MTSP: girls’ education; integrated early childhood
development; immunization ‘plus’; fighting HIV/AIDS; and increased protection of children
from violence, abuse, exploitation and discrimination. In addition, UNICEF has an Integrated
Early Childhood Development unit, in which Dr. Patrice Engle serves as a key consultant.
36
Project HOPE
Bethesda, Maryland
It is Project HOPE'S mission to achieve sustainable advances in health care around the world
by implementing health education programs, conducting health policy research, and
providing humanitarian assistance in areas of need; thereby contributing to human dignity,
promoting international understanding, and enhancing social and economic development.
The essence of Project HOPE is teaching; the basis is partnership.
Governmental Organizations and Affiliates in Donor Nations
First Five California
This initiative stems from the California Children and Families Act of 1998, designed to
provide, on a community-by-community basis, all children prenatal to five years of age with
a comprehensive, integrated system of early childhood development services. Tlirough the
integration of health care, quality child care, parent education and effective intervention
programs for families at risk, children and their parents and caregivers wil} be provided with
the tools necessary to foster secure, healthy and loving attachments. These attachments will
lay the emotional, physical and intellectual foundation for every child to enter school ready
to learn and develop the potential to become productive, well-adjusted members of society.
Programs supported by First Five include those that provide health and social services for
children and their families, provide services for children with special needs, and improve
administration and infrastructure that enable school readiness.
Non-Governmental Organizations with a Domestic Focus in Donor Nations
Annie E. Casey Foundation
Baltimore, MD
The mission of this foundation is to build better futures for disadvantaged children and their
families in the United States. Their efforts are designed to foster public policies, human
service reforms, and provide community supports. Their “Kids Count” research is designed
to measure differences in child health and its determinants across the United States.
Innovation Philadelphia
Innovation Philadelphia is a public/private partnership created to grow the wealth and the
workforce of the Greater Philadelphia Region's Innovation Economy by growing, attracting,
retaining, and connecting technology-based businesses and workforce in the Region.
Innovation Philadelphia accomplishes this mission by providing technology-based and earlystage businesses with traditional seed capital, access to alternative funding, skilled human
capital, commercialization assistance, entrepreneurial resources, and intellectual capital.
37
Canadian Population Health Initiative
Director: Elizabeth Gyorfi-Dyke
Canadian Institute for Health Information
Center for Human Growth and Development
University of Michigan
This center, directed by Dr. Daniel Keating, furthers the understanding of the complex
processes by which human beings grow and develop. With multidisciplinary collaborations
among biomedical, behavioral, and social scientists, the long-range goal of research and
training at the Center is to optimize children's physical, cognitive, and socioemotional
development. Specifically, the center’s objectives are to coordinate, integrate, and conduct
research on normal and abnormal human growth and development, including its biological,
intellectual, behavioral, and social aspects.
Centre for International Child Health
Institute of Child Health
University College London
This centre concentrates its research in four primary areas: 1) Nutrition - Epidemiology and
nutritional factors contributing to subclinical mastitis and transmission of HIV, evaluation of
micronutrient status and programs among refugees, nutritional status and health of school age
children, molecular and microbiological diagnosis of non responsive pneumonia in young
children, epidemiology and evaluation of factors responsible for low birthweight, perinatal
transmission of Hep B, C and HIV, 2) Child Development - Assessment of impact of
nutritional status and psychomotor interventions on indices of child development, evaluation
of micronutrient supplementations during pregnancy on child development, evaluation of
instruments for assessment of psychosocial, emotional and nutritional status of orphaned
children, evaluation of health education programs on knowledge and practice in poor
communities, 3) Disability - The disability research group at CICH focuses on finding ways
to improve the quality of life of disabled children and their families in income poor countries
of the world. This may be through prevention strategies, such as low-cost community based
identification processes, for example, screening children for hearing impairment in
Zimbabwe. Alternatively, it may be through community-based non-specialist interventions.
for example, training health care workers in Uganda and Sri Lanka, parents of children with
cerebral palsy in Bangladesh and Women's groups in Kenya. Current research areas include:
Disability and HIV/AIDS, cerebral palsy and nutritional well being, community groups and
CBR, and the impact of the health communication process on medical treatment of children
with epilepsy, and 4) Children in difficult circumstances - The Children in Difficult
Circumstances (CDC) group is new to CICH. Our main interests are in child labour, street
children, refugees and HIV orphans.
Faculty of note from this centre include Sally
Grantham-McGregor, who focuses her work on issues of nutrition and development in
Jamaica. And Christine Power, who is primarily concerned with the health and
developmental effects of socioeconomic conditions experienced in early childhood.
Pennsylvania State University
38
Department of Human Development and Family Studies
College of Health and Human Development
Collectively, this department-at Penn State University addresses a comprehensive range of
issues related to early child development, from family factors to social policies. The
department is also concerned with both cognitive and sociobehavioral development, and the
interrelationships between these two developmental competencies. In addition, faculty
members have expertise in research methodologies and psychometric approaches, as well as
more applied perspectives, including intervention-oriented research.
Telethon Institute for Child Health Research
Perth, Australia
Director by Dr. Fiona Stanley, the primary research foci of this center include aboriginal
children’s health, epidemiology of infectious disease, developmental ep.demiology, child
nutrition and growth, childhood cancer epidemiology, social, economic, psychological and
cultural determinants of health, adolescent development, suicide prevention, and capacity
building. Projects in this center are based largely in Australia, as well as Papua New Guinea.
39
Health Development Agency
i
Grading evidence and recommendations
for public health interventions:
developing and^piloting
a framework
. i
Alison Weightman1, Simon Ellisi2, Adrienne Cullum2,
Lesley Sander1 and Ruth Turley1
’Support Unit for Research Evidence (SURE), Information Services,
Cardiff University
2Health Development Agency, London
i
This document is also published on the
Health Development Agency website at
www.hda.nhs.uk
Copies ot this publication are available to download from the HDA website (v7ww.hda.nhs.uk ).
Health Development Agency
Holborn Gate
330 High Holborn
London
WC1V7BA
Email’ communications@hda.nhs.uk
ISBN 1-84279-458-2
© Health Development Agency 2005
This work was undertaken by SURE jointly with the Health Development Agency (HDA). SURE forms part of the Wales
Collaborating Centre, one of two HDA Evidence and Guidance Collaborating Centres on Obesity.
I
I
______ _____________________________________________ __ —------------------------------------------------------- 1___
From 1 April 2005. the functions of the HDA will transfer to the National Institute for Clinical Excellence^ The new
organisation will be the National Institute for Health and Clinical Excellence (to be known as NICE). It will be the
independent organisation responsible for providing national guidance on the promotion of good health and the
prevention and treatment ol ill health.
Contents
i
Summary
1
Introduction
2
Methodology and results
3
Search strategy
4
Literature review
:
Results of the literature review
4
4
Consultation with individuals and organisations with expertise in public health and/or grading methodology
7
Developing and piloting the provisional framework
8
Discussion and conclusions
13
Appendix 1 Organisations involved in searching and summarising evidence for public health
15
Appendix 2 Those consulted on the developing framework
16
References and bibliography
17
l
I
lii
Summary
The objective of this work was to develop a practical scale of
Based on the literature review and consultation with
grades of recommendation for public health interventions,
experts, a framework was developed that derives grades of
adapted from the current National Institute for Clinical
recommendation, incorporating
Excellence (NICE) methodology.
A literature review was carried out on the subject
of incorporating research evidence into grades of
recommendation for public health interventions. The
• Strength of evidence of efficacy based on the research
design and the quality and quantity of evidence (the
current NICE system)
• Corroborative evidence (from observational and qualitative
literature search looked at publications from January 2000-
studies) for the feasibility and likelihood of success of an
May 2004 retrieved from 16 databases. The views of a range
intervention if implemented in the UK
<A public health experts were also sought lor suggestions
of other publications to be included in the literature review,
and for their comments at various stages of the developing
methodology.
The precise methods for combining the results from different
types of corroborative evidence and for incorporating the
size of effects, including (cost-)benefits and harms for the
different outcomes measured, are still in development.
The principles fpr development of the framework were that jt
should be:
This provisional framework provides a practical and
transparent method for deriving grades of recommendation
• Adapted from, and clearly linked to, the current NICE
methodology
• Based on detailed and transparent reporting and synthesis
of all relevant supporting evidence (intervention and
observation;,quantitative and qualitative).
The literature review mdicated general agreement that
the randomised controlled trial (RCT) has the highest
internal validity and, where feasible, is the research design
of choice when evaluating effectiveness. However, many
commentators felt the RCT may be too restrictive for
some public health interventions, particularly community
based programmes. In addition, supplementing data from
quantitative studies with the results of qualitative research
is regarded as key to the successful replication and ultimate
effectiveness of interventions.
for public health interventions, based on a synthesis
of all relevant supporting evidence from research The
methodology is being piloted, alongside the current NICE
methodology, within the development of the public health/
prevention aspects of the HDA/NICE guidance on overweight
and obesity. The lessons learned will help to inform the
forthcoming work of the National Institute for Health and
Clinical Excellence.
Introduction
In 2003 NICE and the HD>A were commissioned by the
interventions cannot readily be abstracted from their
Department of Health and the National Assembly for Wales
environment, making context very important. Thus reviews
to develop guidance on the prevention and management
of evidence for public health interventions tend to be
of obesity in childrei-i and adults. This was the first time
dominated by 'lower' levels of evidence, which will in turn
NICE had been tasked to work in collaboration with an
receive lower grades of recommendation.
external body, and pre-empted the announcement that
NICE will take on the functions of the HDA from April 2005.
Crucially, it was also the first time that the applicability of
existing NICE methodology to public health evidence and
recommendations was to be fully considered.
j
Clearly, a range of grades of recommendation is
appropriate to provide guidance for policy makers in
deciding which public health interventions might be
considered for practice and/or further research. These
grades should reflect the (theoretically) most appropriate
Where possible, the development of the guidance was to
evidence for the type of intervention, using a clear and
adhere to procedures laid down by NICE. However, due to
transparent methodology.
the nature of public health interventions and the associated
evidence base, it became clear that further consideration
would be needed in adapting the NICE methodology.
The objective was therefore to develop a practical public
health scale of grades of recommendation adapted from the
current NICE methodology. The framework was to relate
The NICE guidelines to date have been based on a well
only to the grading of evidence and recommendations
known hierarchy of research designs (NICE, 2004a,b; SIGN,
for public health interventions. (The types of evidence
2001 and website), from which recommendations have
that are relevant to other (non-intervention) aspects of
been developed for clinical policy and practice. A parallel
public health will be included in further developments of
scale for grading evidence and recommendations for public
the methodology.) Development of the framework has
health policy and practice does not exist at present. NICE is
incorporated an analysis of the published literature on
currently developing some broad principles for the methods
deriving grades of evidence and recommendations for
used to assess evidence and prioritise recommendations
public health interventions, and consultation with public
that may be applied across all types of question, leading to
health and methodology experts.
both clinical and public health recommendations.
In some cases the 'go!d standard' RC T cannot be performed
r public health interventions for feasibility, cost and
practical reasons (Wanless, 2004; Kelly et al., 2005).
I urth'.rrnore, RCTs tend to be limited to questions of
efficacy or effectiveness; they are less useful, and hence
less appropriate, when considering external validity and
issues of implementation. For example, some public health
—
1
Grading evidence and recommendations for puolic.nealth interventions
Methodology and results
The methodology was designed to answer the following
There were three elements to the development of the
research questions:
framework:
• What are the most appropriate research designs for
• Literature review
determining the^efficacy of public health interventions?
• How might qualitative research and data about
• Consultation with individuals and organisations with
implementation be used to assess whether an intervention
expertise in public health and/or grading methodology
• Piloting of the provisional framework.
is likely to work in the UK?
• How can these different types of evidence be combined
to give a grading for public health evidence and help
prioritise recomrpendations?
The methodology and results for each are described below.
This was an iterative process - for instance, the consultation
with experts at various stages identified further publications
for inclusion in the review and other experts to consult. Early
versions of the framework formed part of the consultation
with experts.
Figure 1 Selection stages for papers included in the review
Methodology and results
3
Box 1 Search strategy
Da tabases searched
ASSIA, CareData, CINAHL, Cochrane Library, Current Contents, Educational Resources Information Center (ERIC),
Embase, EPPI Centre, HDA Evidence Base, HDA HealthPromis, Health Management Information Consortium (HMIC),
MEDLINE, PsycINFO, Sociological Abstracts, System for Information on Grey Literature (SIGLE), ZETOC.
Standard search terms
(public health OR health of the public OR health promotion) AND (grade
*
or level’ or type') AND ((guideline
*
or
guidance or evidence or recommendation
*).!,)
Additional search terms
Additional terms were used for the databases ASSIA, CareData, EPPI Centre, ERIC and SIGLE where complex search
strategies were not feasible. These are available from the authors.
Website searches
Website searches were conducted for relevant organisations involved in searching and summarising evidence for public
health, looking for methodologies for grading public health/health promotion recommendations and reviews/guidehnes
in the topic area. See Appendix 2 for organisations searched.
Search dates
2000-2004 plus follow-up of reference lists for other relevant publications. The searches were carried'out in May 2004.
1
Literature review
recommendations. Any areas of uncertainty were clarified
through discussion with a second reviewer. The purpose was
An extended literature review was carried out on grading
to assess areas of consensus and query. No formal evaluation
evidence and recommendations (see Box 1).
of the publications included was carried out.
Selection and appraisal of relevant
publications ■
Results of the literature review
I
Of the 770 abstracts/titles retrieved, 54 publications were
Type of evidence (research design)
examined in full and 37 were found to be relevant to the
review question. Other papers were suggested by groups and
individuals consulted during the development stages, and 14
additional papers were included, making a total of 51 (see
Figure 1). They are marked
in the References (page 17).
Publications were selected for full text review if the abstract
(or title if no abstract was available) suggested that the paper
included a discussion of the methodology for translating
findings from public health research evidence into grades
of recommendation for interventions. Papers were read
and summarised by one reviewer to determine the authors’
views on the most appropriate type(s) of public health
evidence that should be taken into account when generating
4
An established evidence hierarchy of effectiveness is
used by NICE, and this has a strong link to the grade of
recommendation (NICE, 2004a,b).
The issue of the 'best' evidence for particular types of
intervention (individual, group, community, society/socio-
political) has been considered by Nutbeam (1998) and by
the HDA (Ellis and Grey, 2004). There is general agreement
tnat the RCT has the highest internal validity and, where
feasible, is the research design of choice when evaluating
effectiveness (Nutbearrl, 1998, Kelly eta/., 1993; Sorensen et
a/, 1998; Rimer eta/., 2001; Rychetmk et a/., 2002; Evans,
2003; Hawe etal., 2004; Victora etal., 2004).
Grading evdence and recommendations for public health interventions
However, RCTs are by nature narrowly defined and typically
interventions based on components matching children's
restricted to single/simple issues (Nutbeam, 1998, Tones,
views The reviewers found a relationship between what
2000; Truswell, 2001; Kroke eta/., 2004; Victora eta/.,
children regarded as important and the effectiveness of the
2004). Ii is argued that, because of the complexity of
intervention.
interventions in real world settings, RCTs are subject to effect
modification in different populations (Victora et a/., 2004)
and in any event may be too restrictive for community-based
programmes (Nutbeam, 1998). Many health promotion
programmes draw on political systems and community
networks as part of the intervention, rendering random
allocation nearly impossible. However, in some circumstances,
the design in which geographically isolated populations
become the (randomly allocated) units of comparison (ie the
cluster RCT) may be appropriate and feasible (Nutbeam,
1998; Sorensen et al., 1998, Rychetnik et al., 2002).
Petticrew and Roberts (2003) note that RCTs are best for
questions of effectiveness (does it work7), safety and cost
effectiveness; qualitative studies and surveys are best for
questions of salience (does it matter?), appropriateness
and satisfaction, and qualitative studies alone are best for
questions concerning process (how does it work?) and
acceptability. Of course a single study, particularly but not
exclusively a systematic review, may provide evidence for
several or all of the individual elements - effectiveness,
salience, implementation and cost.
Some methodologies consider the type of evidence as one
Other commentators are of the view that the RCT design
of many factors, and use a single quality assessment/critical
can be appropriate for evaluating complex public health
appraisal tool for all studies to produce gradings, based on
interventions by standardising the function and process of
the intervention, but allowing local variations in the individual
minimisation of potential biases, from poor/weak to good/
strong (Millward et al2003; EPHPP website).
components. This allows the components to be tailored
to local conditions and the needs of specific communities,
Consistency
without threatening the integrity of the intervention (Dane
and Schneider, 1998; Hawe etal., 2004).
The consistency of study results contributes to the grades
of recommendation used in the methodologies of NICE
The importance of supplementing data from quantitative
(2004a,b), the GRADE Working Group (2004) and others
studies with the results of qualitative research to provide
(Margetts et al., 2001, Kelly et al, 2004), and the importance
depth and insigfit into people's experiences and social
of combining different study types is widely accepted.
contexts is regarded as central by many commentators
(Nutbeam, 1998; Sorensen etal, 1998, Stephenson and
Quality of evidence (critical appraisal)
Imrie, 1998; Rychetnik etal., 2002; Pawson, 2003; Petticrew
and Roberts, 2003; Djxon-Woods et al, 2004; Harden et
al., 2004, Jackson and Waters, 2004; Kroke etal., 2004;
NSW Centre for Public Health Nutrition, 2004; Swinburn
etal., 2004; Thomas etal., 2003, 2004), and of particular
relevance to the successful replication and sustainability of
interventions. Using each subsequent study to build on the
inferences of the others, the likely effectiveness of social
programme interventions can be assessed (Pawson, 2003).
In one proposed decision-making framework for evidence
based obesity prevention, the RCT sits alongside other
forms of evidence and each is judged equally on its ability
to contribute to answering different questions (Swinburn
etal., 2004).
In a review of children and healthy eating (Thomas ef
al., 2003) the EPPI Centre cross-matched the findings
of qualitative and quantitative studies and looked at
Single critical appraisal forms are used by a number of
public health groups (Bnss eta/., 2000; Millward eta/,
2003; Ovretveit, 2003; EPHPP website), whereas clinical
medicine review groups tend to use separate forms for each
category of study type or research design (NICE, 2004a,b;
Health Evidence Bulletins Wales 'Project methodology';
BMJ Publishing Group 'Clinical evidence'; SIGN 'Guidelines
methodology'; Canadian Task Force for Preventive Health
Care 'Evidence-based clinical prevention', Centre for
Evidence-Based Medicine), other than the GATE method
(University of Auckland (a)) which has a generic form for
intervention studies.
The conclusions from a review of a large number of grading
systems were that different appraisal forms are needed for
different study types, and that a single evaluation framework
could cause confusion and misleading conclusions (AHRQ,
2002).
5
Separate critical appraisal forms are used for different types
Ellis and Grey (2004) highlight that most reviews of
of research study for NICE guidance. I he overall assessment
effectiveness focus on health outcomes (eg incidence/
of study quality is graded within each study type using a
prevalence) or intermediate health outcomes (eg behaviour),
code based on the extent to which the potential biases have
mainly because they are limited to RCTs and controlled
been minimised (++, very low risk; +, low risk;
high risk of
trials which do likewise. These limitations in both the type
confounding, bias or chance) (SIGN, 2001; NICE, 2004a,b).
of research included and the outcome mean that they
However, NICE does not currently have a critical appraisal
.are severely lacking in evidence about the effectiveness of
form for non-randomised controlled studies, and specific
community and socio-political interventions in addressing the
enhancements ar'd adjustments to NICE critical appraisal
personal and structural determinants of health and health
tools may be required for use with public health research
behaviour (eg knowledge, social/peer norms, professional
evidence.
attitudes, discrimination, poverty, availability and accessibility
>
of services). They are particularly unlikely to include any
The Cochrane Effective practice and Organisation of Care
(EPOC) Review Group has developed critical appraisal forms
evidence about the effectiveness of 'upstream' (socio
political) interventions (Ellis and Grey, 2004).
for intervention studies that have not been adequately
randomised and followed up in the randomised groups
Relevance to the UK population - demographic,
(EPOC Group, 2002). Tljese are: (1) controlled clinical trials
persona! and socio-economic factors
(sometimes called controlled non-randomised trials), (2)
The context in which the intervention is implemented is
controlled before-and-after studies; (3) interrupted time
clearly important. Relevance to the UK population contributes
series studies. Another critical appraisal, methodology for
to the grades of recommendation used in the SIGN, NICE
non-randomised trials is under development within the
and GRADE methodologies (SIGN, 2001; NICE, 2004a,b,
Cochrane Collaboration by the Health Promotion and Public
GRADE Working Group, 2004), but there is currently a lack
Health Field (Jackson ahd Waters, 2004).
of transparency in how this is derived. Specific consideration
The TREND Group (Des Jarlais et al., 2004) has also proposed
a specific appraisal checklist for non-randomised evaluation
studies as a companion to the CONSORT statement (Moher
et al, 2001) for RCTs.
Sa Hence - does it matter?
Relevance of outcome
Several authors stress the importance of looking at a clearly
defined and measured range of relevant health promotion
and health outcomes in complex areas such as dietary
behaviour and physical activity (for instance, Nutbeam, 1998;
Lean, 2000). This includes an assessment of the relevant
outcomes and mcjst appropriate methods of evaluation for
different types of intervention. Kelly et al. (1993) describe
four levels of health promotion: environmental, social,
organisational and individual, all of which have to be
understood and integrated for successful health promotion
interventions. It is emphasised that, from the outset of any
health promotion project, these four levels should be used as
a checklist to consider the likely consequences flowing from
the desired intervention (Kelly eta/., 1993).
of socio-economic issues is recognised (Glasgow et al., 1999;
Kelly et al., 2004; NSW Centre for Public Health Nutrition,
2004), as is the shortage of relevant evidence in this area
(Aldrich etal., 2003; Thomas etal., 2003; Mulvihill and
Quigley, 2003).
Implementation - will it work?
Consideration of issues such as feasibility, plausibility,
acceptability, transferability and sustainability is suggested by
the HDA (Ellis and Grey, 2004; Kelly et al., 2004); the CDC
Guide to Community Preventive Services (Briss eta/, 2000,
Task Force on Community Preventive Services website); and
other authors (Glasgow et a/.. 1999, Evans, 2003; Jackson
and Waters, 2004; Pawson eta/., 2004). It has previously
been highlighted that an intervention should be based on
firm theoretical principles using the knowledge of what is
likely to work from previous research (Pawson, 2003; NSW
Centre for Public Health Nutrition, 2004). In particular,
reviewers should question whether the intervention is
appropriate in relation to the views and preferences of the
target population(s) (Thomas et al., 2003; Pawson et al,
2004).
Grading evdence and recomme,'dations for public health interventions
As noted above, evidence from observational and qualitative
the individuals, interpersonal relationships, institutions and
research is considered central to'irifbrming the assessment
infrastructures through which and in which an intervention is
of these issues (Nutbeam, 1998; Sorensen etal. 1998,
delivered.
Stephenson and 'mne, 1998; Tones. 2000; Rychetnik etal.,
2002, Thomas era/., 2003; Pawson, 2003; Petticrew and
Roberts, 2003; Dixon-Woods etal, 2004, NSW Centre for
Public Health Nutrition, 2004; Pawson et al., 2004). While
there is a need for a transparent and reproducible approach,
there is currently a lack of consensus as to how to grade this
type of evidence.
In summary, a large number of factors should be taken into
account in reaching a decision on the likely success of an
intervention. The grade of evidence and recommendation
should be based on a number of building blocks (individual
studies within a topic) and clear, detailed guidance on the
type and quality of each relevant study should be provided to
steer this process.
Implementation: cost
Estimated cost is considered by the GRADE Working Group
(2004), the HDA (Kelly el al, 2004) and the Guide to
Community Preventive Services (Boss etal, 2000). However,
Consultation with individuals and
organisations with expertise in public
health and/or grading methodology
it is recognised that these data are seldom available from
public health interventions undertaken to date.
At various stages of development, the findings from the
Synthesis of different types of evidence
with (or circulated for comment to) a large number of
There is no consensus from the literature as to how different
types of research study might be weighted in terms of their
contribution to the overall summary of evidence and/or
final grade of recommendation. Significant shortcomings
were found in current approaches to grading levels of
evidence when six prominent grading systems were critically
appraised (GRADE Working Group, 2004), Some reviewers
suggest that decisions about quality may require complex,
contextualised judgements in combination with existing
evaluation methodologies (Pawson etal., 2004). A review
of the integrative approaches to qualitative and quantitative
evidence concludes that more research is required to resolve
the complex theoretical and methodological issues involved
in developing the beat method for synthesis, although a
number of established methods exist, each with advantages
arid disadvantages (Aldrich et al, 2003). The aim should be
literature review and the proposed framework were discussed
public health experts and expert groups within and outside
the HDA, including (among others): the HDA Public Health
Evidence Steering Group; the HDA Obesity Reference Group;
the HDA Evidence and Guidance Collaborating Centres
on Obesity; the GRADE Working Group, the Centers for
Disease Control’s Guide to Community Preventive Services,
the EC 'Getting Evidence into Practice' project; the WHO
Health Evidence Network; the Cochrane Health Promotion
and Public Health Field; the EPPI Centre, the York Centre
for Reviews and Dissemination; the Medical Research
Council's Social and Public Health Sciences Unit (University
of Glasgow); the London School of Hygiene and Tropical
Medicine (Interventional Public Health Group), SIGN, and
NICE (see Appendix 2 for list of respondents).
The questions posed at various stages are listed below with
an indication of the consensus (if any) from those consulted.
to make judgements transparent and to try to protect against
bias in the judgements that are made by being systematic
and explicit (GRADE Working Group, 2004).
• Is it appropriate to class interventions into individual,
group, community/environmental and policy/sociopolitical, or are there other dasses/groupings that should
In a completely new model of research synthesis, a 'realist'
be considered?
.approach to evaluative research has been suggested (Pawson
Response: Consensus that these are appropriate,
er al., 2004), where complexity is acknowledged throughout
however many interventions will cross these
in the task of searching the evidence base. The authors argue
groupings.
that the success of an intervention theory is not simply a
question of the merit of its underlying ideas, but depends on
Vethodology ana results
• What are the 'most appropriate' types of evidence (of
effectiveness) for different types of intervention (eg
individual, social structure, environment, organisation,
appropriate for public health evidence (GRADE - GRADE
group, community, society/socio^political interventions)?
Working Group, 2004: GDC Guide to Community Preventive
Response: Narrow consensus to use RCTs whenever
Services - Briss et al, 2000, realist review - Pawson et al.,
feasible, but accepted that this is unlikely to be the
2004). As our remit was to develop a system based on the
case for socio-political interventions.
• How and where d’p'we capture the magnitude of findings
NICE methodology, we have incorporated elements of these
three very different systems where relevant and possible The
for each component of evidence when formulating a
remainder of respondents were broadly supportive of the
grade of recommendation? Furthermore, is the magnitude
developing methodology, and of carrying out a pilot within a
of the effect size (and implied cost effectiveness)
practical setting to explore the issues raised.
enough to support a recommendation, or should a cost
effectiveness analysis be carried out when such evidence is
not already available?
Response: No consensus on how to capture
Developing and piloting the
provisional framework
magnitude of findings for each component, not
A pragmatic framework was developed, based on the
least because outcome measures will vary. Cost
findings from the literature review and the views of experts
effectiveness is difficult to estimate.
in the fields of public health and health promotion research.
• In considering the factors that determine the relevance,
The framework included critical appraisal of individual studies
generalisability find feasibility of an intervention to UK
and reviews to assess the strength of evidence, based on the
populations (corroboration), are some more critical than
quality and quantity of studies.
others, and hovt should they be weighted?
Response: No consensus on how different aspects
In assessing efficacy, the NICE/SIGN (level 1-4) evidence
should be weighted, but inclusion of corroborative
classification (SIGN, 2001; NICE, 2004a,b) was adapted to
evidence is important.
• How should the combinations of evidence (qualitative and
include non-randomised and quasi-experimental studies, as
these are common public health research methods. However,
quantitative) be combined to obtain a balanced view of
the framework differs further from the NICE system in two
all the important aspects of a public health intervention
significant respects:
(effectiveness, appropriateness, sustainability, etc)’
Response: No consensus.
• The ‘most appropriate' (or highest level of) evidence for
• In the final grading, is. it more helpful to have' (i) an overall
grading system (eg A. B) derived from a narrative summary
of the different types; of evidence: or (ii) a composite
efficacy is not necessarily the RCT, in particular for socio
political interventions
• The issue of 'directly applicable to the target population'
and 'extrapolated evidence’ is separately assessed as
grading (eg A3, B1) that reflects the two components of
'corroborative evidence' and in so doing the framework
(cost)-effectiveness and corroboration, but may lead to a
draws on sources of evidence above and beyond that
lack of clarity (eg is Bl a stronger recommendation than
found in the studies of efficacy.
A3?)
Response: No consensus - some argue that a
The system allows for the grade of recommendation to be
composite grading allows readers to make their own
promoted where the research design used to demonstrate
judgements, while others suggest this is too complex.
efficacy is weakened by design or methods, but where
there is consistent evidence from corroborative studies to
It is clear that a number of issues have yet to be resolved.
Comments and suggestions of respondents (Appendix 2)
were, as far as possible, incorporated into this document
and the proposed framework. This does not mean that
suggest that the intervention is relevant, feasible and could
be implemented for the population in question. This kind of
approach is consistent with the GRADE methodology (GRADE
Working Group, 2004).
respondents endorsed the framework - three respondents
Practical guidance was produced for those developing grades
recommended existing alternative systems as more
of recommendation from the available evidence on efficacy,
Grading evidence and recommendations for outlie health interventions
Table 1 Pilot-public health evidence grading scheme: classification of
recommendations
Class
Basis for decision
*
A [PH]
At least one 1 ++ study or consistent findings in a body of studies
*
* principally rated as 1 + for efficacy
*
* *, with
strong or moderate evidence of corroboration
OR
Consistent findings in a body of 2++ studies for efficacy, with strong evidence of corroboration
S [PH]
At least one 1 ++ study or consistent findings in a body of studies principally rated as 1 + for efficacy, with limited/
no evidence of corroboration
OR
A single 1 + study for efficacy, with strong or moderate evidence of corroboration
OR
A single 2++ study or consistent findings in a body of studies principally rated as 2+ for efficacy, with strong
evidence of corroboration
OR,
Consistent findings in a body of studies principally rated as 2++ for efficacy, with moderate evidence of
corroboration
C [PH]
Consistent findings in a body of studies principally rated as 2++ for efficacy, with limited/no evidence of
corroboration
OR
A single 2++ study or consistent findings in a body of studies principally rated 2+ for efficacy, with moderate
evidence of corroboration
OR
’
___
A single 2+ study for efficacy, with strong evidence of corroboration
OR
|
A body of level 3 or 4 evidence for efficacy, with strong evidence of corroboration
D [PH]
A single 2++ study or consistent findings in a body of studies principally rated 2+ for efficacy, with limited/no
evidence of corroboration
OR
A single 2+ study for efficacy, with moderate evidence for corroboration
OR
A body of level 3 or 4 evidence of efficacy, with moderate/limited evidence of corroboration
OR.
Formal consensus
D [GPP]
A recommendation based on experience of best practice by health professionals and expert groups
'See "ables 2 and 3 for key to study type, quality and strength of evidence.
' ’Body of studies = 3 or more, or a systematic review.
■ ’ ’For national environmental/socio-political interventions, a body of 2+ studies is acceptable.
[PH] public health; [GPP] Good Practice Point.
Source, adapted from SIGN (2001).
Vethodology and results
9
Table 2 Evidence of the efficacy of an intervention - did it work?
Level of
Type qf evidence
evidence
1++
High quality meta-analyses, systematic reviews of RCTs (including cluster RCTs), or RCTs with a very low risk
of bias
1+
Well conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias
*
1-
Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias
2—
High quality systematic reviews of, or individual high quality non-randomised intervention studies
(controlled non-randomised trial, controlled before-and-after, interrupted time series), comparative cohort
and correlation studies with a very low risk of confounding, bias or chance
Well conducted, non-randomised intervention studies (controlled non-randomised trial, controlled
before-and-after, interrupted time series), comparative cohort and correlation studies with a low risk of
confounding, bias or chance
?—■*
Non-randomised intervention studies (controlled non-randomised trial, controlled before-and-after,
interrupted time series), comparative cohort and correlation studies with a high risk of confounding, bias or
chance
□
Non-analytical studies (eg case reports, case series)
4
Expert opinion, formal consensus
"Studies with a level of evidence (-) should not be used as basis for making recommendations.
Source: adapted from SIGN (2001).
corroboration and cost effectiveness. Essentially, the evidence
The framework is being piloted alongside the current NICE
for the efficacy of an intervention (in a particular setting
system within rapid reviews being carried out for the public
or with a particular population) is first assessed based on
health/prevention aspects of the HDA/NICE guidance on
the research design, quality and quantity of studies, and a
overweight and obesity. As a consequence of the initial
decision is made on the 'overall strength of the evidence of
piloting, it has been further amended as summarised in
efficacy for each outcome (eg weight, diet, physical activity).
Tables 1-3. The methods by which the building blocks of
.This is then combined with an overall assessment of the
evidence from different study types might be appraised and
strength of evidence of corroboration for the intervention in
combined to guide an overall grade of recommendation are
question, based on evidence from the efficacy studies and
from elsewhere.
summarised in Figure 2 on page 12.
Greding ev aence and recommendations for public health interventions
Table 3 Evidence for corroboration - will it work? (evidence to support
implementation in the UK today) and does it matter? (evidence of salience and
relevant outcomes for UK populations today)
___________________________________________________
Strength of
I
Type of evidence
evidence
Strong
Consistent findings in two or more studies of ++ quality carried out within the UK and'applicable
*
to the
target population, providing evidence on salience and implementation
Moderate
One ++ study or consistent findings in two or more studies of + quality carried out within the UK and
applicable to the target population
OR
Two or more ++ studies from outside the UK but applicable to the target population, providing evidence
on salience and implementation
Limited
Only one + study from the UK, two or more studies with inconsistent findings (on balance providing
evidence of benefit or harm) or studies of + quality from outside the UK
No evidence
No study of acceptable quality, inconsistent findings (on balance providing no useful evidence) or no
relevant research available
•Applicable - in general terms of age, socio-economic status, ethnicity, gender and cultural/religious practices.
Note: there is no established evidence hierarchy for corroborative studies.
Key to quality: ++, very low risk; +, low risk;
high risk of confounding, bias or chance.
A number of issues were highlighted when the proposed
framework was piloted.
• The presentation of corroborative evidence
provides valuable information to the developers of
recommendations, and aids transparency. There is, as yet,
no agreed hierarchy for corroborative evidence (often
a combination of observational studies and qualitative
evidence), nor is it clear whether corroborative evidence
for one outcome, such as diet, can be extrapolated to
another outcome, such as physical activity.
• Weighting a body of evidence of efficacy is still under
discussion, in particular, how can the evidence be
balanced when there is not complete consistency of
findings?
• The framework does not, as yet, incorporate the size of
the effects including (cost-)benefits and harms for the
different outcomes measured.
Vethodology ana results
I
Figure 2 Pyramid of evidence building blocks on which grades of recommendations may be based
Provisional grade
*
of recommendation
= A, B, C, D (see Table 1)
Evidence of efficacy, corroboration and cost effectiveness
Overall evidence of
efficacy based on
research design, quality
and quantity of studies
(see Table 2)
Consistency across
studies
Grading ev dence and recommendations for public health interventions
Quality
Quality of
individual
studies
(critical
appraisal):
1
2
3
4
Overall evidence of corroboration based on research design, quality,
relevance to UK (salience), implementability and quantity of studies
i (see Table 3)
Evidence of salience
Evidence to support
implementation
Consistency across studies
Consistency across studies
Level of evidence
Quality
Appropriateness
to intervention
type, ie
individual,
group,
community,
socio-political
Quality of
individual
studies
(critical
appraisal):
Individual studies/reviews
Appropriateness of
design
Cohort
Survey
Qual
Expert
Relevance
of outcome
and
relevance
to UK
population
Individual studies/reviews
’The final grade would take into account magnitude/effect size(s) (+ve or -ve)
Key to quality: ++, very low risk; +, low risk;
high risk of confounding, bias or chance.
