GLOBAL EQUITY GAUGE ALLIANCE (GEGA) TECHNICAL WORKSHOP EQITY HAUGE PROGRESS REPORT
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- GLOBAL EQUITY GAUGE ALLIANCE (GEGA) TECHNICAL WORKSHOP EQITY HAUGE PROGRESS REPORT
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GLOBAL EQUITY GAUGE ALLIANCE
(GEGA)
Technical Workshop
Equity Gauge Progress Reports
Entebbe, Uganda
hosted by
The Institute of Public Health - Makerere University
in collaboration with
The Rockefeller Foundation
EQUITY GAUGE PROGRESS REPORTS
1
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Bangladesh Progress Report
Chile Equity Report
China Report
Ecudaor Report
Ouaga Initiative Report
The Nairobi Health Equity Gauge Report
Health Equity Gauge Association of Uganda
SA Gauge Progress Report
Thai Report
The Zambia Report
Zambia Annex 1
Zambia Annex 2
Zambia Annex 3
Zambia Annex 4
Zimbabwe
Bangladesh Health Equity Gauge
Progress Report, January - December 2001
Introduction
Bangladesh Health Equity Gauge (BHEG) is a collaborative project of four
organizations. The organizations are BBS (Bangladesh Bureau of Statistics), BIDS
(Bangladesh Institute of Development Studies), BRAG, and ICDDR,B (International
Centre for Diarrhoeal Disease Research, Bangladesh). Initially the project has support
for two years from the Rockefeller Foundation beginning January 2001.
BHEG has four objectives to fulfill. They are 1) incorporation of equity dimensions,
such as socioeconomic groups, geographical location, health outcome, and healthcare
utilization variables and the like in the existing data collection systems in various
organizations (this will also include assessment of the impact of the poverty
alleviation and community development oriented health progarmmes in reducing
health inequity); 2) establishment of a new system in a nationally representative
sample which can eventually be adopted by the national system; 3) dissemination of
findings among the policy makers, researchers, NGO leaders, and members of civil
society in a regular fashion to facilitate actions to minimize inequity; and 4)
development of national capacity to carryout equity focus research and analysis.
The activity package to achieve the above objectives included the following:
1. Coordination
2. Formation of Health Equity Forum
3. Inclusion of equity focus in collection and analysis of existing data
(ICDDR,B; BRAC; BIDS; BBS; Helen Keller International)
4. New data collection system (implementation, data processing and report
writing)
5. Dissemination workshops
6. Publication of report
Progress
Coordination: Memorandum of understanding between the four partner
organizations has been signed and is operative.
Formation of Health Equity Forum: List of possible members to be included in the
Forum has been prepared. The official launching will take place during the first
quarter of2002.
Inclusion of equity focus in collection and analysis of existing data: Several
meetings of the relevant organizations with data collection system were held. The
organizations agreed to include equity dimensions in their data collection system. The
group representing the organizations also agreed to analyse the existing data on the
basis of specific themes. Immunization issues were selected to be the first theme. A
draft paper entitled “The immunization divide: who gets immunized in Bangladesh”
has been prepared and circulated among the relevant individuals for review and
feedback. It is envisaged that this paper on immunization will be presented in
launching meeting of the Forum.
New data collection system: After a careful review, plan for new data collection has
been slightly changed. Instead of introducing a new system now the possibility of an
add-on to an existing system has been under active consideration. Such existing
system may include Health Watch of BRAC, which is also nationally representative.
Dissemination workshop: First workshop will take place during the launching of
Bangladesh Health Equity Watch some time during the first quarter of2002,
Publication of report: A ‘Research Report’ series on health equity related issues has
been on the plan. Preparatory work, such as design of the cover page, themes of
reports etc. has been progressing well.
The Chilean Health Equity Gauge
Advance Report- December, 2001
Executive Summary
The Chilean Equity Gauge has defined as its general objective: “to improve the monitoring
of health equity in Chile and to build capacity for research, advocacy and community
participation to improve health equity”. To achieve this purpose, four pillars have been
designed:
■
■
■
■
Measurements and data monitoring.
Community participation.
Advocacy/dissemination.
Human resources training center.
Since March 2001, a working team with different backgrounds is developing the activities
within each pillar. The participants are:
Name
Dr. Jeanette Vega
Dr. Liliana Jadue
Dr. Paula Bedregal
Iris Delgado
Rodrigo Burgos
Carolina Flores
Francisca Browne
Vicente Zuniga
Claudio Sapelli
Dr. Hernan Sandoval
Role
Profession
Director
MD, Epidemiologist
Executive Director
MD
Academic Director
MD
Data analyst
Statistician
Communications and dissemination
Journalist
Community participation
Social Worker Social
Social research
Sociologist
Social Program Consultant Interactive Forum production
Economist
Economic analyses
MD, Public Health
Policy consultant
1. Measurements and data monitoring.
One of the tasks of this component is to develop data analysis from primary and
secondary databases from different sources within Chile. Databases come from national
surveys run by different ministries: like Planning, Education, and Health. Vital and
demographic statistical data, morbidity and mortality data are obtained from different
sources like the National Institute for Statistics, governmental ofices and other sources. Up
to date, most of all required databases have been gathered and data analysis is in
process.
The principal instrument to monitor social policies in Chile is the CASEN survey, a serial
national survey applied by the Ministry of Planning every 2 years, that includes information
on education, income and employment, housing and health. The last survey was carried
out in December 2000. As an initial task developed by the Initiative, important
improvements were made to the health module making possible to better monitor health
care needs and access to health care. These improvements were the first objective
designed within the context of the health equity initiative.
Another important product under development is the Policy Lever Analysis. The study will
review the health equity situation for the Chilean population and will describe and analyze
all possible policy levers to identify possible intervention that can be implemented to
improve equity. The first report has been released and the complete policy lever analysis
will be ready in 2002.
A study reviewing the situation for gender and health equity in Chile has been
implemented during 2001 with the support form PAHO. The results will be published in the
Pan American Journal of Public Health in the next issue.
2. Community participation.
This area of development is focused in the identification of community resources to
empower them in strategies to improve health equity. The activities included the
elaboration of a catalogue of community organizations in the country, the characterization
and identification of different organizations to establish alliances and interventions. Two
other activities are under current development, first, a case study to analyze participation
models in Chilean communities and second, the elaboration of a proposal to intervene
poor families to generate strategies to get them out of poverty, with general strategies
addressed to the communities where they live and other specific focused on their health
needs, with equity perspective. This proposal will be funded by FOSIS, a governmental
organization dependent on the Ministry of Planning and Cooperation.
3. Advocacy/Dissemination.
After a period with activities and strategies that had no impact in the media, our
communication team is more consolidated. The efforts have been focused in building our
own capacities to elaborate messages to different audiences that we want to reach and
developing an advocacy plan for 2002.
It has been difficult to implement this strategy because it is a new area of development for
a team originally created by public health researchers in a country with little development
in analytic journalism and almost none communicators specialized in health issues
different from medical technology.
The products up to date include the implementation of a web page, with information on our
results and the launch of a “Health Equity Forum” within the web page designed as an
initial interview to national relevant authorities in a selected subject followed by a
discussion open to all participants who want to express themselves or give opinions on the
interviews. The forum subject is changed every 6 weeks.
4. Human resources training center.
A workshop on Benchmarks of Equity, developed by Dr. Norman Daniels, and co
organized with the Ministry of Health was developed in October 2001. The workshop was
addressed mainly to health service professionals. A follow-up workshop to implement the
benchmarks in Chile, as a tool to evaluate our health system on a district level will be
implemented as part of 2002 activities.
A Public Health Summer School has been organized with the collaboration of Harvard
School of Public Health and the Panamerican Health Organization. This activity will be
held in January 2002. We expect participants form Chile and different countries from Latin
America.
5. Strengths, Weaknesses and Challenges
The Initiative includes a multi-professional working team conformed by highly motivated
professionals committed to their tasks, with an adequate physical infrastructure and
administrative support to develop the activities.
All components are in the process of developing their objectives, thou some of them at a
lower pace; but there are some products that will contribute to make visible the health
equity concept in Chile. Some of the activities worth to be mentioned include the
implementation of the web page, the development of a corporative image with a logo that
identifies the Initiative, production of scientific information and monitoring data and the
Policy Lever study currently under progress, with a preliminary report already released.
Developing the Advocacy and Dissemination component has been more difficult than the
others because of the need to create the experience within the team and the
characteristics of the mass media in Chile, where the installation of a new social subject in
the public agenda is a challenge.
Given that the Initiative is being supported by an academic institution and funded by
external resources from the Rockefeller Foundation, most of the collaborators work parttime. This issue can be seen as strength in the sense that helps to create networks with
different people and organizations, but sometimes it makes it difficult to coordinate
activities within the members of the staff.
Last but not least, the need to look after financial resources to develop new activities is a
permanent stress for the researchers.
6. Required Technical Support
I
■
■
Training in advocacy strategies and techniques to mobilize relevant social actors
and communication media.
Training in strategies and techniques to develop community participation.
Support to further develop some of the components that were not part consider initially as
part of the Initiative:
■
■
■
Community participation intervention activities.
Advocacy and mass media involvement.
Workshop and training activities for human resources.
All of these activities are not currently funded.
Page 3 of 3
The Progress Report on the China Equity Gauge
!□
On Dec. 10, 2000 in Beijin Xinhengji Building, the Central Group
discussed the feasibility of conducting China Health Surveillance
Survey(CHSS). The Central Project Office was set up meanwhile.
From then on, we started the design of CHSS. We also design the
structure of CHSS as follow:
CHSS organization structure of membership
School of Public
Health,
Harvard
University
Yuanli Li
for
Health
Statistics and Information
<
MOH, China
Keqin Rao
> Center
> School of Public
Health, Beijing
University
Zhu Li
CHSS Project Office
Manager, Juncheng Qian
Principal of Each Project
Province Health Bureau
Total: 9
Project Office of Each Project
County/City
Total: 10
Three Township/Street/Community Health Center
of Each Project County/City.
Total: 30
One Inspector and Three Interviewer of each
Township/Street/Community Health Center
Total: 120
i
2D
From April 17 to 19, 2001 in State Second HotelDthe Central
Group discussed the survey design and the questionnaires. The ten
project counties/cities were ascertained primarily.