Quality
Appropriateness of
design
Overall evidence of
cost effectiveness
Consistency across
studies
Quality
Quality of
Process
Feasibility
Quality of
individual evaluation, Plausibility
individual
studies
studies
survey,
Acceptability
(critical
review, Sustainability
(critical
appraisal): qualitative,
appraisal):
expert
Individual studies/reviews
Appropriateness of
design
Economic
studies
Individual studies/reviews
Discussion and conclusions
I
This project set out to answer the research questions listed
The literature review demonstrates that there is no
on page 3. While the literature review and consultation
consensus concerning natural hierarchies for studies
with experts suggest that the RCT design is usually the best
looking at corroborative evidence based on salience and
method to demonstrate the effectiveness of individual and
implementation. We have proposed a simple, transparent
group interventions (and cluster RCTs for many community
system for assessing the strength of such evidence, while
interventions), there is a dominant (if not universal) view that
recognising that this results in a considerable increase in the
it may not lend itself to evaluating the effectiveness of many
amount of data to be considered within a literature review.
complex public health interventions, such as those involving
However, it is conceded that the appropriateness and ease
communities and socio-political (including organisational)
with which these types of evidence can be combined would
'interventions’. In these cases a non-randomised design may
benefit from some further clarification.
be more appropriate.
While the existing NICE methodology does not assess
In addition, evidence from observational and qualitative
corroborative evidence explicitly, it does consider whether
research is central to providing the depth and insight required
evidence is ’extrapolated' and/or 'directly applicable' (SIGN,
for implementing/replicating appropriate and sustainable
2001; NICE, 2004a,b). Essentially, 'directly applicable'
interventions. A combination of different study types
evidence is from studies carried out on populations that are
so similar to the target population thajt applying the same
(quantitative and qualitative) is required to build up a picture
of the likely success of an intervention when implemented in
interventions can be expected to have the same effects. Thus
a specified context, as is the consistency of research results
evidence from UK studies would normally be considered
(where each subsequent study supports the results of the
directly applicable, studies from elsewhere may also be
previous studies).
juaged directly applicable (Robin Harbour, SIGN, personal
Responses from the expert consultation confirm that
communication). The definition of such terms remains open
to interpretation and may lead to inconsistencies in the
this is a complicated area. Various grading systems are
already in place, and some respondents did not feel that
another system was required. Despite this, the majority of
respondents supported this work and its emphasis on the
inclusion of corroborative evidence.
range of issues considered and their implementation. We
have therefore attempted to ensure that there is clarity and
rigour in the assessment of applicability. This includes taking
into account whether the study was Conducted in the UK,
although it is recognised that this is only aiproxy indicator
The provisional framework presented here aims to provide a
of generalisability: there may be interventions implemented
practical, but detailed and transparent, method for deriving
abroad that are more pertinent to some UK populations than
those implemented in the UK. This part of ’the framework
grades of recommendation for public health interventions,
based on a synthesis of all relevant supporting evidence
from research. Decisions on the strength of the evidence for
efficacy within the framework are, where possible, in line
with existing methodologies.
Discussion ard conclusions
would benefit from some further development.
At present the framework does not formally take effect size
into consideration as part of the grading. An intervention
may have a body of high quality evidence to indicate that it
has been effective in changing some outcome, and there may
be strong evidence to suggest it would be implementable in
the UK, yet its effect on the population may be negligible.
Further work will need to be undertaken so that the final
grading and prioritisation of the recommendation will be
based on size of effect (including any differential impact on
health inequalities), as well as the strength of the underlying
evidence, and our confidence in being able to replicate the
intervention successfully in a UK setting today.
This framework is being piloted and compared alongside
the existing NICE system, within the development of the
public health/prevention aspects of the HDA/NICE guidance
on overweight and obesity. The lessons learned will help to
inform the forthcoming work of the National Institute for
Health and Clinical Excellence.
14
Grading evidence and recommendations for puolic health interventions
Appendix 1 Organisations involved in searching
and summarising evidence for public health
i
• Campbell Collaboration
www.campbellcollaboration.org
• Centre for Knowledge Transfer
www.ckt-ctc.ca/English/Links.htm
• Centre for Reviews and Dissemination - particularly the
Wider Public Health project
www.york.ac.uk/inst/crd/wph.htm
• Centers for Disease Control and Prevention
www.cdc.gov and www.thecommunityguide.org/
default.htm,
• Effective Practice and Organisation of Care (EPOC) Group
www.epoc.uottawa.ca/aboutus.htm
• European Project, Getting Evidence into Practice
www.nigz.nl/gettingevidence
• Hamilton Public Health & Community Services, Effective
Public Health Practice Project (EPHPP)
www.city.hamilton.on.ca/PHCS/EPHPP/default.asp
• Health Evidence Network
www.euro.who.fnt/HEN
• International Obesity Taskforce
www.iotf.org ,
• National Coordinating Centre for Health Technology
Assessment
www.ncchta.org
• National Institutes of Health
www.nih.gov
• New Zealand Health Technology Assessment
http://nzhta.chmeds.ac.nz
• Public Health Association of Australia
www.phaa.rtet.au
Appendix 2 Those consulted on the developing
framework
I
The literaiure review was conducted by SURE and the draft
• Tim Gill, Australian Society for the Study of Obesity
methodology was developed in collaboration with the HDA.
• Christine Godfrey, Department of Health Sciences,
In addition, many groups and individuals were consulted
University of York
during the developmental stages of the methodology
• Margot Greer, National Public Health Service for Wales
and have made contributions during the process. Their
• Peter Hajek, Barts and The London, Queen Mary’s School
participation and contributions are gratefully acknowledged,
of Medicine and Dentistry
although their inclusion in the list below in no way signifies
• Robin Harbour, SIGN
their support or endorsement.
• Nicki Jackson, Cochrane Health Promotion and Public
Health Field
• HDA Obesity and Evidence and Guidance teams, including
Mike Kelly, Caroline Mulvihill, Hugo Crombie and Daniel
Warm
• HDA Obesity Reference Group, including Andrew J. Hill
(University of Leeds), Penny Gibson (Royal College of
Paediatrics & Child Health), Ken Fox (Bristol University) and
Mike Lean (University of Glasgow)
• NICE, including Francoise Cluzeau and Jeremy Wyatt
• Public Health Evidence Steering Group Methodology
Subgroup, including Josephine Kavanagh and Sandy Oliver
(on behalf of the EPPI Centre) and Ray Pawson (University
of Leeds)
• Sue Lloyd, Wales Centre for Health
• Anne Ludbrook, Health Economics Research Unit,
University of Aberdeen
• Andrew Oxman and the GRADE working group
• Mike Rayner, British Heart Foundation Health Promotion
Research Group
• Mary Renfrew, Mother and Infant Research Unit, University
of Leeds
• Tim Stokes, National Collaborating Centre for Primary
Care
• Carolyn Summerbell, Teesside University (HDA Obesity
Collaborating Centre)
• Public Health/Prevention Subgroup of the NICE/HDA
Obesity Guideline Development Group
• Malcolm Ward, National Public Health Service for Wales
• UK and Ireland Public Health Evidence Steering Group
• Wales HDA Obesity Collaborating Centre, including
Eddie Coyle (Wales Centre for Health); Chris Roberts and
Nina Parry-Langdon (Health Promotion Division, Welsh
Assembly Government)
• Robert Borush, University of Pennsylvania
• Mary Dixon-Wooiis, Department of Health Sciences,
University of Leicester
• Laurel D. Edmonqs, Care of Children with Obesity Clinic,
Bristol Royal Children's (Hospital
• Nick Finer, Centre for Obesity Research, Luton and
Dunstable NHS Trust
• Penny Gibson, Blackwater Valley & Hart PCT
I
16
Grading evidence and recommendations for public health interventions
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19
Notes
Social Exclusion Knowledge Network
Analytic and Strategic Review Paper
From
Participants from University of Sciences in Philadelphia
Dr. C. Reynold Verret, PhD, KN Director
r.verret@usip.edu
Mei-ling Wang, PhD., MPH, co-KN Director
meilinqwanq49(g)hotmail.com, m.wang@usip.edu,
Participants from Haiti
Marie Yolene Surena, Universite Quisqueya, Port-au-Prince, Haiti,
ysurena@yahoo.com
George Dubuche, MD, MPH, Port-au-Prince Haiti. Projet Haiti Sante
2007 gdubuche@hs2007.org
Acknowledgement: We would like to thank Dr. Vinand Nantulya for his feedback
to the paper, Ms. Melody Corry for her editing, feedback and research
assistance, and to Mojan Javadi and Two Javadi for their assistance with
literature review.
I. Focus and Conceptual Framework
Conceptual Definition of Social Exclusion
Discussions of social exclusion center on the following ideas:
1. Social exclusion is related to inadequacy at systematic levels, such as inadequacy in
policy developments on social protection, employment, education and training, health
and housing policies. (Lisbon Strategy of the European Union)
2. social exclusion is linked to connectedness and participation. It is characterized by
geographic isolation, a lack of means and opportunities to participate in normal
activities of citizens in a given society and the barriers preventing individuals from
participating due to factors beyond their control. (Center for the Analysis of Social
Exclusion, London School of Economics and Political Science, http://www.lse.ac.uk/;
see also Burchardt et al. 1999)
3. social exclusion has to do with particular social characteristics and related labeling of
the individuals with those characteristics , which generate negative consequences for
these groups (see related discussions in “Exclusion en Salud: en paises de America
Latina y el Caribe, 2004, PAHO).
4. Social exclusion involves the process marginalization and related lack of rights
protection. It "refers not only to the economic hardship of relative economic poverty
but also incorporates the notion of the process of marginalization." The process often
generates cumulative effects. (See Shaw, Dorling, and Davey Smith, 1999; Davey
Smith, 1998).
5. Social exclusion generates multiple effects, which in isolation or in combination affects
health through various pathways. (See WHO Commission on Social Determinants of
Health, May 5, 2005).
6. Possible benefits of exclusion and burdens of inclusion. Voluntary social exclusion
can have potential benefits (See, for example, Goodin, 1996). These include:
protecting cultural or social identities and continuities, empowering in-group members.
or gathering support for a cause beneficial to in-group members. The empowerment.
movement of the Native Americans in the United States actively resisted inclusion or
integration. The burden of inclusion can be negative when it is forced upon the will of
vulnerable populations. For example, the forced adoption of native American children
in the United States and aborigine children in Australia generated negative social
consequences on the native communities. (See Kreisher, March 2002; Stone,
November 10,1999)
To sum up, social exclusion is a multi-faceted phenomenon generated by such factors
as geography, group or individual characteristics, access to opportunities and
resources, and barriers to voluntary participation in community activities. The health
inequities entailed by social exclusion are related to the structures and dynamic processes
through which individuals, proceeding through their lives, become excluded and unable to
access social, economic, political and cultural resources to address their health issues.
There are multiple dimensions to the concept of exclusion and the relationships among
these dimensions are mutually reinforcing. In general, it encompasses economic, social,
political, and temporal dimensions. (See Shaw, Dorling, Smith, and Davey Smith (Eds.), 1999;
White,1998; 'Wiley, 2004).
1
2
Forms of Exclusion: Burchardt et al. (1998) provides a widely used conceptual framework
in discussing social exclusion. This framework suggests that it is important for individuals to
participate in “production, consumption, wealth, political and social" dimensions of activity.
(See also Sparkes, November, 1999, p. 1) These discussions point to the following forms of
exclusion that can affect population health:
exclusion from economic opportunities. It has to do with lacking access to the “normal
perquisites, routines, and experiences of everyday life,” such as a lack of access to
employment, inheritance, land, or other economic resources. It was suggested that in
some communities, certain groups are routinely excluded from the labor market, e.g.,
women, the elderly, minorities, the disabled, migrants, and are routinely discriminated
against in employment. (See Galabuzi, 2002, p. 1; Shaw, Dorling, Smith, and Davey
Smith, 1999)
• exclusion from educational resources. For example, the children in remote rural areas,
where transportation is difficult and resources are scarce, are likely to be excluded from
educational opportunities. (See UNICEF, 2004, “State of the world’s children 2004";
Brown, Socially stigmatized children due to certain conditions (e.g., those infected with
HIV/AIDS) have been routinely excluded from schools. A related point is that exclusion
from information resources or tools to access information has contributed to the digital
divide phenomenon. As a result, the benefit of information technology has not evenly
spread to ail population and the divide between “information-rich” and “information-poor"
occurs. Exclusion from information resources generates other forms of disadvantages,
such as access to job market or professional skills updates. (See DiMaggio and Hargittai,
2001)
• exclusion from civil society due to legal constraint or regulation. Examples of affected
populations include migrants, specifically illegal immigrants, or children of legal
immigrants. For example, legal migrant farm workers in the US are not entitled to social
security and health care benefits.
• exclusion from social discourse and political participation. This refers to exclusion from
voicing one’s opinion or representation in the media or in other political processes .
• exclusion from accessing social goods. Individuals with certain social characteristics, such
as the disabled, mentally ill or immigrants find it difficult to access the health systems due
to the lack of accommodation or limited language skills in health care settings.
• exclusion from social production and participation. Some groups may be labeled as
“undesirable, unacceptable, or in need of control, such as gypsies and nomadic travelers.
Or some minorities, who are stereotyped as lazy or lacking the mental acuity to be
constructive members of society, are excluded or limited in their participation in economic
activities.
• exclusion from public policy and intervention. The larger social and policy context plays a
critical role in exclusion. (See Melville, Nov. 14, 2002; also Hong. 2000; Heredia and
Purcell, 1995; and Bouillon and Buvinic, 2003; Hall, 2005; Lipietz and Saint-Alary; 2003;
“From social exclusion and social cohesion: Towards a policy agenda,” 1995; Maxwell,
1999; Olukoshi, 2003; Shah, 2005; Thomas and Wint, 2002;). Some examples are:
social and economic development policies, globalization and mutli-lateral or bilateral trade
agreements, especially those proposed by the World Trade Organization, macroeconomic
stabilization policies, such as structural adjustment, poverty reduction, and related
conditionaliies (i.e., economic shock treatment). For example, the measures for structural
adjustment, a policy tool for the World Bank and IMF, multilateral development banks
(MDBs), and bilateral aid agencies, routinely require tightening of credit, suppression of
wages, privatization of state-owned agencies, reduction of government expenditures, and
•
2
3
liberalization of trade regimes and financial markets. Despite the achievements in
containing inflation and inducing economic growth in some cases, these measures have
produced some unintended social outcomes, especially in increasing unemployment,
declining wages, increasing poverty and wealth gap, and reduction of public investment in
education and health services, as illustrated by the cases of Peru, Somalia, Vietnam,
Nicaragua, Mexico, Argentina, and Brazil. (See Hong, 2000; Heredia & Purcell, 1995.) For
example, price controls and wage reductions have forced rural farmers to migrate to urban
settings for better employment. The debt servicing requirements have led to growing debt
burden on the third world countries. Some third world countries fell into a vicious debt
servicing cycle.by borrowing even more to pay for the interest and amortization. This
leads to furthe1 reduction of public investment in health care and education. (See Hong,
2000). It was estimated that in 1990, Africa owed 46% of their export earnings on debt
servicing along, while at the same time there was a drastic decrease in overall aid to the
region. The other force related to this discussion is the impact of globalization and free
trade initiatives on the communities, especially in employment and population migration
(See Beall, 2002; Hong, 2000). Overall, our review suggests that these macroeconomic
policies often contribute to social dislocations, which have a major impact on social
determinants of health. The consequent erosion of social capital, due to reduced access
to social resources and networks needed, to address health-related issues, has
contributed to exclusion and generates serious implications on population health.
Excluded people
These forms of exclusion generate the following individuals: 1. guest workers, refugees,
migrants, ethnic and linguistic minorities, who are excluded from the benefits of full
participation in civil society; 2. the disabled, chronically ill, mentally ill, and emotionally
vulnerable, such as residents of children's homes, orphans or neglected elderly; 3. the poor,
homeless, unemployed, and abandoned children; 4. those already marked by disadvantaged
social status, with additional stigmatizing health conditions i.e. HIV/AIDS, leprosy, physical
and mental disabilities; 5. socially disadvantaged women, and sexual minorities.
The manifestations of exclusion vary across communities, country contexts, or regions.
There are universal factors as well as factors unique to a particular community.
Cross-national Continuities
Evidence suggests that besides the global factors of exclusion, there are local factors
unique to regions or country contexts. Nevertheless, the global factors, especially poverty and
employment, have a robust interaction with the local factors. For example, in the United
States, racial/ethnic affiliations and immigration status are a major exclusionary factor
(Institute of Medicine, 2003). In the Caribbean, Central America and Andean countries in
South America, such as Haiti, Puerto Rico, and Dominican Republic, Mexico, Ecuador,
Colombia, Peru, and Bolivia, poverty is the common denominator for exclusion whiie a more
nuanced analysis indicates that ethnic/racial and linguistic differences (in some instances due
to the indigenous status) are often relevant factors to poverty. The indigenous, according to
the World Bank, are the poorest of the poor. (See Griffith, 2000) Yet, there are factors unique
to a particular country. For example, in Dominican Republic, migration status (being Haitian
immigrants) is an exclusionary factor, while urban-rural divide contributes to exclusion in
Guatemala and Honduras (Wang, 2004; PAHO, 2004). In North America, racial/ethnic racial
affiliations is a major exclusionary factor. Yet, more distinction is necessary in examining this
factor: in the United States, skin color explains racial/ethnic exclusion, while in Canada, the
aborigine status accounts for racial exclusion In Southeast Asia, gender, education, urbanrural disparity, and poverty-related issues are critical exclusionary factors in India,
Bangladesh, Pakistan, Thailand, Indonesia, and Cambodia. However, there are different
3
4
factors unique to each country. For example, in Thailand, it is the combination of gender,
geography, and ethnic affiliations that is a critical determinant for health inequities. Within
these countries, there are factors unique to particular social and geographical milieus. For
example, gender disparity is more likely to be a critical factor in the rural areas than in urban
settings in India. In East Asia, poverty is a common exclusion factor while this factor interacts
with other factors in very different manners. For example, In China, rural and urban divide,
migration status, linguistic differences, and religion are critical exclusion factors while in
Japan, ethnic distinction and national origin account for exclusion. Even within the same
country, there are regional variations. In China, ethnic differences account for marginalization
in Northwest region while in Central, Eastern and Southern region, urban-rural divide, which is
closely associated with migration status, is a major exclusionary factor. In the Middle-East,
religion, which is closely related to other social, cultural and political factors, is an important
social exclusionary factor. However, there are also unique local factors. For example, in Iran,
rural to urban migration is a key poverty and exclusionary factor. (See Sheykhi, 2000). In
India, religion-related exclusion is often linked to caste/class, ethnic differences, and ruralurban divide. Overall, these factors point to the importance to examine the power dimension
in involuntary social exclusion. In addition, to avoid being entrapped in the conceptual pitfalls
of stereotyping and over-generalizing, it is necessary to examine the interaction between
these local factors and global factors across populations in producing social exclusion.
Definition of Inequities
Summarizing discussions on health and equity, inequities refer to a subset of
inequalities that are deemed unfair. (Evans, Whitehead, Diderichsen, Bhuiya, and Wirth,
2001; Marmot, 1999). Health inequities are disparities in health outcomes due to unequal
health opportunities that are unfair and avoidable, such as disparities in infant mortality, life
expectancies (that are not natural), morbidity, etc. (See Commission of Social Determinants
of Health, 2005; Evans, Whitehead, Diderichsen, Bhuiya, and Wirth, 2001; Marmot, 1999)
Major Conceptual Issues in a Model of Social Exclusion and Health Inequities
Major issues in conceptualizing the pathways between social exclusion ano health inequities:
Dynamics within and between dimensions of social exclusion. Social exclusion is
a complex construct that involves multiple dimensions. Each of them can be further examined
at micro- and macro-levels. Major considerations include: 1. the dynamic between the microand macro- factors within the same dimension. 2. the interaction among different
dimensions. For example, education interacts with other social determinants, which in turn
affect health in the course of a life time. Education also affects literacy, health literacy, or
language and communication skills that are related to social interaction and discrimination,
access to health resources, and quality of treatment in the health care settings.
The continuum of social exclusion. Social exclusion is not always a dichotomous
variable. In many cases, it is a continuous variable. For example, on gender and educational
opportunities, the issue is not that girls are excluded from education and boys are not. A more
sophisticated approach would be to examine the ways in which access to different lengths,
types, and depths of education affects men and women differently in their health outcomes
due to different cultural and social backgrounds.
The dynamics between exclusion and other structural determinants, and between
structural determinants and intermediary determinants. The pathways between social
exclusion, intermediary determinants and health inequities are often multi-directional and
mutually reinforcing. There are direct and indirect pathways between social exclusion and
health inequities. Thus, it is important that we do not examine social exclusion in isolation.
For example, as Galabuzi (2002) pointed out, attention should be paid to how the combined
effects of poverty, gender inequity, unemployment, and neighborhood selection mediate the
4
relationship between social exclusion and health inequities. Our research also suggests that
exclusion from educational opportunities is not the only predictor of ill health. Moreover,
exclusion from education, which characterizes the experience of some minorities or migrants,
interacting with discrimination and hazardous working conditions, might be a powerful
predictor of ill health. In measurement, it is necessary to identify the independent effect from
combined effects of social exclusion on health inequities.
The reverse feedback in the causal relationship between social exclusion and
health inequities. The pathways between social exclusion and ill health are not necessarily
unidirectional or linear. They also work in reverse direction in the causal path. For example,
poverty has a negative effect on health. Yet, the pathway is not unidirectional. Ill health also
aggravates poverty. This negative feedback loop moves in spirals that subject the poor and
less healthy population to worse health and economic situation. The poverty conditions might
also interact with other structural (such as class or cast) or intermediary determinants that
create even a larger gap in health disparities.
Generalizability and unique cases of social exclusion. Since the goal of this
project is to generate global evidence of social determinants of health, it is then necessary to
examine those social exclusion dimensions that can be generalized across all communities.
However, it is equally important to examine the dimensions unique only to a particular
population or community context. They might reveal important information about a specific
social/institutional structure that produces a particular health outcome in that population and
the related need to address it.
The interaction between social exclusion and CSDH themes. Social exclusion is
not an isolated phenomenon particular to a community. Understanding the interaction
between social exclusion and other macro forces and micro factors provide a more accurate
explanation about the correlates and combined effects of these interactions on health
inequities. For example, social exclusion might be further aggravated by such prevailing
systemic forces as globalization and trade-related issues. Several issues are relevant: 1. At
the country level, in what way public policies in social sectors, especially in health, poverty
reduction, education, and social protection and solidarity, can be used as an effective
instrument to dilute the possible negative effects of globalization, such as by increasing
resource allocation to address social exclusion. The model practiced by the Scandinavian
countries might be instructive. 2. At the regional and global levels, it is relevant to discuss
how trade-related globalization initiatives, especially those spearheaded by WTO rules and
bilateral trade agreements, affect exclusion. 3. In addition, it is important to examine the
effectiveness of global interventions, such as debt relief initiatives, poverty reduction
strategies, and Millennium Development Goals. 4. Social exclusion also has significant
interaction with other themes, such as urban settings, gender, employment conditions, and
health systems. These other factors, as focus of other Knowledge Network themes, impact
and are affected by social exclusion. Investigating these links is integral to the work for the
Social Exclusion Knowledge Network.
The need for a comprehensive model to generate interventions to address and
health inequities due to social exclusion. Social exclusion plays a central role in health
inequities. Several issues need major considerations: First, the macro forces at the systemic
level that affect social exclusion need scrutiny, especially in public policies and interventions
and rights protection at global, regional, country, and community levels. Second, the micro
level factors, such as communications at the interpersonai level, labor conditions, housing
segregation, etc., need to be examined. Third, health inequities are not the end result of the
path. They also act as a starting point that further aggravates the social positions of those
excluded population, such as their access to the health system, socioeconomic opportunities,
etc.
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11. Literature Review
A. Existing evidence. The aforementioned framework is used to critically and systematically
review evidence on the robustness and associations between social exclusion and
health/health equity across different country contexts. A preliminary review of existing
evidence shows:
On poverty
As an important socioeconomic status indicator, poverty has long been recognized as
a major cause and outcome of social exclusion (see for example, Pan American Health
Organization, 2004).
1. Poverty has economic and social dimensions and does not necessarily imply
exclusion and vice versa. The underlying factors of poverty are inadequacy in macro-level
policies, systems and context that creates such outcomes as unemployment, wealth gap and
marginalization, etc. (Bessis, 1995; Bhallla and LaPeyre, 1999; see also PAHO, 2004.)
2. Among all sub-dimensions of poverty, unemployment or under-employment-related
poverty generate particularly serious effects on health due to exclusion from the labor market
and social benefits of accessing consumption, maintaining identity, and obtaining recognition
that comes with income-generating activities. Specifically, poverty affects health via the
following pathways:
• deprivation of material conditions affects fulfillment of basic health needs, such as
balanced nutrition.
•the poor are deprived of financial resources to engage in normal social activities
•poverty due to social discrimination excludes access to social capital, such as to
health systems.
• lack of access to health resources (such as disposable income for health care,
access to private and public insurance, health information, etc.) to address, one’s health care
issues. (Dain, 2004; Davey Smith, 1998; see also “An introduction to social policy: Social
need." By Center for Public Policy Management. Aberdeen Business School. The Robert
Gordon University).
•the psychological burden on the poor also makes it more likely forthem to indulge in
less healthy life styles, such as excessive alcoholic consumption and smoking (Shaw, Dorling,
and Smith, 1999).
Inter-American Development Bank (IADB) noted that there is a high correlation
between poverty and social exclusion and the excluded typically constitute the poorest.
These excluded often suffer serious health consequences. (See “About Social Exclusion.” By
Inter-American Development Bank, May 4, 2004; Wilkinson etal, 1989; Wilkinson, 1996;
Wilkinson and Marmot, 1998; Kawachi, Wilkinson and Kennedy, 1999; Raphael, 1999; 2001;
Kawachi, I., Wilkinson, and Kennedy, 1999; Wilkinson, et al., 1989; Wilkinson, 1996;
Wilkinson and Marmot, 1998).
3. Discussions of poverty require an examination of how poverty is determined. Several
major approaches are: A. an absolute index approach: The World Bank uses the indicator of
$31 a month income. B. budget standards: The US demarcates poverty by identifying
income levels based on the food basket cost, below which is the poverty line. C. relative
measures: The European Union uses a comparative measure that sets a poverty line at 50%.
D. others: subjective opinion or a consensual method. (See “An introduction to social policy:
Social need." By Center for Public Policy Management. Aberdeen Business School. The
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Robert Gordon University). Poverty defined as relative deprivation is a useful concept that
can be further modified in different contexts when discussing population health (Townsend, et
al. 1988). For example, Townsend index of deprivation is a composite indicator of
unemployment, percentage of households with no car, the extent of overcrowding, and
housing tenure. (Townsend, 1988).
4. The cumulative effects of poverty during the course of life make it important to look into
its relationship with other determinants. Discussions on the impact of poverty on health
inequities require a more comprehensive understanding of the complex relationship between
education, employment, income inequality, discrimination, deficit of social capital and health
inequities. For example, education interacts with poverty in affecting health inequities. As will
be discussed in the following section, educational attainment is “strongly correlated with”
unemployment and earnings, which determines poverty levels, in developed countries. (See
Sparks, November, 1999, p. 2). Poverty also has a bi-directional relationship with education
in that poverty can pose as a barrier to access to educational opportunities. The interaction
effect between poverty and education then contributes to reduced access to social resources.
such as networks. Together, they subject individuals to higher risk to ill health in the short
term as -well as in a life course.
Entry points for discussing social exclusion and poverty: 1. The precursory conditions that
aggravate poverty of the excluded and that produce ill health outcomes. 2. Exclusion from
employment, poverty, and health inequities. 3. The causal relationships between poverty,
exclusion and health inequities. 4. How social exclusion affects the poor in accessing
balanced nutritional resources. 5. How poverty interacts with other determinants to further
aggravate social exclusion. 6. How social capital affects the social position of the poor and
produces health inequities.
Assessment of Evidence. Among all dimensions of social exclusion, the most discussed
association is between poverty, unemployment, and poor health outcomes. The majority of
evidence suggests that poverty and unemployment affect physical and mental health. (See,
for example, Davey Smith et al. 1994; Davey Smith, Blane, and Bartley, 1994; on mental
health, see Evans, and Repper, 2000) Most of the evidence on income inequality and
population health focus on developed countries. For example, Adler et al. (June, 23, 1993)
examined how socioeconomic status as a whole affects morbidity. Some specific evidence on
exclusion, poverty, and health outcomes has also focused on the populations in developed
countries, e.g., in UK. For example, some epidemiological studies have explored the
relationship between unemployment, exclusion and housing, poor physical health and mental
health outcomes. Most global comparisons on poverty and excluded populations were
produced by inter-governmental agencies and NGOs. For example, the World Bank 2000
Global Poverty Report and poverty reduction strategy papers discuss poverty and its impact at
a broad and general level. The Poverty Center of UNDP has produced more focused
research on poverty and some excluded populations, such as on poverty and children. (See
Children on the Brink of 2004: A joint report of new orphan estimates and a framework for
action, (www.undp-povertycentre-orq); Gordon, Nandy, Pantazis, Pemberton, and Townsend,
funded by UNICEF). Pan American Health Organization has also generated research that
examines some impact of poverty and exclusion (See Dain, 2004, for PAHO). Some
government reports, such as by UK and Australia, have examined the relationship between
low SES and health outcomes. For example, Australia’s report presented detailed
comparative analyses and measures of health status, such as nutrition intake, morbidity, etc.,
among different social classes, (http://www.undispatch.com/archives/world health/) “Health
Status of South Australians by Socio-economic Status.") In general, 1. there has not been
consistent, focused, and detailed studies on the relationship between poverty and ill health for
7
8specific excluded populations. 2. it is necessary to generate a standardized measure of
poverty that accounts for diverse experiences of the excluded in different country contexts. 3.
groups-desegregate data are also needed to analyze the effects of exclusion on health.
On education.
1. Education is a multiplier and gateway to other social gains, such as employment
opportunities, income, gender equality, participation in civil society, political processes, and
access to social capital. It is an effective instrument for integration and maintaining social
cohesion. The major underlying factors of exclusion from education are: inadequacy in
social resources and deficiency in policy interventions and rights protection. 2. The pathways
between education and health outcomes are. A. the socioeconomic gains afforded by
opportunities associated with education have long-term implications for health. B. health
literacy that is associated with normal school education can promote positive health behavior.
C. exclusion from educational opportunities reduces access to social and psychological
sources and increases social isolation and affects access to social support. D. As a common
experience, education creates stronger communities. (Brehm and Rahn, 1997). This bond
between individuals and society established in the educational process directly and indirectly
affects population health. 3. The relationship between education, other structural determinants
(such as SES, ethnic/racial status, gender, access to political power), and intermediary
determinants (labor conditions of child labor) is complex and multi-directional. The effect of
one determinant feeds into others and the combined effects multiply health inequities. For
example, the combined effects of lacking access to education opportunities and gender
inequities have a strong correlation with infant mortality. 4. The macro-level issues also
interact with micro-level issues in enlarging health inequities. These micro issues include:
different content, types, and range of education received by children of different social
characteristics (such as rural vs. urban, boys vs. girls, racial/ethnic/linguistic subgroups, etc.),
the different types of health education needed at the primary versus secondary levels. For
example, primary education might emphasize comprehensive preparation in basic skills,
formation of positive health habits and practices, nutrition, and prevention of child abuse. In
contrast, at the secondary level, besides reinforcing those basic skills, the content of
education might include the teaching of professional skills and reproductive and sexual health.
Major issues on education and social exclusion.
• Exclusion from well-rounded education, such as science and health, excludes the
cognitive sources that one can use to gain health literacy, information for disease
prevention and intervention, and health maintenance.
• Exclusion from languages that are major sources of information, access to power and
social capital. Language barriers and the lack of resources to address this problem is a
recurring issue across different countries. Education affects the ability to use officially
sanctioned language in a given society and has major implications on access social
sources and health resources. Of special concern are the consequences when the
language of education differs from the language of an excluded or marginalized group.
Several issues are relevant: A. For those who do not use the official language, there
are questions about translation and the attitudes of the dominant language group
toward minorities' or toward ethnic languages in health settings? B. For those who use
the official language, there are questions about society’s attitudes toward and services
for those individuals. C. Education also determines one’s access to technology or the
language of science and technology that has major implications for health inequities.
The phenomenon of digital divide affects access to health-related information and
solutions.
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•
«
Exclusion from education is a continuous variable. Fcr example, even when rural
children receive some education, the types, content, and range of education received
might not be the same as those by urban children. This puts them at a disadvantage
point in terms of employment, earnings and occupational status during the course of
their lives. Similarly, when girls receive education, the questions remain: whether the
content, especially in math, science and health, and expectations for girls are the same
as those for boys; if the educational system makes specific attempts to address gender
specific health needs. The fact that educational levels of women are a reliable predictor
of infant mortality point to the need for examining the complex interaction betv/een
macro- and micro-level factors and dynamic pathways between education and health
inequities. The same point can be made about specific educational needs of cultural,
racial, ethnic, social minorities.
Education also affects health inequities by addressing justice and human rights-related
issues in the curricula and communication in social forum. For example, the most
effective way to address prejudice and discrimination against socially marginalized
groups is through education, especially at the early stages of life in school and social
settings. Health education has also been noted as being highly effective in tackling
public health concerns such as HIV and STDs.
Assessment of Evidence: Most studies, such as Desai and Alva (1989), articulate a
possible strong association between education and population health, especially from the life
course approach. Many innovative programs and policies have been implemented to address
the encompassing implications for exclusion from education. Nevertheless, there still lacks
focused and consistent research on the relationship between education and the health
outcomes of excluded groups in the short term and in the long-term. There has been some
documentation of successful educational programs addressing quality of education, retention
of children in general, gender-sensitive education, and those including health literacy and
service in school-based education, such as Bolsa in Brazil, Progresa Opportunidades in
Mexico, Balochistan Primary Education Project in Pakistan. Evidence suggests that a long
term, comprehensive evaluation and assessment component in this discussion is still lacking.
Gender
According to WHO (1998), gender “is related to how we are perceived and expected to think
and act as women and men because of the way society is organized, not because of our
biological difference.” As such, gender is a multiple dimensional construct that encompasses
biological components but also has social, cultural and psychological implications. For
example, perspectives about gender roles and functions can range from simple/restrictive
(such as reproduction and nurturing) to complex/flexible (biological, social and political). The
major underlying factor that contributes to gender exclusion is: discriminatory social, cultural,
economic, and political practices against men or women who do not have resources or
recourse to address the consequences of those practices. (Ostlin, George, and Sen, G„
2001). Gender-related exclusion often determines unequal access to resources and
networks, unequal opportunities in public representation, and unequal participation in the
making of institutional policies. Gender-related exclusion is reflected in air aspects of social
life and its manifestations vary from society to society. These can be different levels and
types of education for boys and girls, access to the range and amount of health care received,
and division of labor and related occupational status. These practices affect economic
rewards conferred within and outside the household, the range and types of liberties one is
permitted to exercise, and possibilities for social and political representation. (See Sen, A.
1992). Gender interacts with other intermediary factors, such as education, class,
employment, to produce health inequities. The relationships between gender and health
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inequities can proceed through the following pathways: 1. biologically defined health needs
in different life stages that are not recognized and accommodated. For example, nutritional
needs for women at pre-partum stage are different from other stages of the life course or from
men. The risk factors in morbidity and mortality, such as in mental health, reproductive health,
cardiovascular diseases, and possibly in musculoskeletal system, are different for men and
women. (Danielsson and Lindberg, 2001) 2. inequalities in health outcomes and health care
that go beyond biological differences in sexes, which, as mentioned earlier, are affected by
unequal, social, cultural practices in gender relations. For example, women's advantage in life
expectancy is a widely recognized natural biological difference in gender. Yet, this advantage
disappeared in deprived communities in developing countries. And for males, excess male
mortality is largest in former Russian Republics and Eastern European countries due to nonbiological factors, especially homicide among the young and war. The variation of this
biological-survival advantage across different countries underscores the importance of
examining non-biological factors in addressing gender-related health inequides. One possible
pathway is that women and men are excluded from equal participation in certain aspects of
social life and that exerts negative health impact on women.
Major issues: 1. whether excluding women from education or certain types of
education leads to their decreased access to economic resources and employment. This form
of exclusion determines women’s social status, their power relation with men in the
household, their possession of health care resources (such as health literacy), and their
participation in society, social discourse, and political process. It further determines women’s
influence over allocations of social resources to protect their health. It is a complex cycle of
feedback that enlarges health inequities. Like some other structural determinants, such as
SES and marginalization, the seriousness of gender inequity has its intergenerational
implications. Exclusion of women leads to socially disadvantaged children and the vicious
cycle leads to increased health vulnerabilities and risks that further excluded them from
upward social mobility. 2. whether cultural and social norms have contributed to the
exclusion of men and women who do not fit in traditional definitions of gender roles and result
in violence against men and women. These multiple interactions can exert very negative
effects on the population. In this sense, gender-related social exclusion has a circular, multi
international effect with other structural determinants. 3. how differences in cultural and
social experiences among women and men of different socioeconomic status account for
different health outcomes.
Assessment of Evidence: 1 .most scientific evidence on gender and health inequities
was based on studies on developed societies. (See Doyal, 1995; Green and Rafflin, 1993;
Heston and Lewis, 1992; Krieger, 1995; Lerner and Kanel,1986; Verbrugge, 1985;). 2. These
studies indicated strong associations between gender and health inequities in general and in
specific areas, such as heart diseases in developed countries. 3. There were much fewer
studies on gender exclusion and health outcomes on developing countries. 4. The few
studies on gender and health inequities in developing countries discussed gender and health
in such areas as malnutrition, mortality, morbidity, pregnancy-related issues and mental
health. (See for example, Evans, et al. Eds, 2001; Bhuiya and Ansary, 1998; OKojie, 1994;
Paltiel, 1987; Paolissio, and Leslie, 1995; Rahman, et al. 1994; Santow, 1995; Vlassof, 1994).
5. As a whole, there lacks sex-desegregate data on health outcomes. Data on the
relationship between gender, exclusion, and health outcomes are lacking. Most of the global
comparisons were generated by intergovernmental agencies or NGOs. For example, WHO
pointed to the high mortality rate of pregnancy in developing countries. WHO’s 1998's
technical paper on gender and health, WHO report on gender and health (2003) and PAHO’s
report on gender and health (2003) presented a strong association between gender and
health inequities in developing countries. However, few studies specifically'examine the
interaction between gender, social exclusion and health outcomes. Even fewer studies have
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examined the interaction between gender and other exclusion dimensions or factors, such as
age, poverty, racial/ethnic backgrounds, and health outcomes at the global level. One study
by the World Bank did make an attempt to address the social dilemmas of one excluded
population, albeit with peripheral mentioning of health. In this report, World Bank presented
comprehensive evidence in gender differences in access to opportunities, resources and
participation across the range of civil services and social and economic life chances. This
report specifically pointed out that there have not been detailed studies and data on rural
women’s health. (See Grieco, 2002).
On marginalization and discrimination
Marginalization encompasses several interrelated dimensions, such as ethnic/racial,
cultural, geographical, sexual, physical and mental capacity, social stigma, linguistic,
residential/housing status, and migration status. Discrimination against marginalized groups is
often wrought in explicit or implicit forms that lead to exclusion. This phenomenon is often
more prevalent than what individual communities recognize or are willing to recognize. 1.
Underlying factors: The distinction between “in-group” and “out-group” by the use of various
criteria, such as skin color, cultural differences, sexual orientations, physical capacities,
housing conditions, and migration status often leads to the generation of unequal social,
political, cultural policies and rules that discriminate against marginalized groups. 2. However,
the process is not dichotomous. It is a more nuanced process and environment of
differentiation and inequity that produce corresponding degrees and types of health inequities.
Even within the in-group, certain social/cultural factors produce various forms and degrees of
discrimination. 3. The interaction between global (i.e., race/ethnicity) and local factors (such
as class) produces gradients of health inequities. For example, when compared to
Caucasians, African Americans as a group have shown a statistically significant difference in
major health indicators. Yet, within the same population, the low-income African American
men have an even more pronounced difference from middle-class African American men or
women. (Institute of Medicine, 2003). 4. The pathways from marginalization to ill health are
through ’lack of secure sources for food, shelter and stable employment, 'stress due to loss of
social support networks, need for social adjustment in a new environment or changing
environments, "the risks of working in hazardous environments, with few or no mechanisms
for self-protection or organized protection (i.e., such as through unions), -fear for harassment,
•exposure to environmental toxins, e.g., the pesticides) (Wang, 2004, case studies in
Cambodia, US, Thailand; see also Drever and Whitehead, 1997; Toole and Waldman, 1997;
Corvalan et al., 1994). Degree of marginalization often interacts with employment,
occupational status, political participation, access to health resources, working conditions, and
living conditions to produce negative health outcomes. It is then important to examine these
structural mechanisms and intermediary pathways through which exclusion of social groups
lead to health disparities.
Forms and Range of Prejudice and Discrimination
• On social characteristics: The minority health research in the United States has
systematically documented the differences among African Americans, Native Americans,
Hispanics, Asian Pacific Islanders and Caucasians in various health outcomes, such as in
infant mortality and life expectancy, cancer morbidity, and differential treatment of health
care. However, as mentioned earlier, the interaction between race and other SES factors
differentiates health outcomes of the subgroups in a given racial/ethnic group.
» On physical disabilities: the physically disabled and mentally challenged are more likely to
experience discrimination in social settings and their needs are often not accommodated.
Poor, ignored elderly are more likely to experience negative health consequences than
those who are of a higher SES status. Income and employment would produce further
gradients of health inequities in this group.
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On migration status: These groups include: refugees (who flee from countries in conflict),
displaced persons (due to natural disasters, such as the recent Tsunami in Southeast
Asia), immigrants who experienced hardships and discrimination (such as those in
Europe, America, the Middle East), migrant workers (the Mexican guest farm workers in
the US or Southeast Asian house workers in Hong Kong and Singapore), trafficked
persons (trafficked commercial sex workers in Thailand, India, Cambodia, Holland, etc.)
These groups are at higher risks of mortality and morbidity, such as in physical injuries,
communicable diseases, neonatal problems, malnutrition, mental, psychological, and
emotional problems. In addition, SES factors and other social characteristics, such as skin
color, further differentiates the health outcomes of this group. For example, Cubans as an
immigrant group have shown better health outcomes than other groups in the Hispanic
population.
> Residential/housinq status: It has a more complex, bi-direction, causal relationship to
social exclusion. It involves the discussion of: 1. urban-rural divide in developing
countries. Rural residents are invested with much fewer resources, which affect all
aspects of social life (See, for example, Hovenga, 1998). The rural residents have less
access to health facilities. There are fewer health providers available. The quality of care
is inferior. Even when well-equipped health care infrastructure is available, other
inefficiencies, such as transportation or good roads prevent the residents from accessing
the health care. 2. housing status. The distinction between having a shelter and not
having a shelter, which characterizes the homeless and street people, has pronounced
effects on health status. 3. The kind of housing that one has, in a slum or a regular
residential area, also affects health. 4. Neighborhood. Questions raised here are: the
kinds of neighborhood one lives in, i.e., the kinds of infrastructure, access to services, and
community cohesion and safety. These issues are closely related to access to healthy
food, clean water, exposure to violence, environmental hazards, community bond and
support, good roads and convenient transportation, access to health care, etc. (See
Hovenga, 1998) Poverty, class, and gender can be a major factor of differentiation in
exclusion in this case. For example, rural-urban divide is a major exclusionary factor in
China; however, well-off rural farmers have little difficulty accessing health care or
improved housing. (Wang, 2005)
• On religious affiliations. Religion also interacts with other social determinants, such as
gender, class/cast, political affiliations and race, in producing graduations of health
inequities. For example, in South Asia, the strong interaction between religion and cast is
a major exclusionary factor. (See detailed discussions in the section on religion).
• On gender. Gender discrimination entails discussions of biology, sexuality, and
socialization experiences. As mentioned earlier, differences in male and female biology
and gradients in social/political/economic experiences contribute to social exclusion. It is
worth noting that the gradients in socialization experiences, such as SES backgrounds,
generate different health outcomes. For example, in Africa, poor women in rural areas of
Africa are more likely to be infected with HIV than those well-off in urban settings.
(UNAIDS report, 2005). Gender discrimination also needs to focus on the discussion of
male exclusion. Homosexual men or men of lower SES or cast, ethnic origins face various
degrees of discrimination. For example, in some countries, homosexuality is illegal. (See
Wang, 2005)
Assessment of Evidence: Most of the evidence on marginalization and discrimination has
been produced in developed countries. For example, minority health research in the US has
produced a large number of studies on health disparities among ethnic minorities, especially
among Native Americans and African Americans, and Caucasians due to discrimination. (See
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“Unequal Treatment.’’ 2003). So far, these studies presented the strongest scientific
evidence on discrimination as an exclusionary factor for ill health. Other reports made similar
attempts to address the negative effects of social exclusion, albeit with little mention of health
outcomes. For example, the Scottish government produced a report on the effects of social
exclusion on some marginalized groups, with little analysis of health effects. This research,
which provides new empirical evidence based on detailed surveys in 3 urban areas of
Scotland, found that: women, the unemployed, elderly, people with health problems and
those in low income groups are more likely to experience transport related social exclusion.
(“The Role of transport in social exclusion in urban Scotland.” Scottish Exclusive.
http://www.scotland.gov. uk/cru/kdO1Z blue/rtseuc_03.htm). One attempt by the UK’s
Exclusion Unit Report Breaking the Cycle (2004) did produce general evidence that the
excluded elderly suffered specific physical and mental health issues, such as mortality and
loneliness. It also pointed out that exclusion itself aggravates ill health. The Joint NGO report
in response to New Zealand government’s Second Periodic Report to the Committee on
Economic, Social, and Cultural Rights pointed to the need to improve housing for the excluded
populations, without addressing health effects. In general, most of the global comparisons are
produced by inter-governmental agencies, such as UN and its affiliates. For example, UN
High Commission for Refugees regularly reports on the status of displaced populations. The
2003 report from the “Permanent Forum on Indigenous Issues” (May 12, 2003) pointed out
that the indigenous were displaced from lands and are more likely to suffer extreme poverty.
PAHO’s report on “Exclusion in Health" (2004) was a comprehensive attempt to investigate
the exclusion factors as barriers to access to health care. In a 6-country study, this report
concluded that exclusion in health seemed to be related to poverty, marginality, racial
discrimination, cultural patterns (such as language), informal structures in employment,
underemployment and unemployment, geographical isolation, lack of basic services, such as
electricity, drinkable water and basic sanitation and a low level of education or information on
the part of service users. Despite the rigorous methodology and quality of the data, this study
focused specifically on exclusion from health care instead of social exclusion as a whole.
On religion
First, the underlying factors that account for religion-related exclusion and health
inequities are as follows: Religion can be considered as a unique cause of marginalization.
When there is a clear case of a community composed of “religious majority" and “religious
minority,” the majority, in many cases, tends to have more power to define the rules for
institutional or informal, social sanctions that affect many aspects of social lives of the
minorities, such as in education, economic opportunities, health resources, gender relations,
health practices, etc. In this case, the dominant or “state-sanctioned” religious group defines
what is normative and important in health priorities and therefore apportions government and
social resources to support those priorities, with the intended and unintended effects on “non
dominant” religious groups. As is obvious in this case, the minorities generally lack power to
negotiate and ameliorate their social positions. The major pathway between religion-related
exclusion and health inequities is through discrimination. Discrimination occurs in overt and
covert forms. Overtly, this can lead to reduced denial of access by minorities to resources,
including health care. This power imbalance is also likely to lead to wars, massive migration,
genocide, violence against women and children in extreme cases. In most cases,
discrimination takes other less violent forms, such as contempt and harassment that
perpetuates discrimination. For example, some communities allocate fewer public resources
to the religious “out-groups.” Some religious groups are forced to concentrate in less desirable neighborhoods, areas, or environments. They might be subject to blatant or less
obvious forms of oppression, such as interpersonal verbal abuse, neglect in cultural and
media representation, discrimination in employment and education, exclusion from community
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and political participation, which can result in negative physical outcomes and mental or
emotional distress.
Second, religious institutions can be an important component of social capital. They
can be potent vehicles of inclusion. It can play and in some cases has played a positive role
in improving access to health care. Religious organizations and affilated charities are often
effective channels through which access to health care is provided or facilitated. Religious
institutions provide elaborate networks and a range of services that influence health: such as
services for disaster response, reproductive health, disease outbreaks (such as HIV), and
other initiatives that have positively improved health disparities. They are often effective in
reaching socially and geographically excluded populations, such as the indigenous, homeless,
slum dwellers, abandoned children, abused women, and elderly, etc. In this sense, they can
be effective in filling the void of government action in addressing health disparities.
Third, religious-related teachings and practices can have both positive and negative or
positive effects in improving population health. The use of Islamic teaching to preach
monogamous relationship to reduce HIV prevalence is an example. The Mormon teachings
against use of tobacco and alcohol consumption have long been noted as a protective factor
for this group. (Koenig, McCullough, and Larson, 2001). Nevertheless, it must be noted that
religious teachings or practices can serve to suppress the exercise of rights of certain social
groups, such as women, and can incur negative health consequences at the population level.
Assessment of Evidence: There are few studies examining the interaction between religion as
an exclusionary factor and health outcomes. 1. Most studies examine the role of religion in
healing and in supporting positive health behavior. 2. Most studies were conducted in the
context of developed countries, primarily in the Untied States. 3. The methodological rigor of
these studies needs to be evaluated. For example, religiosity is found to help coping behavior
for kidney disease (Baldree et al., 1982). O’Brien (1982) found that 52.4 patients indicated
that religion was “usually” or "always” associated with their adjustment to hemodialysis. It was
said to have a positive effect on the patients undergoing coronary artery bypass graft (Saudia
et al.,1991) Harris et al. (1995) found that beliefs and practices predicted better physical
functioning, lower anxiety, higher self-esteem, fewer health worries, and less difficulty with the
transplant medical regimen and better compliance. A study on 100 HIV or AIDS patients
showed that prayer or other spiritual activities played a major role in their life. (See Carson,
1993) Similar findings can be found among diabetic patients. (Landis, 1996). An interview
on 51 seniors in Rhode Island showed that out of 66 coping strategies, prayer was most used.
(See Manfredi and Pickett, 1987) Overall, similar results were generated from informal
research (See, for example, Koenig, McCullough, and Larson, 2001, p. 86). In 1980s, a
Gallup poll on 1.485 adults indicated that almost 80 percent of the US population receives
comfort and support from religious beliefs.
On the role of religion in affecting health behavior, some studies suggested that
religious persons are more likely to engage in healthier life styles and less likely to smoke,
abuse alcohol, use illicit drugs, and engage in risky sexual practices or other hazardous
behaviors. They eat more healthily, have lower serum cholesterol levels, and may exercise
more, (see Koenig, McCullough, and Larson, 2001, p. 3). Still, there are studies, such as by
Riley et al. (2001), indicating the negative health outcome of religious practices. Overall, in
terms of the relationship between social exclusion, religion and health outcomes, there needs
research to examine: 1. the role of religion as a macro-level force in social exclusion or
inclusion and its impact on health outcomes. 2. effectiveness of religion as a positive tool to
broaden access for excluded populations. 3. effectiveness of religion in promoting positive
health behavior. As we will discuss in the following sections, there have been a large number
of health programs applying faith-based approaches and teachings, such as CORE supported
by USAID and ACP or “HIV in Uganda” program in Uganda. Yet, the outcome assessment
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and evaluation component of these programs needs further research, especially in addressing
the health outcomes of the excluded.
Elements of Social Capital
The role of social capital in integrating communities has aroused some contentious
debates among social scientists and community practitioners. The debates center on: 1. the
connotations of “social” and “capital" in the building of community. One major issue is: how
“social networks” and “economic capital affect the community. 2. definitions of social capital.
Among different types of capital, the tension between bonding and bridging capital has been
subject to close scrutiny. In Putman’s (2000) original definition, bonding (exclusive) social
capital refers to relationships that are inward-looking and tend to strengthen in-group loyalty
and cohesion (i.e., family, ethnic, fraternal, and religious organizations). Bridging (inclusive)
social capital refers to relationships that are outward-looking and embrace diverse social
groups (e.g., youth groups, civil rights groups, etc.) 3. if it is always beneficial. For example,
bonding social capital can generate negative impact on population health by, for example,
upholding a potentially harmful health practice, such as the group ritual of heroine injection in
Southwest region of China that has contributed to very high HIV prevalence . 4. the need to
include discussions of power, especially in relation to economic capital, in evaluating the
social capital in communities. 5. macro-level factors, such as policies and interventions that
contribute to the strengthening or incurring the deficit of social capital. (Crombie, et al., March,
2005). Most discussions on social capital originated from sociology or economics. In this
section, we will focus on elements of capital relevant to the discussion of health inequities. In
population health, social capital refers to "collective characteristics of communities and
societies that determine population health status.” (Kawachi, and Berkman, 2000). It is
generally agreed that the key elements of social capital are: social networks (the tangibles),
trust, and norms (the intangibles). (See Productivity Commission, July, 2003, “Social capital:
Reviewing the concept and its policy implications.” Australian Government; Bourdieu and
Wacquant, 1992; Coleman, 1988; Coleman, 1990; Loury, 1992; Putnam, 1993; see also
Kawachi and Be'kman, 2000, p. 175).
1. social networks: A network is an interconnected group of individuals that have an
attribute in common. (See Productivity Commission, June, 1993). Examples of networks that
affect the operation of population health are: families, kinships, neighborhoods, employment
affiliations, community organizations, and institutions.
Social networks have generated major discussions in population health. Among social
networks, civil societies, communities and public institutions (such as health care agencies)
are relevant to health inequities. Measures of social networks include: A. measures of
characteristics of networks, mainly the structural measures: size, density (extent to which
members are connected to each other), boundedness and homogeneity; B. measures of
individual social ties: frequency of contact, multiplexity (number of transactions flowing
through a set of ties), duration, and reciprocity (extent to which exchanges and transactions
are reciprocal). Civil society, as an important element of social networks, is “that zone .
between the individual and the state which is occupied by a crisscrossing network of voluntary
associations." (Kawachi and Berkman, 2000, p. 179). The activities of civil society are usually
not part of the formal political system, commerce, or government. (See Baum, and Ziersch,
2003). The other important element of social networks is community, which refers to a group
of people who “share a sense of identity or have common concerns.” (Baum and Ziersch,
2003, p. 322; Berkman, and Glass, 2000). Participation and volunteering are major
mechanisms for social networks to generate strong social cohesion. The services provided by
social networks, especially in health and educational services, are instrumental in
strengthening health-related social capital. Social networks foster emotional,
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mental/psychological support, material support, rights and policy support, and increasing
participation. (See Putman, 1993; Kawachi and Berkman, 2000). What sustains social
networks is participation, which is a central element to WHO Health for All Strategy. This
program ranges from “consultation to structural participation in which lay people are the
driving force of initiatives. (Baum, and Ziersch, 2003, p. 323). There have been several
pronounced cases in which civil societies and community mobilization have made a difference
in population health. The mobilization for increasing access to HIV medicine for the poor
populations in developing countries by NGOs was an often cited case in point. (Loewenson,
R. (Civil society influence on global health policy. See WHO Training and Research Support
Center. http://www.tarsc.org/WHOCSI/gIobalhealth.php)
2. trust: Trust affects population health in a major way. For example, minority health
literature in the US shows that If the health care system functions in discriminatory manner,
the marginalized groups would be mistreated (See Institute of Medicine, 2000; see case
studies in Lima, 2005). Lack of trust can make marginalized groups underutilize beneficial
health resources. Mistrust due to the Tuskegee Syphilis Study (REF) continues to influence
interactions with the health system of African Americans in parts of the United States. This
mistrust is likely to start the vicious cycle of decreased participation by those groups in
mainstream health care institutions or their resorting to the use of emergency services as a
“last-minute" solution.
3. norms. Social norms that affect health are: “honesty, law abidingness, the work
ethic, respect for elders, tolerance, and acceptance of diversity, and helping people in need.
(Putman, 2000). For example, unequal gender norms can expose women to higher risks of
STDs. The recent increase in HIV prevalence among married women in Cambodia is related
to husbands’ refusal to use protection in marital relationships while extramarital sex is a
common practice among those married men. (Wang, 2004).
These elements of social capital can affect human capacities, both physical,
emotional, and intellectual, and human capital also impacts social capital. (Brehm and Rahn,
1997). The bi-directional pathway between social capital and exclusion has implications on
health. On the macro-level, the underlying factors of the deficit of social capital are
multiple social forces, among which social and political context factors, such as globalization,
labor markets and organizations, economic pressures, and organizational links, have the most
impact. These forces at the macro level impact job stability, food security, migration patterns,
land ownership and related issues that expose certain populations to major health risks. (See
Berkman, and Glass, 2000; Granoveter, 1973; Marsden and Friedkin, 1994; Morris, 1994).
Exclusion from social capital affects health inequities through the pathways of lacking
"support, social influence, social engagement, access to jobs and material resources, access
to health resources." (Baum, and Ziersch, 2003, p. 323). These pathways then exert direct
consequences on physical and mental health, such as exclusion from health systems,
elevated risks to physiological stress and responses, vulnerabilities to health-damaging
behaviors (such as substance addiction), problems with medical adherence, and exposure to
infectious diseases, such as HIV and STDs.
A large number of studies in social epidemiology have investigated the relationship
between social support and health outcomes. World Bank reports specifically pointed out
that social capital can be an effective tool for poverty reduction. (2004 World Bank report.
http://www1.worldbank.org/prem/poverty/scapital/home.htm) (See for example Macinko &
Starfield, 2001; Kawachi & Berkman, 2000; Narayan 1999; Kahssay, Oakley 1999; World
Bank Social Capital. http://www.worldbank.orq/povertY/scapital/index.html; World Health
Organization. The Ottawa Charter for Health Promotion, Health Promotion 1986; 1 :i-iv.; Baum,
2002; Cox; 1997; Muntaner, 2000; Ziersch, 2002. Campbell, 1999. Macintyre & Eliaway.
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2000; Baum 2002;; Cattell, 2001; Ashton & Alvarez-Dardet; 2003; Alvarez-Dardet & Ruiz,
2004; Berkman & Kawachi, 2000; Lynch, Due, Muntaner, & Davey Smith, 2000; Muntaner,
Lynch, Davey Smith, 2000; Lynch, 2000; Kawachi & Berkman, 2000; Kawachi. Kennedy,
Lochner, 1997; Kawachi, Kennedy, & Glass, 1999; Wilkinson, 1996; House J, Landis &
Umberson, 1988; Wilkinson, 1999; Wilkinson R. 1997; Lynch et al., 2001; Ross 2000;
Brodsky, 1996; Daniels, Kennedy, Kawachi, 2000; Davey Smith, Frankel, & Ebrahim,
2000). These studies demonstrate that social support is central for improving population
health. Similar conclusions were derived from reports by inter-governmental agencies,
governments, or NGOs. For example, ‘Health Survey for England, 2000, found "... a strong
relationship between perceived social support and mental health .. . Among men, those with
some lack of perceived support were 1.53 times as likely to report poor health as men with no
lack of support.” (Baum and Ziersch, 2003). 1. Most of these studies focused on developed
societies. 2. There lacked consistent and rigorous evaluation of programs that have
strengthened social capital and have generate positive health outcomes. 3. Even fewer
studies examined these issues in developing countries or that focused on the relationship •
between social capital, excluded groups, and health outcomes in global context.
Existing Gaps: An Overall Assessment
• Most of the existing research on social exclusion and health has been conducted in
developed countries, such as United Kingdom, Australia, Canada, Sweden, and United
States. There is a lack of data examining the social exclusion and health inequities in
resource-poor populations. Additionally, even the research in developed countries has not
been systematic and did not target excluded groups specifically.
• Lack of coherent, comprehensive, and systematic research and related studies, especially
rigorous scientific studies on various dimensions of social exclusion, internal dynamic of each
dimension, and on interactions among various dimensions, and their relationship to health
inequities. Existing data examine certain excluded groups in isolation, i.e. focusing only on
one dimension or one characteristic of exclusion without taking into account inter-group and/or
intra-group differences or combined effects. E.g, when discussing health issues of
indigenous, the focus on poverty or material conditions provides only a partial picture of
causal relationships. Understanding the interaction of multiple causes is critical to our
understanding of the SD and to the search for solutions. There also needs reliable and valid
measures of various dimensions of social exclusion.
• Lack of consistent and systematic research on combined effects between structural and
intermediary determinants on health inequities, such as between exclusion dimensions,
discrimination, and working/housing conditions or access to health care.
• Lack of information on social exclusion and its links to other cross-cutting WHO themes,
such as globalization, early child development, in producing ill health.
« Lack of large-scale, comparative, population-level research examining the similarities and
differences of social exclusion in global context.
• Lack of a systematic framework of evaluation of existing programs in different dimensions
of social exclusion.
• There is little discussion on global-level, inter-sector, and public policies and interventions
in development and social sectors to link exclusion, health outcomes, and to long-term social
change. It is necessary to examine how macroeconomic policies, especially structure
adjustment and debt servicing related issues, have affected resource allocation for social
development and related health outcomes. This will point to the need to render population
health a central focus in development policies and programs at bilateral and multilateral levels.
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B. Prioritize the Associations between Social Exclusion and Health Inequities. We
have identified and prioritized associations that can be acted upon and used as the basis
upon which to outline policies and programs on social exclusion at country, regional and
global level.
Overall Commentary on Polices and Interventions. Our review of interventions shows that
there are short-term solutions for every dimension of social exclusion. Nevertheless,
sustainable solutions require coordination between policy, programs, and expenditures
commitments with an overarching goal of social reform. For example, there needs policies
that break the cycle of poverty and that utilizes the asset of the excluded and "public
expenditures and institutions that provide equitable access to education, health care, and
other social services." (See related discussions from Sheykhi, 2000).
•
•
On policy environment, interventions require a supportive “enabling environment," “fiscal
space,” “policy space" and “social space" to address social exclusion. Political will with an
internationally supported and harmonized policy platform is likely to create momentum and
viability for interventions. The work on exclusion by the European Union and Iran are
relevant cases in point. The Lisbon Strategy proposed by the European Union was
designed to generate a comprehensive policy platform to tackle social exclusion at the
systemic level. 1. It promotes a better understanding of social exclusion through
continued dialogue and exchanges of information and best practice, on the basis of
commonly agreed indicators. 2. It is integrated into existing budgetary framework at
central and local levels by mainstreaming inclusion in Member States' employment,
education and training, health and housing policies, such as through the use of Structural
Funds at the community levels. 3. It develops priority actions targeting specific groups
(for example minority groups, children, the elderly and the disabled) by Member States
with flexibility within each state due to their unique situations and circumstances.
Certainly, given the expansiveness of the framework, the effectiveness of this policy
platform remains to be seen. Nevertheless, political will at a collective, cross-national level
is necessary to generate large-scale changes. The case of Iran is relevant to this point.
Since 1990s, Iran has stepped up its integrated interventions (policies, programs, and
cultural change) in poverty alleviation, family planning, support for the elderly (with
monthly cash allowance), strengthening universal health care systems, and empowerment
of women in reproductive health issues. Similar legislative initiatives can also be found in
Quebec, Canada, Belgium, and France, which links poverty reduction to education,
employment, health, social services, and housing. (See Eliadis, and Ledue, October 7,
2003, Canada Policy Research Initiative, http://policvreearch.qc.ca/paqe.asp?
pagenm=v6n2_art_11)
On program effectiveness, integrated intervention programs are likely to break the vicious
cycle of exclusion. For example, the Bolsa program in Brazil is an effective case in point.
Bolsa Escola, which covers approximately 99% of municipalities in Brazil, aims to break
the vicious cycle of poverty and exclusion by targeting school retention through the use of
a multi-pronged strategy. The thrust of the program is to provide cash incentives for poor
families to make their children stay in school. It has the following features: 1. it is
supported from the highest levels of the government. The program was passed by the
Congress and sanctioned by President Fernando Enrique Cardoso. 2. it is extensive but
it has a clearly identified target population. 3. the policy framework coordinates with and
is supported by other legal instruments, such as the child labor law that prohibits children
to work under sixteen. 4. it has clear stipulations of enforcement criteria. 5. the
administrative, financial and regulatory responsibilities were distributed vertically and
horizontally between different levels of central and local government. 6. it has an effective
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evaluation mechanism. A Council of Social Control was established to evaluate the
program, monitor fiscal integrity and execution. The outcomes in education retention,
reduction of child labor, decrease in street children, and income increase in the poorest
population v/ere assessed. Similar initiatives include: Trogresa” in Mexico, the
“Programa de Asignacion Familiar” (PRAF) in Honduras, the "Red de Proteccion Social” in
Nicaragua, and the “Beca Escolar” in Ecuador. (World Bank. "Brazil: An assessment of
the Bolsa Escola Programs.” 2001). 7. it has a clear transparency component. To avoid
misuse of funds, the implementation personnel were prohibited to be affiliated with local
governments. 8. it has a sustainable component: Brazil government has made a
legislative commitment in fiscal allocation in educational programs. 9. It synergizes with
other programs, such as training teachers in poor areas and incentives for families to
avoid sending children to hazardous working conditions. The other program that
demonstrates the need for program integration to intervene the vicious cycle is World
Bank’s Indigenous Peoples and Afro-Ecuadorian Peoples Development Project
(PRODEPINE). It was designed to achieve the combined goals of poverty reduction,
ethnodevelopment, capacity building, and land regulation that can impact health. It has
channeled resources directly to areas in which over 50% of the population are indigenous
or Afro-Ecuadorian in South America. By 2000, it had achieved tangible success: the
grassroots organizations had gained 22,700 hectares of land; paralegals received training
in land regulation; about 2,328 students won scholarships in higher education, 77
completed intensive courses in irrigations, social conservation and agro-forestry, 500 Men
and women interned in a agro-ecology program, and 459 locally managed business
projects were approved.
The need for a “bottom-up,” "culture-sensitive” and "self-development" framework for
policy and program interventions. The aforementioned PRODEPINE program also
demonstrates that major input for effective interventions should derive from individuals
who are closest to the problems. The major goal of PRODEPINE is to improve the quality
of life of the indigenous, under which it also aims to strengthen cultural and ethnic identity,
self-determination and territoriality, and self-management. In this framework, culture is
seen as positive source of development. Unlike other Bank projects for indigenous in the
period 1992-1997, of which only half involved active consultation with the indigenous,
PRODEPINE took an "ethnodevelopment" approach and actively included the indigenous
representatives in every state of the project. It has channeled resources directly to areas
in which over 50% of the population are indigenous or Afro-Ecuadorian in South America.
These culturally sensitive measures have shown tangible positive outcomes on overall
social development, as mentioned earlier. The importance of addressing precursors of
gender inequ ty.
Our review shows that gender has cross-cutting implications. The intersection between
gender and other social determinants suggests that interventions should target those
precursors of gender inequity, such as poverty and education, to generate gender-related
solutions. One possible model is to integrate gender components in existing successful
education-centered programs, such as Bolsa Escola.
Use existing social capital in the communities through forming a wide range of coalition,
including public-private partnership. The experiences of tackling the care of HIV/AIDS
patients in Thailand and Cambodia showed that communities and social networks can play
an important role in providing care in areas in which local governments are inadequate.
(Wang, 2004; Interviews with personnel at CARE, Cambodia, such as Masaya Kato,
project manager, 2004, Cambodia.) In Thailand, local communities, who worked with
Buddhist organizations and NGOs, shared the care of HIV/AIDS infected and affected. In
Cambodia, the orphans of the HIV infected have been cared for by NGOs, such as CARE,
Family Health International, faith-based organizations, etc., and the communities. The
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Islington Project in Britain illustrated the possibility to use public-private partnership to
address social development goals of improving poverty, education, housing, etc. (See
Power and Wilson, February, 2000). Thus, it is important to support the strengthening of
social networks in macroeconomic development policies as well as to correct those
macroeconomic measures that have contributed to the deficit of social capital.
In specific: There exists programs that can be modified or scaled up at global, regional,
country, and community levels. (See Appendix A for a more detailed list of programs).
Education.
1. Existing global initiatives that can be modified by integrating health-related goals include:
UNESCO’s Education for All Campaign and related Fast Track Initiatives, Dakar Framework
for Action, WHO Global Education initiative, Effort to implement Millennium Development
Goals 1-7, Global Campaign for Education, ICTs for Educational Capacity Building, micro
banking and micro-lending programs, Global Fund financed programs, World Bank's poverty
reduction strategy programs, Global Fund for AIDS, TB and Malaria, G-8's African initiative.
2. Government initiatives that have used a comprehensive framework of intervention and that
have shown some effectiveness: Mexico's Programs de Education, Salud y Alimentation
(PROGRESA), Bolsa Escola Programme of Brazil, the Balochistan Primary Education Project
in Pakistan, Food for Education in Bangladesh, Red de Protection Social (cash incentives for
poor households), PACES vouchers program for the urban poor, BESO universal education
program in Ethiopia, elimination of school fees in Uganda, school waivers for girls in Malawi.
Mexico’s Telesecundaria is an innovate TV education program that specivically aims to reach
excluded population in the remote areas. 3. Programs by NGOs: programs that have a
specific focus, such as ActionAid International's “Reflect" program to address adult literacy or
programs that have a comprehensive nature, such as BRAC in Bangladesh that combines
income generation and women’s empowerment. 4. Comprehensive programs by
intergovernmental agencies: The World Bank's Project Population et Lutte contre le SIDA
(PPLS) develops a comprehensive information, education, and communication (IEC) strategy
and campaign to address HIV/AIDS and other reproductive health issues.
Major policy and program implications:
•Access to affordable education in school-based programs; retention of children of excluded
populations in basic education. "Quality and quantity of education deemed sufficient for
positive health outcomes. ’Gender and health-sensitive education. ‘Education and health
education for excluded illiterate adults. ‘Use of language in schools for culturally and
linguistically diverse children. ‘Using schools as health centers for socially excluded.
•Educational opportunities or health education in the refugee camps or trafficked victims.
•Diversity education for health professionals emphasizing dignity and respect for culturally
diverse and excluded groups. ‘Promoting access to education through innovative information
technology and bridging digital divide. -Policies for inclusion in institutions of higher learning.
Gender
1. global initiatives: UN Girls Education Initiative, 25x2005-Accelerating Progress in Girls
Education Initiative; Girls Education Movement in Africa. 2. Government programs to support
education for girls: Pakistan’s Balochistan’s Primary Education Program (to increase girl’s
enrollment), Food for Education in Bangladesh (support poor girls), African Girls Education
Initiative, District Primary Education Program in India (gender equity). 3. programs by
intergovernmental agencies: WHO’s “Safe Motherhood" and “Family Planning." 4. NGOs:
Women’s Agenda for Change by Oxfam to support health of the commercial sex workers,
Botswana’s Diphalana Initiative to keep pregnant girls in schools. Couples in the Know
Program by CARE, Cambodia, (focusing on education on sexually transmitted infections, HIV
transmission and self-protection, reproductive health, domestic violence, sexuality,
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discrimination against HIV as a social stigma, care and support, alcohol and drug use), antiFGM campaign in Burkina Faso, the educational project in Cote d'Ivoire, CEDPA, CEOSS
Projects in Egypt, CPTAFE in Guinea, Project Video in Guinea, MVWO in Kenya, similar
projects in Nigeria, Senegal, Tanzania, Uganda, etc.