Tabl: The basic situation of surveillance site
City/County
code Urb/Rual Area
province
1
2
1
2
3
4
5
6
7
8
9_
10
j_
9_
2
1
9
1
9
9
2
2
2
2
z
z
z
X
X
x
Guangdong
Guangdong
Jiangsu
Zhejiang
Hebei
Shanxi
Hubei
Sichuan
Shaanxi
Gansu
Shenzhen
Nanhai
Suzhou
Tongxiang
Xianghe
Taiyuan
Xiaonan
Yibin
Langao
Yuzhong
Code of
administration
Households to
be surveyed
440301
440682
320501
330483
131024
140101
420902
512501
612426
620123
540
540
540
540
540
540
540
540
540
540
Note:! means urban, 9 means rural, d for eastern, z for middle, x for western
cod
e
1
2
3
4
5
6
7
8
9
10
3Q
Tab2: The basic situation of the surveillance site-specific
City/Count Populati
IMR
MMR
Per capita
on
Per
Per
income
y
1000
100000
Yuan
2000
2000
2000
2000
Shenzhen 4329400
5.99
28.36
20240
Nanhai
1094994
7.74
9.1
6764
2070000
6.84
Suzhou
7.8
9274
7.5
Tongxiang 655737
0
4807
306216
97.99
Xianghe
15.2
3692
Taiyuan
2274816
7.00
33.9
6019
Xiaonan
820982
13.0
89.7
2618
Yibin
750298
11.12
64.48
3829
Langao
170072
21.4
85.6
1172
Yuzhong
422440
31
72
1381
Townshi
ps/Streets
2000
45
18
58
24
17
57
18
34
19
27
From April 20 to 22, 2001 in Suzhou’s town area and suburb,
conducted pilot test. After the pilot test, we adjusted the content of
questionnaires, also we gained the experience of survey. The site of
2
I
pilot test is Yangzhi community in urban area and Meihua
community in suburb area.
On Apr. 20, we discussed with leader, staffs of the Health Bureau of
Suzhou City, the staffs of Community Health Center. The discussing
content included two aspects. One is their needs about health
information in their working of promoting people’s health. Another is
about the questionnaire content and how to organize household
survey in community. On the morning of April 21, we interviewed
each membership of two households by the questionnaire, visited the
community health center, in the afternoon we interviewed one farmer
household in Meihua Community. On April 22, we discuss with each
involver the pilot test situation, last we finished a summary about this
test survey. It is very helpful for formal survey.
4a
After the pilot test in Suzhou City, the questionnaire was adjusted.
We have to try it in one county. From June 27 to 28, 2001 we used
adjusted questionnaires to conduct the pilot test in rural
area-—Xianghe County. We gained the experience of such survey
in rural area.
On the morning of June 27, we discussed with the leaders, staffs of
the Health Bureau in Xianghe County about their needs and the
questionnaire and the survey organization in rural area. In the
afternoon, we conducted household survey. Professor Yuanli Liu,
3
Manager Juncheng Qian, the member of Central Office Miss Jing
Wu and Miss Chunyu Li interviewed one farmer household
respectively. On the morning of June 28, we went to a poorer
township in Xianghe County. Two households were interviewed by
local interviewer from the Health Bureau of Xianghe County. In
the afternoon, we met together to discuss the situation of this pilot
test. We obtained the experience on four aspects. One is to find
questions how to fit for the rural conditions. The second is if the
questions are understood completely by the interviewee. The third
is how to efficiently organize the survey in rural area. The fourth is
to test how long interviewing one household cost in rural area.
50
On July 16, 2001 the official correspondences were sent to each
project province health bureau by Center for Health Statistics and
Information(CHSI), which was about getting their agreement to set
up the China Health Surveillance System in the province as a site.
All project province health bureau answered to agree with the plan.
The project principal of ten provinces
4
Tab3: Agreement situation and the project department or principal ot each provinces
telephone
principal
province
028-6137801
Sichuan
Bugang Ma
0571-87709038
Yarning Gu
Zhejiang
0931-8821301
Gansu
Huaiqi Wang
025-3611764
Jingmao Chen
Jiangsu
020-83820687
Guangdong
Zhe Yang
0311-7043766
Jingbo Zai
Hebei
029-7344900-3035
Shannxi
Mingxia Dai
027-87821870
Yanqing Cao
Hubei
0351-3283763
shanxi
Jianwu Zhao
6D
On August 21, 2001 the official correspondences were sent to each
project county/city health bureau by CHS1, which informed them
to attend the training and working meeting.
?□
By September 7, 2001 we accomplished the booklet Design of
China Health Surveillance System and Guideline of Household
Survey, the booklets and questionnaires were printed by the
printing factory.
8D
From September 19 to 20,2001 The training and working meeting
took place in State No2 Hotel in Beijing, one leader and one
technical staff were trained. Meanwhile on the meeting, a
microcomputer was sent to each project county/city.
Training content include: 1 .why should we want to set up the China
Health Surveillance System? 2. The whole design was introduced.
3. How to sample the project township and street, how to sample
the surveillance household. 4. To introduce all questions in the
questionnaire and to explain the key indicators and
the trainee
any doubt
have. 5. Simulating training of interviewing by
5
listening to the recorder for each trainee. 6. All trainees fill
household’s member situation of themselves in the questionnaire.?.
To demonstrate how to use the software of data entry for the trainee,
which is made by the Central Project Office. 8. All trainees enter
the questionnaire data of simulating interviewing and self-filling in.
Except for receiving one personnel computer, each project county/city got
600 sets of questionnaire, 6 books of the guideline and the design, one
recorder tape for simulating interviewing and all training paper
materials, one data entry software.
9D
I
After the training and working meeting, on Sep. 29,2001 the
official correspondences were sent to each project counties/cities to
demand to start the project working.
10Q
On Nov. 5,2001 the official correspondences were sent to each
project counties/cities by CHSI to demand good field working and
quality control, meanwhile inform that the Central Project Office
would inspect the field working.
1 !□ From Nov. 7 to 19, 2001 the central group members of CHSS were
divided into four subgroups to supervise the filed working over ten
field sites. The supervising main content included: 1.organization
situation for each site, 2. training situation to the interviewer, 3.
check the questionnaires, 4. talking with each interviewer about the
interviewing conditions of households, listen to their any
6
comments, 5. follow the interviewer to the surveyed household to
observe the whole interviewing process.
Tab 4: The supervising schedule of CHSS to the site
Oct. 29, 2001_______________
City/count
y
Supervising date
Yuzhong Nov. 7 to 9
Nov. 9 to 11
Xiaonan
Nov. 12 to 13
Yibin
Shenzhen Nov. 13 to 15
Nov. 15 to 18
Nanhai
Nov. 8 to 9
Xianghe
Nov. 13 to 15
Suzhou
Tongxiang Nov. 16 to 18
IIP 14 to 16
Langao
Nov. 17 to 18
Taiyuan
122
Supervising persons
Yuanli Liu, Juncheng Qian
Yuanli Liu, Juncheng Qian
Keqin Rao, Yuanli Liu_______
Keqin Rao, Yuanli Liu_______
Keqin Rao, Yuanli Liu
Rongwei Ye, Jing Wu_______
Rongwei Ye, Jing Wu_______
Rongwei Ye, Jing Wu _____
Juncheng Qian, Chunyu Li
Juncheng Qian, Zhu Li,
Chunyu Li
On Nov. 20, 2001 four central subgroups members discussed the
findings of supervision in the 502 room of MOH, at the same time
the next arrangement was made including the schedule of data
analysis.
13
On Nov.
23,
2001
the Central Project Office sent the
correspondences as a summary of this supervising to each project
county/city to notify the experiences and existing problem in each
site in the name of CHSI, also to inform the next arrangement
including the deadline to send the database and related material.
The main results of this supervising as following
The Project office of each city/county has been set up. Most of the
7
principal are the leader of health bureau. Each project city/county had a
training meeting for the interviewer. Each project city/county make a
good sampling by the demand of Guideline. Before the survey, much
propaganda was conducted in each site in newspaper, television, open
letter to the residents with official seal and so on. Resident’s meeting took
place in some surveillance site. It’s very important to make sure the
surveyed households know CHSS and to obtain their cooperation. A
small gift was made in most project site for the surveyed household.
Many difficulties were overcame by each project site using different
method. A little interviewers need to understand more about little
questions such as some social and psychosis questions.
Some
interviewers have to translate the standard Chinese into the dialect using
in the local place, then the question can be understood by the interviewee.
The most inspectors checked the questionnaires in time and repeat
interviewing part of the household. We found Some psychosis question
was answered by other family member when the interviewee was
unavailable. So we demand the interviewer to tick the question and the
name in the questionnaire answered by other family member.
14Q
Form Dec. 15 on , the Central Project Office was collecting and
cleaning the data base and related material.
By now, we received the data of 8 project city/county. One project site
was postponed by some reasons. One project site have some problem in
8
I
computer ability.
Tab 5: numbers of the surveyed households and all kinds of member demanded to be
interviewed
City/Coun Urb/
Rual
ty
Shenzhen
Nanhai
Suzhou
Tongxiang
Xianghe
Taiyuan
Xiaonan
Yibin
Langao
Yuzhong
15D
1
9
Area
d
d
1
2
2
2
9
z
z
z
j_
2
1
2
X
9
X
X
household
s
mem
bers
Two
week
morbi
dity
inpati
ents
Childr
en
under
7
adults
marter
nals
556
543
540
541
541
540
540
541
2069
1546
2180
2013
1647
1842
1699
1844
190
246
173
140
169
365
277
308
59
49
62
35
58
39
77
37
158
72
202
82
83
146
110
124
1585
1410
1743
1626
1408
1293
1468
1474
21
17
40
8
15
28
21
35
After the data cleaning, we will conduct data analysis and writing
report. We will finish the writing report before May 30.
16Q
A workshop will take place for ten counties/cities before June 30,
2002.
9
I
I
REPORT OF PROGRESS, PLAN AND ACTIVITIES OF THE
EQUADOR EQUITY GAUGE TEAM
January 10 of 2002.
1.- List of primary institutions responsible for managing the Equity Gauge.
Alternatives to Social Development Foundation (ALDES).
Stakeholders:
. .
Health Commitment of El Tambo. (Unit of Ministry of Health, Communitarian
Organizations, Teachers, Municipality).
Mastery in Public Health — Cuenca University.
Municipality of El Tambo
2.- Briefly description the scope of the Equity Gauge.
Our Equity Gauge is focused in a municipality based (same to county) This is the
smallest unit the administrative and politic division in Ecuador; also smallest unit with
the capacity to generate policies (with the local value). Our scope is done/ take in urban a
rural areas.
El Tambo is a municipality with 9.000 habitants living in a urban center (downtown) and
28 little rural communities, The population has a 90% of indigenous people and lO/o of
mixed race. The rural area is where the majority of indigenous people live.