Major policy and program implications:
• Enrollment and retention of girls, -child labor and exclusion. -Prevention and intervention
in exclusion of socially marginalized men. -Health literacy, nutrition education and school
meals for excluded girls and poor pregnant women. -Prenatal health education that also
involves men for excluded pregnant women. -Prevention and intervention on violence
against women. Involving men in gender education issues. -Employable skills and
protection of rights for excluded men and women, -increasing network support for the
excluded women and men.
Poverty
1. global: Global effort to improve MDGs 1-8, The Heavily Indebted Poor Countries Initiative
(HIPC) has to date provided $31 billion in debt reduction to 27 countries pursuing economic
reform programs, 23 of them in Africa, G-8 Africa poverty reduction initiative, micro-banking
and micro-lending programs. Current negotiations of NGOs with World Trade Organization
that addresses poverty and improving health access for the poor. UK Prime Minister’s
Commission for Africa initiative and related development efforts. 2. government-initiated
programs: Haiti’s National Council for Popular Finance to give credit to small farms. China’s
anti-poverty campaign. 3. programs by inter-governmental agencies: World Bank’s PRSP
programs. 4. programs by NGOs: the International Labor Organization’s programs to
promote non-discriminatory employment policies with regard to HIV status and programs in
the work place. On-the-Job HIV/AIDS program by Family Health International. BRAG on
micro-financing in Bangladesh.
Major policy and program implications:
•Addressing macro and micro issues of poverty and health through education and
employment. -Provide channels and networks of employment information for the excluded
through creative means of communication. -Provide incentives for employers and
governments to recruit and retain the excluded. -Provide information and regulation on
occupational health and safe work environment (e.g., use gloves and masks in pesticiderelated field work) -Provide rights protection for the health of the excluded. -Assessing
existing resources in public and private sectors in meeting the needs of the excluded to
address inadequacy and redundancy. -Generating global platform to protect the economic
means of the excluded, e.g. through the commitment of G8 leaders. -Use employment as a
conduit for access to health care system and for improving health literacy (prevention and
intervention), such as through job-based health insurance; integrating health education into
employment training; using employment network as a conduit to transmit health information
and provide network support. -Upgrade transportation for the excluded to access health care
in urban dwellings and in rural areas.
Marginalization
Given the complexity of marginalization, tackling this dimension of social exclusion is
challenging but it deserves most attention and effort. The groups that will benefit from
immediate action: abandoned children, displaced populations (such as refugees and
trafficked populations), diverse linguistic and cultural groups (such as the indigenous),
disabled, and individuals with stigmatized diseases and their children. (We will possibly work
with other networks to address the urban neglected populations, such as the street people
and slum dwellers).
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discrimination against HIV as a social stigma, care and support, alcohol and drug use), antiFGM campaign in Burkina Faso, the educational project in Cote d'Ivoire, CEDPA, CEOSS
Projects in Egypt, CPTAFE in Guinea, Project Video in Guinea, MYWO in Kenya, similar
projects in Nigeria, Senegal, Tanzania, Uganda, etc.
Major policy and program implications:
• Enrollment and retention of girls. ’child labor and exclusion. 'Prevention and intervention
in exclusion of socially marginalized men. ’Health literacy, nutrition education and school
meals for excluded girls and poor pregnant women. ’Prenatal health education that also
involves men for excluded pregnant women. ’Prevention and intervention on violence
against women. Involving men in gender education issues. ’Employable skills and
protection of rights for excluded men and women, -increasing network support for the
excluded women and men.
Poverty
1. global: Global effort to improve MDGs 1-8, The Heavily Indebted Poor Countries Initiative
(HIPC) has to date provided $31 billion in debt reduction to 27 countries pursuing economic
reform programs, 23 of them in Africa, G-8 Africa poverty reduction initiative, micro-banking
and micro-lending programs. Current negotiations of NGOs with World Trade Organization
that addresses poverty and improving health access for the poor. UK Prime Minister's
Commission for Africa initiative and related development efforts. 2. government-initiated
programs: Haiti’s National Council for Popular Finance to give credit to small farms. China’s
anti-poverty campaign. 3. programs by inter-governmental agencies: World Bank’s PRSP
programs. 4. programs by NGOs: the International Labor Organization’s programs to
promote non-discriminatory employment policies with regard to HIV status and programs in
the work place. On-the-Job HIV/AIDS program by Family Health International. BRAG on
micro-financing in Bangladesh.
Major policy and program implications:
•Addressing macro and micro issues of poverty and health through education and
employment. ’Provide channels and networks of employment information for the excluded
through creative means of communication. ’Provide incentives for employers and
governments to recruit and retain the excluded. -Provide information and regulation on
occupational health and safe work environment (e.g., use gloves and masks in pesticiderelated field work) -Provide rights protection for the health of the excluded. -Assessing
existing resources in public and private sectors in meeting the needs of the excluded to
address inadequacy and redundancy. ’Generating global platform to protect the economic
means of the excluded, e.g. through the commitment of G8 leaders. -Use employment as a
conduit for access to health care system and for improving health literacy (prevention and
intervention), such as through job-based health insurance; integrating health education into
employment training; using employment network as a conduit to transmit health information
and provide network support. -Upgrade transportation for the excluded to access health care
in urban dwellings and in rural areas.
Marginalization
Given the complexity of marginalization, tackling this dimension of social exclusion is
challenging but it deserves most attention and effort. The groups that will benefit from
immediate action: abandoned children, displaced populations (such as refugees and
trafficked populations), diverse linguistic and cultural groups (such as the indigenous),
disabled, and individuals with stigmatized diseases and their children. (We will possibly work
with other networks to address the urban neglected populations, such as the street people
and slum dwellers).
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1. global level: ICTs Intercultural Dialogue and Diversity project,’for indigenous peoples, UN
Habitat’s Housing Policy and Development Section, its Housing Rights Programme, and its
Global Campaign for Secure Tenure, addressing homelessness, land, and urban-related
exclusion. United Nations High Commission for Refugees’ Evaluation and Policy Analysis
Unit, addressing, via analysis, the welfare of displaced people. UN's Economic and Social
Council's (ECOSOC) Permanent Forum on Indigenous Issues and its Commission on Social
Development. International Disability and Development Consortium and International
Association of Homes and Services for the Ageing (IAHSA) which have a global reach and
address concerns of specific excluded populations. Nev/ Partnership for Africa’s Development
(NEPAD) priority area of health. 2. programs by intergovernmental agencies: Indigenous
Knowledge Program by World Bank. 3. programs by NGOs: . “No Home too Far” program
by PATH help isolated Cambodian migrants in Thailand to maintain close communications
with homes to avoid risky situations and behaviors, (maintain a social support system by
mail). YouthBuild, based in the US, is an innovative, comprehensive program that integrates
school, work, social action, leadership development, and personal transformation. The
program targets unemployed, socially-excluded youth who build houses for homeless and
low-income families, while studying to complete secondary school, and learning
empowerment and leadership skills. Work by International Rescue Committee (providing
health education and services for the refugees in Congo) supported by UN High
Commissioner for the Refugees,
Major Policy and Program Implications:
•Promote communication with and understanding of the marginalized groups and of their
health needs in schools. -Promote egalitarian legislations, such as in addressing the health
needs, Title VII of the Federal Civil Rights Act in the US, and communication, such as anti
discrimination messages in the media, and representation in the media and social discourse.
•Establish and strengthen the community associations, such as through civil societies/NGOs,
to serve the health needs of the marginalized. -Provide access to linguistically and culturally
sensitive materials in social and health settings. -Find creative means of communication,
such as through mobile clinics and theatres, to promote health literacy and access to health
care for the geographically isolated. -Equip the health professionals with intercultural
communication skills to interact with the marginalized. And integrate culturally appropriate
care for the marginalized.
Elements of Social capital. Social capital, such as the health and education services
provided by civil societies or institutions, can provide most cost-effectiveness means of
addressing the health needs of the excluded. This is also the area that integration of effort
within multiple sectors can make the largest difference in the short term.
Most of the programs are supported by national governments or NGOs: 1. Humana
People to People in Soweto, South Africa, door-to-door effort to reach the excluded about HIV
health literacy. Similar programs “Door-to-Door Outreach” in Brazil. Mobile Counseling
Services in India. “Magnet Theatre" by PATH: a regular interactive theatre program that
communicates sensitive issues about HIV in Kenya. “Community theatre in Benin” on family
and reproductive health by PATH. Home Care Program for People with HIV/AIDS in
Cambodia
2. government-initiated programs: In UK, the Social Exclusion Unit generated the innovative
project “time bank," a co-operation project where the sick, elderly and other excluded groups
support each other’s daily needs. 3. inter-governmental agencies have a potential to further
strengthen social capital, through such initiative as the Healthy Cities by UN-Habitat.
Major Policy and Program Implications:
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23
•Interventions in causes for the deficit of social capital. -Interventions in the negative elements
of social capital, such as the bonding capital that causes “honor killing’’ in Pakistan.
■Rights protection and social interventions on the network needs of the excluded. -Health
needs assessment of the excluded. -Evaluation on the effectiveness of current social support
programs. -Assessing resources allocation to serve the health needs of the excluded.
-Integrate and coordinate different social support services among inter-governmental, national
and local agencies and among public and private sectors.
Religion
Religion itself has multiple interactions to social exclusion. Applied properly, religious
connections can be a potential positive public health tool to address the health needs of the
excluded. According to Walkup, (See Walkup, 2004), faith-based organizations fund and
provide much of the 40% of health services in developing countries not provided by national
governments. Faith-based health organizations often serve the most needy, most vulnerable,
and hardest-to-reach populations (due to geography, social and political unrest, etc.) in the
developing world. In some cases, governments actively have enlisted the support of religious
organizations to address HIV, such as in Uganda and Thailand. In specific,
• The AGP in Uganda, a multisectoral program enlisting the support of religious leaders to
address HIV.
° The use of Buddhist temples as community centers for the care of HIV infected.
= SANRU, Public-private partnership by faith-based organizations and government to
ensure access to health services in the former Zaire.
« CORE initiative by USAID to fund faith-based programs for HIV/AIDS, including African
Network of Religious Leaders, American Jewish World Service [AJWS] (Kenya), Asia
Network of People Living with HIV/AIDS, Catholic Relief Services [CRS] (Global),
Church World Service (Armenia, India, Indonesia, and Sierra Leone), Christian
Conference of Asia [CCA] (Asia-wide), Ecumenical Advocacy Alliance (Global), Global
Network of People Living with HIV/AIDS (GNP+) (Globai), International Community of
Women Living with HIV/AIDS (Southern and East Africa), Islamic Relief (Global),
Adventist Health International (AHI), Lott Carey International (Uganda), Lutheran World
Relief [LWR] (East and West Africa), The Organization of African Instituted Churches
[OAIC] (Kenya and Uganda), Pan-African Christian AIDS Network [PACANet] (Africa
wide), Ponleur Komar (Cambodia), Positive Muslims (South Africa), Samaritan's Purse
(Mozambique), Women's AIDS Run (Africa-wide), World Alliance of YMCAs/World
YWCA (Sierra Leone and Angola), World Conference of Religions for Peace (Africa
wide). Sangha Metta Project, a program in which Buddhist monks offering care and
spiritual help for the sick.
Major policy and program implications:
•Interventions on the negative aspects of religion that can affect the health of the excluded.
•Use religious networks to reach the excluded populations and increase their access to health
care. -Integrate religious resources to increase education and strengthen social capital for the
excluded. -Use religious teachings as guidance for positive inter-group communication and
health. -Use religious opinion leadership to promote public health prevention and intervention.
C. Inventory of Operationalization Framework, key stakeholders who are researching,
implementing and evaluating interventions and policies on social exclusion in the government,
academe, inter-governmental agencies, and in the field. (Please see Appendix B for the list)
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Priority
111.
Areas of Social Exclusion Work for 2005-06
A. Mapping the framework for a knowledge network: 1. guided and assisted by the CSDH,
we will identify the stakeholders. 2. based on existing international academic collaborations
between USP, and other stakeholders, such as CUBES/UNESCO, Innovation Philadelphia,
we will examine the potential contribution of our partners in South Africa, Cambodia, and Haiti
to the knowledge network. As whole, we will generate an exhaustive inventory of all
stakeholders who conduct research, and implement policies and programs in addressing
issues related to social exclusion and health outcomes. These are
actors/participants/stakeholders who have already demonstrated expertise in examining and
generating solutions to issues related to social exclusions and health.
B.
Establish operational mechanisms for data collection:
•
Identify work priorities. We will follow the Commission’s guidance to set up a task agenda.
We will make every attempt to engage in broad-based consultations to generate
knowledge that vertically, integrate actions at local, national, and international levels to
increase social participation, community support, and policy interventions.
Set up a communication framework and Initiate communication with potential
collaborators.
Obtain agreements from potential collaborators to include their data in the knowledge
networks and establish framework for assigning work and communicating, monitoring, and
receiving research output.
Set up collaboration mechanisms for data collection: propose joint research proposals,
assistance to leverage fundraising to private and public foundations, assisting policy
analyses and program evaluations (such as for community organizations, country
agencies, and inter-governmental agencies), assistance in information/
communication/technology management and support, and possible support for program
implementation.
Plan meeting schedules: At least 3 KN in-person meetings will be held in Haiti,
Philadelphia and possibly a third member site (depending on geographic distribution of
members) over the duration of this project.
•
•
•
•
C.
Data analysis:
Assess and evaluate evidence based on criteria established by WHO experts. Based on
WHO criteria, we will generate a comprehensive evaluation and assessment protocol to be
applied to the analysis of scientific evidence, existing programs, and policies.
• Synthesize and identify results that can be generalized in universal contexts vs. results
that have specific country implications.
• Identify knowledge gaps that need systematic, consistent, and long-term effort to fill at
multi-level and multi-sector effort.
• Produce recommendations that link scientific evidence, program implementation and
policy actions. Particular attention will be paid to generating a global policy platform to
address social exclusion and health inequities that take into account the differences in
individual countries' contexts and experiences at a multi-level, stakeholder-inclusive,
culturally sensitive, collaborative, cross-sector effort.
Example of Policy and Program Mapping:
1 Address health needs of socially excluded.
2 Integrate population health objectives into macroeconomic policy and development
programs to create a “fiscal space” and "policy space” to address health inequities.
Relevant to this point is the need of dialogue and collaboration among all stakeholders at
•
24
25
3
4
5
6
the multi-levels, such as between World Bank, IMF, and WHO or among governments,
civil societies, WHO, and other UN agencies.
Integrate health in social programs in education, gender skills, anti-stigma, anti
discrimination.
Increase social network capacities to address the health needs of the excluded by
strengthening the collaboration between the public and private sectors.
Incorporate health services into social services for the excluded.
Increasing rights protection for the excluded in social space, health care system, work
place, and community activities.
D. Communication mechanisms:
» Internal and external Communication: 1. We will regularly report to the Commission about
all issues governing the operation, data collection and dissemination, coordination,
administration and communication issues. 2. We will communicate with other knowledge
networks through an internal WHO-established framework, including CSDH's Share Point
website. 3. There will be continuous telephone contact and conferences between the two
co-hubs and respective KN members. Between members, the primary mode of
communication will be via internet and email as well as through CSDH’s Share Point
website, depending on member-site technological capability. 4. Externally, we will set up
a central communication command, such as through a web site that serves as a major
venue for external communication for information on social exclusion and health inequities.
» Disseminate research results: With the guidance of the Commission, 1. we will regularly
communicate our results to other KNs, major stakeholders among NGOs/civil societies,
local and country governments, inter-governmental agencies, etc, in the form of research
summaries or newsletters. 2. We will initiate consultations and meetings with members In
the network and we will convene conferences for stakeholders and outside interested
parties. Through the access channels of the CSDH, our work and corresponding results
will reach the following global agencies. If permitted, we will publicize our results in all
major community, regional, global health meetings, academic publications, and other
leadership summits where our information can be of utility to global leaders and policy
makers. These include: 1. Global, Intergovernmental, regional, country-level
development-related (e.g., poverty, gender skills, employment, etc.) meetings. 2.
specialized meetings in health at global, regional, and country levels. These may include
but are not limited to: UN meetings, G-8, APEC, African, WTO conferences, World Health
Assembly, WHO regional consultation meetings, international AIDS Conference, People's
Health Assembly, Global Leaders Forum, World Conference on Health Promotion and
Health Education, etc.
E.
Establish a framework for sustainable solutions to social exclusion and health
inequities in data collection and global action:
Overall: In the long-term, and after the work and mandate of the CSDH have expired, it is
hoped that these contacts and the established Network on social exclusion could continue to
serve as a clearing house, research partnership and knowledge pool from which the global
community can draw. The hub-leaders in Philadelphia and Haiti will:
• Establishing a central network of data collection, policy planning, program
implementation and community action on health conseguences of social exclusion
in the long term.
• Linking private and public effort in allocating the resources to address the health
impact of social exclusion.
• Implementing a comprehensive monitoring and evaluation system on the policy
interventions and program outcomes.
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Appendix A
A list of References of Intervention Programs to Dimensions of
Social Exclusion
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Education: Useful references:
Global initiatives: UNESCO’s Education for All Campaign and related Fast Track
Initiatives, Dakar Framework for Action, WHO Global Education initiative, Effort to
implement Millennium Development Goals 1-7, Global Campaign for Education, UNICEF's
education programs in Iran and China, ICTs for Educational Capacity Building, micro
banking and micro-lending programs, Global Fund financed programs, World Bank’s
poverty reduction strategy programs, its disease-specific programs like the Bank’s multi
country AIDS program and its socn to be launched global strategy for malaria, several
bilateral poverty reduction programs, Global Fund for AIDS, TB and Malaria, G-8’s African
initiative.
• Mexico’s Programa de Educacion, Salud y Alimentacion (PROGRESA), Bolsa Escola
Programme of Brazil, the Balochistan Primary Education Project in Pakistan, Food for
Education in Bangladesh, Red de Proteccion Social (cash incentives for poor households),
PRAF household allowance program in Honduras, PACES vouchers program for the
urban poor, BESO universal education program in Ethiopia, elimination of school fees in
Uganda, school waivers for girls in Malawi, and free universal primary education in lowincome in Kenya.
o Improving educational quality: Government initiatives: SIMCE in Chile (also “Extension
Jornada Escola,’’ i.e., Full School Day Initiative in Chile), Money Straight to School
program in Brazil,
o Successful models to support families in retaining children in schools by governements:
the experiences of Mexico’s Programa de Educacion, Salud y Alimentacion
(PROGRESA), Bolsa Escola Programme of Brazil, the Balochistan Primary Education
Project in Pakistan, Food for Education in Bangladesh, Red de Proteccion Social (cash
incentives for poor households), PRAF household allowance program in Honduras,
PACES vouchers program for the urban poor, BESO universal education program in
Ethiopia, elimination of school fees in Uganda, school waivers for girls in Malawi.
• Integrate health in education: Primary School De-worming Program in Kenya, PIDI
Integrated Child Development Project (nutrition, health, and education), Integrated Early
Childhood Development in Eriterea, School meals program in Kenya, Sesame Street Goes
to Egypt (including health, education and gender skills). LoveLife, South Africa's largest
national HIV prevention initiative, is a bold and ambitious attempt to reduce HIV infection
among South African adolescents by promoting sexual health and healthy futures for
young people.
« Comprehensive approach: The World Bank’s Project Population et Lutte contre le SIDA
(PPLS) develops a comprehensive information, education, and communication (IEC)
strategy and campaign to address HIV/AIDS and other reproductive health issues. The
President of Burkina Faso launched a multimedia adolescent health campaign, including a
rural radio program, radio drama series, radio and television s;pots, pamphlets, posters, a
comic-style booklet, two dramas, and youth-friendly training for service providers that
disseminated HIV/AIDS messages. Other similar programs (mainly by NGOs): “Journey
for Life’’ in Ethiopia, "Stop AIDS, Love Life" in Ghana, PRISM Project in Guinea, youth
lifestyle radio show in Namibia, mass communication campaigns in Nigeria, KUBA (Life
Force) campaign in Rwanda, Maternal Health/Family Planning Project in Senegal,
HIV/AIDS campaign in Sierra Leone, Lifeline in South Africa, Behavior Change
Communication Program in Tanzania, Then Zambia Integrated Health Package
Communication and Community Partnership (ZIHPCOMM) program with CARE,
AFRIcare, and Manoff Group with HEART Campaign in Zambia, Sports for Life (promoting
positive health behaviors in reproductive health and prevention by youth leaders), and
•
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•
•
•
Sante Faimilale et Prevention du SIDA (SFPS), a regional practice involving Ivory Coast,
Cameroon, Togo, Burkina Faso, Mauritania, and Niger.
On bridging technological divide, Telesecundaria (Mexico), Telecurso (Brazil), Enlaces
(Chile), and SHOMA for rural and urban students (South Africa)
To support excluded children (children who have dropped out or have never been in
school), COBET in Tananzia, COPE in Uganda (finishing 5 grades in 3 years), EDUCO in
El Salvador (provide household incentives for children in remote area), BRAC to support
children in rural areas in Bangladesh, Nueva Escuela Unitaria in Guatemala (innovative
program to support children in rural areas).
To support adult literacy: ActionAid International’s "Reflect” program.
Gender
Useful references:
UN Girls Education Initiative, 25x2005-Accelerating Progress in Girls Education Initiative;
Girls Education Movement in Africa.
• Local programs to support education for girls: Pakistan’s Balochistan’s Primary Education
Program (to increase girl’s enrollment), Food for Education in Bangladesh (support poor
girls), African Girls Education Initiative, projects in Kavango, Namibia to increase girls'
enrollment, Hamlet Girls' Schools Project in Yemen, District Primary Education Program in
India (gender equity)
• Integrating health in education: Initial Education in Mexico (teaching mothers about childrearing practices); Gendering Adolescent AIDS Project in South Africa. “Safe Motherhood”
and “Family Planning” programs by WHO.
• Addressing excluded women: Schools for pregnant women in Bosnia and Herzegovina,
Women’s Agenda for Change by Oxfam to support health of the commercial sex workers,
Botswana's Diphalana Initiative to keep pregnant girls in schools.
• Gender skills, health, and communication: Couples in the Know Program by CARE,
Cambodia, (including education on sexually transmitted infections, HIV transmission and
self-protection, reproductive health, domestic violence, sexuality, discrimination against
HIV as a social stigma, care and support, alcohol and drug use); Sesame Street Goes to
Egypt (including health, education and gender skills).The African Women's Media Center
Program, with special emphasis on reporting on HIV/AIDS in African and women.
“Community theatre in Benin” on family and reproductive health by PATH and China’s
adolescent health program by PATH on gender and health literacy. Entre Amigas by
PATH in Nicaragua on gender and health, targeting women in poor areas.
Other programs that have a special emphasis, such as female genital mutilation: anti-FGM
campaign in Burkina Faso, the educational project in Cote d'Ivoire, CEDPA, CEOSS Projects
in Egypt, CPTAFE in Guinea, Project Video in Guinea, MYWO in Kenya, similar projects in
Nigeria, Senegal, Tanzania, Uganda, etc.
•
Poverty
Useful references:
• Global: Global effort to improve MDGs 1-8, The Heavily Indebted Poor Countries Initiative
(HIPC) has to date provided $31 billion in debt reduction to 27 countries pursuing
economic reform programs, 23 of them in Africa, G-8 Africa poverty reduction initiative,
micro-banking and micro-lending programs. Current negotiations of NGOs with World
Trade Organization that addresses poverty and improving health access for the poor. UK
Prime Minister’s Commission for Africa initiative and related development efforts, Global
Business coalition of companies against HIV/AIDS (a model for British Petroleum’s on-thejob HIV/AIDS program), Poverty Reduction Strategy Program (PRSP) by World Bank,
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•
•
Global Coalition for AIDS, the Global Fund’s co-investment programs, the International
Labor Organization's programs to promote non-discriminatory employment policies with
regard to HiV status and programs in the work place.
Specific programs: European-Haiti Coordination Network and the National Council for
Popular Finance in Haiti, On-the-Job HIV/AIDS program by Family Health international,
Haiti’s National Council for Popular Finance to give credit to small farms.
Notable examples to address poverty and exclusion: The World Bank’s Indigenous and
Afro-Ecuadorian Peoples Development Project (PRODEPINE) channels resources directly
to areas in which over 50% of the population are indigenous or Afro-Ecuadorian. By 2000,
it had achieved tangible success in land acquisition, regulation, access to education,
conservation, employment and business opportunities, etc. The other: World Bank's
Indigenous Capacity-Building Program. It helps locals indigenous groups to identify
needs, prioritize development goals, and maximize their own resources. Indigenous
peoples design most of each country's program. Several capacity building projects focus
on conservation by Afro-Latin communities. For example, Sustainable Development of
Belize River Valley Communities provided 3 communities with training in natural resource
management, ecotourism and organizational skills in the Pacific Coast region of Colombia.
Marginalization
Useful references:
• Special-emphasis projects: Work by International Rescue Committee (providing health
education and services for the refugees in Congo) supported by UN High Commissioner
for the Refugees. Indigenous Knowledge Program by World Bank, Incorporating
indigenous knowledge (IK), customs, and values into projects. "No Home too Far" program
by PATH help isolated Cambodian migrants in Thailand to maintain close communications
with homes to avoid risky situations and behaviors, (maintain a social support system by
mail). MOST (Management of Social Transformations program) and Social Exclusion and
Integration Best Practice cases. YouthBuild, based in the US, is a comprehensive
program that integrates school, work, social action, leadership development, and personal
transformation. The program targets unemployed, socially-excluded youth who build
houses for homeless and low-income families, while studying to complete secondary
school, and learning empowerment and leadership skills. Croatian Association for HIV
sponsored programs that focused on anti-discrimination in HIV campaigns.
•
Global effort: ICTs Intercultural Dialogue and Diversity project,’ for indigenous peoples,
UN Habitat’s Housing Policy and Development Section, its Housing Rights Programme,
and its Global Campaign for Secure Tenure, addressing homelessness, land, and urbanrelated exclusion. United Nations High Commission for Refugees’ Evaluation and Policy
Analysis Unit, addressing, via analysis, the welfare of displaced people. UN's Economic
and Social Council’s (ECOSOC) Permanent Forum on Indigenous Issues and its
Commission on Social Development, international Disability and Development Consortium
and International Association of Homes and Services for the Ageing (IAHSA) which have a
global reach and address concerns of specific excluded populations. New Partnership for
Africa’s Development (NEPAD) priority area of health.
Social Capital
Some useful references:
• In UK, the Social Exclusion Unit generated the innovative project "time bank,"
a co-operation project where the sick, elderly and other excluded groups
support each other's daily needs.
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•
•
•
•
»
•
•
•
•
•
•
Humana People to People in Soweto, South Africa, door-to-door effort to reach
the excluded about HIV health literacy. Similar programs "Door-to-Door
Outreach” in Brazil. Mobile Counseling Services in India.
“Magnet Theatre” by PATH: a regular interactive theatre program that
communicates sensitive issues about HIV in Kenya.
LINC (US), a program that sets up a virtual world of health literacy, that can be
modified in different community contexts.
MAYA community ownership in education in India, a program that involves
community to promote youth awareness.
“Community theatre in Benin” on family and reproductive health by PATH.
Home Care Programme for People with HIV/AIDS in Cambodia.
Projects by Community Arts Networks that can include health messages in art.
Rural Advancement committee in Bangladesh support village workers to
implement programs. And Women's microfinance program in Bangladesh
supports women to be self-reliant.
Aga Khan Rural Support Program facilitates villagers to strengthen networks.
Center for Social and Economic Development in Bolivia supports economic
building and community solidarity.
Orangi Pilot Project in Pakistan supports poor settlers to implement community
projects.
Religion
Useful references:
• The ACP in Uganda, a multisectoral program enlisting the support of religious leaders.
• The use of Buddhist temples as community centers for the care of HIV infected.
• SANRU, Puolic-private partnership by faith-based organizations and government to
ensure access to health services in the former Zaire.
• CORE initiative by USAID to fund faith-based programs for HIV/AIDS, including African
Network of Religious Leaders, American Jewish World Service [AJWS] (Kenya), Asia
Network of People Living with HIV/AIDS, Catholic Relief Services [CRS] (Global),
Church World Service (Armenia, India, Indonesia, and Sierra Leone), Christian
Conference of Asia [CCA] (Asia-wide), Ecumenical Advocacy Alliance (Global), Global
Network of People Living with HIV/AIDS (GNP+) (Global), International Community of
Women Living with HIV/AIDS (Southern and East Africa), Islamic Relief (Global),
Adventist Health International (AHI), Lott Carey International (Uganda), Lutheran World
Relief [LWR] (East and West Africa), The Organization of African Instituted Churches
[OAIC] (Kenya and Uganda), Pan-African Christian AIDS Network [PACANet] (Africa
wide), Ponleur Komar (Cambodia), Positive Muslims (South Africa), Samaritan's Purse
(Mozambique), Women's AIDS Run (Africa-wide), World Alliance of YMCAs/World
YWCA (Sierra Leone and Angola), World Conference of Religions for Peace (Africa
wide). Sangha Metta Project, a program in which Buddhist monks offering care and
spiritual help for the sick.
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Appendix B
inventory' of Operationalization Framework
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Individuals.
Experts recommended by the Commission of Social Determinants of Health.
Dr. Sulamis Dain, Professor of Economics, Institute of Social Medicine, State University of
Rio de Janeiro.
Dr. Pascual Gerstenfeld, Division of Statistics and Economic Projection, Economic
Commission for Latin America and Caribbean Region.
Dr. Daniel Lopez-Acuna. Director of Program Management. Pan American Health
Organization.
Dr. Jose Arnoldo Sermeno Lima, Direction de Integration Social, Secretaria General del
Sistema de la Integration Centroamericana (Central America)
Dr. Micky Chopra, University of Western Cape, South Africa, EQUINET.
Dr. Elisabeth Carmen Duarte, Direcora, Esplanada dos Ministerios, Ministerio Da Saude,
Secretaria de Vigilancia em Saude, Departamento de Analise de Situacao de SaudeDASIS, Brasil. (Especially the Program of Bolsa)
Dr. Rocio Rojas, MD, MPH. Technical officer, Health of the Indigenous Peoples Initiative,
Technical and Health Services delivery. PAHO.
Rodolfo Guzman Garcia, Secretario Tecnico, Coordination National, Opportunidades,
Mexico.
Dr. Elenora Dal Grande, Department of Health, Government of South Australia.
Dr. Sok Pun, CARE, Cambodia. And Masaya Kato, CARE, Cambodia.
Ms. Pry Phallay Phuong, Women’s Agenda for Change, Cambodia.
Dr. ING Kantha Phavi, Minister of Women’s Affairs, Cambodia.
Dr. Trevor Peter, Clinton Foundation. Gaborone, Bostwana.
Dr. Kaoru Ishikawa, Ambassador, Director, Multicultural Cooperation Department, Ministry
of Foreign Affairs, Japan.
Dr. Dennis Raphael, York University, Toronto, Canada.
Hua Hsu, Deputy Director, China AIDS Foundation.
• Rifqah Kahn, Bush Radio, South Africa.
• Nguyen Quynh Trang, Policy Project Vietnam.
• Rosanna Barbero, Oxfam, Cambodia.
• Martin Khor Kok Peng, Third World Network, Malaysia.
• Manuel Carballo, Executive Director, International Center for Migration and Health,
Vernier, Switzerland; Professor, Columbia University, USA.
• Pulin Nayak: School of Economics, University of Delhi.
• Pierre Chauvin, MD, Ph.D, DSc, Equipe Avenir, National Institute of Health and Medical
Research, France.
• Prof. Dave Gordon, Townsend Centre for International Poverty Research, U. of Bristol.
. Dr. Kevin O'Reilly, WHO.
• Glenys Parry and Patrice Van Cleemput, School of Health and Related Research,
University of Sheffield, UK.
• Mrs. Elaine Squires, Poverty and Social Exclusion Division, Dept, of Work and Pensions.
• Dr. Neil Williams, medical director, Safety Surveillance, Santa Fe Aventis.
• Helene Gayle, Global Health Leader. President of International AIDS Conference, 2006.
• Mr. Alberto Minujin, Senior Officer, UNICEF.
• Dr. Julie Evans, Department of Public Health, University of Oxford.
• Mr. Aranthan Jones, Senior Staffer to Congresswoman Donna Christiansen, US
Congress.
Institutions
45
46
•
•
•
•
*
•
«
•
•
•
•
»
•
»
•
•
•
•
»
•
®
•
«
•
•
•
»
•
African Medical and Research Foundation.
Cape Town Refugee Center
McGill Centre for Teaching and Research on Women, Montreal.
Department of Health, Government of South Australia.
Centre for Research on Social Inclusion: Macquarie U., Australia.
University of Bristol, UK. Townsend Centre for international Poverty Research.
Institute of Fiscal Studies. (Britain's leading independent microeconomic research
institute)
Institute of Public Policy Research. ‘Network of Gender and Development, UK.
Poverty and Social Exclusion Division, Department of Work and Pensions, UK.
Salisbury Centre for Mental Health, UK.
Social Exclusion Unit, Office cf the Deputy Prime Minister. National Assembly of Weles.
Chronic Poverty Research Centre. Ghana.
Centre for the Analysis of Social Exclusion.
The African Women's Media Center Program.
Global Health Council.
Minority Health Office, USA.
Canada's International Development Research Centre (IDRC)
Danish International Development Agency (DZ\N1DA)
Danish Refugee Council
Swedish international Development Agency
European Community Humanitarian Office (ECHO).
Academy for Educational Development.
Canadian International Development Agencies: poverty reduction projects in Asia.
US Department of State, Bureau of Population, Refugees and Migration.
World Bank Post Conflict Unit.
Children and Armed Conflict, Social Science Research Council.
Australian Housing and Urban Research Institute, Southern Research Center.
UK’s Department for International Development (DFID).
Chronic Poverty Research Centre, Centre for Policy Analysis, Accra-North, Africa
National and Local Governments: National governments: Haiti, Brazil, Honduras,
Guatemala, Mexico, Uganda, Kenya, South Africa, Nigeria, Tanzania, China, India, St. Lucia,
Cambodia. Local governments: Cape Town, Phnom Penn, Shanghai, Port-au-Prince,
Nairobi..
NGOs/Civil Societies.
»
’
Gender-related: Self-Employed Women's Association, India. UK Gender and
Development Network. Women’s Global Network for Reproductive Rights (WGNRR).
European Women’s Lobby, the International Federation of Family Planning Associations
(IPPF). Population Council (Man and Reproductive Health). International Center of
Research on Women. Women’s Agenda for Change in Phnom Penh Cambodia. Oxfam
International: education and gender diversity. UNRISD (Reproductive Issues and Social
Development), Europe.
Refugees and displaced populations: The International Committee of the Red Cross
(ICRC). United Nations Relief and Works Agency for Palestine Refugees in the Near East
(UNRWA)Medicines sans Frontiere, The International Rescue Committee. Women’s
Commission for Refugee Women and Children (supported by IRC). The Norwegian
46
47
•
•
•
•
<>
•
•
•
Refugee Council. European Council for Refugees and Exiles. The Foundation for the
Refugee Education. Amnesty International. Action contre la Faim. Interagency Network
for Education in Emergencies.
On education: Basic Education Coalition. Community Organization Development Institute
(Thailand), Education Action Aid India. World Education and World Learning (Southeast
Asia). ActionAid International with Global Campaign on Education and One World South
Asia to promote access to education.
Disability: Acting Through Ukubuyiselwa (ATU) in Johannesburg South Africa that works
with disabled, chronically-ill or violence-afflicted populations.
Cross-cutting themes: HOPE Worldwide. Social Watch. Family Health International.
AIDC (alternative information and development center) focuses on globalization,
employment, and health.
Health-specific: Regional Network for Equity in Health in Southern Africa (EQUINET).
Africa Alive: a multi-national network of nearly 100 public and private sector youth and
AIDS organizations in 6 African countries (Nigeria, Kenya, S. Africa, TAnzaiia, Uganda,
Zambia, and Zimbabwe. China AIDS Foundation: addressing excluded populations in
rural areas. Alliance. PATH.
On Children: The Coalition to Stop the Use of Child Soldier. Enfants Refugies du Monde.
Consortium for Street Children. Defense for Children International. Childwatch
International Research Network. Save the Children. Middle East Children’s Association.
Young Lives (international NGO) (addressing children’s poverty in all continents. Partners:
Center for Economic and Social Studies (CESS) India. Dept of economics of addis
Ababa, Ethiopia. Ethiopian Dev. Res. Institute, Addis Ababa, Ethiopia. General Statistical
Office, Gov. of Vietnam. Grupo De Analisis Para El Desarrollo (GRADE), Peru. Institute of
devel. Studies, U. of Sussex, UK. London School of Hygiene and Tropical Medicine, UK,
Medical Research Council of South Africa, RAU University, Johannesburg, S. A.
Research and Training Centre for Community Dev. Vietnam, Save the Children, UK, South
Bank U., UK, Statistical Services Centre, U of Reading, UK.
Faith Based organizations: American Jewish World Service, Corpus Haiti, All Africa
Council of Churches, Asia Network of People Living with HIV/AIDS, Catholic Relief
Services [CRS] (Global), International Community of Women Living with HIV/AIDS
(Southern and East Africa), Islamic Relief (Global), Lutheran World Relief [LWR] (East and
West Africa), Pan-African Christian AIDS Network [PACANet] (Africa-wide), Ponleur
Komar (Cambodia), Positive Muslims (South Africa), Samaritan's Purse (Mozambique),
World Conference of Religions for Peace (Africa-wide), AIDS Interfaith Network, Jesuit
Refugee Service, World Vision International (for the poor and oppressed); Tzu-Chi
Foundation, a Buddhist organization that supports displaced populations. FRED DE SAM
LAZARO in Thailand, Buddhists supporting the care of the sick, especially poor HIV
patients.
Anti-discrimination, egalitarian communication: Australian Anti-Racism Advocacy
Coalition. Network against Racism (ENAR) in Europe.
Other themes: Friends of the Earth: working on transport-related issues to improve
exclusion.
International Organizations
WHO's Commission of Social Determinants of Health, WHO and its regional affiliates (such as
PAHO), Special Rapporteur on the Right to Education, UN-HABITAT, Special Representative
for Children and Armed Conflict, Commission on Human Rights. UNDP, United Nations
Development Programme Post Conflict Division, UNESCO, UNFEMM, UNICEF (and its
affiliates, such as NGO Working Group on Girls), United Natipns High Commission for
47
48
Refugees, United Nations Office for the Coordination of Humanitarian Affairs, United Nations
Human Settlements Program, United Nations Development Fund for Women, UN Commission
of Social Development, United Nations Children’s Fund, World Bank, World Food Program,
G8, Asian Development Bank, African Development Bank, African Union, International Labor
Organization, and Economic Commission for Latin American and then Caribbean, USAID.
United Nations Relief for Palestine Refugees (UNRPR).
Regional Bedies. Comision Economica para America Latina y el Caribe in Latin America,
Programa de Promocion de ia Reforma Educativa in America Latina y ei Caribe, Inter
American Development Bank, African Development Bank.
Related Processes: (some were mentioned earlier)
UN-Related initiatives: WHO's Global School Health Initiative, Education for All, CUBES,
Health, Nutrition, and Population Team (HDNHE), World Bank, STEP of International Labor
Organization, UNDP, UNIFEM and UNICEF programs for aging, indigenous, youth, displaced
populations, and trafficked victims, MOST (Management of Social Transformations program),
Social Exclusion and Integration Best Practice cases, ‘ICTs Intercultural Dialogue and
Diversity project,’ “ICTs for Educational Capacity Building,” UN Girls Education Initiative,
25x2005- Accelerating Progress in Girls Education Initiative. Global effort associated with
promoting Millennium Development Goals in “education and gender equality," ‘‘hunger,’’ “child
health and maternal health,” slum dwellers,” “access to essential medicines," and “science,
technology and innovation," G8. the Africa initiative and related development effort.
48
ANALYTIC AND STRATEGIC REVIEW PAPER:
HEALTH SYSTEMS KNOWLEDGE NETWORK
Jane Doherty,' Lucy Gilson,
Second draft
26 August 2005
i
Submitted to the Commission on Social Determinants of Health, World Health
Organisation
by
The Health Systems Knowledge Network Hub
Centre for.Health Policy. University of the Witwatersrand.
Health Policy Unit, London School of Hygiene and Tropical Medicine.
EXECUTIVE SUMMARY
I his review scans and summarises I he international literature related to health systems and equity,
focusing on existing reviews and articles that document new lines of evidence and thinking.
We note that the available literature covers a wide range of issues, but provides limited detailed
or rigorous evidence, particularly with respect to the actions and interventions that promote
equity.
In reviewing this literature we address the following three questions:
1. How can the social factors influencing access to and uptake of population/public health
interventions, health promotion and personal health services, be addressed, particularly where
these have an impact on equity in the opportunities for health?
2.
3.
1 low do key policies and organisational dimensions of health systems impact on access to
population health interventions, health promotion and personal health care services, social
differentials in heath outcomes, and other social determinants of health?
How can the policy space for health systems based on equity values be developed and
maintained?
The health system as a social determinant
Using the health care system as an entry point, the review begins by presenting data that illustrate
that health services tend to be used proportionately more by richer than poorer social groups.
Existing patterns of health system inequity, thus, clearly demonstrate ,how the opportunities to
benefit from health care are themselves socially differentiated.
I
It then analyses the social factors affecting access to, and uptake of, health services and shows
how these engage with features of the health care system. Overall, it argues that the interaction
between household health-seeking behaviour and experience of the health system generates
differential health and economic consequences across social groups. The long-term costs to
households of seeking care sometimes lead to impoverishment for poorer households.
The review then applies this analysis to the Commission’s conceptual framework, showing that
the health (care) system acts as a social determinant of health, interacting with other social
determinants as well as the social and political context. Adding to the Commission’s framework,
we note that the health system can, moreover, itself interact with the social and political context.
This highlights the potential for policy change within and by the health system to influence that
context. In other words, health systems both reflect existing patterns of social inequality and
provide a site in and from which to contest them.
Addressing policy and organisation in the health system to promote equity
The review examines aspects of the health care system that contribute to, or mit'gate, inequity.
These include:
.
«
priority-setting;
•
resource allocation;
o
financing (covering various mechanisms of cost recovery, development aid and. pre
eminently important, tax-based funding; as well as the disbursement of conditional grants
and vouchers to support use of health care interventions)
«
organisation of the health system (including decentralisation and community
participation, integration of services, re-orienting health care to primary care delivery,
targeted versus universal approaches, and public-private interactions);
®
human resources; and
•
management and regulation.
The review concludes that national health systems founded on values of equity, solidarity and
redistributive justice may reflect normative values, and value and entitle citizens, in ways that
differ from other national and trans-national systems operating within wider economic contexts,
including market-oriented macroeconomic policies, conflict and globalisation. Health systems
may provide an entry point for broader societal transformation in the interests of poor and
marginalised people, both through structural and cultural or value-driven change. However, this
potential is often under-developed. Developing health systems of this nature is not simply a
technical process structured around evidence. Instead, as there are likely to be competing
interests, it demands political, health sector and social leadership.
Building health systems based on equity and social justice: maintaining the policy space
The literature on how policy-makers can maintain the space - at global, national and local levels to build health systems based on values of equity and social justice in the face of broader forces
such as market reforms, conflict and globalization, is scant but growing. The review notes the
importance of:
I. Developing strong political support for the notions of equity and social justice, both within
2.
3.
4.
5.
Ministries of Health and across government;
Promoting inter-sectoral action for health;
Strengthening the voice of the poor to make claims, and government legitimacy;
Constructing values-based health care systems and preventing excessive fragmentation within
them;
Strengthening the ability to implement new policies and interventions that promote-equity.
»
Gaps in the literature
From the wolk that we have been available to do so far, we note several areas of weakness in this
review that could be addressed through the knowledge network. These are:
•
the role and nature of state action in promoting health equity in different contexts;
•
the potential of particular health system strategies to promote equity, including health
promotion and broader public health interventions;
•
how to support and sustain policy implementation;
•
differential household experiences of health systems, and variation within households;
•
limited geographic coverage.
Priority interventions
Despite these gaps, a number of lessons and potential areas of action emerge from the review.
Case study analyses of examples of these actions could add to the knowledge base in this field.
1)
Leveraging policy action:
•
The health system needs to use its leverage with other sectors and spheres of government
•
to promote healthy public policy.
Good governance and accountability are a prerequisite for equity-focused priority-setting
and decision-making within health systems.
it
. I
•
Equity cannot be improved without strengthening the health system, especially the public
sector. To this end. any policy change needs to be assessed as to its potential overall
impact on the health system.
Achieving equity-promoting health system interventions:
2)
»
Build the health workforce to ensure the equitable distribution of appropriately skilled
and adequately motivated staff across the health system and country.
»
3)
Ke-orient health systems towards the provision of primary health care within a District
Health System.
Financing health care and allocating health care resources:
»
A comprehensive approach to financing, founded on the ideals of solidarity and cross
subsidisation, is vital to guard against the differential consequences of health care use and
promote equity.
»
Increase the proportion of government spending that is dedicated to health, along with
increased donor aid and debt relief.
»
Reduce out of pocket spending as a proportion of total spending on health care, including
the removal of user fees through a properly planned and appropriately implemented
strategy.
0
Contain the development of private insurance mechanisms and where they exist take
steps to prevent risk-rating by, and promote risk equalisation across, insurance schemes.
o
Overall resource allocation should be needs-based, taking account of inter- and intraregional disparities.
i
•4) Strengthening management and implementation capacity:
o
o
Develop the skills of public managers as stewards of the health system.
Pay attention to transforming the organisational culture of the public sector to enable
better management and implementation.
=
Develop effective regulation of, and wise interaction with, the private sector to harmonise
the efforts of public and private providers.
»
Information is vital in developing and implementing policies that support equity. This .
information needs both to be sensitive to measuring inequity, and dynamic in its
engagement with issues of process and outcome.
t
Areas ofsynergy or overlap with other knowledge networks
Finally, there are a number of areas where this network would benefit from engagement with
other networks. Likewise, there are a number of areas where some clarity is needed on which
network will take prime responsibility for investigating issues. These areas of potential synergy
and overlap are:
o
Community-based interventions, health promotion and implementation lessons (Priority
Public Health Interventions);
°
The impact of gender and on access and power relations between providers and patients.
and between providers themselves (Gender, Social Exclusion):
•
Global influences over health systems including health worker migration, trade in health,
commercialisation and the role of the state (Globalisation);
«
Community-participation and accountability (Social Exclusion);
•
Health care for the urban poor, inter-sectoral action for health (Urban Settings).
iii
TABLE OF CONTENTS
EXECUTIVE SUMMARY
1
1
OBJECTIVES OF THIS REVIEW
1
2
APPROACH TO THE LITERATURE SEARCH
1
3
STRUCTURE OF THE PAPER
1
4
KEY
DEFINITIONS
I
2
5. HEALTH INEQUITY AND THE ROLE OF THE HEALTH SYSTEM AS A
SOCIAL DETERMINANT
4
5.1
Who benefits from health care services?
5
5.2
What affects access and influences differential consequences?
(>
5.3
A framework for understanding the health system as a social determinant 12
6. ADDRESSING POLICY AND ORGANISATION IN THE HEALTH SYSTEM
TO PROMOTE EQUITY
15
6.1
6.2
priority-setting
i
Resource allocation
15
17
6.3
.Financing health care and health
6.3.1
jCost-recovery mechanisms
6.3.2
Development aid and government allocations of tax funding
6.3.3
Vouchers and conditional cash payments
18
18
21
22
6.4
Organisation of health systems
6.4.1
Decentralisation and community participation
6.4.2
| Integration
6.4.3
Re-orienting health care delivery towards primary care
6.4.4
Targeted versus universal approaches
6.4.5
Public-private interactions
22
22
24
25
25
26
6.5
Human resources
28
6.6
Public sector management and regulatory capacity
31
IV
7.
BUILDING HEALTH SYSTEMS BASED ON EQUITY AND SOCIAL
JUSTICE: MAINTAINING THE POLICY SPACE
32
7.1
Strong political support for the notions of equity and social justice
33
7.2
Inter-sectoral action in support of health equity
35
7.3
Strengthening the voice of the poor to make claims and government
legitimacy
37
7.4
Constructing vahies-based health care systems and preventing excessive
fragmentation
39
7.5
Strengthening policy implementation
8.
CONCLUSION
42
44
ANNEX 1:
IDENTIFYING THE KNOWLEDGE NETWORK MEMBERSHIP 48
ANNEX 3:
SUMMARY OF THE FINDINGS OF OTHER REVIEWS
ANNEX 4:
THE TEXT
SUPPORTING EVIDENCE FOR STATEMENTS CONTAINED IN
64
66
I
II
v
OBJECTIVES OF THIS REVIEW
1
The Commission on Social Determinants of Health has requested knowledge network hubs to
provide:
1.
(a)
an in-depth review and analysis of what is known about:
the priority associations between social determinants of health/health equity (with
special emphasis on inequities in health);
(b) the policies, programmes and institutional arrangements that positively enhance
opportunities for greater health equity and;
(c) the priority areas that the knowledge network will undertake.
2.
an in-depth mapping of the country, regional, and global institutions and individuals
currently doing work in the thematic area of the knowledge network.
This paper seeks to address these objectives for the health systems knowledge network within the
limits of,the time frames and resources provided. The concluding section of this paper. Section
8, comments, amongst other things, on the extent to which the paper has been able to meet the
objectives.
2 APPROACH TO THE LITERATURE SEARCH
The review is based on literature sourced from within the consortium managing the hub as well as
from institutions networked with the consortium members. Some key references from existing
materials have also been followed up. Given the wide scope of work on health systems, it has not
been feasible to conduct a general electronic search. Nor has it been possible to access
substantial quantities of grey literature, given the difficulties associated with identifying and
locating copies of this type of literature. It is anticipated that wider literature, including grey
literature, will be fed into the review once the knowledge network has been initiated.
Because of time constraints, the focus of the review is on providing an overview of the full range
of relevant topics and issues rather than a more detailed assessment of’a limited set of topics. The
paper focuses on reviews of international experience and articles documenting new lines of
investigation. We have specifically sought out reviews that are in press or forthcoming to ensure
as up-to-date an evidence base as possible.
3 STRUCTURE OF THE PAPER
In its work, the health systems knowledge network will consider three main questions:
1.
How can one address the social factors influencing access to, and uptake of, population or
public health interventions, health promotion and personal health services, particularly where
2.
these have an impact on equity in opportunities for health?;
How do key policies and organisational dimensions of health systems impact on access to
population health interventions, health promotion and personal health care services, social
differentials in heath outcomes, and other social determinants of health?
I low can the policy space for health systems based on equity values be developed and
maintained?
Section 5 draws on an analysis of the social factors affecting access to and uptake of services to
provide an overview of the role of the health system as a social determinant of health, relating this
to the Commission’s conceptual framework. In so doing, it talks to question (1) above, although
Section 6 explores the answers to question (I) more fully, whilst at the same time addressing
question (2). Section 7 tackles question (3).
These sections are preceded by Section 4 which provides some definitions. The concluding
section. Section 8. highlights what appear to be the major areas of action required tp improve
equity and, in responding to objective (c) above, begins to identify priority areas that'the
knowledge network might want to undertake (finalising these areas requires further consultation
with the Commission and the knowledge network itself).
Our overall aim is to outline the available evidence briefly and to draw conclusions based on that
evidence. 1 lowever, we recognise that at times we may err towards the more instrumental
approach of apparently using literature to justify our argument. Where this occurs it reflects partly
a degree of consensus across a range of reviews with which we concur, and partly the limits of
the available evidence base.
With respect to the in-depth mapping of institutions and individuals working in the thematic area
of this paper. Annex 1 provides a first draft of principles and approaches that could be used to
guide the selection of knowledge network members. Further consultation with the Commission
and others is required before the mapping can be finalised.
4 KEY DEFINITIONS
A health system includes all the actors, institutions and resources that undertake health actions,
with health actions being all those interventions whose primary intent is to improve health. This
covers promotive, preventive and curative actions. Although the defining goal of a health system
is to improve population health, the World Health Organisation (2004) notes that health systems
also have other intrinsic goals: they seek to be responsive to the population they serye and to
ensure that the financial burden of paying for health is fairly distributed across households (see
boxes in right-hand column of Figure 1). Thus, a health system is central to ensuring social
responsibility for health and health care, bringing benefits to society that transcend individual
gain. This role of the health system as an element of the social fabric of any country (Gilson
2003) is a particularly important feature in later discussions on the role of health systems in
promoting equity.
A health system includes numerous elements, amongst them governance structures, different
sources of finance, a range of financing intermediaries, different levels of care and differeht types
of providers across the public and private (for-profit and not-for-profit) sectors, institutions in
other sectors (especially water, sanitation and education), users and citizens. The World Health
Organisation (2004) outlines four key functions that determine the way health systems transform
inputs into the outcomes that society values (sec boxes in left-hand column of Figure 1): the
generation of resources, financing, service provision and the leadership or stewardship that
organises other elements, reflecting and promoting social values and rights. The last function is
the task of government as it has the ultimate responsibility for the performance of all national
2
health systems (whatever the combination of public and private providers and financing
intermediaries). This explains the importance attributed in later sections ol this paper to issues ol
governance, accountability and power relations.
Figure .1:
Functions and goals of health systems
FUNCTIONS THE SYSTEM PERFORMS
Delivering services
(provision)
I
N
1
GOALS I OUTCOMES OF THE
HEALTH SYSTEM
I------------------------------------------- 1
Coverage
Responsive
services
Creating resources
(investment and
training)
P
U
Health
Financing
(collecting, pooling,
purchasing)
T
S
Stewardship
(oversight)
Provider
Performance
(quality, efficiency)
People protected
from financial risk
Source WHO (2004)
An array of factors - including the broader socioeconomic environment as well as powerful actors
and even those working within the health system - influence how these elements interact in
practice to promote health (or ill-health) and health equity (or health inequity). Consequently,
health systems are made up not simply of a set of technical processes and interventions. On the
contrary, they are often the domain of political engagement and allow the expression of the
interests of global, national and local elites. They are also shaped by the practices of those who
work within them. As discussed later, this has implications for understanding how to encourage
health systems to accept equity and social justice as the basis for achieving health and,
consequently, as principles guiding their organization and operation.
Turning then to the concept of health equity, this review uses the definition applied in the
Commission’s conceptual framework, namely, ‘Health equity can be defined as the absence of
unfair and avoidable or remediable differences in health among populations or groups defined
socially, economically, demographically or geographically’ (Commission on Social Determinants
2005c). Healdi equity is therefore more than just ‘health equality:’ it implies that the opportunity
to benefit from health services is distributed according to need rather than according to factors
such as inbome, insurance status, geographical location, gender or age.
High levels of existing inequity imply that interventions under focus in this review must primarily
seek to allocate resources preferentially to those with the worst health status (vertical equity)'.
until relatively recently, this concept has received less attention in the literature than horizontal
3
equity, which refers to equal treatment for equivalent needs (Mooney and Jan 1997). As
discussed below, this implies understanding and influencing the redistribution of social and
economic resources for equity-oriented interventions in the health system, and understanding and
influencing the power and ability people (and social groups) have to make choices over health
inputs as well as their capacity to use these choices towards health' (EQUINET Steering
Committee 1998).
As the Commission's conceptual framework shows, health equity is affected by a number of
social determinants, only one of which is the health system (the concept of (he health system as a
social determinant is developed in a later section). Consequently, this paper is concerned with the
degree to which the health system could, and does, address the causes of health inequity that are
within its control. In doing so, it refers to examples of the 'health disadvantage,' ‘gaps’ and
■gradients'1 approaches to redressing inequity referred to in the Commission's conceptual
framework (Commission on Social Determinants 2005c) whilst preferring, as discussed later, the
‘gradients’ approach.
Finally, in.referring to those who typically have limited opportunities to utilise services within the
health system, this document often uses the term 'thepoor.’ Noting that this term is not intended
to be used to label or stigmatise people experiencing different forms of deprivation, in defining
this category, Goudge, Khumalo and Gilson (2003) include the following:
1.
2.
3.
4.
those on the margins of formal employment, who could be included within formal systems
of employment;
those outside the formal sector, either self-employed or working in the informal sector, who
are'-able to contribute towards their health care costs;
poor people who are not able to contribute to their own health care costs; and
the,poorest groups who are not only not able to pay but also, due to social exclusion, exist on
the margins of society where they are very difficult to reach (especially women and children,
particularly in rural areas).
The review will integrate and explore these and other individual, family and social dimensions of
poverty-that impact on the opportunity to access and utilise services and resources within the
health system.
5. HEALTH INEQUITY AND THE ROLE OF THE HEALTH
SYSTEM AS A SOCIAL DETERMINANT
In this section we first review the available evidence on who benefits from health care services
and what factors influence access to, and uptake of, these services. This perspective provides an
entry point for considering the role of the health system as a social determinant and relating this
understanding to the Commission’s conceptual framework. Recognising the wider dimensions of
health systems, as outlined in the definitions of the previous section, the paper will subsequently
explore their service, resourcing and governance dimensions. Nonetheless, the focus of this
section and indeed the paper, is on preventive and curative care provided through facilities, rather
than on broader population health interventions, such as health promotion. This is partly because
of time constraints and partly because of uncertainty with respect to the scope of this knowledge
network viz-a-viz the knowledge network on public health interventions.
4
j
5.1 Who benefits from health care services?
Existing patterns of health system inequity clearly demonstrate how the opportunities to benefit
from health care are themselves socially differentiated. Generated mostly quite recently, the
available evidence from developing countries clearly documents (he inequities ol curative care
provision.' A recent benefit-incidence analysis by Castro-Leal et al. (2000), for example,
estimates the monetary value of curative services, and how that monetary value was distributed
across the population, for seven African countries. They find that the share of spending that went
to the poorest quintile of households was significantly less than that to the richest twenty percent.
Gwatkin, Bhuiya and Victora (2004) quote a study of 21 countries across the developing world as
confirming this trend: "the top 20% of the population gained on average over 26% of total
financial subsidies provided through government health expenditures [on curative services],
compared with less than 16% in the lowest 20% of the population.’ Schellenberg <7 al. (2003)
show that, even within a rural Tanzania community that could have been assumed to be uniformly
poor, utilisation was lower amongst the poorest families. Much less information is available on
preventive or population health interventions, although some analyses of immunisation coverage
suggest that it is also regressive (Gwatkin, Bhuiya and Victora 2004). While data are poor, it
seems that there are considerably greater inequities in relation to private as opposed to
government services even, in some cases, within the not-for-profit sector (Gwatkin. Bhuiya and
Victora 2004).
One of the reasons for the distribution patterns discussed above is the predominance of spending
on hospital-based, often urban services, which the poor generally do not use. Castro-Leal et al.
(2000) make the point that ‘budget re-allocations towards primary care would in themselves
improve the targeting of spending to the poor,’ an argument which is made convincingly by
Starfield, Shi and others in work in developed and developing countries (see. for example.
Starfield 2001, 2002 and 2005, Starfield and Shi 2004, Shi, Green and Kazakova 2004).
Gwatkin. Bhuiya and Victora (2004) comment that all levels of care tend to be regressive but that
■poor-rich differences seem much larger for higher-level than for primary care.' Implicit in the
thinking of later sections, therefore, is the assumption (hat district health systems development.
and especially the development of capacity to deliver primary health care, is a necessary strategy
for the promotion of equity.
Unfortunately, much of the literature that examines the impact of interventions on the poor does
not differentiate the impact on women, nor look at the intra-household allocation of resources.
However, Castro-Leal et al. (2000) were able to determine that women in the poorest quintile use
health services less relative to their male counterparts than do women in rich quintiles. I’hus,
poverty and gender inequality combine to aggravate the health inequity experienced by women.
Women are represented disproportionately in vulnerable population groups, arc subject more to
cultural and ideological influences that affect access to, and utilisation of, health services, and arc
confronted with higher opportunity costs in seeking care (Standing 1997). These problems persist
despite extensive health sector reforms in the 1990s which, although having sometimes included
improved equity as one of their objectives, in fact appear to have increased the cost of, and
constrained access to. care for poor women (Ravindran and de I’inho forthcoming).
The available findings suggest that health care provision tends to reinforce social differentials,
and so appears to support Tudor-Hart’s ‘inverse care law’ which states that the availability of
good medical care tends to vary inversely with the need for it in the population served (Hart
1971). This problem persists, even where interventions intended to benefit the poor are
’ See, for example : Schellenberg et al. 2003; Victora. Barros and Vaughan 2000.
5
introduced. 1 hus. whereas Victora. Barros and Vaughan (2000) found that the considerable gap
between the poor and the wealthy in Brazil in the early 1980s was diminished after interventions
were introduced a decade later, this only occurred where reduction in mortality was no longer
possible for wealthier groups. In addition, they comment that their study of the Brazilian health
system over more than twenty years suggests that most interventions reach the private sector (and
therefore the wealthy) years before they arc made available to the general population through
government services. ‘This has been the case for vaccines, antibiotics, surfactant therapy,
neonatal intensive care, antenatal screening, and many other technologies ... [I]n the rare event
when new interventions are delivered through the governmental system but are not available
commercially, the wealthy are also entitled to use them, and - being better informed
acquire access to these technologies before the poor.’
will
While persistent health inequities appear to be the norm in many countries, there are instances
where good improvements in life expectancy and child mortality have been achieved, including
amongst the poor, even within the context of low per capita income. The most well-known of
these are the three countries China. Costa Rica and Sri Lanka, and the Indian state, Kerala
(Halstead. Walsh and Warren 1985, Commission on Social Determinants 2005a). The factors
underlying these success stories are discussed in later sections.
5.2 What affects access and influences differential
consequences?
This section draws on a synthesised account of relevant literature, rather than providing a detailed
review of the wide range of studies that exist in this field. It is important to note that health
seeking behaviour is very complex, as demonstrated by the different models that exist to
understand it and the critiques of such models (Hausmann-Muela, Ribera and Nyamongo 2003).
The paragraphs below look, first, at barriers to accessing and utilising health care from the
perspective of the household, and give some idea of how structural determinants combine with
features of the health system io affect access and utilisation. Second, they consider some of the
consequences of health care use in order to show how the health system may itself lead to
differential consequences that reinforce pre-existing social stratification. This section draws on a
guiding framework (Figure 2) that has been developed and applied in a series of studies
investigating how poor households cope with the costs of ill-health (Russell 2001).
A variety of factors influence access to health services. When there is illness in a household (Box
I in Figure 2). a number of decisions arc made. First, is treatment of one sort or another
neededfor this condition and person? (Here, the term ‘need’ refers to the household’s
assessment of need, rather than the ‘objective' assessment of need by a clinical expert.) If the
household decides that it docs need treatment, should the household self-treat, seek traditional
or alternative treatment, or visit a Western provider, or use some combination of these
providers? If care in the Western health system is needed, should the household sec^ care in the
public or private sectors? 'flic response Io these decisions and the factors and environments
underlying this response influence the differentials in access to, and benefit from, health services
noted earlier.
iI
6
Figure 2: Conceptual framework lor understanding how households cope with illnessrelated costs
HOUSEHOLD DECISIONS
Health System
Community
level
Box 3; Health care expenditure
& income losses
Box 6:
HEALTH SYSTEM
Costs & methods of
financing;
Distance/time to
facility;
Lack of information;
Perceptions of
quality;
Attitudes of health
workers.
: Box 2:
I Health seeking
I behaviour &
; treatment strategies,
: (delaying or not
seeking care,
I cheaper sources of
care, taking partial
doses, seeking
exemption)
Box 1: Illness
occurrence
;
I
■
I I
I
:
;
Box 4:
Financial Coping
strategies
(borrowing, selling
assets, reducing
other basic needs
expenditure)
Box 5: Household
Livelihood
(assets, income,
debt & access to
basic needs)
Box 7:
SOCIAL RESOURCES
social networks information, decision
making support,
financial help
Community
organisations Information, financial
help, home-based care
Source: Russell (2001)
A range of social factors, first, influence decisions about health-seeking behaviour (Box 2 in
Figure 2). including some social determinants: :
1.
2.
Household livelihood (Box 5): It is a well-known phenomenon that the poor tend to self-rate
their health status higher in relation to self-ratings by the more affluent, despite lending to
suffer from more ill-health (for example, Castro-Leal <7 al. 2000 and McIntyre and T'hiedc
forthcoming). Differential ratings may lead poorer households to refrain from seeking care
when higher income households do, simply because poorer households cannot afford to be ill.
that is, to take time away from income-earning activities. The household livelihood set
encompasses not only the security, sources, levels and distribution of income but also the
assets and endowments that households have individually and draw from social groups (such
as extended families, community networks and formal collectives).
Cultural beliefs about disease and healing (linked to Box 2). These shape how households
understand illness and may prevent households from identifying illness or suggest that, as
illness has social causes, it cannot be effectively treated by providers operating within the
Western medical paradigm. Interestingly, Russell (2004) notes that widespread public
confidence by Sri Lankans in the effectiveness of Western medicine as a system of treatment
- and the explicit role taken on by the state in ensuring that this care is universally available -
contributes to the willingness of households to contemplate using Western providers, despite
a tradition of using Ayurvedic medicine.
3.
Power relations within the household (underlying all household decision-making). As
mentioned earlier, there is little literature looking at the intra-household allocation of
resources (Standing 1997). However, it is known that women are represented
7
disproportionately amongst the most vulnerable and that their access to health]services is
olten curtailed by socio-cultural factors. Power relations within the household are likely to
determine who is allowed to seek health care (and what sort of health care). This, together
with greater opportunity costs, may account in large part for low utilisation rates amongst
poor women (see, for example. Castro-Leal 2000, Standing 1997).
Further, social norms, such as the emphasis on 'innocence' in young women in some societies
prevents them from seeking information about sex or services relating to their sexual health.
Social stereotypes about sexual behaviours, including the acceptability of older men
‘marrying' much younger women, increases the risk of HIV infection in the next generation
(Rivers and Aggieton 2003).
i
Unfortunately, social and cultural norms cannot be easily characterised: they have been
caught in the rapid transition of cultures over the past 100 years, influenced by colonialism,
migrant labour systems, traditional values and urbanisation (Voluntary Services Oycrsctis
2003). Nor are they always amenable to simple assessment. The weakness in currdnt levels
of understanding of the role of stigma in HIV transmission, for example, is evident in
inequity in the uptake of health services for prevention and control of AIDS. '
Stigma is. for example, not simply a psychological response. It may be a means to respond to
disease without challenging the conditions that cause it (Bond 2002). Society needs to
explain or control disease, and blaming the victim is one response used as people seek to
isolate and distance themselves from the problem. The negative impact of such a response is
to make stigmatised people responsible for taking action on their affliction, rather than
society as a whole (Bond 2002). This can leave the underlying structural causes of the
disease untouched, as has been the case with females or adolescents. Stigma is thus a way of
sustaining power relations. Groups already ‘.scapegoated’ for other reasons, including
migrants, commercial sex workers and poor women, are more vulnerable to such stigma.
AIDS-related stigma plays into, and reinforces, class, gender, sexual and racial' inequalities in
society (Bond 2002. Jenkins 2000).
4.
Knowledge about illness and appropriate treatment options (linked to Box 2). The poor tend
to be less educated, have less access to information, and less knowledge about health and
health care issues (Bennett forthcoming). Hence, they are less likely to identify correctly
when treatment is needed or to know where to access such treatment. This underlines the
importance of health promotion.
5.
Access to social networks and resources (Box 7): The social networks and resources
available to households may provide information used in determining whether and where to
seek care, or may be a source of cash used to purchase care or pay for transport costs (sec
below). However, the limited available evidence suggests that these resources may be
distributed differentially across households according to their income level (Russell 2004).
Interestingly, in South Asia, despite a rapidly growing HIV epidemic, there is a prevailing
silence about violence against women and girls (including domestic violence, abuse in the
working environment, sexual abuse and other forms of exploitation that they experience in
the process of earning a living). While there arc reported to be high levels of social cohesion
in these societies, this has not broken the silence and enabled the societal acknowledgement
of behaviours that increase risk of HIV infection, which leaves individuals susceptible to risk
and impedes individual and social prevention efforts (Shah et al 2002).
1
8
Young people face similar dissonance between social norms and reality, undermining the
support they get from adult society. In many societies, the lamily and immediate community
traditionally provided young people with information and guidance about sex and sexuality.
In ma'ny parts of the world, however, recent and rapid urbanisation and migration have
dispersed and weakened family and community networks, leading to the youth using other
sources of information (Rivers and Aggieton 2003). In Zimbabwe, for example, surveys have
found that sexual information tends to be obtained not from family members, but from the
media, school and friends
A second set of factors influencing access, namely health system features, interact with broader
social factors, as shown on the left-hand side of Figure 2:
1.
Geographic barriers. The poor - whether they live in rural or peri-urban settings
lend to
have worse geographic access than urban dwellers, as historically health care facilities tend to
have been located in urban settings (Bennett forthcoming). This acts as a deterrent to seeking
care.
;
2.
Drug availability. The availability of drugs has a specific influence over health-seeking
behaviour and limited availability can be enough by itself to lead patients to use alternative
providers. Indeed, the expectation of drug availability at private providers is one factor
underlying the use of these providers even by the poor.
3.
Financial barriers. These act in numerous ways to prevent access to health care. User fees.
which represent the immediate and direct costs of health care, tend .to be widespread, even in
low-income countries and even for public services and, as discussed later under financing
mechanisms, have a history of deterring the poor from seeking care. Apart from official user
fees, there may also be unofficial lees charged by health workers unhappy with their
government salaries, either because the amount is too low or because payment is irregular.
Unofficial fees may be monetary or paid in kind, and may be paid to professional health
workers, other types of staff or even to the facility itself (Goudge, Khumalo and Gilson
2003).
The immediate but indirect costs of accessing health care are also a deterrent, and many
exceed direct costs considerably (McIntyre and Thiede forthcoming). These may include
travel costs and the opportunity cost of missing work and neglecting other duties (for
example; Castro-Leal et al. 2000, Bennett forthcoming).
4.
The responsiveness of the health sector. There is considerable evidence to show that even
poor households make use of the private sector (Bennett forthcoming), partly' because private
providers may be physically more accessible, especially in remote areas, and also because of
the better responsiveness of the private sector compared to the public sector (supporting
evidence is provided in Annex 4 under point (i). The features that ensure that influence the
responsiveness of health care providers include:
i.
The availability ofan appropriate range ofservices. This is discussed under the section on
priority-setting.
ii.
Convenient'services in terms of:
•
Opening hours. The opening hours of public services - and the time taken wailing in
queues - deter access, especially for daily wage earners who are reluctant to lose earnings
(Russell 2005, Bennett forthcoming).
9
°
1 he integration ot services. Integrated services allow patients to receive a number of
services at one visit. This helps to minimize the time taken up by seeking health care.
Respectful treatment including (Gilson. Palmer and Schneider 2005):
iii.