3.- Description of the political, social an economical context of the Equity Gauge.
Ecuador is one of the countries in the Americas with the most inequities. According to
the Human Development Report of 2001, it is located in the 72 place of the index of
Human Development, with a Gini index of aprox. 0.58, that reveals the existence of large
internal inequalities. National studies show the huge disparity which exists m the
distribution of the country’s wealth: in 1998, 10% of the wealthiest population held
42.5% of the national revenue, while the poorest 10%, had barely 0.6%
1
income gaps between first an fifth quintile Ecuador
1988-1999
20 00 |
IT... ‘
|
i
I
18.00 t
|
, ^8:44-
......................... /
16.00 I-
B2
14 00 H-y;
3.04
it
12.00
10.00 -t
■
;.;4'
:
8 00 r
600 I
4.00 -I
2.00
0.00
1988 1989 1990 1991 1992 1993 1994 1995 1996 1997
1998 1999
Distribution of consumption by quintils
Ecuador 2000
I
®1er quintil (20% mas 11
pobre)
5
■2do quintil
9
□3er quintil
53
^4to quintil
20
■5to quintil (20% mas ,
rico)
The poverty index reaches 80% (44% in urban areas and 77% in rural areas), access to
basic services is at 55.6% (urban 64% and rural 44%). The differences in the functional
aspects and development indexes are permanent between the city and the countryside,
with the education index at 68.9 in the city and 44.2 in the countryside, health at 68 in the
city and 43 in the countryside.
These disparities also express themselves on the local level; if we compare urban and
rural areas in the province of Canar, which are predominately indigenous (approx. 80%
of the population), we see that the incidence of poverty between the urban and rural zones
rises to 79% (71% urban and 82% rural), the infrastructure or access to services index, is
2
barely at 53%. Chronic malnutrition in minors under 5 years of age is at 43% (urban 32.5
and rural 47). These macro-determinants of rural living and ethnicity are important
elements in the origin of the current inequalities.
The municipalities with majority Indian population have more vulnerability, as you can
see in the following graphic.
Index of social vulnerability by municipalities
Ecuador 1999
SSH
lyZZCt ’.vi:
100 -
....... .
90
I
80
70
60
50
40
z
1QQ
I I
'
H El Tambo
■ Duran
:j
60
□ Espindola
E Guamote
■ Paltas
EH Sta Isabel
30
20
10
0
Differences based on gender can also be observed, such as access to education: illiteracy
in men is at 9.5% (4.3 urban and 17% rural) while it is believed to be at 13.8% in women
(8% urban and 25% rural).
3
Illiteracy in men and women
By different municipalities - Ecuador 1999
60
50 Bi ilil :Oli
IS®
I
•k
40
J
illf
30
I
20 g
10 it
0^
women
men
-ro
^5
E
|CD
o
Q
0)
■U
o
E
LU
0
ro
CO
"to
0_
w
TO
co
The decision spaces and the political participation is limited to the women
women elected Ecuador 2000
100%^H-I <4 I-I diI
80%
' i
60%
40%
20%
0%
I 1
'I
i
i
1
I ;
! I
i
1
If lI
11 H
■ total candidates elected
■ - 'j
® Women elected
ST
.
aj <»
tots
gj-t-'
5 till
git
sy-ii S"4s
E
4
4.- List the comparative population groups that you have selected for your Equity
Gauge
Categorization Disparities in health Size of disadvantage Public awareness
group
of population outcomes
groups______
High Moderate Low High Moderate Low High Moderate Low
X
X
X
Socio
Economic
X
X
X
Gender
X
Geography
X
location
X
X
X
Race
ethnicity
5.-List the quantitative equity measurement indicators that you have selected for
your Equity Gauge.
Dimension
of health
Population
group____
Socio
Economic
Gender
Health care Access
financing health care
Underlying
health
determinants
Health status
• Illiteracy rate
• Population
below
the
poverty' line
• Percentage of
malnutrition in
under-5
year
olds.
• 5
]primary Amount Per
causes
of capita
financing by
mortality
primary the Minister of
causes
of health.
Family health
morbidity
expenses
civil
of
• Third dose of Percentage
society
with
DPT
representation in the
vaccination
• Percentage of committee of health.
Pre-natal
and Number of spaces of
between
coordination
birth care
and
• Distance
in institutions
minutes to he population.
nearest health Percentage of decisions
taken in the health
center
committee enforced.
primary Family health
• 5
causes
of expenses
mortality
• 5
primary
causes
of
morbidity
• Third dose of Percentage of women’s
representation, in health
DPT
committee
vaccination
• Percentage Pre
natal
and
birthing care
• Distance
in
minutes from
the
nearest
health center
• Percentage of
homes
with
female heads of
household_____
• Illiteracy rate
• Percentage of
homes
with
female heads of
household
to Social
Participation
5
; Geography • Illiteracy rate
Population
i location
the
below
I
I
I
I
poverty line
• Percentage of
malnutrition in
under-5
year
olds.
health
• Family
expenses
• Indoor running
water costs
• Percentage of
homes
with
female heads of
household
• 5
|primary
of
causes
mortality
primary
• 5
of
causes
morbidity
of rural
• Third dose of Percentage
representation
in health
DPT'
council
vaccination
• Percentage Pre
natal
and
birthing care
• Distance
in
minutes to the
nearest health
center
6.- Describe the use of any qualitative information / data in your Equity Gauge.
We are using 3 qualitative indicators specially about the services
Time spent in a medical consultation
Availability of medicine at public health center.
Reason to assist to this health center.
7.- Describe your public participation plans and activities.
We defined 4 sector to our public participation:
Indigenous organizations;
Workshop to discus use of alternative health.
To implement a leadership school
Decision makers in the local level.
Support the elaboration of the municipality budget
Have a ‘‘Day of health and Equity” in El Tambo
National Movement of municipalities
Decentralization and health — experiences and positions -
Health Sector.
.
National workshop to discus indicators of inequity in health.
Presentation of our experiences in different events about decentralization, health
reform, and human resources.
To Implement the course about local management and equity
International seminary “Participation, Health and Decentralization
Course
6
8.- Describe your advocacy plans and proposed “actions” to help to reduce inequity
in the setting of Equity Gauge
Time
Outputs
Strategy
Actors
Advocacy
frame
Actions
___
2002
6
documents
Translation
of
Dissemination of Health
of national
Ministery.
texts..
materials
(national and Memory of circulation
meeting and
local)
workshops
Uni vers i ty
April 2002
Constructing
Municipality. Workshops.
AME
Promote
arguments,
August
to
policies, proposal (association of people
2002
training
in
municipalities)
and
recommendations MoH
Public
Jun 2002
haealth.
(national)
Program
m
University
training
in
local
management
and health to
municipalities
and
health
sector
institutions
Direct
2
March
Municipality Give
engagement and AME
agreements 2002
technical
active lobby with PAHO / MoH assistance
with
! policy-makers
Department
Municipality
to
Social and Ministry
Development of health.
to El Tam bo
Municipality
Empowering the Indigenous
Leadership
1
school July 2002
poor
and Organization school
and functioning.
Health
disadvantages
equity.
Committee
Civil
Society Health
Health Party. Celebration January
campaigns and Committee
Workshops,
of 3 key 2002
challenges
to Indigenous
debates about days.
policies
Organizations. the health and 3 workshops
Women
in the year.
local
Organizati ons development
7
9.- Wrap-up What has been going well in our Equity Gauge?.
•
•
•
•
•
•
•
•
Reactivation of the health committee and definition of new roles.
The number of members in the committee increased, an have a indigenous
representation.
The women advisors of municipality are participating in the committee.
2 professional are assisting to the mastery of public health.
Designed draft of program to course in local management with national influence
National workshop about monitory of health with participation of represents of
Pan-American Health Organization, United Nation Women Found, Ministry of
health. National association of Municipalities, NGOs, and functionaries of El
Tambo.
Implementation of actions in health. With volunteers and public health center.
Advance in the analysis of inequities in El Tambo
What has been difficult and less successful ?. (Limitations, difficulties and actions less
successful):
•
•
•
•
•
•
The knowledge about of the indigenous world is insufficient.
The mayor don’t have a strong incorporation in the process.
In the advocacy and in the political process we don’t had to build a framework in the
municipality - local council of development or assembly with social participation.
The analysis of inequities is incomplete.,
The train about measurement do not started.
Is necessary count with national support.
What are we main constraints?.
We are establishing a specific process with indigenous organizations, and To begin a
learning of them leaders
To implement at local management and health equity learning program.
To define a agreement with municipality to technical assistant from Equity Gauge.
To agreement with Ministry of Health.
What additional support we needed?.
We needed support in analysis and presentation of information to the users.
To support in the learn in equity.
10.- What thoughts, ideas and suggestions do you have for a Global Equity Gauge
Alliance.
In GEGA we needed to development a process to interchanges and forums about equity
between nearly countries.
8
The advocacy to global institutions (united nations, etc..) must a interesting process ofthe
GEGA.
Could GEGA to provide, assistance and consultant in decentralization and equity to
governments of the national or local level?
9
Universite de Ouagadougou
UERD
Save the Children
Pays Bas
The Population
Council
Global Equity Gauge Alliance Workshop
Entebbe, February 10-16, 2002
The Ouagadougou Urban Health and Equity Initiative
(Status summary as of January 2002)
’i
Background and rationale
The French-speaking countries of sub-Saharan Africa (SSA) are witnessing a mounting
population and health crisis. Mortality remains extremely high and trends to lower infant
mortality and longer life spans observed since the 1950s have stagnated and even reversed
themselves in several countries. The prevalence of STDs including HIV is growing rapidly,
especially in cities. Fertility in SSA is double that of any other region of the world and there
are increasing rates of premarital adolescent fertility. Population growth is also very' hi^i, on
the order of 2.5% per annum and. unlike the rest of tlic world, the net increment to population
size in SSA is projected to continue growing until 2040. This places increasing stresses on tlie
natural environment, complicates the design and implementation of policies to deal with health
problems, and the rapid growth in cohorts of children limits the ability of governments and
families to invest in their health and schooling. While the region is one of the least urbanized
parts of the world, with less than 35% of the population living in cities, most population growth
is now urban owing to strong rural-urban migration. As a consequence, the number of city
residents in the region is projected to nearly triple between 2000-2030. Many of these new city
dwellers will live in overcrowded slums or in penpheral semi-urban informal settlements where
health conditions are poor. This urban growth, combined with a breakdown of traditional norms
and a weakening of the family's ability to govern the behavior of youth, facilitates the spread of
S'fDs, the occurrence of unwanted pregnancies, unsafe abortions and illicit ding use, and is also
leading to a rising inequity in access to basic health services.
Ouagadougou, the capital of Burkina Faso, exemplifies the emerging urban health and
social crisis. The health services in Ouagadougou are unprepared to serve the basic
health needs of its residents as the city’s population continues to increase by 4.3%.
Increased disparities in health, education and general welfare in Ouagadougou are
concealed by current statistics Despite ‘visible’ and alarming signs of increasing
inequities and of worsening social malaise in Ouagadougou, social development
policies continue to focus almost exclusively on rural areas.
In 2001, the Burkinabe Government published the "Cadre Strategique de la lutte
contre la pauvrete. This document states that one of the Govemement’s principal aims
is to guarantee access to basic social services for the poor and more specifically (J)
promote access for the poor to education and (2) promote access for the poor to
health (Ministere de 1'economie et des finances, 2000). The same document also
states that all development policies must be equitable
Objectives
An experimental study will be launched in Ouagadougou to test the hypotheses that
outreach activities and community mobilization can i)
i. improve health and ii) reduce
Ouagadougou Health and Equity Initiative
infant and child mortality in disadvantaged urban neighborhoods of Ouagadougou,
thereby improving health equity.
Partners and stakeholders
Partners in the Ouagadougou Health and Equity Initiative
Partners are the lead agencies and individuals who are promoting the Ouagadougou
initiative to institutional stakeholders and the wider community.
Unite d’enseignement et de recherche en demographic (VERB)
In accordance with the Government strategic plan to combat poverty, UERD has re
organized in 2001 its research and training agenda into a main objective: To provide
evidence-based policy recommendations to increase access and improve the
utilization of basic social services (health, education, housing). In Ouagadougou, the
three focuses are integrated into the “Observatoire de Ouagadougou^ The cross
sectional theme of gender inequities in health and education is coordinated by
Christine Ouedraogo of UERD.
Figure 1: Partners in the three components of the Ouagadougou Observatory
Measure
(Observatory)
EQUITY
GAUGE
PILLAR
Intervention
(Initiative)
Advocacy
(Initiative)
Component
Health___ __Education
UERB
VERB*
(Pilon, Kobiane)
(Baya, Pictet)
IRD
Univ de
Montreal The
Population
Council*
SCPB (Zina),
Mwangaza
Diakonia
Habitat
VERB
(Dabire)
Univ de
Montreal
The pilot research activities of the health component of the Ouagadougou Observatory
is supported by the Rockefeller and Mellon Foundations; the measure/research pillar
is also supported by Aire - Developpement.
Save the Children Pays Bas (SCPB)
SCPB is a Dutch NGO founded in 1980 and a member of the International Save the
Children Alliance whose members operate in over 120 countries in the World. SCPB
has been operating in Burkina Faso since 1982, notably in the rural district of Kaya
(see below).
Mwangaza Action
Mwangaza is a Burkinabe NGO affiliated to the Cooperative League of the United
States of America (CLUSA). It is specialized in community mobilization and the
participatory learning approach around health issues. It has worked on a number of
projects with UERD: in the rural province of Bazega ESC with the Population
Council on reproductive health and female genital mutilation, and the province of
Ouagadougou Health and Equity Initiative
Sissili on community-based services, as well as on the Programme de participation
communautaire pour la sante de la reproduction et la sexualite des Jeunes.
Institutional Stakeholders
Stakeholders in health are institutions who have a mandate to improve health (and
equity) in health: the Ministry of Health, The Ouagadougou Regional Health
Department, The Ouagadougou Municipality, WHO, Unicef, UNDP, le Comite
national de lutte contre le sida (CNLS), Health NGOs, bilateral donors and embassies,
etc. UERD and SCPB have discussed the initiative with The Regional Health
Department, WHO, UNDP, CNLS, 1NSD, the Italian Cooperation, the Dutch
Embassy, IRD1 and the Centre Muraz. While all these stakeholders have shown their
support for the initiative, most are constrained by their lack of resources to devote to
the capital city (rural areas are their priority) and/or their own agendas (HIV/AIDS,
child welfare, etc ). Discussions with local stakeholders have shown that the term
“equity in health” is sometimes used but that the concept’s definition and
programmatic implications need to be clarified before the stakeholders can fully
contribute to the initiative (i.e. in its intervention and advocacy components).
Stakeholders in Health are therefore the first targets of our advocacy efforts.
This also true for education. The Ministry of education and its partners have targeted
20 priority districts all of which are rural. As Ouagadougou has the highest enrolment
rates of the country, it is not expected that the government and bilateral donors will
invest in Ouagadougou in the next five years. UERD and Diakonia are advocating for
more research on the specific problems that it has identified in Ouagadougou during
its exploratory research: inequity in access to the formal sector (both private and
public), increased costs, large classes, ‘double flow’ management, low parental
demand for quality.
Indeed, the preliminary results of the coordinated contextual mapping activities in
health and education show that both sectors in Ouagadougou encounter the same
problems in terms of equity in access and in the utilization of services. Moreover,
health and education are intimately related at the individual and family levels (ill
health in the household is an obstacle to child education and low educational
attainment is related to inefficient health seeking behaviors). On the aggregate level,
the ‘disadvantaged groups’ usually suffer inequities in both sectors. Finally, equity
research in both fields use the same type of conceptual framework, data and indicators
(see Figure 3 page 9). HERD organized a workshop in September 2001 where,
together with Nouna and Niakhar teams we developed the instruments to integrate
population-based studies on education the three observatories, thus allowing for crosscultural and urban-rural comparisons.
Pilot activities and results
The Ouagadougou Health and equity initiative pilot was officially launched in July
2001 with a series of contextual mapping and data collection activities:
1 UERD and IRD plan to collaborate on a Health Geographical Information system for Ouagadougou.
Ouagadougou Health and Equity Initiative
Contextual mapping
The contextual mapping aims to answer the following questions:
1. What are the healthcare problems in Ouagadougou? How are they inequitable?
How different are they from healthcare problems in rural areas?
2. What characterizes the urban/Ouagadougou setting? How is the urban social
setting different from the rural setting?
3. What intervention do we envision that a) solves at least part of the healthcare
problem in Ouagadougou and b) takes into account the socially diffuse urban
setting? Can/should it be community-based?
4. How can we test this strategy in Ouagadougou?
Data and methods
Nationwide survey on migration and urban assimilation, 2000-2002 (UERD,
University of Montreal).
• Health Survey in Ouagadougou, October 2001 (UERD)
• Pilot demographic surveillance system: baseline census (January 2002)2.
UERD adapted the HRS design to the Ouagadougou setting. The
Ouagadougou HRS takes into account
■ heterogeneity of habitat and household living arrangements;
■ social groups other than the household,
■ expected individual and household mobility;
■ health related infrastructure;
■ use of pocket pcs to collect data.
• Interviews with religious opinion leaders, health professionals and individuals
on contraception and abortion.
• Survey of maternity wards.
• Analysis of referral system in maternity wards.
• Mapping and observation of two urban “communities”.
• Discussions on the concept of equity in Burkina Faso.
• Interviews with key stakeholders.
•
Preliminary results
What are the healthcare problems in Ouagadougou? How are they inequitable?
How different are they from healthcare problems in rural areas?
A) The healthcare problems in Ouagadougou:
1) Healthcare in Ouagadougou is expensive and health related costs have greatly
increased in the last decade (cost recovery schemes, CFA Franc devaluation and
“informal tariffs”)
2) Healthcare is of poor quality, particularly for the disadvantaged groups who do not
have access to the private clinics and medical doctors
3) People have low expectations of health service delivery, to the point that people do
not even go to the public health center.
4) Client-provider relations are very' unequal. Patients are passive, intimidated and feel
socially inferior to the heath service provider. The health providers, consciously or
not, exacerbate this unequal relationship and often use it to cover-up their
The baseline census for the education component of the Niakhar and Nonna population observatories
are currently being fielded.
Ouagadougou Health and Equity Initiative
5)
6)
7)
8)
unwillingness to serve, their incompetence, or simply to extort money from their
patients.
Traditional beliefs about witchcraft are highly prevalent in Ouagadougou and effect
health seeking strategies.
The Health system is under increased pressure with the expansion of HIV/AIDS. The
pressure is strongest in the cities (and particularly in Ouagadougou) where the general
hospitals and clinics are located.
Migration and social change in Ouagadougou are creating additional stress on the
health system as demographic pressure increases and traditional social control and
solidarity mechanisms break down.
Increased demand has lead to an increase in the cost of healthcare in the public sector
and an increase in the supply of private and informal health care.
B) Consequences in terms of equity:
High cost, poor quality, low expectations and unequal social relationships between
client and provider increase health inequities as the socially vulnerable groups
1. are discouraged to seek “modern healthcare”
2. receive less attention and inferior healthcare from service providers
3. are more often victims of predatory practices
than less disadvantaged social groups
C) Difference with the rural areas
Inequities are greater because there is a greater range of health service
providers (public/private; modern/traditional; formal/informal)
Inequities are not geographical but social and economic
There is no ‘village solidarity’ in the city (though there is in certain
settings something akin to neighborly solidarity
What characterizes the urban/Ouagadougou setting? How is the urban social
setting different from the rural setting?
Contextual mapping preliminary results show that ‘communities’ in Ouagadougou (if
they exist at all) are non-territorial, socially diffuse, heterogeneous, conflict ridden
and that people are mobile : Neighborhoods in Ouagadougou are not urban villages,
even in the semi-rural periphery.
Non territorial neighborhoods in Ouagadougou are not isolated, autarchic, self
contained spatial entities. Neighbors do not have the same sense of collective
ownership of their surroundings that they may have in rural areas or in some slums in
other cities in the developing world. Each individual has his own Territory”
depending on his activities, his mobility, his sex, his age. People leave their
neighborhood daily and some are never there during the day. Many neighborhoods do
not have physical boundaries, and residents living in the same area define the
boundaries of their neighborhood differently.
Diffuse : community relations are looser than in rural areas. Traditional systems of
social control and information circulation are less efficient; social networks are more
varied and are non territorial. Networks in the city vary from one individual to
another, depending not just on gender, but on the individuals’ activities, educational
attainment, social class, migration history and economic resources.
Ouagadougou Health and Equity Initiative
Heterogeneous : the urban seeting varies greatly between residential and business
districts, the loti (zoned) and the non loti (occupied land that is not yet zoned), the rich
and the poor neighborhoods. People may settle according to ethnic groups or their
village origins, but tend to leave their culture, values and kin in the village.