°
Positive, courteous altitudes and behaviour, including listening to, and taking time with
the patient. '1 here is evidence from many settings that poor health worker attitudes
undermine the performance of public services (for example, Russell 2005. Freedman ct
al. 2005, Bennett forthcoming). One example is recounted by a South African study
where public sector staff were characterized as being rude, showing favouritism and
ignoring the needs of patients (for example, by taking tea breaks while patients are
waiting and sending them away without being seen at the end of the day). Health workers
tend to treat poorer patients more dismissively which can act as a deterrent to accessing
public health care, and contribute to the diversion of patients to the private sector.
=
Thoroughness. In public settings high workloads mean that clinicians cannot perform
proper consultations and rush through their encounters with patients (for example,
Gilson. Palmer and Schneider 2005).
•
Good communication which allows a reciprocal relationship between providers and
patients.
(
»
Technical competence. While this may be perceived to be superior in the private sector,
in reality the clinical quality of care provided by private providers is often indifferent and
sometimes poor, either due to lack of knowledge or due to distorted incentives, especially
arising from payment mechanisms (Bennett forthcoming). In addition, private providers
seldom provide public health services (such as immunisation, antenatal care and TB
care).
‘
»
Continuity ofcarc. This is valued by patients, even poor patients, and tends to be a
feature more of private than public providers.
Privacy and confidentiality, including to reduce stimgatisation. As noted in the earlier
discussion stigma as a social phenomenon may deter people from accessing services of a
sensitive nature, particularly where their past experience of health care providers has
shown a lack of respectful or courteous behaviour or where using such services .will have
wider social repercussions. I he lack of privacy in many public sector settings dfives even
poor people to use the private sector (with consequent economic implications)(see, for
example. Gilson. Palmer and Schneider 2005).
Several of these features of responsiveness combine to create patient ‘trust’ in the provider.
and wider health system (Gilson, 2003). Russell (2005) defines trust as, ‘user confidence that
the health worker, and the system which they represent, works for the best interests of the
patient and has the technical and personal competencies to do so.’ Patient trust is important
because it allows patients to have confidence in the motives and decisions of the provider,
given that they are in the vulnerable position of experiencing uncertainty around their
condition and have little medical knowledge. In addition, it facilitates communication,
patient focus, patient disclosure and adherence, and ultimately enhances the utilization of
health services (Russell 2005, for example). Inherent in the definition of patient trust in the
provider is acknowledgement of the fact that trust can be invested at both the personal and
institutional levels (see Box 1). As mentioned in an earlier section, the state can promote
trust through commitments to equity (as is the case in Sri Lanka).
I
10
Box‘1:
Features of patient trust in the individual health worker and the health
system
Personal level trust
• Develops through face-to-face encounters with providers (both medical and non:
medical);
•, Needs time to develop;
• Is influenced by levels of trust in wider society; and
• Can bolster or undermine institutional level trust.
Institutional level trust
• Allows patients to trust the system without personal knowledge of the health workers
representing the system; and
• Is based on an awareness that, for example:
c the health system has a track record of being able to perform expected delivery
functions such as ensuring the availability of staff, pharmaceuticals and
equipment;
o the system is based on norms, procedures and other institutions that support fair
treatment;
o health worker remuneration systems that support professional practice;
o there are professional training systems in place to ensure high standards;
o there is institutional oversight such as licensing, ethical codes, quality controls,
and disciplinary procedures to maintain standards;
o there are procedures in place that ensure health worker accountability.
Source: Adapted from Russell (2005), Gilson, Palmer and Schneider (2005)
Finally, Figure 2 shows that the interaction between household health-seeking behaviour and
experience of the health system generates important health and economic consequences (Boxes 4
and 5). The long-term costs to households of seeking care may consume a significant share of
poor household’s income (McIntyre and Thiede forthcoming). In part, these costs arc generated
by the geographic availability of care, the price of care and the nature of the care provided. For
example, inappropriate drug consumption as a result of inappropriate prescribing of drugs by
providers or irrational use of drugs by households (such as not purchasing or using the full
regimen, using several drugs, demanding unnecessary injections) adds to the costs of accessing
care, as well as possibly generating negative health outcomes with longer-term costs (Homedes
and Ugalde 2001, Goudge, Khumalo and Gilson 2003). Similarly, poor referral systems and poor
chronic disease care may increase the costs of accessing care, as well as generating poor health
outcomes. Also important to the long-term costs of care are the indirect costs resulting from loss
of income.
The literature Currently suggests that total cost burden levels of 10% of total household income or
40% of non-food income are catastrophic for household livelihoods (Xu et al. 2003). However,
even lower levels of cost burden may be too much for poor households to bear (Russell 2002).
Impoverishment may result from the use of savings, sale of assets and increased indebtedness as a
result of having to finance care out-of-pocket, especially in the case of long-term chronic illness,
such as AIDS. Impoverishment can be aggravated when financial barriers lead to the decision not
to seek treatment, resulting in severe or chronic illness and even death (McIntyre and Thiede
forthcoming). As Russell (2005) found in Sri Lanka, the urban poor are particularly vulnerable to
further impoverishment because they tend to be unskilled and, if they are in the formal sector.
eam daily wages; they also tend to have less access to the social resources that could help them to
cope with illness and the related costs. In contrast, higher income groups are more likely to have
II
financial proteclion against health care costs, access to sick leave benefits and access to social
resources (McIntyre and Thiedc forthcoming).
1
Overall, therefore, the differential opportunities to access care and the differential consequences
of accessing care feed back into the production of social differentials in the opportunities for
health. Indeed, the way in which the social and health system factors influencing paltems of
health care access and use across population groups are managed demonstrates the extent to
which the system reproduces the dominant social and economic patterns.
II
5.3 A framework for understanding the health system as a
social determinant
Drawing on the experience presented in Sections 5.1 and 5.2, Figure 3 presents this paper’s
application of the Commission's conceptual framework to the health systems domain. The boxes
in the upper section of the Figure describe the ‘vicious cycle’ set up by inequity, with Social
stratification leading to differential exposure and vulnerability to ill-health, leading to health
inequity and then on to differential consequences of ill-health, which in turn reinforce and
perpetuate social stratification.
The boxes in the lower section of the Figure show how social determinants influence this cycle.
Structural determinants (such as income, education, gender, ethnicity and social cohesion) set up
social stratification. The dotted arrow above this box symbolises policies and interventions that
may influence structural determinants so that they worsen social stratification, leave social
stratification untouched, or confront social stratification so that the ‘vicious cycle’ becomes less
intense or disappears (much of the rest of this paper is concerned with identifying policies that
achieve the latter). Negative or neutral impacts on equity may reflect a failure to respond to
equity concerns (deliberately, unwillingly or inadvertently) or problems with implementation.
Intermediary determinants ensure that social stratification is carried forward into the next steps of
the cycle (again, policies and interventions may influence these determinants in a negative,
neutral or positive way, and may reflect either a failure to develop policy or a failure to
implement).'1 Amongst these intermediary determinants, living conditions, working conditions
and food availability have primarily been seen to influence the generation of differential exposure
and vulnerability (but may have impacts further along the cycle as well, as shown by the Figure).
The health system has primarily been seen to influence the translation of differential exposure and
vulnerability into health inequity through providing access to health care. However, it also has
prior impact through contributing to the barriers to adopting health-related behaviour, and
subsequent impact through the creation of differential consequences (for example, by leading to
the impoverishment of households due to high user charges).
Importantly, structural and intermediary determinants influence one another (as shown by the
double-lined arrows between the two grey boxes). Thus, gender inequalities in society at large
may translate into power relations within the health system that favour men and lead to decisions
within the health system that reinforce patterns of gender-based access to resources. Conversely.
-------------------------------------------
..........
.
i
(I
I or example, the health system can a) fail to identify or mount a response to an existing inequity (for
example, by failing to include reproductive health services in an essential package), b) aggravate an
existing inequity and its differential consequences (by imposing retrogressive user fees which lead to
impmiir.hmcnl) oi i) lad m its implementation of an inlet venlioli (for example, by failing Io target the
pom appiopnalcly lliiough an exemption mechanism for user lees).
12'
health system features that reduce social exclusion within communities, for example, could
elevate the status of marginalised communities, improving their access to resources in general.
These features might include participatory decision-making structures or mechanisms for
ensuring health system accountability to the population. Likewise, there is interaction between the
various sorts of intermediate determinants (as shown by the double-lined arrow that loops back on
itself just to the left of the intermediary determinants box), with health policy literature paying
particular attention to the potential for the health sector to influence policies around social
welfare, education, nutrition, water and sanitation, in the interests of good health. This implies
that policies to reduce health inequity must of necessity be multifactoral.
As the dark arrows at the bottom of the Figure show, the social determinants of health arise
within a wider global, national and local context of values, rights and macro-level policies that
influence health. The impact of globalisation is pertinent here. For Mackintosh (2001), then,
’health care systems, as social institutions, are built out of the existing social structure, and can y
its unique inequalities within them.’ As a result ‘unequal legitimate claims upon a health care
system, and unequal experiences of seeking care, are important elements of poverty and social
inequality in people’s experience.’ This is echoed by the UN Millenium Project’s Task Force on
Child Health and Maternal Health which states that ‘as core social institutions, dysfunctional and
abusive health systems intensify exclusion, voicelessness, and inequity, while simultaneously
defaulting on their potential - and obligation - to fulfill individuals’ rights and contribute
affirmatively to the building of equitable, democratic societies’ (Freedman el al. 2005).
The bi-directional nature of the arrow between ‘context’ and the health system adds a new
element to the Commission’s framework, pointing to the potential for policy change within and
by the health system to influence that context. Indeed, following Mackintosh (2001), we suggest
that health systems are ‘a key site for contestation of existing inequality.’ For example, health
systems can play a role in addressing social inequalities through redistribution. 1 lealth .systems in
many developed - and a few upper-middle income countries such as South Korea and Costa Rica
- have performed this role as a basis for addressing social inequality and exclusion (Koivusalo
and Mackintosh 2004). The welfare state in Western European countries such as the United
Kingdom, Scandinavia and Germany also highlight the redistributive role that health systems may
play. They tackle inequalities through applying the policy principles of inclusion, universality and
solidarity. This arena for policy action - that is, the policy space associated with the health
system’s efforts to tackle inequities - is the focus of Section 8.
Figure 3: Framework demonstrating the role played by the health system as a social determinant of health
A
ii
II
”
II"
Worsen
No impact
Lessen
A
Worsen
No impact
Lessen
"
”
"
A
Worsen
No impact
Lessen
■>
;;
"
Worsen
No impact
Lessen
II
II
STRUCTURAL
DETERMINANTS
-
THE HEALTH SYSTEM AS AN INTERMEDIARY DETERMINANT
Other intermediary determinants
SOCIAL AND POLITICAL CONTEXT <4
14
6. ADDRESSING POLICY AND ORGANISATION IN THE
HEALTH SYSTEM TO PROMOTE EQUITY
I
This section looks at aspects of the health system that have the potential to undermine or generate
equity-promoting interventions.
6.1 Pricrity-setting
There is increasing evidence that health services - particularly those provided by the public sector
- tend to fail to match the needs of the poor in terms of the range of services provided. This is
partly because, as discussed in a later section, the poor tend not to have a voice in determining
priorities (Bennett forthcoming).
i
Indeed, for much of the 1990s, priority-setting in the public sector has been associated with the
implementation of ‘essential packages of care’ determined at a national, and even global, level.
The concept of a ‘package’ was promoted by the 1993 World Bank Report, Investing in Health,
which developed an illustrative package based on estimations of the main causes of the burden of
disease, and cost-effectiveness analyses of interventions targeted at these main causes (World
Bank 1993). For thinkers in the World Bank, this process of prioritizing services was intended to
benefit the poor enormously, as it would supposedly deliver highly cost-effective interventions
against conditions that disproportionately affect the poor.
As summarised by Doherty and Govender (2004), the World Bank approach to determining
sendee packages has been critiqued for several reasons. These include methodological problems
in the calculation of the burden of disease and cost-effectiveness, which raise questions around
the appropriateness of interventions included in the package. Another critique centres around the
dominance of efficiency concerns, rather than equity, in the construction of the package.
Paalman et al. (1998) note that ‘the fact that the most efficient interventions ... tend to
specifically benefit the poor is more a result of coincidence than of principle.’ Musgrove (2000)
quotes Gwatkin and Guillot (1998) as substantiating this finding more fully. Thus, the cost
effectiveness approach does not intrinsically protect equity. Indeed, cost-effectiveness principles
might argue against the extension of services to populations in remote areas, as the cost of
delivery increases in such circumstances.
Consequently, World Bank (1993), Bobadilla et al. (1994) and Musgrove (2000) all emphasize
that governments need to make explicit choices between equity and efficiency concerns when
prioritizing services (implying that a political decision could be made to prioritise equity at the
expense of efficiency). Nonetheless, Rannan-Eliya (2001) rejects the cost-effectiveness approach
outright, stating that ‘cost-effectiveness of interventions and a disease-focused approach to
allocational efficiency are irrational and inefficient guides to resource allocation and may lead to
erroneous use of resources.’ He states on the basis of the Sri Lankan experience that ‘unless
equity bf access is the highest priority, choices about rationing will be made which inevitably hurt
the poor’ (Rannan-Eliya 2001). These sentiments are shared by Alvarez-Castillo, Ravindran and
de Pinho (forthcoming), who argue that this priority-setting approach is intrinsically unfair,
especially to poor women, as many of their health care needs are under-estimated and hence
excluded from the package of government-financed services.
15
The critique of the dominance of the World Bank approach to priority-setting in the 1990s is part
of a broader discomfort with the role of ‘global policy elites’ in the determination of developing
country policies and programmes (as expressed, for example, by a book - Ravindran and de
Pinho (forthcoming) - produced by the Initiative for Sexual and Reproductive Rights in Health
Reforms). Apart from distorting national priorities and encouraging the development of vertical
programmes, this has contributed to the fact that ‘health systems have been too readily
reimagined as a collection of cost-effective interventions and strategic purchasing' (Mackintosh
and Koivusale 2005). Thus, for example, Gwatkin (2000) cautions that there is a danger that the
current drive to meet international targets will result in coverage being extended amongst easierto-reach. and therefore wealthier, sub-populations.
,
Another weakness of past international health care initiatives has been that, whilst focusing on
services that, in theory, would disproportionately benefit the poor, they have seldom addressed
the enormous problems associated with ensuring that these services reach the poor on the ground
(Bennett forthcoming). Thus, for example, a pro-poor essential package in Bangladesh was
undermined by other barriers to access facing the poor (Ensor et al. 2002). While recently
popularised Poverty Reduction Strategy Papers for governments are potentially a valuable tool for
ensuring that the health care needs of the poorest are prioritised, focussing as they do on
mechanisms for poverty alleviation, including the reduction of geographic and financial barriers
to health care, they tend also not to address the enormous challenges of effective implementation
(Bennett forthcoming) (the inherent and continuing weaknesses in developing country health
systems are discussed in more detail later).
in trying to understand the impact of essential packages, it is noteworthy that, while many
countries have adopted the approach, these have seldom been evaluated. However, a recent
experiment which has attempted to use evidence on burden of disease and cost-effectiveness to
prioritise and deliver services at the district level in Tanzania is TEHIP or the Tanzania Essential
Health Interventions Project (see point (ii) in Annex 4 for a description of some of TEHIP’s
activities). In TEHIP. priority-setting was driven more by the shares of the burden of disease that
cost-effective interventions could address, and cost-effectiveness knowledge was used only to
eliminate interventions known to be grossly cost-ineffective.
I
The net effect of decentralized basket funding plus the health system inputs described in point (ii)
in Annex 3 was a relative and absolute increase in resources for the delivery of prioritized, costeffective interventions addressing the largest shares.of the local burden of disease,; an increase in
the utilization of government health services, and a decrease in mortality in infants, children
under five, adolescents and adults. This was achieved with relatively limited resources. The
district health systems received health-basket incremental funding of about US $0.92 per capita
per year additional to conventional district health budgets that covered salaries, supplies, drugs
and vaccines (personal communication with Don de Savigny, former TEHIP research manager).
TEHIP shows that, as seen in the Bamako Initiative, a dynamic process of using local (rather than
national) information coupled with local problem-solving, planning and ownership is vital for
appropriate decision-making and consequent implementation.
I
The importance of combining local decision-making with co-ordinated efforts to improve the
functioning of the local health system is expressed within a new concept called ‘MESH’, which is
based on the experience of resource allocation for Aboriginal health care in Australia and being
proposed in South Africa (Thomas et al. 2005). It is based on Mooney’s proposals for using
capacity to benefit as a key principle in resource allocation (Mooney 2003), which involve four
steps: establish the good to be achieved, in collaboration with those who will benefit; sec how
that good can be made belter with the resources available; where regions need help creating the
16
infrastructure needed to do better, adjust the allocation formula to allocate funds for (his purpose;
and make due allowance in the allocations for variations in the cost of access across regions. The
infrastructure of relevance is encapsulated in MESH, referring to the Management, Economic,
Social and Human infrastructure necessary to create a sustainable and effective foundation for
primary health care. Here, management capability refers to the management of finances and
service provision as well as leadership, the process of eliciting community preferences and health
care needs, and planning infrastructural improvement. Building economic infrastructure relates
to improving geographic access to health facilities and the development of other amenities,
sendees and employment. Social cohesion includes unity and organization within communities.
as well as interaction between communities and government and between the different spheres
and sectors of government. Human infrastructure includes the effective deployment of human
resources and the development of appropriate skills. The concept of MESH locates priority
setting firmly within a comprehensive approach to local health system development, drawing
together many of the concepts that are discussed later in this paper.
6.2 Resource allocation
Resource allocation processes tend to favour better-off areas and communities (Bennett
forthcoming). To counter this, needs-based formulae are a mechanism that has emerged in the
1990s to re-direct financial (and hence other) resources to more needy areas, especially rural
areas with less-developed health services. At their simplest, these formulae depend entirely on
estimates of relative population size and EQUINET Resource Allocation Theme Group (20(15)
have shown (hat such formulae may be perfectly adequate in estimating the direction anil size of
resource re-allpcations in low-income contexts. More complex formulae adjust population
figures accord ng to age and'sex breakdowns and standardised mortality ratios. In countries with
sophisticated data, like the United Kingdom, deprivation indices are also included. In fact.
McIntyre, Muirhcad and Gilson (2002), using data from South Africa and deploying small area
analyses, were able to develop a general index of deprivation in a data scarce context, and show
that, because of its close correlation with ill-health, it would successfully lead to more equitable
resource allocation among provinces if included in the current, less sophisticated formula. The
index also has the potential to be useful for intra-provincial resource allocation, in order to deal
with the problem of identifying pockets of deprivation within better-off provinces.
Different forms of decentralisation can work together with resource allocation formulae to shift
expenditure patterns at the local level. Bossert et al. (2003b), in a study in Colombia and Chile,
found that equitable levels of per capita financial allocations were achieved at the municipal
level, with'local funding choices and, in the case of Chile, a horizontal equity fund, adding to the
impact of a formula. Importantly, the equity fund partially re-allocated resources raised by
wealthier municipalities to more disadvantaged ones. Although resource re-allocation is more
likely to succeed under devolved systems (for reasons discussed further in the section on
decentralisation), Bossert, Chitah and Bowser (2003a) found that, under the Zambian system of
more limited decentralisation, equitable resource allocation between districts was achieved by
means of a formula. Equally, though, there have been several instances where decentralisation
and/or formulae have not led to a reduction in the overall level of inequity (Goudge, Khumalo
and Gilson 2003).
Resource re-allocation is not simply about the technical process of deciding on relative need.
Green et al. (2000), Okorafor et al. (2005) and EQUINET Resource Allocation Theme Group
(2005) all continent on the strong political interests that are challenged by such formulae. These
17
ate likely to block change (as was the case when decentralisation reforms were int'roduced into an
area in Pakistan (Green et al. 2000), especially when the capacity of technicians can be called into
question. An exception may be where re-allocation formulae focus simply on allocating new
funds to poor areas, rather than re-distributing existing funds (as was the case in Colombia
(Bossert ct al. 2003)). In addition, the process of shifting resources needs to be well-paced and
managed, to ensure that new funds are absorbed and utilised effectively. The MESH approach
described above is partly a mechanism to build the capacity to use resources into the resource
allocation formula itself (Thomas et al. 2005). Essentially, the aim is to complement the
redistribution of operating costs with the addressing of MESH infrastructural needs, especially in
cases where there arc backlogs. In South Africa, this is especially important at the primary health
care and district level, as these services are being eroded by resource allocation mechanisms
under a system of fiscal federalism (Okorafor et al. 2005).
6.3 Financing health care and health
This section deals both with some of the ma jor sources of finance (including household sources
such as out-of-pocket payments and insurance premiums, development aid and government
allocations of tax funding) as well as some pertinent pro-equity mechanisms for targeting funds,
namely vouchers and conditional cash payments.
6.3.1 Cost-recovery mechanisms
A number of cost-recovery mechanisms have emerged since the late 1970s to deal with chronic
resource shortages faced by the tax-funded public health sector. In attempting to assess the
evidence generated since 1995 on the impact of these mechanisms on access in low-income
settings, Palmer et al. (2004) comment that, despite the diversity of the literature, hard evidence is
limited and is seldom generalisable. The methodological weaknesses faced by the studies that
they reviewed are summarized in Box 2, and are illustrative of the problems generally
experienced with the literature on health systems and equity.
Box 2:
»
»
•
•
•
•
•
•
«
o
o
Weaknesses of studies that investigate the impact of financing mechanisms
on access in low-income settings
Studies tend to be descriptive.
They are on a small scale.
They have limited socio-economic data, including because studies tend to use data
initially intended for other purposes.
,
Baseline data are limited.
Controls are absent, including because studies tend to make use of natural experiments.
There are sampling problems.
Effects are measured over only a short timeframe.
The desired outcome of the intervention is not clearly defined.
More than one intervention is implemented at a time, making it difficult to disentangle
effects and control for confounding variables.
Except for three studies, in Columbia, Mexico and Niger (see below), evaluations are not
set up prior to, and alongside, implementation.
They do not examine the reasons that explain why implementation occurred as it did.
Source: Palmer e! at (200-1)
18
Nonetheless, it is possible to draw some conclusions from the international literature. Different
mechanisms for cost recovery arc discussed below, in order of the increasing degrees of cross
subsidy that they achieve. The evidence presented below makes it clear that, in order to promote
equity, governments need to take a comprehensive approach to financing arrangements that is
based on the principle of solidarity, that ensures that sufficient cross-subsidies between the rich
and the poor are achieved through one or other mechanism, and that financial protection is
afforded in the face of catastrophic illness (McIntyre and Gilson 2005). There is overwhelming
evidence that private financing does not fulfil these criteria and, on the contrary, worsens inequity
(see Section 7.4).
1.
User fees.5 Although often justified on the grounds that the increased revenue generated will
improve the quality and quantity of services, as well as put an end to informal charging, user
fees tend to create a financial barrier to accessing care, and to preventive care in particular.
User fees represent a greater burden for poor households (van Doorslaer ct al. 1999, McIntyre
and 1 hiede forthcoming), contributing to exclusion and self-exclusion from health care.0
This is confirmed by, amongst others, Gilson <7 al. (2002), Ravindran and Maccira
(forthcoming) and Bennett (forthcoming). Conversely, in South Africa in the mid-1990s,
when user fees were removed for primary care services in the public sector, utilization
increased. Utilization also increased more recently in Uganda with the abolition of user fees
(see, for example, Laterveer, Munga and Schwerzel 2004). However, the extent to which
user fees deter utilization - and for what kinds of services - is not clear, especially when
quality improvements arc introduced simultaneously. In addition, indications are that the
extra revenue generated for public services by user fees is relatively limited, especially when
collection costs are taken into account (for example, Bossert, Chitah and Bow'ser 2003,
Laterveer, Munga and Schwerzel 2004).
The equity impact of user fees has led to calls for their abolition in developing countries.
While Giljon and Mclnytre (forthcoming) support this notion, they caution that fee removal
is not a simple exercise. In particular, additional resources need to be made available to the
health system so that it can deal with the increased utilisation that follows on fee removal,
while health workers need to be consulted and supported to avoid problems with morale as
workloads increase (see also Section 7). If user fees are retained, it is critical that exemption
mechanisms for the poorest are simple and effective: currently, the poor (end not to benefit
from exemptions (Palmer et al. 2004, Ravindran and Maccira forthcoming). Those eligible
for exemption should be identified prior to needing health care, as it is ineffective and unfair
for health workers to make this decision. A variety of means is available to identify the
poorest (for example, Ravindran and Maceira forthcoming). Mechanisms also need to be put
in place to avoid regional inequities arising from the differential ability of public facilities to
raise user fees (as was found, for example, by Bossert, Chitah and Bowser 2003 and
Ravindran and Maceira forthcoming). This might include an ‘equity fund’ which re
distributes a proportion of user fee proceeds to worse-off districts (Bossert, Chitah and
Bowser 2003).
2.
Community-based insurance. Such schemes have potential for improving access because of
their ability to pool risks and protect the poor against catastrophic costs (McIntyre and Thiede
' Most of tlje research on user fees derives from Africa, although there is also some evidence from Brazil
and China.
" Except in a Ugandan study in which some rural facilities saw a rise in utilization.
19
forthcoming). Indeed, evidence quoted in Palmer et al. (2004) and Ravindran and Maceira
(forthcoming) shows that community-based insurance has a greater equity impact than user
fees. For example, utilization increased for the insured versus the uninsured (who had to pay
user fees) in a Rwandan study, and the probability of utilization within the insured group was
similar for different socioeconomic groups, whereas amongst the uninsured it was higher for
the better off. Likewise, a study in Niger showed a significant increase in uptake by the poor,
women and children in a district imposing a local tax plus a small user fee. versus a district
simply using a higher user fee (Palmer et al. 2004).
, i
However, while numerous community pre-payment schemes have been set up (across Africa
and Asia, in the main), they tend to be small in size and suffer from low levels of enrolment.
The data for such schemes tend to be weak, and Palmer et al. (2004) comment that analyses
over-emphasise the value of achieving higher levels of enrolment and improving the financial
health of schemes, and under-emphasise the real benefits to enrolees and communities,
including equity gains. There is little evidence on how to scale up successful schemes, or
explanation of what makes some schemes fail.
One exception is the increasingly detailed information that is emerging from Vimo SEWA' in
India (see. for example. Ranson 2002, Ranson, Sinha and Chatterjee forthcoming). Apart
from life and assets insurance, Vimo SEWA has provided voluntary insurance for
hospitalisation to informal sector workers in Gujurat since 1992. Data suggest that the
scheme does provide beneficiaries with financial protection, but that this protection is less for
those with more expensive hospitalisations. Factors limiting the degree of financial
protection include capping of benefits, the lag time between discharge from hospital and
reimbursement, the high rejection rate of claims, and the difficulties and costs beneficiaries
face in compiling supporting documentation for claims. Data with respect to increased
access were inconclusive because of data deficiencies. Ranson, Sinha and Chatterjee
(forthcoming) note that the rural poor face long distances and high transportation costs in
accessing care, problems which an insurance scheme cannot address and which require
government investment in infrastructure. With respect to giving the poor a voice to shape
health care services, the scheme has been very successful. Nonetheless, there are a' number
of shortfalls with respect to influencing provider behaviour, some of which relate.to the lack
of a regulatory framework.
....... “
In discussing the limitations of community-based financing schemes, McIntyre and Thiede
(forthcoming) note that community-based insurance is really only a mechanism for the poor
to pool their risk, and does not achieve what would be more important cross-subsidies,
namely from the rich to the poor. As prepayment is voluntary, it is likely that it is the very
poorest who are not able to join these schemes, or who default soon after enrolment
(Ravindran and Maceira forthcoming). Especially as the coverage by such schemes tends to
be low. community financing arrangements should therefore be seen as complementary to,
and not as substitutes for, other financing arrangements that achieve greater cross
subsidisation (Ekman 2004).
3.
National and social health insurance. This form of insurance is mandatory for the population
it targets, and engineers income cross-subsidies from the more affluent to the poor. It
therefore has the potential to impact considerably on equity. I lowcvcr, Palmer et al (2004)
note that most studies investigating national and social health insurance are descriptive in
nature. What data there are (for example, from Columbia and Costa Rica) tend to be
' Sell employed Women s Association.
20
inconclusive. However, a recent article from Thailand (which, in recent years, has achieved
universal coverage) shows that it has been able to demonstrate a reduction in the incidence ol
catastrophic expenditure and the number of households that were impoverished as a result ol
out-of-pocket health care payments (Limwattananon, fangcharoensalhien and 1’rakongsai
2005).
There is some indication, though, that, where insurance does not have universal coverage, it
can lead to widening inequity between those belonging to a scheme (typically those employed
within the formal sector) and those who do not (typically those employed within the informal
sector) (Ravindran and Maceira forthcoming)). In addition, health insurance premiums can be
inequitable when there are insufficient cross-subsidies between income and risk groups:
there is some evidence from Latin America, for example, that women are charged higher
premiums (because of the costs associated with reproduction) (Weller et al. forthcoming).
An innovative solution to such problems may be a system which is being proposed in Ghana.
This seeks to combine social health insurance for formal sector workers with district-wide
community-based pre-payment schemes. Contributions for low-income households will be
subsidised by government and donor funds, while there will be risk-equalisation between all
the individual schemes that make up, in effect, a universal national health insurance system
(McIntyre and Gilson 2005).
6.3.2 Development aid and government allocations of tax funding
The WHO Commission for Macroeconomics and Health demonstrated that the health systems of
poor countries are chronically under-funded and called for massive investment in health systems.
including a doubling of development aid over time to fund an essential package of adequate
coverage. While additional aid is sorely needed, development aid has a history of being tied to
programmes that are not necessarily national priorities or are vertical in nature (with damaging
effects on the broader health system).
Sector-wide Approaches (SWAps) have been introduced in many African and some Asian
countries to pool government and donor funds in order to replace many donor-funded projects
with on?, sector-wide programme. Under this system, national leadership needs to be
strengthened in order for governments to play a proper role in determining priorities (Walt el al.
1999) while aspects of SWAps that impact negatively on health care equity should be limited (for
example, the lack of ear-marking of pooled funds for priority services, the predominance of
financial accounting mechanisms over service delivery and quality, and the reduction of the
financing stream to non-governmental organisations, many of which service the poor (Ravindran
and Maceira forthcoming). Of some concern is the recent move away from SWAps by some
donors who favour general budget support through allocation of donor funds to Treasuries. The
ability of Ministries of Health to influence how money is spent will probably weaken under this
arrangement (McIntyre and Gilson 2005).
Increased donor interest in developing country public sectors should be matched by increased
commitment by country governments to funding the health sector out of the tax base. For
example, in the Abuja Declaration of 2001, African Heads of State committed their governments
to working towards spending 15% of government funds on the health sector (Organisation of
African Unity 2001). This is especially important given the range of problems experienced with
many other forms of financing, especially with respect to promoting equity.
21
As van Doorslaer el al (1999) showed in OECD countries, and is widely accepted in developing
countries (.McIntyre and Gilson 2005), lax-based funding generally lends to be pro-poor in ils
overall redistributive effects. 1 lowcvcr, greatly improved debt relief and cancellation is required
to enable governments in developing countries to improve the amount of lax funding available to
social services (McIntyre and Gilson 2005).
6.3.3 Vouchers and conditional cash payments
Two new and unusual forms of financing health care interventions, for which there is still only
limited evidence, include vouchers and conditional cash payments.
Vouchers provide an entitlement to a specific good or service, with the recipient usually free to
choose between a number of providers. Vouchers effectively represent a cash transfer to the
recipient and allow targeting of this transfer, usually along the lines of biological vulnerability
(Hanson, Worrall and Wiseman forthcoming). Vouchers have been used, with some success, for
insecticide-treated bed-nets for pregnant women in Tanzania (pilot experiences) and for
reproductive health services for sex workers in Nicaragua. A voucher system needs to be able to
identify needy recipients and be reasonably certain that the vouchers will not be transferred to
non-needy persons, and represents a reasonably limited intervention as far as fair financing
mechanisms are concerned.
Conditional grants, in contrast, involve payments made to households, conditional on attendance
at certain priority services, including preventive services and nutritional support, as well as
education attendance. The evidence on such payments currently derives solely from Latin
America: conditional cash payments would be inappropriate in countries where there are
insufficient resources to provide free, quality services (Palmer el al. 2004). Conditional payments
do appear to have the potential to improve the uptake of interventions (as was found, for example.
in the PROGRESA scheme in Mexico, and in Honduras and Nicaragua (Hanson, Worrall and
Wiseman forthcoming). Gertler (2004), for example, also found a significant improvement in the
health of children as a result of PROGRESA, showing that the effect of the programme increased
the longer the children stayed on the programme. A benefit incidence analysis across the three
Latin An'terican countries further found that all three programmes were relatively well-targeted at
the poor (Hanson, Worrall and Wiseman forthcoming). However, the perverse incentives that
could be generated by such programmes (such as encouraging families to have more children) are
not well understood.
i
The relative value of conditional grants versus other forms of social grant, in terms of health gain
and health care uptake, has also not yet been assessed. Yet, as evidence from South Africa shows
that social grants do generate household level health gains (Case 2001), this inter-sectoral policy
intervention may represent an equity and health promoting action that is not dependent on health
care provision and use.
6.4 Organisation of health systems
6.4.1 Decentralisation and community participation
As argued earlier, primary care, organised through the district health system, is a key strategy for
delivering care to the poor. Decentralisation to the district level has been promoted as an
organisational change that can allow local-level decision-making to enhance the responsiveness.
22
efficiency and equity of the health system. Peckham et al. (2005) comment on the limitations ol
frameworks for analysing decentralisation and concur with Bennet (forthcoming) and Kawonga,
Nunn and Maceira (forthcoming) that the evidence on the impact of decentralisation on equity is
mixed, inconclusive and context-specific. For example, Peckham et al. (2005) find that ‘there is
a lack of any real definitive evidence to support the key assumptions that have been made about
decentralisation leading to improvements and benefits in process including co-ordination,
accountability, responsibility and cost.’
Decentralisation has been somewhat successfill in promoting responsiveness, however (Peckham
et al. 2005). Decentralisation may enable citizens to acquire control over the disposal of
resources and the shaping of services, by participating in decision-making processes so that
politicians truly reflect their interests. Gwatkin, Bhuiya and Victora (2004) note that the focus
should be on ‘creating an effective demand and pressure for relevant health services on the part of
poor people, to counterbalance the influence of well-off groups that traditionally define priorities
and design programmes.’ There is however some caution that efforts to strengthen voice and
demand from poor people and communities need to be complementary , and not a substitute for,
health care systems that provide the procedural systems and arc organised to respond to the needs
of poor communities (Loewenson forthcoming, EQUINET Steering Committee 2004).
Community participation can vary in its scope, with lower orders of community participation
tending simply to seek to achieve greater outreach of health services and more efficient
management of local health services, and higher orders seeking to influence policy-making,
resource allocation and health services administration. ‘It is the higher order of community
participation, wherein community participation is seen as a citizenship right, that can strengthen
accountability to communities,’ note Murthy et al. (forthcoming). They find that ‘the nature of
accountability promoted through the participation of community as part of health sector reforms
is more administrative in nature than political or strategic in nature and more in implementation
than during design. They mainly promote accountability of health workers and providers
pertaining to inputs and outputs, than of health managers and policy makers with respect to social
relevance and impact of policies.’
Indeed, as many community participation strategies are lower order and are limited to
consultation, it is often questionable whether the poor, especially the poorest of the poor, benefit
from these strategies. Weaknesses in community participation mean that, for example, in the
field of sexual and reproductive health services, community involvement tends less to influence
the introduction of contested, new or low priority services (such as abortion) than services
belonging to The conventional wisdom,’ such as antenatal care (Murthy et al. forthcoming).
This could be explained by the fact that, in many communities, the poor have little time to
participate in activities without compensation, community structures are often controlled by
powerful elites, and there are asymmetrical relations, in terms of power and information, between
community members and health workers. Standing (1997) notes that local health committees are
often set up solely to mobilise centrally determined programmes, that participation is low
(especially amongst women), that often the interests of the most vulnerable are not represented,
and that equity considerations are sacrificed when services are confronted by other pressures,
especially rising costs. Loewenson (forthcoming) comments that it cannot be assumed that the
mere presence of participator}' mechanisms like councils and boards will yield the benefits of
community participation.
Thus, although in theory decision-making by local bodies should best represent local interests,
this only occurs when power is truly devolved to the local level and certain conditions to promote
the voice of the marginalised prevail. Murthy et al. (forthcoming) include in these conditions: the
transfer ot resources; free and lair elections to local bodies, with quotas for representation by
marginalised groups; provision for elected bodies at lower levels to be represented at higher
levels of decision-making, so as to influence policy; and the transfer of adequate information and
powers to elected representatives so that they may adequately assume their roles. Many of these
provisos relate to the problem of ensuring that local elites do not capture or distort the
representativeness and outcome of community participation initiatives. Given the weaknesses and
lack of sustainability of past health system policies to organise for effective involvement of
communities and civil society in health, this is an area where community knowledge and
experience and a significantly more systematic assessment is needed. This should be located
within the context of different types of political economies and health systems.
6.4.2 Integration
Since the 1980s, debate has raged around the relative merits of horizontal versus vertical services.
Currently, vertical approaches, whilst sometimes logistically simple and necessary in the short
term. are viewed as inefficient in the long-run (see, for example, Freedman et al. 2005). Mills et
al. (forthcoming) show how much more comprehensive and long-term are health system.
responses to the usual constraints faced by low- and middle-income countries, as opposed to
those provided by disease-specific programmes (see Table 1).
i
Integration of services for a specific population group (such as children in the case of the
Integrated Management of Childhood Illness) has gained popularity (although Briggs et< al.
(2003) note that there are too few studies to conclude that integration has a positive impact).
Doherty and Govender (2004) describe this form of integration as ‘the bundling of services across
several diseases using a common delivery technology and point of contact with the beneficiary.
In doing so. it addresses more of the burden of disease at less cost than would individual
interventions separately, improving efficiency. It also facilitates the training of health workers in
dedicated skills.’ Integration also has the potential to enhance the responsiveness of the health
system, an issue which has already been discussed.
In a review of the impact of integration initiatives around sexual and reproductive health services
in developing countries (before the advent of anti-retrovirals), de Pinho et a/, (forthcoming)
conclude that, while there is a policy shift towards integration in all countries (and particularly
amongst donors), integration has been poorly implemented. Obstacles to implementation include
the lack of political will to allocate sufficient resources, failure to achieve administrative
integration, and socio-cultural barriers such as the stigmatisation of certain services.
, I
Unger, de Paepe and Green (2003) propose strategies for implementing disease control
programmes - and a ’code of best practice' - so that they strengthen existing health systems.
This is especially important following the introduction of anti-retroviral programmes which,
unless well-integrated into the general health system, pose a threat to its sustainability by
diverting resources.
24
Table'!:
Typical health system constraints and possible disease-specific and health
system responses
Health system response
Constraint
Disease-specific response
Developing risk-pooling strategies
Financial
Allowing exemptions or
inaccessibility: inability reducing prices for focal
to pay, informal fees
diseases
Reconsidering long-term plans for capital
(Physical inaccessibility: Providing outreach for focal
investment and siting of facilities
distance to facility
diseases
Inappropriately skilled Organizing in-service training Reviewing basic medical and nursing
staff
workshops to develop skills in curricula to ensure that basic training
includes appropriate skills
focal diseases
Poorly motivated staff Offering financial incentives for Instituting performance review systems,
the delivery of particular priority creating greater clarity about roles and
expectations, reviewing salary structures
services
and promotion procedures
Restructuring ministries of health,
Weak planning and
Providing ongoing education
recruiting and developing a cadre of
management
and training workshops to
dedicated managers
develop planning and
management skills
i
Lack of intersectoral
Building systems of local government that
Creating disease-focused,
action and partnership cross-sectoral committees and incorporate representatives from health,
task forces at the national level education, and agriculture and promoting
the accountability of local governance
I
structures to the people
Poor quality care
Offering training for private
Developing accreditation and regulation
among 'private sector sector providers
systems
providers
Source:
Mills et al. (forthcoming)
6.4.3 Re-orienting health care delivery towards primary care
As already noted, there is widespread evidence to show the equity gains that result from budget
re-allocations towards primary care (see, for example, Starfield 2001, 2002 and 2005, Starfield
and Shi 2004, Shi, Green and Kazakova 2004).
In a review of relevant literature Tollman et al. (forthcoming) explain that primary care services
act as a fulcrum of a comprehensive care and support system - providing a link to programmes
working in the wider community as well as facilitating patient access to district referral services.
They identify the equity-enhancing aspects of primary care to include: physical, financial and
cultural accessibility; the provision of comprehensive, integrated, personalised and continuous
care; responsiveness to patients’ non-health needs (such as courteous and respectful care); the
role of primary care facilities as a community resource use and their focus on the the elements of
the disease burden that disproportionately affects poor people. Well-functioning primary care
level services, thus, represent the face of the health system for many and have the potential to
inspire trust in the system as a whole. However, such gains do require the provision of good
quality and responsive care, as discussed in Section 5.
6.4.4 Targeted versus universal approaches
In discussing ways of providing services, it is helpful to make a distinction between targeted and
universal approaches. Bennett (forthcoming) provides a useful summary of the features of these
different approaches (see Box 3). Hanson, Worrall and Wiseman (forthcoming) review the
experience of a number of targeting approaches, including resource allocation formulae,
contracting NGOs to provide health services in rural areas, user fee exemptions, conditional
payments, vouchers and market segmentation using self-selection. They find that programme
design and implementation issues were key to explaining observed outcomes. Additional
important factors were the incentive effects and the costs of the mechanisms.
Mills (forthcoming) uses the example of Sri Lanka to emphasise, though, that improvements in
health outcomes through targeted interventions are optimised if they operate off a basic
■platform' of functioning health sendees. Indeed. Freedman et al. 2005 argue that ‘the crux of
the problem is not just how to use resources to target a needed intervention to a population that
has low access or utilisation (what is often labelled a ‘pro-poor’ inten'ention.) Rather, the core
issue is how to create a system that encourages, supports and sustains increasing inclusion, that is,
redistribution.' This coincides with our view that, although pro-poor interventions (such as
exemptions mechanisms or targeted provision of bednets), may sometimes be appropriate in
redressing inequities, these interventions will only contribute to that goal if they occur within a
health system characterised by the ‘gradients approach’ as described in the Commission’s
framework document.
I
Box 3: The differences between targeted and universal approaches
Targeted approaches
■
1
• Direct resources at specific sub-communities.
• Have the advantage that they:
o Use limited resources carefully.
o Disrupt local economies less (e.g. the targeting of subsidized condoms or
insecticide-treated nets at poor communities avoids crowding out private
retailers).
• Have the disadvantage that they:
o Have higher administrative costs because poor households need to be ,
identified.
o May fail to identify the poorest households and to prevent leakage of
resources to non-poor households (particularly when the programme is
neither accountable nor transparent).
t
Universal approaches
• Improve the functioning of the health system altogether (in the process also benefiting
the poor).
• Have the advantage that they:
o Avoid the costs of identifying the poor.
o Secure political support more easily as they also benefit the non-poor.
• Have the disadvantage that they:
o Tend to be captured by the non-poor.
Source: adapted from Bennett (forthcoming)
6.4.5 Public-private interactions
Private providers clearly play a significant role in many low- and middle-income countries with
respect lo the provision of primary care services (Berman and Rose 1996, Palmer et al. 2003).
Private sector providers have (Ims come to be seen by governments as additional resources that
26
can alleviate the burden on public services and allow an extension of health system coverage. As
mentioned earlier, patients often prefer the private sector for a number of reasons (Khc <7 al.
2002, Mills et al. 2002, Palmer el al. 2003). Such reasons include geographic accessibility and
convenient opening hours, more favourable staff attitudes towards patients and perceived better
quality in terms of shorter queuing times, greater privacy, and quality of diagnosis, treatment and
counseling. With the introduction of user fees in public facilities, poorer sections of communities
sometimes turn to self-medication and private practitioners (see. for example, Khe et al. 2002).
Whilst private providers are often thought of in terms of curative care, there is growing interest in
the role that they could play in meeting public health objectives especially with respect to rolling
out primary care services (Mills et al. 2002). In some contexts, private sector provision of health
care is sought because the costs of public sector care are high. One of the reasons that private
providers are often able to provide cheaper services is because they are adjusted to the purchasing
power of the client, such as when partial doses of drugs are sold (Mills et al. 2002).
While the private sector is sometimes thought of as ‘homogenous and financially self-sustaining’,
in reality this sector is highly heterogeneous (Giusti et al. 1997). Not-for-profit private providers
have often been instrumental in bringing primary care to poor communities. In Uganda, for
instance, the non-governmental sector pioneered the development of primary health care
initiatives which now account for about 65 percent of the current primary health care delivery in
the country (Berman and Rose 1996). A recent review of contracting arrangements with non
governmental organizations suggests that this can be a very effective approach in rapidly
extending care to marginalised groups at low cost (Loevinsohn and Harding 2005), with many of
the anticipated difficulties of contracting not materialising.
The potential for for-profit providers to contribute to care of the poor is less obvious, however.
especially with respect to its ability to meet public health objectives. Palmer et al (2003) note, for
example, that whereas there appears to be a general perception in South Africa that the quality of
care is good (or better than at public facilities), there is evidence that suggests that ’general
practitioners often deliver care of questionable technical quality, especially with respect to the
quality of diagnosis and use of appropriate drugs’. In an international review, Weller et al.
(forthcoming) make a similar comment about the quality of sexual and reproductive health
services. Mills et al. (2002), in reflecting on the role of the private sector in low-income
countries, find that consumers of private sector primary care in these countries arc often unable to
assess the technical quality of services, tending to place more weight on aspects of perceived
quality, such as interpersonal skills of providers and the comfort of the environment in which
treatment occurs, both of which may be unrelated to technical competence.
Mills et al. (2002) argue that the effectiveness of private services is by and large also rather low:
'poor treatment practices have been reported for diseases such as tuberculosis, and sexually
transmitted infections, with implications not only for the individuals treated but also for disease
transmission and the development of drug resistance.’ For example, Chabikuli et al. (2002), in a
study of urban private practitioners in South Africa, found that ‘knowledge of recent
developments in STD syndromic management and effectiveness of prescribed drugs was poor...
and less than half the prescriptions overall were judged as effective.’
Furthermore, while public-private interactions may expand coverage and improve services for
some, there is evidence that they may contribute to worsening inequity, especially where they
involve for-profit partners (see Box 4).
27
Box 4: Ways in which public-private interactions may impact negatively on equity
•
•
•
•
<>
PPPs tend to be based in commercial centres, and do not reach remote communities.
This is even true of social marketing projects, and means that public and donor subsidies
are 'captured' by more urban people in higher income groups.
Many forms of PPP, including some that involve not-for-profit providers, only serve those
who are able to pay. Out-of-pocket payments are particularly inequitable in that they
require lower-income groups to pay proportionately more than high-income earners.
Because of the financial burden they place on poor families, they also delay visits to
health services.
PPPs can reduce - rather than free up - resources available for providing essential care
to the indigent. At the national level, this is evident when donor funds are diverted to
PPPs. At the international level, it is evident with the current focus on infectious disease
programmes, rather than other components of sexual and reproductive health services.
Differentials in care are experienced between paying and non-paying patients, such as in
hospitals with private wards, and in cases where fees are charged for diagnostic services
and drugs.
The presence of an active private sector contributes to the ‘brain drain’ of personnel from
the public sector.
Source:
Ravindran and de Pinho (forthcoming).
Given such problems with quality, effectiveness and equity, as well as the financial incentives
that operate in the for-profit sector, governments need to be cautious about setting up pub’icprivate partnerships for health care provision to the under-served, especially in the case of the forprofit sector and where government’s capacity to manage contractual arrangements is weak (this
is discussed further in a later section looking at management and regulation). Private providers
(including the for-profit sector) may be able to make valuable contributions in specific contexts.
Positive examples relate to the distribution of bednets for malaria (Hanson, Worrall and Wiseman
forthcoming) and management by general practitioners of conditions of public health significance
(such as sexually transmitted infections and tuberculosis). However, public-private interactions
should preferably occur within the context of strong over-arching government policies .on
engagement with the private health sector and strong regulatory frameworks. It is important that,
where public health systems are weak, the private sector does not gain ground at the expense of
the public sector, with potentially serious consequences for costs and equity.
6.5 Human resources
The Joint Learning Initiative (2004) provides an extensive analysis of the human resource
situation in the health sector in developing countries, and the challenges that need to be overcome
in ensuring that service provision is sustainable. The report notes that all the countries reviewed
’suffer from numeric, skill and geographic imbalances’ and that ‘improving within-country equity
requires attracting health workers to rural and marginal communities - and retaining them.’
I iealth workers are also distributed inequitably between the public and private sectors, while
international inequity is worsened by ‘unplanned international migration, with the loss of nurses
and doctors crippling health systems in many poor sending countries.’
Improving the human resource situation in low- and middle-income countries is clearly an urgent
priority if their health systems are not to be further undermined and inequity worsened. This is
particularly so given the HIV/AIDS epidemic and mounting international efforts to deal with this
and other diseases: while these efforts provide an opportunity to improve human rcsources for
28
health, they also threaten to overburden the health systems of developing countries (Gilson and
Erasmus 2005, Freedman et al. 2005).
The host of pertinent human resource strategies is not reviewed here. Instead, four speci lie
strategies are singled out because they relate directly to equity (acknowledging that many other
factors affect equity indirectly). Specific emphasis is given to public health systems as these
continue preferentially to serve the poorest communities in any country (despite some use of
private care providers). The strategies considered are: tackling the absolute shortages of human
resources experienced in the public sector; reviewing the appropriate mix of cadres and skills;
addressing the factors encouraging international migration: and tacking action to promote the
retention and productivity of healtlt workers particularly in rural areas. These responses need to
be shaped in ways that neither punish workers nor leave poor communities unfairly underserved.
Work in east and southern Africa signals that, while generic approaches may be outlined, these
need to be configured into different policy mixes in different countries, together with measures to
strengthen institutions and capacities for policy implementation (Padrath et al. 2003, Gilson and
Erasmus 2005).
Given the existing problems, one clear requirement is to increase the number of health workers in
the public sector and their distribution to levels of the health system where demand and
workloads'are highest. Recently, Karnowski et al. (2004) investigated the human resources
required at: the district level to implement the package of services recommended by the
Commission for Macro-economics and Health (CM 11) in Tanzania and Chad, both currently and
in 2015. Their model was based on need for health care, adequate service coverage, intervention
specific tasks and staff productivity and, for future human resource availability, included current
human resource availability, training capacity and attrition. They found that ‘future human
resource availability was grossly insufficient to meet the human resource requirements necessary
to scale ,up priority interventions to the scale recommended by the CMH.’ The largest gaps
existed m staff with nursing and midwifery skills. This severe shortage of human resources is
likely to be the pattern in many Sub-Saharan countries, which means that there needs to be a
massive-programme to train appropriate cadres in order to be able to deliver the basic package in
future.
Clearly it will be important to examine alternatives to doctors and professional nurses: mid-level
and auxiliary workers are likely to be less expensive to train, produced more quickly and able to
deal with many conditions adequately, and may be more likely to stay in the public health sector.
especially wl en they are recruited from the local community and have qualifications that are not
recognised internationally (Freedman et al. 2005, Hongoro and McPake 2004). Although there is
some experience of such cadres, for exampie in Tanzania, very little detailed evaluation of their
potential in an equity-promoting strategy is available. Skilled birth attendants are particularly
important to develop (Freedman et al. 2005), as are community health workers, especially with
the emergence of chronic diseases, and both have particular roles to play in reaching marginalised
communities. Both sets of cadres are essential in ensuring the re-orientation of health systems
towards primary care that has already been noted as a key strategy in tackling inequity. However,
past experience of birth attendants and community health workers indicates the importance of
ensuring that they are given tasks for which they are appropriately skilled, well supervised and
managed, and appropriately remunerated. Sustainability of community health worker
programmes is also linked to adequate resourcing of the entire programme in which they work
(Freedman et al. 2005, Walt 1990). In some cultures, such workers are also essential to
overcoming die cultural barriers faced by women in accessing care (in some Muslim societies, for
example, women cannot easily travel alone, mix with men or visit male health workers). Finally,
expanding the number and skills mix of lower level cadres (who are mainly women) could
29
improve gender equity in employment, although government should avoid shifting
responsibilities onto unpaid communitv health workers and women carers in the home (Standine
1997).
There is a growing literature on international migration, including Martineau, Decker and
Bundred (2002), Buchan. Parkin and Sochalski (2003), Padarath et al. (2003), Physicians for
Human Rights (2004), Freedman et al. 2005. and Global Health Watch 2005-2006. These
analyse a variety of ’push' and ‘puli’ factors that impact on the movement of healthcare workers.
arising both within and beyond the health system. Factors endogenous to the health care system
(push factors) are low remuneration levels, work-associated risks including diseases like
111V. A1DS and TB. inadequate human resource planning with consequent unrealistic work loads.
poor infrastructure and sub-optimal conditions of work. Exogenous ‘push’ factors are also noted,
including political insecurity, crime, taxation levels, repressive political environments and falling
service standards. Movement is also influenced by pull factors, including aggressive recruitment
by recipient countries, improved quality of life, study and specialisation opportunities, and
improved pay. These push and pull factors are mitigated by ‘stick’ factors in source countries,
which lead to greater personnel retention, including family ties, psychological links with home,
migration costs, language and other social and cultural factors. ‘Stay’ factors influence decisions
to remain in recipient countries and influence rates of return of personnel. These include
reluctance to disrupt family life and schooling, lack of employment opportunities in the host
country and a higher standard of living in the recipient country (Padrath .et al. 2003).
A second set of urgent actions, therefore, revolve around reducing ‘pull’ factors for migration,
essentially through international agreements to limit recruitment from developing countries. The
effectiveness of such action is, however, not yet clear. One linked set of discussions focuses on
the possibility of reparations to compensate developing countries for their human resource loss,
reparations which could then be used for expanding domestic training, for example,. A second set
of linked discussions focus on encouraging the return to their home countries of those currently
working in the North. Such a return might be encouraged on patriotic or personal grounds and
could be facilitated by financial support or revisions to human resource systems that allow
migrant workers to freeze their pensions during periods abroad and then renew payments into
them on their return.
The third set of urgent actions in the human resources field focus on addressing the ‘push’ factors
that encourage migration and are linked to the actions needed to improve staff recruitment,
retention and productivity in the public sector (Hongoro and MePakc 2004). Essentially policies
in this area need to focus on valuing health workers (Freedman et al. 2005; Global Health Watch
2005-6). Many of the policies relate to providing incentives, including some combination of both
financial and non-financial incentives. The latter range from improvements in working ■
environments and better access to housing and other living conditions improvements, to the
feelings of being recognised, appreciated and cared for that result from strong human resource
management procedures and positive interactions with community members and patientls. Little
evidence is yet available about the impact of different incentives on health worker motivation and
performance (Gilson and Erasmus 2005).
‘
'
However, the notion of ‘workplace trust’ allows specific investigation of the influence of the nonfinancial incentives arising from personal relationships over health worker motivation (Gilson,
Palmer and Schneider 2005). This workplace trust is built up through trusting relationships
between: colleagues (which is rooted in shared experiences and values, and enhanced by effective
teamwork); health workers and their supervisors (which is linked to personal behaviours and is
inter-linked with trust in the employer); and between health workers and their employer (which is
30
based on the style of organisational leadership and the nature of human resources management,
especially procedural justice in decision-making and constancy).
There is so,me evidence from the developed world, that such trust may contribute to motivation
and, in rum, to improved health worker performance. There is also some suggestion that
workplace trust can contribute to the development of a strong client orientation in worker
behaviour and improved trust between health workers and patients (Gilson, Palmer and
Schneider 2005). It may, therefore, be possible to build a virtuous cycle of workplace trust and
patient-provider trust, enhancing the responsiveness of the health system to all patients and so
tackling the inequities that result from, for example, poor health worker attitudes and behaviours
towards, in particular, patients from poor and marginalized groups. This adds a new dimension to
understanding how human resources may impact on equity, and acknowledges the importance of
focusing on the human rights and livelihoods of health care workers in building equitable health
systems (Freedman et al. 2005, Global Health Watch 2005-06).
It is also important to consider the gender-based experience of health workers and, as reflected
within its own institutional character, the health system’s influence on health system inequities.
Standing (1997) notes ‘the interlinking and reinforcing nature of gender, class and professional
status' within the health system, leading to the dominance of senior positions by men. Mumtaz et
al. (2003) identified, in a study of women community health workers in Pakistan, that female
health workers face ‘abusive hierarchical management structures, disrespect from male
colleagues, lack of sensitivity to women’s gender-based cultural constraints, conflict between
domestic and work responsibilities, and poor infrastructural support.’ The implication for this is
that the health,system needs to develop a more supportive style of management that encourages
women health workers to exercise their ‘voice,’ develops career paths for women, takes account
of gender-based constraints in organisational issues, and expects respect for women health
workers from' male colleagues. Such actions, together with measures to enhance dialogue between
communities and health workers may, then, create environments that facilitate fairer treatment of
patients.
A final set of human resource policy actions to consider focus on the role of private sector
providers. Given the absolute human resource shortages being faced in the public sector, one
approach to improving human resource availability might be to contract private providers to work
within public facilities or to provide care to poorer patients. Few studies have examined this
option in any detail. One from South Africa, reflecting the discussion in an earlier section,
identifies problems in the quality of private provider care and highlights the difficulties of
managing such contracts effectively (Mills et al. 2004).
Two final important points to note in relation to tackling human resource problems are, first, that
such action will require strong governmental leadership and multi-sectoral action: the health
sector cannot address the problems by itself (Gilson and Erasmus 2005, Freedman et al. 2005).
Second, national action must be supported by international action to address the factors pulling
health workers to migrate, including addressing the influence of trade and health policies such as
the General Agreement on Trade and Services.
6.6 Public sector management and regulatory capacity
Public sector management capacity tends to be weak across the developing world. This
contributes to inefficiencies, to the malaise felt by front-line health workers, and to difficulties in
implementing change. Gilson (2003) notes that reforms in the 1990s to improve management.
31
termed 'the New Public Management,’ have been criticised ‘for endangering the trust and long
term co-operation between client/patient and provider critical to the effective delivery of health
and welfare services, by replacing high trust relationships between employees and managers with
low trust ones.' Khaleghian and Das Gupta (2004) describe a wider number of the features of the
New Public Management and show how these arc not always applicable to essential public health
functions. They suggest that government bureaucracies should rather concentrate or, building
management capacity, improving accountability (both hierarchicallywirhin government and
externally to the public), and improving the organisational climate. This last point is echoed by
Blaauw et al. (2003) who assert that too little attention has been paid to what they call the
’software’of health systems, namely their organisational cultures, as opposed to the hardware
(such as physical infrastructure, number of personnel and drugs).
It is important to note that management transformation is key to the process of strengthening the
capacity and the legitimacy of the state. This means that, apart from equipping managers with
technical skills backed by operating systems, it is important to equip them with skills that help
them to build trust, shift the organisational culture, develop organisational relationships and
networks and strengthen engagement with the public (Blaauw et al. 2003, Gilson 2003).' This
includes redressing inequities that afflict the workforce itself, including gender issues. The aim
would be to encourage a values-based style of management that is particularly committed to
serving the needs of the poor and marginalised. The form of management required in the public
sector generally has, thus, considerable differences from that required in the private sector.
However, few of the plethora of management training and strengthening approaches that have
been undertaken in developing countries have taken this issue seriously. Neither have they been
effective in developing the more technical skills of resource and service planning and
management. Often funded by external sources they are generally too limited in scope and too
short-lived to have much effect (Global Health Watch 2005-06).
Apart from improving management within its own ranks, government needs to strengthen its
stewardship role: this was one of the strong messages in the World Health Report of 2004
(World Health Organisation 2004). In this capacity, and given the existence of multiple private
providers, governments must specifically build their capacity to regulate the private sector to
ensure that societal goals are not jeopardised - but are preferably enhanced - by its actions. Such
regulation may partly occur through contractual arrangements. However, governments also need
to build their capacity to manage such arrangements as governments tend to perform this function
badly. Indeed, given existing capacity constraints, Mills et al. (2001) suggest that the radical and
wide-ranging reforms envisaged by the New Public Management are not an appropriate strategy
for low income countries. They propose, instead, more gradual reform processes that encourage
necessary improvements in capacity to be built over time.
[
7. BUILDING HEALTH SYSTEMS BASED ON EQUITY
AND SOCIAL JUSTICE: MAINTAINING THE POLICY
SPACE
' ,
<
National health systems founded on values of equity, solidarity and redistributive justice'may
reflect nonnative values, and value and entitle citizens, in ways that differ from other nafional and
transnational systems operating within wider economic contexts, including market-oriented
macroeconomic policies, conllicl and globalisation. Indeed, health systems may provide an entry
32
poinl lor broader societal transformation in the interests of pool and marginalised people, both
through Structural and cultural or value-drive change (freedman el al. 2005). I his section focuses
on how to realize this potential of health systems. Wc note that this is not simply a technical
process structured around evidence. It is one based on values, where there arc likely to be
competing interests, and that demands political, health sector and social leadership.
The literature on how policy-makers can maintain the space - at global, national and local levels to build health systems based on values of equity and social justice in the face of broader forces
such as market reforms, conflict and globalization, is scant but growing. Much of it has emerged
as a result of critiques of healtli sector reforms in the 1990s which are characterized as largely
technocratic in character and founded on a neoliberal ideology that elevates the role of the private
sector (see, for example, Global Health Watch 2005-6, Ravindran and de Pinho forthcoming).
This body of literature suggests a number of strategies that re-assert the importance of the state in
securing health, and emphasize the importance of values and community views in shaping the
health system.
7.1 Strong political support for the notions of equity and social
justice
In many countries during the last decade of the last century, the notions of equity and social
justice appeared to be in abeyance as governments grappled with the problem of resource
shortages (through introducing user fees, for example, at the expense of equity). Experience has
shown that the principles of equity and social justice need to be brought to the fore and to be
made a concern across the whole of government to ensure that government policies do not, even
inadvertently, aggravate inequity further. This will require leadership from the health system to
manage actors inside government, across different sectors, and outside government to create
support for, and take advantage of, windows of opportunity to introduce change. It also requires
that political leadership at higher levels enable and reinforce these processes. Some examples that
signal the critical importance of political factors in achieving equity-promoting change are
discussed below.
Sri Lanka is an example of a country that, for many decades, has explicitly upheld equity as a key
driver of its policies, resulting in excellent health outcomes relative to its GDP. In Sri Lanka, the
government has assumed the responsibility of providing universal health care free at the point of
entry, has established an extensive network of public health services, and ensured that hospital
care is available'for catastrophic illness. The reasons for Sri Lanka's success include (McNay,
Keith and Penrose 2004): cultural, social and historical reasons (such as relative gender equality.
democracy, consensus on national priorities); synergies between health and other policies
(including free education, subsidization of food, improvements in water and sanitation); and
policy decisions in health which, in many ways, ran counter to the received wisdom of the
international community (including an emphasis on public financing of inpatient rather than
outpatient care, the creation of a motivated and trained workforce, and the rejection of cost
recovery as a financing policy).
Like Sri Lanka, China, Costa Rica, Cuba and the Indian state of Kerala have also achieved
remarkable improvements in health outcomes. With Sri Lanka, they shared five common social
and political factors: historical commitment to health as a social goal; a social welfare orientation
to development; community participation in decision-making processes relative to health;
universal coverage of health services for all social groups; and intersectoral linkages for health
(Halstead; Walsh and Warren 1985, Commission on Social Determinants 2005a). However, al!
t
33
of these countries' health systems have proved vulnerable to external shocks and domestic
political change (Commission on Social Determinants 2005a).
'
The Brazilian Government has underpinned its policies aimed at universal comprehensive and
redistributive health services with a constitutional provision of the right to health, its a means of
enabling social and legal processes to secure the principles of the system against encroachment
from contrary political influence and economic policies.
Mexico City is an example of a city which recently embraced notions of equity and experienced
considerable success in providing free health care and drugs to the poor, and food support to the
elderly (Laurell, Zepeda and Mussot forthcoming). The free health care programme covered 65
percent of the target population after only three years. Unfortunately, the literature does not yet'
analyse what facilitated the introduction of these new policies by the new city council when prior
governments had focused on pro-market policies and small-scale, targeted programmed, although
the election of a new political party was certainly a critical factor. The paper by Laurell et al
(forthcoming) signal that many of the initial gains were made by a redistribution of available
resources within the public social welfare system, and that the mobilisation of new resources
from economic activities was more difficult to lever. Interestingly, the successful experience of
Mexico City occurred within a health system which in general had little impact on fair financing,
quality of care and democratic governance, although had instituted reforms in the late 1990s that
had some impact on access by the poor to health care (Gomez-Dantes, Gomez-Jauregui and
Inclan 2004).
Unfortunately ihe available health literature about these experiences suffers from four key
weaknesses. First, there is; limited attention to constructing a ‘typology’ of states in terms of
governing principles and the organisation of power, that would be useful in explaining why some
countries are able to carry forward equity-promoting change while others are not. Second,
although some literature is emerging, there remains little understanding of how to build, organise
and consolidate the political support for equity and social justice where states are weak,
particularly in the many conflict and post-conflict settings of Africa. Third, there is little
examination of the particular strategies used in managing the powerful national anq local level
actors influencing health systems that are commonly resistant to equity-promoting change (such
as medical professional organisations, the pharmaceutical industry and, even, locally powerful
leaders). Fourth, little connection is generally made to the wider literature examining how states
have managed socio-economic development more generally. Yet such literature has important
lessons for the health sector. For example, from analysis of ten countries’ experience in
eliminating hunger and deprivation, Dreze and Sen (1989) conclude that across two very different
development strategies (growth-led vs. support-led security) the two common features of positive
experience were the extensive use of public provisioning to enhance living conditions, and
marshalling the diverse sections of the population in the process of social and economic
transformation (see the next section on this last issue).
i
1 lowevcr, it is possible to identify two major challenges to establishing the policy space:required
to implement pro-equity policies. The first derives from international public policies that weaken
or distort the national long-term measures needed to make and secure universal systems] For
example the New Public Management approach, referred to earlier, was introduced throiigh
health care reform proposals in the 1990s and emphasised a greater role for private'provision and
finance with the state merely providing the safety-net for the poorest (Koivusalo and Mackintosh,
2004, Mills et al 2001). These policies were actively promoted and supported with aid resources
despite knowledge that tiering or segmenting services according to ability-to-pay reinforces
I
34
existing inequalities, and undermines the ability of the health system to promote inclusive and
universal access to health care according to need.
The increased commercialisation of health services initiated through some of these reforms is
reinforced by a second policy pressure that further narrows the space for national policy-making.
This is the increasing role of the World Trade Organisation agreements in services and healthrelated policy. For example, a country that has opened its market to financial services, including
foreign insurance firms providing health insurance, may find it more difficult to implement a
redistributive;, universal social health insurance scheme, reinforcing societal segmentation. I hus,
there are debates as to whether, in practice, there is the policy space and capacity for states to
ensure that in any conflict between limits posed by trade agreements and public health
obligations., the latter are respected and honoured. The impacts on health of new trade
agreements such as the General Agreement on Trade in Services (GATS) is still relatively
unaudited and unknown: it is understood that these pressures will be more thoroughly discussed
in the knowledge network on globalisation and health.
7.2
Inter-sectoral action in support of health equity
The adoption of the Health for All strategy in 1978 marked a forceful re-emergence of social
determinants as a major public health concern, explicitly stating 'the need for a
comprehensive health strategy that not only provided health services but also addressed
the underlying social, economic and political causes ofpoor health ' (original
emphasis). The PHC philosophy incorporated: a commitment to shift health resources from urban
hospitals to meeting the basic needs of rural and disadvantaged populations; confronted 'medical
elitism,’ or reliance on highly specialized doctors and nurses; and made an explicit linkage
between health and social development. PHC included among its pillars intersectoral action to
address social and environmental health determinants. The Alma-Ata declaration specified that
PHC 'involves, in addition to the health sector, all related sectors and aspects of national and
community development, in particular agriculture, animal husbandry, food, industry, education,
housing, public works, communication, and other sectors; and demands the coordinated efforts of
all these sectors.’
During the 1980s, the concept of intersectoral action for health (IAH) took on increasing
prominence, with 39th World Health Assembly discussions including working groups on: health
inequalities; agriculture, food and nutrition; education, culture, information and lifestyles; and the
environment, including water and sanitation, habitat and industry. The 1986 Ottawa Charter on
Health Promotion then identified eight key determinants ("prerequisites") of health: peace,
shelter, education, food, income, a stable eco-system, sustainable resources, social justice, and
equity. It was understood that this broad range of fundamental enabling factors could not be
addressed by.the health sector alone, but would require coordinated action among different
government departments, as well as among nongovernmental and voluntary organizations, the
private sector and the media.
According to the Commission’s background paper, while a formal commitment to IAH became
pan of many countries' official health policy frameworks in the 1980s, the track record of actual
results from national implementation of IAH was poor (Commission on Social Determinants
2005a). The paper attributes this to countries attempting to implement IAH in isolation from the
other relevant social and political factors supporting this framework, namely: broad commitment
to health asa collective social and political goal; the crafting of economic development policies
to promote social welfare; community empowerment and participation; and equity in health
1
.35
services coverage. Further. IAH was weakly supported by decision-makers in other sectors who
complained that health experts were often unable to provide quantitative evidence on the specific
health impacts attributable to activities in non-health sectors such as housing, transport,
education, food policy or industrial policy, particularly given the complexity of causal networks
and time lags in producing these effects. This was compounded by institutional factors such as:
vertical boundaries between sections in government: integrated programmes often seen as
threatening to sector-specific budgets, direct access of sectors to donors, and sectors' functional
autonomy; the weak position of health and environment sectors within many governments; few
economic incentives to support intersectorality and integrated initiatives; and government
priorities often defined by political expediency, rather than rational analysis.
in recent years in the developed world, however, integrated planning by different sectors, in the
interests of health has gained ground. Sweden and Britain under the Labour government stand out
as countries that have taken a social determinants of health approach to government policy
(Canada is another example although, more recently, the strength of this approach may be
declining) (Commission on Social Determinants 2005a). In Sweden, policy is based oma culture
of solidarity that makes equity a central and explicit aim. National health objectives are targeted
at determinants rather than health status, and a variety of sectors is involved in the process of
health policy development from the early stages. The British approach is distinctive for
'simultaneous emphasis on broad redistributive efforts coordinated at national level and on
locally managed area-based initiatives’ (Commission on Social Determinants 2005a). For
example, income, employment, education, early childhood development, and regeneration
initiatives are combined in disadvantaged areas through ‘Health Action Zones’ involving
partnerships between government, the private sector and communities that develop innovative
ways to reduce health inequalities, breaking through organisational boundaries.
The growing emphasis on the inter-linkages between health and economic development at a
macro-level (Commission for Macroeconomics and Health 2001) may also provide an entry point
for renewed intersectoral action in developing countries. In addition, the integration of health
across sectors has increasingly come to be seen as part and parcel of sustainable development
(see, for example, Harrison, Flynn and Brown 2004, who provide a list of the capacjitics - in
terms of infrastructure, processes and tools - required to achieve this integration effectively).
However, as the Commission’s background paper (Commission on Social Determinants 2005a)
notes, one of the biggest problems in achieving intersectoral action for health in developing
countries is achieving sustainable co-ordination across different government sectors (and even
across different sections in health ministries), especially in the local government sphere.