Conflict-ridden: the city is the setting where traditional and modern values coexist and
clash, where the younger generations are exposed to different ideologies and have the
most freedom to adopt new lifestyles. More “traditional” conflicts that exist in rural
communities are exacerbated in the city.
Mobile: Preliminary results from the Migration and Urban Assimilation survey show
that among the 2,838 adult residents of Ouagadougou that we interviewed, 88 % had
moved at least once (to or within Ouagadougou). Many return to the village for
extended periods of time or on a seasonal basis.
What intervention do we envision that a) solves at least part of the healthcare
problem in Ouagadougou and b) takes into account the socially diffuse urban
setting? Can/should it be community-based?
Figure 2 shows the two pronged strategy that the partners in the health initiative
propose to test this year. The two pronged approach was successfully implemented by
SCPB in the rural province of Kaya. It now needs to be adapted and tested in the
urban setting. The SFPS projects have attempted this approach in Ouagadougou with
the Programme d’assurance qualite (AQS). The traditional AQS implemented in
Burkina focus exclusively on improving the quality of family planning services, and
in Ouagadougou, the AQS are Health Center-based and do not have a community
based component. SCPB will therefore build on its AQS experience in Kaya, where it
extended AQS to other health activities. SCPB will adapt the tools it has designed for
the Kaya program, and, with Mwangaza action, design and test outreach activities and
community mobilization schemes around themes such as patients rights, equity,
quality of care and basic hygiene and healthcare. The interface provider/client is part
of the problem that is addressed by the intervention AND the proximate variable
where impact is achieved.
Figure 2: A two pronged intervention strategy to improve equity in healthcare
Ouagadougou Health and Equity Initiative
ER
tohwestservk
1ir=>
Community
-leaders
TRAIN &
J|g|
ORGANIZE
PROVIDERSto
--5
-
Increased
access & use
of health
services for/by
disadvantaged
groups
- outreach
activities
- client/provider
interface
Smaller
disparities in
heal ill
outcomes
between
advantaged
and
disadvantaged
groups
sematoail
How can we test this strategy in Ouagadougou
HERD, SCPB and Mwangaza will launch a pilot project in three neighborhoods in
Ouagadougou to identify and test simple health strategies that, if successful, would be
gradually up-scaled and integrated in the two-celled experiment described below.
A two-cell stepped-wedge experiment is envisioned to test whether community
participation and service outreach around the themes of quality of care will have an
impact on project endpoints.
Project experimental cells. The treatment cell will include all the health center
catchment areas where NGOs, in collaboration with the health center staff, will
involve the community in the organization, the management and evaluation of health
services and outreach activities. A comparison cell will be composed of catchment
areas where no community involvement nor outreach activities will be organized
before the end of the experiment.
Stepped-wedge design. A step-wedge design is needed to take into account the
characteristics of Ouagadougou, the institutional capacity of local NGOs, the
experimental nature of the intervention and the ethical principles relative to the use of
comparison cells.
The first step of the experiment will be launched in two of Ouagadougou's four health
districts. In each of these two districts, two health centers will be selected where
NGOs will assist the health personnel and the community in planning, implementing
and evaluating service outreach activities, as described above. Intervention outputs,
coverage, community involvement and changes in health perceptions and behavior
will be monitored. Simultaneously, health perceptions and behavior in two
comparison areas in the same two districts will also be monitored.
Step 2 : Once the intervention activities are successfully running in the four initial
treatment areas, two more treatment areas and two more comparison areas from the
two initial districts will be added.
The experiment is thus scaled-up by increments of four treatment and four
comparison areas in the first two districts. Once all the catchment areas in these
Ouagadougou Health and Equity Initiative
districts are included either in the treatment cell or the comparison cell, the
experiment expands, at the same pace, in the other two health districts.
The experiment ends when there are 16 catchment areas in each cell (32 total). If the
experiment shows that the community outreach strategy is effective, then it will be
implemented in the remaining areas.
Challenges and questions
Measuring improvements in health equity
- Designing an experiment to evaluate the impact of the intervention on health
indicators. Can we reasonably expect that increased access to health services by
empowered clients can be measured with the classic health oucome indicators
such as child mortality?
Interventions to improve equity in health
designing relevant community strategies adapted to the Ouagadougou setting: how
can a community based intervention be implemented in a city where social
interactions are non territorial and diffuse, where districts are heterogeneous, and
where the population is very' mobile...?
involving the private-for-profit, the non-profit/charity organizations and the
informal health providers in the promotion of patients rights and the improvement
of healthcare: the private and informal sectors are heterogeneous, their markets
vary greatly.
Involving public stakeholders in health in an intervention that undermines
personal interests.
- Taking into account / involving the ‘parallel informal sectors (drug peddlers,
soothsayers) to understand and “rationalize” health seeking behavior.
Advocate health equity
- adapting the notions of equity, patient’s rights, quality in health care to the
Ouagadougou context into operational concepts that
o are culturally relevant
o mobilize local stakeholders and
o empower people.
Ouagadougou Health and Equity Initiative
i
Figure 3: Diderichsen framework applied to health and education
Stratification sociale
Stratification sociale
—~
------------------------- —>
Positionsocial©
^ | compenser la stratification sociale
- 'S'* Reduire i’exposition
->
I
-<■
| Exposition
s differentielle
If
Susceptibiiite
■ differentielle
T
Reduire les risques d'echec
—1
2
I
Exposition specifique
-—t-—
j
■ •
M
■-
ineSa!es.... ..
□
<■
I
■>
y
i
I Consequences
: differentielles
>0
i
Rattraper les cas d’echec dyitables
I
O
j Risque d'echec soolakef r
:■ -fC
Reduire la yulnerabilrte
P£ve<w
Position sociale
compenser la stratification social^.
Influencer ou
«•••• =... .........
—•—1
. .......
2
I
o
INDIVIDU
SOCIETE
INDIVIDU
SOCIETE
Influencer ou
■k1
Equity in education
Equity in health
S3
Echec scoiaire deftotW
—
Reduire
ou prevenir les consequences
de I'echec definitif
.. ”> I
______
A
Consequences
^Wsociales de ia naiadie
Stratification sociale supplementaire
W1’ ’
.
Mecanismes qui jouent un role dans la stratification des etats de sante
Points d'entree programmatiques
,
Stratification sociale supplementaire
Consequences ■
sociates de I’echec
scolaire
Mecanismes qui jouerrt un role dans la stratification des niveaux d'education
Points d'entree programmatiques
Source: Adapted from Diderichsen, in Challenging inequities in health, from ethics to Action, chapter 2, Evans, Whitehead, Diderchsen, Bhuiya and Wirth (eds), Oxford
University Press. New York, 2001
Page 9/9
UERD/pictet- ] 4/01/02
The Nairobi Health Equity Gauge
May 2001-December 2001
The Nairobi Urban Health Equity Gauge (NUHEG) is a partnership between the African Population and
Health Research Center (APHRC), the National Council on Population and Development (NCPD) and the
Urban Slums Development Project of the Nairobi City Council (USDP/NCC). The Nairobi Gauge is
currently being funded by The Rockefeller Foundation for an initial period of two years starting May 1,
2001. This brief report provides an overview of activities that have been carried out since then.
1. Project equipment
On August 8,2001, a meeting was held at the National Council on Population and Development offices in
Nairobi to hand over computers and printers to the partners. The Rockefeller Foundation sent a
representative to attend the ceremony. All partners are now connected to e-mail facilities to ease
communication between them.
2. Contextual Mapping
Understanding the national and local context of the Nairobi Gauge is a crucial initial step for
implementing the project. The project partners have completed first drafts of the following documents:
a)
b)
c)
d)
e)
Macro-Economic environment (by NCPD)
Socio-economic differentials in Nairobi (by APHRC);
An inventory of NGO activities in the slums of Nairobi (by USDP/NCC)
Human right situation (by USDP/NCC); and
Health sector reform and policy in Kenya (by APHRC - in progress)
3. Data Analysis
Data analysis is still on-going, mainly using the!998 Kenya Demographic and Health Survey and the
2000 Nairobi Cross-Sectional Survey. The APHRC, in charge of the Measurement pillar of the Nairobi
Gauge, has been working on the indicators that will be used to disseminate the findings from the project.
So far, APHRC has completed analyzing the data along the following indicators: infant, child and under
five mortality, child immunization, prevalence of diarrhea, fever and cough, and type of delivery care.
3. Advocacy and Community participation
Initial contacts are being made to start off these two pillars. Substantial groundwork is needed to deal
properly with this aspect of the Nairobi Gauge because of local political intricacies and the volatile nature
of file slums of Nairobi.
4. Dissemination
A pamphlet introducing the Nairobi Health Equity Gauge has been printed and is being distributed to key
Kenyan governmental institutions, local and international NGOs, and the donor/policy community in
Kenya and abroad. A brief description of the Nairobi gauge appeared in the first issue of the newsletter ot
the APHRC. A member of the Nairobi Gauge team participated recently in an important radio broadcast
on health equity issues. Upon invitation by the California Family Health Council, the project made a
presentation at the “Work and Health Conference” held in San Francisco in March 2001. Another
presentation on the Nairobi Gauge was made at the annual meeting of the American Public Health
Association held in Atlanta in October 2001.
Health Equity Gauge Association of Uganda
1.
Primary institutions responsible for managing the Equity Gauge
□
2.
The scope of the Equity Gauge
□
□
□
□
□
3.
The design of the EG is based on the three pillars of: measurement, community
participation and advocacy.
Measurement: study and document the status and distribution of selected indicators
at regional/district level. The districts in the study are taken from four regions in
Uganda each corresponding to a ranking by quartiles of the Human Poverty Index
Community Participation: Involve communities in identifying and confirming the socio
economic rankings; involve communities in defining their health equity concerns
Advocacy: For all three pillars, study findings will be disseminated with a view to
providing timely, relevant and accurate decision making and/or altering policy
direction in the short and long term
Decentralisation
The gauge will review how decentralisation affects: control of resources for
health care at the implementation levels; capacity to implement decisions to
improve essential medical supplies; distribution of human resources for health
care e.g. potential to attract and retain staff
The gauge will also make a comparison of the districts based on phasing of
decentralisation thus: Group 1(1994) - Mbale; Group 2 (1995) - Rukungiri;
Group 3 (1997) - Kiboga and Adjumani
Describe the political, social and economical context of the EG
□
□
□
□
4.