Blaauw et al. (2004), in looking at governmental relationships and HIV/AIDS sendee delivery in
South Africa, note that 'there is a tension between achieving short term delivery objectives through mechanisms such as centralization and verticalisation - and broader, more.long term
developmental goals - such as the strengthening of the local sphere of government.’ They
emphasise, too, the importance of‘coordination of coordination' mechanisms and activities.
including the development of shared values between different parts of government. Gilson and
Erasmus (2005) meanwhile highlight the barriers to achieving the coordination resulting from the
different mindsets of different sectors of government. From experience in Africa, they argue that
Ministries of Health generally play a weak role in encouraging the intersectoral action necessary
to underpin health human resource policy implementation. This weakness reflects the different
mindsets and language of. say, health anti finance ministries, the weak capacity for human
resource planning and management within Ministries of 1 Icalth and the generally complex nature
36
of health system governance in any country that have themselves been subject to massive reform
over the last ten to twenty years.
In general, the literature on inter-sectoral action remains primarily descriptive with few clear
conclusions on how to bring about effective action. A central task of this knowledge network will
be to document positive experiences of how the health system has been able to encourage and
lever action on health across the whole of government so that we are able to draw stronger
conclusions about the actions necessary to initiate and sustain such action. We would also seek to
understand the political environments and health sector actions that have facilitated and sustained
such actions across government. Examples of this include:
1. making health a priority across government: examining examples of high level political
leadership (that is, at the level of the executive), levels and patterns of national resource
allocation and earmarked funding mechanisms for health such as the President’s Special
2.
3.
Intitiave on Human Resources for Health in Zambia and Brazilian taxes on finance
transactions allocated to health;
integrating health in other sectors or joint service provisioning (for example, health impact
assessment and management in investment and trade programmes, sectoral co-operation in
environmental and occupational health; work on integration of actions on HIV and AIDS
across sectors); and
political processes and institutions that build integration, such as parliamentary roles in
budgeting and policy oversight.
7.3
Strengthening the voice of the poor to make claims and
government legitimacy
Health sector reforms in the 1990s encouraged bigger roles for the private sector in providing
health care services. This was partly in response to perceived inefficiencies and poor quality care
in the public sector. However, the disappointing performance of the private sector has redirected
focus on the central role of the state not only in regulating care, but also providing services (for
example, Freedman et al. 2005). The state will be most effective in carrying out this role when it
is viewed as legitimate and is trusted by its citizenry, and when its autonomy is protected in the
face of powerful international interests, including those of aid agencies and multinational
corporations. This last point - the preservation of government autonomy - was referred to briefly
in earlier sections on priority-setting and stemming the brain drain. However, full treatment of
the topic is not possible here, given the vast literature on donor aid, as well as the influence of
multi-nationals (little of which is linked directly with issues of health system equity). This is also
a potential overlap area with the knowledge network on globalisation.
Going back to the issue of state legitimacy, Gilson (2003) proposes that trust - within the
management structures of the health system, between providers, between providers and patients.
and between patients and the system as a whole -plays an important part in conferring legitimacy
on the state. Russell (2005) also notes that in Sri Lanka, for example, the fact that the state has
clearly taken on the responsibility of making universally available health care free at the point of
delivery has built the foundation for public trust in the state, and contributed to the success of, for
example, public financing arrangements. Recognising ‘the still slim but growing body of
multidisciplinary research and literature in this area,’ Freedman et al. (2005) specifically suggest
that public trust and government legitimacy can be enhanced by policy actions that improve
access to health care, reinforce the commitment to health as a right and improve health resource
allocation to under-served areas.
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37
At the same time, they emphasise that in order to promote equity, such actions must be complemented
by steps to strengthen the voice of the poor and marginalized to make claims of entitlements. Such
entitlements reflect commitments made by the state to its citizens in terms of, for example, access to
and quality of care. As an entitlement, health care access is a right of all citizens, not a gift given bv
those who are powerful. Claims to health rights are asserted through social action, through formal lettal
or regulatory mechanisms and through procedural systems that build relationships between citizens and
the state and through which mutual obligations of entitlement and accountability are expressed
(Freedman el al. 2005). London (2004) has pointed out that the social rights to healthlof poor
communities are more likely to be claimed through collective political and social action, given the weak
access such groups have to legal and procedural mechanisms.
To strengthen the claims of poorer communities states and non-govemment organisations have
taken, sometimes complementary, action including documenting and publicising inequities in
health and health care between population groups; acting as watchdogs overhealth service
performance: overseeing policy implementation; developing and promoting patients charters;
seeking legal redress through court action; establishing essential health care entitlements;
promoting consumers' rights movements; and establishing effective mechanisms for including
public participation and involvement in health facility management.
Many of these actions can also be considered mechanisms of accountability. As such they also
confer state legitimacy (and, of course, a prerequisite for accountability is the proper functioning
of democratic institutions). Accountability includes two elements, ‘answerability’ of those who
hold power to citizens and ‘enforceability’ of penalties in the event of failure to do so (Murthy el
al. forthcoming), and can be applied to the political, financial and administrative domains.
Accountability can also either be horizontal (that is, between sections of government) or vertical
(that is. between government and the community).
Accountability and community participation strategies that have been attempted, both by
governments and by civil society, across the developing world, include a diverse range of
activities (Murthy et al. forthcoming): constitution of permanent or time-bound stakeholder fora
for policy formulation and-monitoring of implementation; holding of consultations with
stakeholders on policy; decentralisation of health management; promotion of community
financing; formation of community health structures for managing local health clinics and
hospitals; client regulation through patients’ rights charters; self-regulation by professional
associations; health superintendency (oversight) by government; placing of advertisements in
media and holding of public hearings around public inputs on proposed policies; creation of task
forces to strengthen health service accountability; pressure from below on health policies,
legislation and their implementation; consumer protection acts, consumer forums, ajid public
interest litigation; ombudsmen centres; audits into, for example, mortality; right-to-information
campaigns; and citizen monitoring of health expenditure and quality.
While field studies have found these mechanisms to enhance public involvement in health
systems, they also report a number of factors constraining their representativeness, performance
and power. These include: weak participation from the poorest groups, limited access to
resources, information and training, resistance from health professionals who perceive them as
interfering in primarily technical decisions and weak formal authority (Loewenson et al 2004,
Ngulube et al 2004). The same problems have been found to affect participatory mechanisms
(such as committees and boards) in a range of studies (Kahassy and Baum 1996, Ri'fkin 2003,
Bennett et al 1995, Gilson et al 1994, Mubyazi et al 2003, Macwangi et al 2004). Programmes
that aim to build participation thus explicitly recognize and deal with such barriers, and clo so in tt
iI
1
38
sustainable and consistent manner to build more meaningful forms of participation, particularly
for poor communities (Rifkin 2003).
Such probleins indicate that accountability mechanisms and forms of participation are located
within the wider framework of relationships and interactions between the state and society, and
the wider context of how power is exercised. Sen (1990) proposes that such public action should
be seen in a broad perspective to include not only what is done for the public by the state, but also
what is done by the public for itself by demanding state action and through making governments
accountable, .Such action is argued to promote the political incentive for governments to be
responsive, caring and prompt. Thus, the public is both beneficiary and primary instrument.
However, these relationships between citizen and state are changing, as are the values that inform
them. They are differently expressed and organised in state-driven welfare systems organised
around principles of solidarity, universality and equity, than in systems built on flexible labour
and liberalised markets (Navarro et al. 2003). For example, trends towards commercialisation of
health services through fee charges and privatisation of essential health-related services like waler
supplies is reported to have changed the status of communities - from citizens with public rights
and responsibilities into consumers with market power, or lack of it. This weakened the ability of
poor communities to demand and access such services (Municipal Services Project 2004, Van
Rensburg and Fourie 1994). In these circumstances there is evidence that it is the more powerful
medical interest groups, or the wealthier urban elites, who have been able to exact concessions
under diese reforms, sometimes at the cost of poorer, less organised rural health workers, or the
urban and rural poor (Van Rensburg and Fourie 1994, Bennett et al 1995).
This has raised new debates around how to strengthen the voice of poor communities in health.
While the primary focus for communities is at national level, marginalized communities now also
need to gain a voice in systems where decisions affecting health and livelihoods are made beyond
the national level in global institutions and exchanges, and within the boardrooms of foundations
and multinational companies. What forms of state-citizen interaction and what vehicles of state
authority can speak with, rather than only speak for, such communities, and in so doing
strengthen the accountability and authority of states? What forms and rules of fair process are
needed to give voice and weight to the health claims of poor communities within this
environment? (Kalumba 1997, Lafond 1991, Storey 1989).
7.4
Constructing values-based health care systems and
preventing excessive fragmentation
While nluch of the equity-focused health system literature focuses on how to improve access for
the poor, especially through government services, a parallel body of literature focuses on how to
expand the size and use of the private sector, partly to relieve government services from the
burden of providing for the rich, and partly to provide alternatives to government services for the
poor, especially where there is poor access to state services or where the quality of public sector
services is low. Indeed, as mentioned in an earlier section, poor populations are accustomed to
dealing with a pluralistic pattern of health providers, choosing to use private providers for
selected conditions.
However, in a new book, Mackintosh and Koivusalo (2005) present evidence on the relationship
between healthy life expectancy and private and public health care expenditure as a percentage of
total expenditure. This evidence indicates that healthy life expectancy is significantly higher,"and
child mortality is significantly lower, in countries with lower levels of private health expenditure
relative to public expenditure, after allowing tor level of economic development and the influence
39
of AIDS in sub-Saharan Africa. In addition, countries that spend proportionately more of their
GDP through public expenditure or social health insurance have significantly better health
outcomes in terms of healthy life expectancy and child mortality. Higher income countries have
better health outcomes both because of their higher incomes and because they have higher levels
of public health expenditure. In contrast, countries that devote a higher proportion of their GDP to
private health expenditure do not display better health outcomes in these terms even after
allowing for the effect of higher incomes on health outcomes. Finally, they present other analyses
of Demographic and Health Survey data across 44 low and middle income countries which show
that greater levels of government health expenditure as a percent of GDP are associated with
better access to care for the population.
The latter findings echo earlier analyses of financing systems in OECD countries which
concluded that countries with health care systems funded largely through private financing
intermediaries have particularly regressive systems, whereas those funded primarily by social
insurance were moderately regressive and those from taxes, were either progressive or mildly
regressive (van Doorslaer. Wagstaff and Rutten 1993).
Drawing on a wide range of country experiences, Mackintosh and Koivusalo (2005) go on to
raise strong concerns about the commercialisation of health care systems that has resulted from
the growing role of private sector financing mechanisms. They analyse commercialisation as
occurring through three main pathways, depending on the economic development of a country:
1.
Informal commercialisation in low-income primary care. This is the pre-dominant form in
most low-income countries in Sub-Saharan Africa and South Asia, and in the Asian
transitional economics. It is represented by private, small-scale, largely unregulated
provision, especially for the poor and lower middle-income groups living in urban areas. It
includes the unlicensed and off-prescription sale of drugs. This type of care is usually
financed by out-of-pocket payments (which arc regressive), and generates incentives for
unethical practice.
2.
Corporatisation and segmentation in middle-income hospital care. This is occurring to a
lesser extent than suggested by the high profile accorded to these developments. !
Corporations tend to be reluctant to sustain ownership and provision of hospital care, and
recently there has been extensive profit-taking, risk-shedding and corporate exit from this
3.
sector. These markets therefore tend to be financially fragile, with firms continually looking
towards opportunities for public contracting and subsidies.
Globalisation in input supply and labour markets in the health sector. In contrast to the
hospital sector, this is strong and increasingly dominant in medical technology and
pharmaceuticals. Multi-national corporations have had a strong influence on international
policies on trade in goods and intellectual property rights, with a view to protecting corporate
interests (and in many cases strengthening monopolies), with negative implications for access
to drugs in developing countries. Recent increases in the migration of health workers from
developing countries is undermining both the staffing and the financial sustainability of
developing country health systems.
They identify the pressures towards increasing commercialisation as including: at a global level,
international market integration, new incentives for international investment and international,
regional and national regulatory changes that encourage corporate restructuring; economic crises
in many developing countries; at a national level, the encouragement of public-private
partnerships, partly as a result of international health policy and partly as a result of
commercialisation of national health systems; the legitimisation of high levels of out-of-pocket
I
40
spending (even by the poor) as a result of health sector reforms in the 1990s; and the rapid
integration and commercialisation of the international labour market.
Yet, the argument that market failures experienced in the health sector justify public provision
and strong regulation, are well-established. Market failures result from asymmetrical power
relations and access to information, as well as fee-for-service reimbursement systems that
incentivise over-servicing. Indeed, ‘neither the public sector nor the private sector work in the
idealized way that market-based approaches theorise. Instead, both rich and poor face a
pluralistic market with a wide and chaotic array of services of wildly varying quality’ (Freedman
et al. 2005).
The consequences of commercialisation include not only regressive financing patterns but also a
reinforced segmentation of the health system into different financing and provision systems for
the rich and poor. Although some argue that such systems can better serve the poor by allowing
public resources to be devoted to them, others suggest that there is a dual danger. On the one
hand, fragmented financing and provision prevents the rich from cross-subsidising the poor and
the healthy the sick, and obstructs equity-promoting policy (see Section 6.3.1). On the other
hand, fragmented systems hold the political danger of undermining support for equitable systems
by allowing the development of different interests and concerns across more and less powerful
social groups (Nelson 1989). As a result, the legitimacy of the state’s stewardship role across the
whole health system may also be undermined, leaving it unable to implement its governance and
regulatory functions.
From the Latin American experience of fragmentation, Londono and Frenk (1997) have thus
argued that health care systems should be founded on a universal entitlement to services, rooted
in citizenship, and that entitlement should be funded through financing approaches which enable
and promote cross-subsidy and met through a range of providers. This reflects the emerging
universal financing approach ofThailand, for example, as well as the experience of countries like
Canada. Such an approach represents a different understanding of health systems than that
currently prevailing within international health policy debates. The UN Millennium Project's
Task Force on Child Health and Maternal Health summarises this new understanding in Table 2.
Table 2: Task Force approach to health systems
Item
|
Conventional approach
Task Force approach
Health system as core social
institution
Patients/users
■Specific diseases or health
conditions, with focus on individual
risk factors
Commercialization and creation of
markets, seeking financial
sustainability and efficiency through
the private sector
Consumers with preferences
Role of the state
Gap-filler where market occurs
Equity strategy
Pro-poor targeting
Primary unit of analysis
Driving rationale in
structuring the health
system
Inclusion and equity, through
cross-subsidization and
redistribution across the
system
Citizens with entitlements and
rights
Duty-bearer obligated to
ensure redistribution and
social solidarity rather than
segmentation that legitimates
exclusion and equity
Structural change to promote
inclusion__________________
Source: Freedman et al. (2005)
41
Within this framework, government may take action to encourage appropriate collaboration with
private providers (see Section 6.4.5). However, to fulfil its stewardship role it wilfaiso need to
develop its capacity to regulate private providers to provide comprehensive and good quality care
(see Section 6.6). One strategy to enhance this capacity includes encouraging patients to act as a
watchdog over private providers - for example, by providing information about quality or probity
that patients then use when deciding where to go for care (Freedman et al. 2005). However, as
noted, there remains limited evidence on how to strengthen regulatory capacity and only patchy
evidence on the potential impact of informal regulation.
7.5 Strengthening policy implementation
Many equity-promoting policies flounder because of problems in implementation: this makes it
difficult to sustain progressive initiatives and erodes the legitimacy of the state. Such policies are
almost always subject to contestation as, in seeking to benefit powerless groups, they challenge
the status quo and the associated vested interests (for example, Reich, 1996, Nelson 1989,
Williams and Satoto 1983).
In addition, as health systems themselves reflect the wider patterns of social inequality in any
society (Mackintosh 2001), such policies challenge the norms, traditions and hierarchies within
health systems. These institutions shape health professional practice, influencing who gets access
to health sen ices, as well as the treatment and nature of care offered to different social groups.
Recent experience in Tanzania, for example, demonstrates how poor people’s experience of abuse
at the hands of providers is a key facet of their experience of their social exclusion (Tibandebage
and Mackintosh 2005). In South Africa, meanwhile, nurses’ critical attitudes towards groups such
as pregnant teenagers, teenage mothers, patients with HIV/AIDS and poor patients judgements
have been shown to be rooted in their own values which, in turn, reflect the class and other
divisions in the society as a whole (Jewkes et al. 1998).
Resistance to policies from within health systems is illustrated by health worker responses to the
removal of fees in South Africa, which included greater rudeness towards patients (Walker and
Gilson 2004). These problems also reflected the increased workloads that resulted from the policy
change, weak preparation for its implementation and the limited communication with health
workers about it. Other experiences of implementing equity-promoting policies in Africa' also
show the types of conflict that can arise between the driving beliefs and views underpinning
implementors’ behaviour and the equity goals of policies (Gilson 2005).
Unfortunately, with some exceptions, the literature seldom analyzes the reasons why
interventions fail (or even succeed), making it difficult for policy-makers and planners to learn
from past experience. However, Gilson et al. (1999), drawing on an evaluation of financing
reforms in two African countries, provide a detailed analysis of strategies that can support
implementation, including the incorporation of implementation concerns into the policy-making
process. The broad principles behind these strategies are summarised in Box 5. One of these
principles, around securing better policies through monitoring and evaluation, relates not so much
to measuring progress towards targets, but to instituting ‘early learning’ mechanisms that allow
the process, as much as the design, of interventions to be adapted as implementation proceeds.
Nolen et al. (2005) provide a range of recommendations with respect to strengthening health
information systems to health equity challenges.
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42
Box 5: Strategics to improve implementation
1. Strengthen policy formulation as a foundation for implementation:
.
Support leadership by providing technical analysis;
Strengthen the strategic skills and awareness of technicians; and
Build implementation concerns into design development.
2. Strengthen implementation processes:
.
Source:
Accept the need to work within a changing policy environment;
Enable implementation through leadership;
.
Plan for implementation; and
Secure better policies through monitoring and evaluation.
Gilson el al. (1999)
Looking specifically at strategies to enhance economic access by poor households to health care,
Goudge, Khumalo and Gilson (2003) also draw out lessons from experience across the
developing world (see Box 6). These lessons highlight the multi-factoral nature of intervention.
the need for implementation to be carefully managed, and the importance of adaptability to
changing circumstances.
Box 6: Lessons for implementing strategies to enhance economic access
Taking the views of the poor into account in policy design (whether it be resource
allocation, community financing, drug use interventions or exemptions);
2. Enabling implementation and management to be flexible in order to meet the
unforeseen needs of the poor;
3. Creating a sense of ownership and control by communities to ensure commitment to a
policy;
4. Rooting policy design and implementation on an adequate understanding of the
characteristics of poverty - the mobility, lack of participation in formal systems,
differing needs to due vulnerability and insecurity of income, the stigma associated
with being poor, and greater reluctance to take risks;
5. The need to ensure that the non-poor accept that the poor should be beneficiaries,
including politicians and bureaucrats;
6. Ensuring the commitment and motivation of health staff, responsible for
implementation is crucial for success;
7. To recognize the importance of solidarity and the willingness to share risks,
particularly in success of community financing schemes, where to some extent the
wealthier groups will subsidize the poorer groups
1.
Source: Goudge et al. (2003)
As noted, part of successful implementation is overcoming resistance to equity-promoting policy
changes, even from within the health system itself. Experience in Africa suggests that a core
obstacle is the practice of power within health systems, linked to the hierarchical and quite
authoritarian nature of public sector bureaucracy (Gilson 2005). Gilson and Erasmus (2004), thus
suggest that equity-promoting policy implementation is likely to require changes in organisational
culture based on shared values and objectives, respect and open communication, both in relation
to patients but also to those who work within the health system. These sorts of developments to
43
the organisational software of health systems also serve to complement and strengthen
developments in the hardware of structure, financing mechanisms, and legal frameworks
separately identified as necessary to the health system's promotion of equity.
8. CONCLUSION
This review .reaffirms the role of the health system as a social determinant of health equity which
interacts with other social determinants as well as the broader social and political context. The
health system often contributes to inequity and is not the sole promoter of health equity, but
nonetheless has enormous potential to act as a driver of change towards health equity across the
whole of government.
i
.-1 comment on the evidence surveyed in this review
In terms of answering point (a) set out in the objectives for this paper (see Section 1), the health
system,literature consistently comments on the limited evidence linking interventions with equity
impacts (for.example, Palmer et al. 2004 and Bennett forthcoming). Many studies are
descriptive, and only a handful use robust study designs to measure causal relationships. In
addition, proving clear causal links between intervention and impact is difficult given that health
system change tends to be multi-causal, slow and strongly shaped by local contexts. However,
where the case study designs that could investigate such complex phenomenon arc used, they
rarely apply the explicit theoretical frameworks that would permit analytical generalisation.
This reviewhas also been limited by the time available to conduct it. As mentioned earlier, we
seek to provide an overview of the full range of relevant topics and issues rather titan a more
detailed assessment of a limited set of topics, and our approach has involved a particular focus on
reviews of relevant experience and articles documenting new lines of investigation. Many of the
preliminary findings of this paper are therefore based on knowledge that has emerged consistently
from different articles, with the caveat that such knowledge is not strictly tested. We have also
been able to draw on two parallel international processes and reports focussing on health system
and equity issues - the Report of the UN Millennium Project’s Task Force on Child Health and
Maternal Health (Freedman et al. 2005) and the Global Health Watch Report 2005-2006.
Qualitative information that is built on sound methodologies makes an important contribution to
this body of knowledge, particularly in understanding the contexts, values, processes and actors
influencing health systems (Commission on Social Determinants of 1 lealth 2005b). Theory also
has a role to play, especially where empirical evidence is thin. The paper seeks to draw on
available theoretical perspectives to clarify causal pathways. Beyond causal explanation, the
paper also seeks to place emphasis on understanding successful strategies for policy
implementation, particularly those that create synergies between different interventions (within
and outside the health care sector).
Data and time limitations have also meant that we have not. in attempting to answer point (b) of
the objectives, been able systematically to sift policy and implementation recommendations
according to the criteria of 1) likelihood of equity-promoting impacts, 2) likelihood of sufficient
evidence (of sufficient robustness), 3) high potential for policy uptake, or 4) contribution to
existing efforts. Nonetheless, we do identify some possible priority actions drawn from the
available evidence, and as reflected in the conclusions of other recent reviews of health system
and equity needs.
.
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44
Gaps in knowledge
Given the-literature that we have been able to review, we specifically note the following gaps in
this paper. Following further reflection, we propose that filling some of these gaps through
focussed literature searches and assessment of existing experience form one element oi the
knowledge network’s future work. The weaknesses of current studies already noted and the gaps
around these issues in the international literature indicate a clear need for longer-term research in
this field. We hope that the work of the knowledge network can begin to address some of these
gaps in the short-term.
The gaps are five-fold:
1)
Weak understanding of the role and nature of state action in promoting health equity in
different contexts, which necessitates further work around:
•
Assessing the influence and potential of state action in relation to equity-promoting
policy comparing experience across political, social, economic and health systems (with
reference to factors such as the way power is organised, state legitimacy, the level of
: technical and administrative efficiency, relationships between the slate and citizens, for
example, as well as exploration of the nature of a 'developmental state’):
•
Considering how to preserve and restore equity in conflict and post-conflict situations
where states are weak and communities disrupted;
•
Considering how to protect equity under conditions of market reform, liberalised trade
and commercialisation;
•
Investigating how health systems can leverage national and local level inter-sectoral
action on health, integrate health across all spheres of government including levering
resources for health across all sectors; and
•
Investigating the mechanisms and procedures by which citizens exert influence on the
health sector to enhance equity and understanding how participatory mechanisms can
contribute to the development of national commitment to principles such as solidarity.
2) Weak understanding of the potential of particular health system strategies to promote equity.
which include further assessment of:
•
how to produce and manage the health workforce in ways that promote equity (including,
for example, the role of the manager in changing organisational cultures and building
employee trust, and the relative balance between non-financial and financial incentives in
motivating and retaining health workers);
3)
•
what mechanisms can encourage the private sector to support equity within a universal
financing system;
®
how to devise health promotion efforts that are equity-enhancing and create synergies
with other aspects of health system reorientation towards equity; and
•
consideration of the role of traditional and alternative sectors in promoting health system
equity.
Weak understanding of implementation needs, which necessitates further work around:
•
how to encourage a ‘gradients’ approach to redressing inequity;
•
strategies that can promote successful implementation of new policy interventions
intended to promote equity (that is, a focus on how to implement change, including
scaling up of successful experiences);
•
strategies for the sustained development of public sector leadership and management
capacity;
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45
4)
•
strategies for building the organisational software necessary to sustain equity-promoting
health systems: and
•
approaches to building information and monitoring systems that are well-used by policy
makers and planners.
Weak understanding of differential household experiences of health systems, to be addressed
by analysis of available secondary data, such as:
«
analysis of longitudinal data from Demographic and Health Surveillance Sites in order to
understand health service utilisation patterns by the poor (dis-aggregated into different
sub-populations, especially women);
°
synthesis of available experiences from in-depth studies (including some longitudinal
ones) investigating the factors influencing how households cope with the costs of illhealth, covering the role played by social networks and resources as well as the health
system (there arc five to six such studies known to the authors, review of which would
o
add to the conceptual frameworks and understandings outlined in Section 5); and
evidence on the value ofcash transfers and other social grants in promoting access to
care.
5) Limited geographic coverage, requiring additional evidence from other regions, especially
Eastern Europe.
Priority ureas for action
The gaps identified above notwithstanding, the following areas appear to be key lessons and
potential areas of action emerging from the review. Case study analyses of specific examples of
these actions could add to the knowledge base in this field. In highlighting these lessons we draw
attention to their similarity with those of the two other reviews of health system and equity issues
recently conducted (see Annex 3).
1)
Leveraging policy action:
®
The health system needs to use its leverage with other sectors and spheres of government to
promote healthy public policy.
°
Good governance and accountability are a prerequisite for equity-focused priority-setting and
decision-making within health systems.
o
Equity cannot be improved without strengthening the health system, especially the public
sector. To this end, any policy change needs to be assessed as to its potential overall impact
on the health system
!
2)
Achieving equity-promoting health system interventions:
o
Build the health workforce to ensure the equitable distribution of appropriately skilled and
adequately motivated staff across the health system and country.
»
Re-orient health systems towards the provision of primary health care within a District Health
System.
3)
»
®
Financing health care and allocating health care resources:
A comprehensive approach to financing, founded on the ideals of solidarity and cross
subsidisation, is vital to guard against the differential consequences of health ca're use and
promote equity.
Increase the proportion of government spending that is dedicated to health, along with
increased donor aid and debt relief
I
46
•
Reduce out of pocket spending as a proportion of total spending on health care, including the
removahof user fees through a properly planned and appropriately implemented strategy.
•
Contain die development of private insurance mechanisms and where they exist take steps to
•
Overall resource allocation should be needs-based, taking account of inter- and intra-regional
prevent risk-rating by, and promote risk equalisation across, insurance schemes.
disparities.
4)
Strengthening management and implementation capacity:
•
•
Develop the skills of public managers as stewards of the health system.
Pay attention to transforming the organisational culture of the public sector to enable better
management and implementation.
Develop'effective regulation of, and wise interaction with, the private sector to harmonise the
efforts of public and private providers.
•
•
Information is vital in developing and implementing policies that support equity. This
information needs both to be sensitive to measuring inequity, and dynamic in its engagement
with issues of process and outcome.
i
Areas of synergy or overlap with other knowledge networks
Finally, there are a number of areas where this network would benefit from engagement with
other networks. Likewise, there are a number of areas where some clarity is needed on which
network will take prime responsibility for investigating issues. These areas of potential synergy
and overlap are:
•
Community-based interventions, health promotion and implementation lessons (Priority
Public Health Interventions);
•
The impact of gender and on access and power relations between providers and patients,
and between providers themselves (Gender, Social Exclusion);
•
Global influences over health systems including health worker migration, trade in health.
commercialisation and the role of the state (Globalisation);
•
Community-participation and accountability (Social Exclusion); and
•
Health care for the urban poor, intersectoral action for health (Urban Settings).
ANNEX 1:
IDENTIFYING THE KNOWLEDGE
NETWORK MEMBERSHIP
Membership dellnition
I
I) Core members invited to attend meetings and guide development of network, as well as
to provide inputs as appropriate and possible (10-12 people) . .
2) Other people and groups involved in aspects of network’s programme c.g. by reviewing
documents, conducting country-level work etc.
Principles for selection ofcorc members - to strive for balance in membership across:
«
Geographical areas, with particular focus on low and middle income country and
o
Country, regional and global level initiatives
o
Knowledge sources in global initiatives, country governments, civil society, research and '
academic organistions
transitional country membership and allowing for different language groups
®
Expertise in different dimensions of health systems
o
Different disciplinary perspectives
Proposed process for finalising selection of core members:
»
Initial ideas on selection grid (se below) discussed within hub and with Commission
(Sept 05)
»
Try to fill gaps
o
Ask for inputs from wider circle of connected people
«
Approach potential members - and snowball additional ideas through them
Acronyms used in grid below:
ALPS Affordability Ladder Programme (Margaret Whitehead, Liverpool University)
CHP Centre for Health Policy
CREHS Consortium for Research on Equitable Health Systems (Anne Mills, London School of
Hygiene and Tropica! medicine + 7 national partners, including Viroj Tangcharoensathien,
Thailand)
EQUINET Regional Network on Equity in Health in Southern Africa
EQUITAP Asia Equity Network (Ravi Rannan-Eliya, Sri Lanka)
!
GEGA Global Equity Gauge Alliance
HSAN Health Systems Action Network (developing from Montreux meeting)
PHM People’s Health Movement
R11SRI IS Reproductive health and sexual rights and health system reform project
UN Millennium Project Task Force on Child health and Maternal Health (Columbia University)
48
Initial grid, as a stimulus to discussion:
Geographic area
Initiative level
Knowledge
scarce
Specific expertise
Disciplinary
perspectives
Africa:
Country/Regional
EQUINET
EQUITAP
Lat Am Social
Medicine
Association
West Africa
equity network
WHO Afro
NEPAD
NGO/social
groups:
Equity experts:
EQUINET; W
Africa equity
network;
NEPAD; WHO.
Afro
Health
Economics:
Asia:
EQUITAP;
RHSRHS project;
CREHS, ALPS
GEGA: PHM;
RHSRHS
Global
HSAN
WHO Afro
Governmental:
NEPAD
Lat America
International
Research:
Social Medicine
Association [gap]
UN Mill Project
Task Force
RHSRHS: ALPS
CREHS
HSAN
GEGA
ALPS
CREHS
EQUINET
Pacific/M East/
Transitional
Countries
Starfield
Mackintosh
Mooney
Whitehead
Gap filling:
Conflict;
Dvelopment;
Accountability
Mooney'
EQUINE!
CREHS
EQUITAP
Development
economics:
Mackintosh
Pub Health/Epi:
Starfield
Whitehead
LatAm Social
Medicine
Association
EQUINET
[gap]
Law/human
rights:
High Income
Countries: e.g.
EQUINET
UN Mill Project
Task Force
Gavin Mooney
Margaret
Whitehead,
Social science:
[gap]
Policy analysis
CHP/EQU1NET
49
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63
ANNEX 3:
SUMMARY OF THE FINDINGS OF OTHER
REVIEWS
Millennium Project’s Task Force on Child Health and Maternal Health proposals
for strengthening health systems to support achievement of MDG 4 and 5
(Freedman et al. 2005)
Health systems, particularly at district level, must be strengthened and prioritized:
•
they are key to sustainable, equitable delivery of technical interventions
•
they should be understood as core social institutions indispensable for reducing poverty and
advancing democratic development and human rights
•
to increase equity, policies should strengthen the legitimacy of well governed states, prevent
excessive segmentation of the health system , and enhance the power of the poor and
marginalized to make claims for care
Financing:
»
bilateral and international financing institutions should substantially increase aid
•
countries should increase allocations to the health sector
•
user fees for basic health services should be abolished
Human resources:
•
the health workforce must be developed according to the goals of the health system, with the
rights and livelihoods of the workers addressed
Information systems:
•
indicators of health system functioning must be developed and integrated into policy and
«
budget cycles
health information systems must provide appropriate, accurate and timely information to
inform management and policy decisions
•
countries must take steps to improve vital registration systems
(There are also proposals on sexual and reproductive health and rights, child mortality, maternal
mortality and global mechanisms)
64
Global health Watch 10-point agenda to repair and develop health systems
Alternative World Health Report launched in Cuenca and London by David McCoy and
Mike Rowson (http://www.eciuinctarrica.org)
8.
9.
Provide adequate funding for health care systems
Take better care of health sector'workers
Ensure that public financing and provision underpin health care systems
Abolish user fees that put people into poverty
Adopt new health system indicators and targets that incentivize countries to improve the
health system rather than simply tackle specific diseases
Reverse the commercialisation of health care systems by using regulatory and legislative
instruments; and search for ways in which the private sector’s resources can be harnessed for
the public good
Strengthen health management and adopt the District Health System as the model for
organising health systems
Improve donor assistance within the health sector
Promote community empowerment to improve the accountability of the health system
10.
Promote trust and ethical behaviour to combat the corrosive effects of commercialization.
1.
2.
3.
4.
5.
6.
7.
65
ANNEX 4:
SUPPORTING EVIDENCE FOR
STATEMENTS CONTAINED IN THE TEXT
' Lack of trust in the public sector can drive patients - and even the very poor - to use the private
sector. For example, Russell (2004) found that, in two poor communities in Sri Lanka, people
tended to use the private sector for moderate, acute illnesses: 48% of the study population (95%
confidence interval) who sought treatment outside of the home for acute illness went to the
private sector - this included 26% of patients from the poorest income quartile (these were
households that struggled to meet daily food and fuel needs and, in incurring medical costs,
would have had to sell assets etc.) - and most would have preferred to use private. This was
because it was much quicker getting access to a private doctor, private doctors spent more time
on the consultation and listened carefully to the patients’ complaints, and because patients - and
their families - were able to build a strong relationship with their doctors over time (resulting in
the notion of a ‘family’ doctor). By way of contrast, at the public facilities there was
overcrowding, long queues, cursory consultations and, in the hospitals, high occupancy rates.
Russell (2004) concludes that, ‘despite the strengths ofSri Lanka's public health sector, poor
relationships act as an access barrier and push a range of income groups [including the very
poor] to the private sector. ’
" The following was written by Don de Savigny, TEHIP Research Manager, 2004, and extracted
from Doherty and Govender (2004):
‘The emphasis cn decentralization and SWAp health-basket funding in the mid-1990s quickly
illuminated the challenge of how district-level health systems could do evidence-based health
planning that would improve the technical and allocative efficiency of local choices with respect
to resource allocation and service provision. In Tanzania this was taken up by a large-scale
demonstration project run by the Ministry of Health, called the Tanzania Essential Health
Interventions Project (TEHIP) (Finlay et al. 1995). This study ran from 1997 to 2004 involving
districts with a combined population of over 700,000 people.
TEHIP benefited from a parallel health research program that followed health system changes,
health-seeking behaviour trends, and health impacts. It also had a research and development
component tasked with inventing practical tools for decentralized planning that would address
needs arising during district health planning and priority-setting. The latter added a number of
tools and processes into the district-planning toolkit including:
1) an annual District Health Intervention Profile that provided a graphical display of
the regional burden of disease in terms of intervention-addressable DALY shares from
sentinel demographic surveillance systems;
2) a computer-based District Health Accounts tool that allowed districts to do budget
and expenditure mapping in terms of allocation of health resources;
3) a computer-based Health Mapping tool that could be used at a district level to
visualize Health Management Information System data from community and health
facility levels;
66
4) a District Integrated Management Cascade process that improved the efficiency of
supportive supervision of health services;
5) a Community Ownership of Health Facilities Strategy that freed up resources to
renovate physical infrastructure; and
6) a number of capacity building processes for strengthening District Health
Management and Administration (de Savigny <7 al. 2002).
www.idrc.ca/tehip’
67
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