The Health Equity Gauge Association of Uganda is a registered non-profit making
concern. It’s members are multidisciplinary professionals who have worked together
for close to 18 months. They are drawn from the Institute of Public Health;
Decentralisation and Innovative Consultancy Services; Ministry of Health. Plans are
underway to expand membership to include other stakeholders.
Political Reforms: Uganda has undergone political reforms over the last twenty
years geared towards good governance, community involvement and participatory
decision making and democracy
National Health Policy: subscribes to the two national goals for poverty eradication
- expanded economic growth and increased social development. The Poverty
Eradication Action Plan of 1997 ...
Constitutional provision: the constitution states that “Every Ugandan shall enjoy
good health”
Health Sector Reforms: there is further emphasis on further decentralisation;
reaffirmation of Primary Health Care with the principles of quality, gender
mainstreaming and a minimum package of health care services
Comparative population groups that you have selected for your EG
□
District populations in the four quartiles ranked by Human Poverty Index. Thus Mbale
is in the 1st quartile, Rukungiri in the 2nd; Adjumani in the 3rd and Kiboga in the 4th.
Each district population is regared as homogenous.
y
5.
Quantitative equity measurement indicators for the EG
□
□
□
□
□
□
6.
Use of qualitative data in the Equity Gauge
□
7.
□
Strategy will be involvement of the public/communities in the identification of
inequities, discussion of inequities, and advocacy to responsible agents for the
purpose of addressing these inequities
Involvement of the stakeholders in the primary research (i.e. at community level,
confirmation of key concerns in health equity)
Advocacy plans and proposed ‘actions’ to help reduce inequity in the setting of the EG
□
□
9.
Obtained through Key Informant Interviews (KI) with health providers, focus group
discussions (FGD), participant observations in health care and rapid participatory
rural appraisal (RPRA)
Public Participation Plans
□
8.
Indicators of health status (children’s growth and nutritional status, Child (under 5)
mortality, life expectancy at birth, maternal mortality ratio, measures of disability in
general)
Indicators of major determinants of health status (safe water and sanitation, food
supply, adequate housing, poverty, educational attainment, income inequality in the
society
Indicator to assess the equity in health care financing (burden of payment for health
care
Indicators for health care resource allocation (public expenditures for health,
distribution of qualified health care personnel in the public sector, distribution of
health-care facilities at the primary, secondary, tertiary an quaternary levels)
Indicators for utilisation and quality of health care (immunisation coverage of infants,
antenatal care coverage, safe delivery coverage, contraceptive prevalence rates,
quality of primary care services (availability of essential drugs at HC II and HC III)
Access to health care referral services
All findings packaged and disseminated to policy makers, implementers, consumers
and other stakeholders in Ministry of Health, Parliament and the community in
general
In particular, this feed-back is expected to change the flow and allocation of
resources for health care services
Progress of the EG
□ Doing well: Equity Gauge and advocacy messages have been well received by policy
makers at the central level as well as other stakeholders in health care provision.
There is good collaboration between Ministry of Health officials and the EG
□ Difficult: Interpretation of secondary data for measurement indicators
□ Main constraints: lack of critical mass of personnel versed in measurement
□ Additional support: T/A for interpretation of findings; fora to exchange ideas and
experiences between gauges on global and regional basis
South African Equity Gauge Project
Project Management
• t he project is a partnership between an NGO, the Health Systems Trust (HST), South
African Legislators (both National and Provincial) and Local Government. HST has
strong partnerships with the Department of Health in work that is being done in other
projects. These partnerships assist as a conduit for providing qualitative information on
inequities and possible strategies for reducing inequities to the Equity Gauge, as well as
for allowing an “Equity Gauge Lens” to be highlighted in our interactions with the DoH
Project Scope
• The Equity Gauge Project attempts to monitor, and promote, progress towards equity
nationally, across a range of socio-economic, health and health status indicators.
Wherever data permits indicators are compared across provinces, rural and urban settings,
socio-economic groupings, race, and gender.
Political, Social and Economic Context
• South Africa is the 2nd or 3rd most inequitable country in the world.
• Trends in equity have only recently begun to be monitored — data prior to 1994 was
woefully inadequate, with almost no reliable data on the health of the black population.
• Apartheid policies resulted in huge inequities between black and white, between rural and
urban, and between areas which were formerly “SA” and those which were formerly
“homelands”.
• Almost every indicator, whether it be .socio-economic or health related, highlights a huge
gap between white communities and poor black communities living in rural areas and
informal settlements. In recent years the impact of HIV/AIDS, whilst disproportionately
affecting disadvantaged communities is serving to increase existing inequity.
• South Africa has a democratic government with a commitment (although not always
realised) to a culture of accountability and transparency.
• Commitment to Equity is enshrined in our constitution, in our legislation and is the focus
underpinning most policies developed since 1994.
• We have a federal system of government with a national assembly and nine provincial
parliaments.
• Our electoral system of proportional representation mitigates against national and
provincial parliamentarians being as fully accountable to their constituencies as is
desirable.
• Local government was reorganised in 2000 and there is a commitment to devolve
responsibility for the provision of PHC to this sphere of government This will hopefully
improve accountability of service providers to their constituencies.
• At provincial level 85% or more of spending is allocated to health care and other social
services. However health care spending remains skewed to the tertiary level.
Macro-economic environment
• South Africa is a middle income country with a neo liberal public sector and macroeconomic policy. Over the last 7 years SA has established a stable and (slowly) growing
economy. The proportion of government spending to service debt repayments has been
significantly reduced in the last two to three years.
•
•
•
In 1994 SA had a commitment to a Reconstruction and Development Programme (RDP)
which emphasised redistribution of resources to previously disadvantaged areas and
communities alongside job creation.
During the last four to five years a Growth, Employment and Redistribution programme
(GEAR), which emphasises economic growth and fiscal restraint as its first priority has
replaced the RDP.
The extent to which the macro economic policy was shifted in response to international
pressure is unclear.
The Health System
• Prior to 1994 there were 17 Departments of Health in SA, all very “hospital oriented”.
Since 1994 emphasis has been upon integrating departments into one unified DoH, which
is District based with an emphasis upon PHC.
• The greatest inequity in health care provision is between the private and public sector
with approximately 60% of funding spent in the private sector on 20% of the population.
• Re-organisation of local government in 2000 has cleared the way for devolution of
responsibility of providing PHC from the provincial sphere of government to the Local
Government sphere. This devolution is intended to promote equity by improving
accountability. However serious constraints of capacity and finance available to about
50% of municipalities have the potential to do the opposite and, increase rather than
reduce inequity.
• Health care financing to provinces is allocated using a formula, which although
containing a “backlogs” component, is in fact regressive.
• Since 1997 Provinces have been allocated a block grant from which they individually
decide upon amounts for education welfare and health. This has reversed equity trends in
health care spending, but it is unclear what impact this has had upon promotion of equity
in health status.
• Community involvement in the planning and delivery of health services is problematic,
despite the existence of clinic committees and hospitals boards.
Advocacy and Public Participation Environment
Judicial and legal system
• South Africa has a strong commitment to human rights enshrined in the constitution.
• The right to basic needs being provided by the state was tested in the courts recently, with
a slightly ambiguous outcome.
Other non-governmental agencies and initiatives
• NGO activity is relatively subdued (especially in comparison to activity prior to 1994).
• The notable exception is in the field of HIV/AIDS where there has been a growing
amount of high profile and successfill activism. In 2001 The Treatment Action Campaign
(TAG) took the Government to Court over the issue of access to Nevirapene, and the
court ruled in favour of TAG.
The Media
• The media is in theory free. Sometimes it appears that what might be deemed “critical
reporting” is constrained through the contradiction imposed for journalists with the
desire to support a relatively inexperienced democratically elected government.
whilst at the same time wanting ensure that the press fulfils its function of exposing
malpractice and wrongdoing.
Qualitative Data
llie project has not utilised qualitative research as such, although we have used participatory
forms of needs assessment throughout our activities.
Public Participation
Public participation was initially limited to working with stakeholders and to encouraging
media participation in Equity Gauge activities. In order to begin to place more focus upon
this component we have established a pilot community participation project During the latter
half' of 2001 we began to build links with communities in one of the poorest parts of the
country. This area is one in which a number ofNGOs have been active for some considerable
time and yet it has been very hard to bring about change. However, because of the work that
has been undertaken there, there exists a large amount of information on health and health
status. The aim of the work planned by the Equity Gauge is to use the information we have,
particularly on health status, and to make this information available to the community in a
format which is meaningful to them, and then to support the community in using the
information to promote change.
Advocacy Activities and Plans
Effective and strategic dissemination ofIEC materials
This has been one of the strongest components of the work of the Gauge. We have produced
a number of publications, written in an accessible format which target “non-technical
audiences.
Direct engagement and active lobbying with policy makers and decision-makers
The nature of how the SA Gauge evolved has meant that this component is very strong. Much
of the work of the gauge has focused upon direct engagement with key policy makers in
national and provincial parliaments.
Constructing convincing and effective arguments, policies, proposals and recommendations
for improving levels ofequity
This has been a part of the work of the Gauge and has been integrally linked with the two
areas of activity outlined above.
What has been going well?
• The SA Project was developed in conjunction with legislators and academics, and this
has facilitated what has become a successful ongoing relationship with our partners.
• An integral component of the project has been capacity building, which has taken the
form of workshops, site visits and the production of materials in accessible formats,
specifically targeting legislators. The project has documented inequities across a
range of indicators.
• The project has successfully focussed upon providing information about financial
resource and allocation issues and how these are impacting upon equity.
• We have had some success in raising the profile of the huge equity gaps existing in
the country. For example, from anecdotal evidence it appears that the project has
impacted on legislators knowledge and understanding of health and equity issues, and
resulted in more equity-oriented questions being tabled in the national assembly and
provincial parliaments.
•
•
Whilst we have been most successful in getting coverage through the print media, we
have had some success in coverage in other media.
The re-organisation of local government, and the policy intention to decentralise
health care, has created a need for the project to develop links with local government
political and administrative structures. It appears that the project been successful in
beginning to build links between national and provincial legislators and councillors at
the local level.
What has been less successful?
• We have been less successful in promoting action to reduce equity gaps.
• Our work at community level is not yet as strong as it could be.
Challenges and Questions for the way forward
Capacity Development
Capacity development has turned out to be a basic component of the Equity Gauge. Capacity
development is by definition a slow and time intensive process. What should be the balance
of capacity development and other activities within the project?
Advocacy
How do we keep a focus and energy for promoting change in a way that is relevant and
meaningful for partners? Our current monitoring is broad, and reflects the range of indicators
which impact upon equity in health and health care. Whilst this is important in assisting
stakeholders in monitoring progress towards equity, it presents difficulty for promoting
action and advocacy - there is just too much that needs to be done. We are considering the
possibility of continuing to monitor a broad range of indicators, whilst focusing upon one or
two issues around which to develop advocacy campaigns.
Public Participation
Defining what community participation in a national equity gauge should be - are pilots to
demonstrate models of good practice the way forward? Or should we be building broad based
coalitions with other organisations undertaking community action projects?
Measurement
Updating an Equity Gauge regularly when much of the data on key indicators is only
collected every four or five years. With the process of decentralisation of health care to the
district level set to become a reality over the next few years, indicators will need to be
monitored at the district level. This requires a substantial collection of data in order to
provide baseline information.
Antoinette Ntuli, Solani Khosa, Alfred Maluleka
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Monitoring of Equity in health service systems in Thailand
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Thailand is a country facing with high differences of health status and health
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and reducing the ratio of population under poverty line but it also bring the problem of a
wide income gap. Inequity in health status has been reported among population in
different geographical areas. Although Thai health care system is under reform for more
effective health care services, equity is not explicitly written as a main goal of the health
care reform. In order to put equity as a high priority in health development plan, Thai
equity gauge has been carried out to raise awareness of the existing inequity level and
monitor progress towards reducing inequity gap.
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4. To advocate use of equity indicators for monitoring of inequity in health and
health care among related stakeholders
5. To establish network for monitoring on equity at the provincial level
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in order to monitor progress towards equity, sets of indicators on inequity have
been established by analyzing data from secondary sources. These data can be classified
into population-based and facility-based data. Data from National Socioeconomic
Surveys, National Health and Welfare Surveys, Provincial Statistics, Resource
Allocation Reports, Mortality and Morbidity Reports and other statistics and reports
from related government agencies have been analyzed. Indicators on inequity in health
and health care included: health status indicators, determinants of health indicators,
health care financing and resource allocation indicators and health care utilization
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To make the monitoring more effective, participation of the related stakeholders
such as community leaders, women’s groups, local health workers, staff of subdistrict
administrative organization and media & journalist are necessary. These related
stakeholders have been included to discuss about the existing inequity level, equity in
their own ’s view and sample indicators that they can use in their work for monitoring
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of equity. Concomitantly with public participation activities, advocacy actions have
been planned. Indicators and information on inequity will be disseminated to media and
politicians at local and national level to raise awareness and provide tools on reduction
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group and government staff at the local and provincial level has been planned so that
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However, these indicators have to be identified for their appropriate use at the national
or international comparisons. Some more specific indicators such as perceived health
status, perceived quality of care and accessibility to health services among population in
2 different socioeconomic groups are needed for program implementation towards
progress in equity in details. Data collection from primary sources have to be carried out
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Survey and mapping of related stakeholders from the selected province to
participate in the Thai equity gauge have been performed Project orientation has been
made to these stakeholders to make them understand objectives of the project and ready
to participate in the activities of the project.
Workshops have been organized to discuss among health care staff, staff of
subdistrict administrative organization, community leaders and women’s group from the
selected province to discuss about the existing situation of inequity, equity in their own
views, how to pursue for more equity, and equity concepts and equity indicators for
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subdistrict administrative organization, community’s leaders and women’s group have
been carried out after discussion about equity in their own’ s view. Equity under the
views of local health care staff and people focused only to equality in receiving of
health care services. When process leading to equity has been discussed, they have
recommended to improve equality in resource allocation, accessibility to health
services, quality in health care provision and reduce existing inequality in service
provision. In addition, they have proposed some simple indicators which can be
established by data from health facilities records such as utilization rate, mortality rate
and length of stay by insurance schemes, type of diseases and age group.
-<> Small grants project have been announced for related stakeholders to submit
proposals on equity issue. To date, 2 postgraduated student have been granted to carry
out their Master’s theses on equity. Two more proposals from local health care staff and
I proposal from staff of Faculty of Social Sciences and Humanities, Mahidol University
have been submitted and under review and consideration process. ►
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community people. Because of its ambiguous meaning, they are unclear for “What to
do” and “How to do” to pursue for more equity. In order to encourage for public
participation or make an advocacy, other issues such as “health care reform” may be
easier to use as existing point rather than equity itself.
Culture plays an important role in inequity. Buddhists people usually
believe that those who are not equal to other people in any aspects are their own karma.
They tend to accept inequity or inequality rather than to try to reduce it.
To establish indicators from secondary data, one may face problems with
reliability, validity, comparability and fluctuation of data, particularly, when data from
several sources have been compared and combined.
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equity, raising awareness and policy formulation will be focussed. Raising awareness
will be performed by feeding information through media and civil society group. To put
equity as a high priority in health agenda, working with administrators of subdistrict
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translate information and indicators into friendly, attractive, simple and interesting
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The Equity Gauge of Zambia
Summary Progress & Achievements
By Dr T. J. Ngulube and Dr Kamima M. Mwanza
The Centre for Health, Science and Social Research (CHESSORE)
P. 0. Box 320168, Woodlands, Lusaka
Fax: (... 260-1-) 263201;
email: chessore@zamnet.zm
Introduction
With funds released in July 2001, the equity gauge of Zambia commenced on formal activities. The
initial desire was to start with a national launch of the equity gauge programme at national level
involving legislators, policy makers and national level NGO’s. However, the rapidly changing
political landscape made this step difficult as parliament went into an unusually long recess (March
to November 2001). Legislators were gearing up to defend their seats and the wheels of
government could not move at their usual normal pace.
This scenario resulted in changes to the order of carrying out programmes. Instead, work had to
start at district level. In spite of the efforts made to complete the activities well before the start of
campaigning for the national elections, it was still not possible to get legislators at district level to
attend equity gauge activities. Many were in the process ofchanging political parties and were not
sure whether they would make it back to parliament. Nonetheless, workshop activities went ahead,
with the first one done for Lusaka district (September) then Chama District (October), Choma
District and Chingola District (both in November, 2001).
Methodology
Consent to undertake the equity gauge project was obtained at central level from the ministry of
health and the central board of health through the offices of the director planning and the director of
public health and research, respectively. In order to ensure local ownership of the equity gauge
programme of activities at district level, the district health authorities (at the DHMT) were given a
copy of the equity gauge proposal and asked to identify and invite stakeholders in their districts
from a suggested set of stakeholder category as contained in the proposal document. All logistical
arrangements for districts workshops were made by and through the offices of the district directors
of health.
The equity gauge of Zambia has used workshops as a major tool for establishing equity gauge
activities and equity gauge culture in the health services in Zambia. It is planned that TWO
workshops’ programmes on equity in health be held in each of the 4 districts where the programme
has started. The first series of workshops were planned to mobilize people and views on equity in
1
health in the 4 districts. In this set of workshops, definitions of equity in health were arrived at and
key stakeholders as well as equity issues of concern identified. In addition, the roles to be played
by the various stakeholders were identified as well as the desired activities to be undertaken by
each category of stakeholders in order to bring about and enhance equity in the districts. The
workshops were participatory in nature with stakeholders subdivided into 3 or more groups to
discuss an issue of equity. After the discussions, each group chose a spokesperson that presented
and justified their deliberations during plenary sessions. Where necessary, the views were
adjusted/ amended following input from the audience. Three plenary sessions were held to share
views on issues in each of the three pillars of advocacy, community participation, and
measurement.
Each workshop was concluded with an estimate of the desired quantity of resources needed to
undertake the desired activities and participation by the identified stakeholders. The stakeholders
selected some participants from among them to undertake this task. These budgets were later
incorporated into annual district budget of health activities by the DHMT.
Results
The results from the workshop are presented below, firstly to give the views on issues affecting
equity in Zambia from the 109 participants that completed a semi-structured questionnaire. This is
followed by a presentation of views and ideas expressed and consensus reached at the district
workshops.
(a) CURRENT PERCEPTIONS ON EQUITY ISSUES & EQUITY IN HEALTH CARE IN ZAMBIA
The background to the Equity Gauge of Zambia activities is one of socioeconomic divisions
between people within each district (97, 89% of respondents). It is perceived by 89% that these
socioeconomic divisions are either very deep or deep, while 6% felt that they were not deep. These
divisions are reflected by a number of visible characteristics in the two main categories of rich and
poor (Annex 1, Box 1 and Box 2).
There is a feeling that the government in Zambia is democratically elected through free and fair
elections (Yes = 60.6%, No = 33% and 6% didn’t know). Similarly, the feeling on local council
representation was 62.4% (Yes), 24.8% No and 11% didn’t know, respectively. In terms of
governance, the general impressions were 20.2% that government is accountable and transparent,
74.3% that it is not and 5.5% did not know one way or the other. Similarly, for local government the
impressions were 15.6% that there is transparency and accountability, 77.1% there is none of
these and 6.4% did not know. With respect to the administration of justice, the performance of the
Judiciary in Zambia was rated not to be very independent (53.2%), very independent (15.6%) and
not independent (28.4%).
Overall the human rights culture was rated to be very strong (19.3%), weak (67.9%) or that it did
not exist at all (11.0%). As such, it was felt (by 57.8%) that there are still some people who are
denied their human rights and a number of group categories identified (Annex 1, Box 3).
2
Perception on Equity Issues and Equity Perspectives in Today’s Zambia
I
The existence of socioeconomic divisions in Zambia has given rise to inequities in the provision of
social services to the people such that it was felt (71.6%) that poor people in Zambia had NO
access to fair legal representation and that the judicial system in Zambia (the courts) generally do
not uphold (safeguard) the interest of poor people (Not Very favourable, 58.7%; Not favourable at
all, 25.7%). In addition there is a feeling of corruption or patronage (86.2%) within the government
circles, which was rated to be (Very High, 53.2%; Moderately High, 11.9%; High, 16.5%; Low,
4.6%; and very low, 9.2%). The corresponding ratings for corruption within communities were
35.8% as very high; 20.2% moderately high; 22.0% high; 12.8% low; and 6.4% to be very low,
respectively.
Up to 43.1% felt that there was freedom of the press in Zambia today (48.6% No, 5.5% didn’t
know) and that the press in Zambia is not concerned with highlighting the plight of the poor (37.6%)
with others feeling otherwise (42.2% as being moderately concerned and 19.3% very concerned).
In addition, there is a communication gap between the POOR and the RICH groups in Zambia
today, which is thought to be growing (80.7%), rather than narrowing (14.7%).
Zambia is considered a poor country (52.3%) like most respondents thought of their districts to be
similarly poor (65.1%, poor district; 25.7%, rich district).
In addressing issues of governance and development, the perception was that the government was
influenced by outside forces (92.7%), such as by the IMF, the World Bank and donor agencies to
varying extents (56.9%, influenced very much; 35.8%, influenced to some extent, and 3.7% felt not
influenced at all). As such, these development agencies are stakeholders in the development
efforts in Zambia.
It was felt (78.9%) that the Government funding to the Health Sector was not adequate, and that
the majority (55%) believed that the consideration for EQUITY was a key public policy objective in
Zambia today (35.8%, felt NO while 8.3% did not know). A number of issues were identified to be
part of the equity objectives in the current policy guidelines, principally community participation
initiatives (Annex 1, Box 5). However, the feeling was that more effort was needed in order to
strive and achieve greater equity in health (Annex 1, Box 4). Otherwise as things currently stand
71.6% of respondents felt that the POOR and the RICH used different Health care Systems, where
(a) The rich have better services at private health facilities, while the poor had no access to the
same; (b) The rich had access to better health services outside the country-while the poor did not;
(c) The rich had access to high cost facilities at Government Health Centers, while the poor did not
have access to the same; (d) that the poor resorted to the use of traditional healers who were a
cheaper and more convenient alternative; and (e) that the rich had a choice of going either to
private or to public health facilities, while the poor had no choice but to go to public health centers
where services were thought generally poor, including lack of medicine.
It was felt (49.5%) that the private health care sector had not expanded in most districts in Zambia
over the past 10 years (40.4% said yes and 2.8% did not know). It was recognized that this would
have an effect on equity in health and health care. The view was that in its present set up, the
private health care in Zambia serves to Increase Inequity (37.6%) largely as a result of economic
3
and distributional access to these services (28.4% thought it decreased inequity, 15.6% did not
know).
I
Perception on Health Policies and Health Reforms In Zambia Today
Workshop participants recognized a number of stakeholders who were thought to be party in
making Health Policy Decisions in Zambia (Annex 1, Box 6). In addition, 40.4% thought that the
Non-Governmental Organisations (or Civil Society) were involved in Health Policy decision-making
(with 36.7% saying NO while 17.4% did not know). With respect to the financing of the health
services, several stakeholders were similarly recognized as playing a role (Parliament (52.3%),
Cabinet (16.5%), Ministry of Finance (27.5%), Ministry of Health (25.7%), Donor community
(4.6%), NGOs (0.9%), CBoH /or the DHMTs (2.8%). Some 3.7% of the respondents did not know
where this was done.
Respondents identified the following areas as being in need of urgent policy initiatives in the next 6
months: (1) On issues of equity; (2) Community participation; (3) Supply of essential drugs; (4)
Motivation of health workers; (5) Funding to the health services; (6) HIV/AIDS; (7) Salary increases
for health workers; (8) Conditions of services for health workers; (9) Provision of Health care for all;
(10) Exemption guidelines to provide free health services for selected poor people; (11) Capacity
building to increase trained personal; and (12) Further health reforms’ initiatives to be
implemented. Up to % of respondents did not know which areas the health reforms needed to
focus on in the immediate future.
The participants were aware of the on-going major Health Reform initiatives in Zambia (55.0%),
while 15.6% said they were not aware and 11.9% could not commit themselves either way.
Participants recognized both some positive and negatives attributes from the on-going health
reforms in Zambia today (Annex 1, Box 7 and Box 8).
(b) DELIBERATIONS FROM THE ZAMBIAN EQUITY GAUGE WORKSHOPS
The view from participants was that this was a good initiative worth pursuing. In order to have
meaning, it was suggested that the equity gauge of Zambia should have two clear objectives to it,
these being (a) to bring about equity in health and health care, and (b) to bring about a culture of
equity in the community. It was felt that the two needed to go together if there were to be a positive
impact on equity in health care. It was agreed that in order to have these two objectives met, there
is need for increased efforts with regard to community participation. Current arrangements, though
good in themselves, do not appear sufficient to attain desired stated goals. The arrangements and
community participation structures can be frustrating and exact a high cost in terms of time and
other opportunity missed [the opportunity costs], (Annex 1, Box 9a & Box 9b). A need exists to
have greater involvement of community groups and structure as a way to have influence and
impacton health and health care.
Increased Stakeholder Involvement: The above examples were cited as a justification for greater
and wider community involvement in health and health care as outlined in the proposed GEGA
model. In this model of approach, there are three pillars around which the activities will be centred
- these being Advocacy, Community Participation and Measurement. The district workshops
planned to come up and constitute a main district committee (serving as a district board on equity)
4
I
and one or more sub-committees to perform assigned tasks. Under guidance of the sub
committees, a number of stakeholders (Annexes 2 & 3) will carry out assigned activities and tasks
with the objective of developing a culture of equity as well as improving on equity in health and
health care whether on advocacy or community participation. The impact and outcomes from these
activities will be assessed and quantified using agreed upon indicators (as suggested in Annex 4).
Follow-up Work
As part of the initial set of activities, the equity gauge of Zambia remains with three major tasks to
implement and accomplish successfully. These are as follows:
(a) With national elections now out of the way (held 27th December 2001), a new parliament is
expected by January 2002. Depending on the work programme of the new parliament a
national inaugural Zambia Equity Gauge workshop can be expected around March or April
(with the GEGA meeting in Kampala taking place in February 2002). But in reality, we
anticipate that the national inaugural equity gauge workshop meeting would be held after
the second round of district workshops.
(b) In the meantime, the research team is studying and consolidating the views expressed in
order to come up with suggested activities for the next workshop sessions. The key thrust
in the next rounds of district workshop sessions will be to optimize, prioritize and agree on
the desired set district indicators on equity in health and health care as well as on work
activities as a way to implementing equity in health in each of the four starting districts.
When completed, the data and experiences will feed into the national inaugural equity
gauge workshop. The second year of our work activities will see increased activities in the
equity gauge of Zambia implementation programme.
(c) It is planned that by the end of the second year of activities the experiences gained from
the pilot phase will be used to extend the equity gauge programmes to other districts of
Zambia. Additional resources and funding will be required in extending the coverage of
districts with equity gauge activities. Due to the tight work schedule and (in part) the
uncertain political environment then, it was not possible to obtain donor participation and
funding for our equity gauge programmes. This is another area we plan to do more work
in. The participation in equity gauge activities from district health authorities and the
Central Board of Health (CBOH) were both excellent and supportive.
There was also good participation from other stakeholders/partners taking part in this project work,
such as the Participatory Assessment Group (PAG) and the University of Zambia, School of
medicine (Department of community medicine).
5
ANNEX 1: CURRENT PERCEPTIONS ON EQUITY ISSUES & EQUITY IN HEALTH CARE IN ZAMBIA
Box 1: How can you tell that someone in your district is well-off (RICH)?----------------
Usually with posh cars
Have good jobs.
Are able to go out of country for medical treatment.
Have good clothes/shoes.
Have big bank accounts.
Usually with cell phones
They tend to have no respect for others.
Their children go to study abroad.
Have a lot of property.
They kohouQ
behave so
as thnnnh
though RVfirvhodv
everybody knows
knows them.
them.
Can afford anything they want.
Have access to dean water & sanitation.
Have access to electricity.
Their children go to private schools.
By the business someone runs.
By the way they talk and cany themselves.
Can afford cable TV.
Associate with well to-do people in society.
Are usually educated.
Go to private medical centers.
They don’t get involved in local neighborhood activities.
Good accommodation & leave in quiet conducive residential areas.
Box 2: How can you identify a poor person in your district?
Have Door shelter
W usual|y exPect he,p from othere-Be99'n9-
They look miserable.
llnemnloved
Mostly^not educated.
Most walk long distances.
They don’t have property.
Have no shoes.
Cannotafford basic needs of life.
Sw-,.
Have poor clothing.
No access to clean water and sanitation.
They are crime prone.
Have poor or no medical care (Unable to pay for medical care).
Cannot send children to school, especially higher education.
Mostly depend on traditional healers and Government health services.
Are generally and mostly malnourished - Don't have adequate food.
---------- ------------
Box 3: The following Groups were identified as (at risk of being) denied of their Human Rights?
On Economic Grounds
The poor.
Civil servants.
Police officers.
On Physiological Status
Women.
Children and the youth.
The disabled.
The aged.
On Expression of their Conscience
On Social Grounds
Politicians that go against those in power.
The illiterate.
Journaliste-lndependent Media.
The vulnerable.
Individuals who say their minds on national issues.
Street kids.
Sex workers.
Opposition members.
Opposition parties.
Orphans.
People detained for a long time without hearing.
Foreigners, especially those in prison
Those without relatives in high offices
Box 4: Issues on EQUITY in Health to be emphasized on as part of Government policy on Health?
Equal access to health care for both the rich and poor.
Press freedom.
Preventative rather than curative measures.
Staff motivation.
Free X-Ray and other surgical conditions.
Community participation.
Eradicating corruption.
Introduce cost effective health services.
Availability of drugs.
Free medication for all vulnerable groups.
Equity measurements.
Monitoring and evaluating equity issues.
Accessibility to health care.
Capacity building for health staff.
Pay more attention for the poor.
Adequate Rinding.
The rich to pay more than the poor.
Issues must be implemented fully.
Increased salaries for health workers.
Re-train health staff.
To send any person out of the country for medical services where necessary.
Conduct workshops/seminar for communities and other stakeholders - empowering people.
Involve the grassroots in the planning process, implementation and evaluation of health issues.
Box 5: The main HEALTH EQUITY issues identified in current Government policies
There are the health reforms.
Provision of drugs
Community involvement.
There is fairness
There is equal access to health services.
Decentralization of Health delivery system
There has been training of health care providers.
Affordability of available resources
Have provided training to community health workers
Policies have made it cheaper for all to afford health care
There is community mobilization, senstization and empowerment.
Efforts are being made to close the gap between the rich and the power
Exemption categories including treating the very ill even if they have no money to pay
zfforts made to take affordable and quality health care service closer to communities.
Box 6: Group Categories of people and Organizations thought to be involved in making policies on Health
CB°H.
The Government.
Counselors.
Ministry of Health.
Members of parliament.
The community.
District Administrators.
Health workers.
DHMT/Provincial Health Office.
Stakeholders.
Cabinet.
Ministry of finance.
Politicians.
Provincial Medical Officers (PMO).
Donors.
Box 7: The POSITIVE elements brought about by Health Reforms in Zambia
Accountability-Health providers.
Community participation
Decentralization in decision-making
Change of attitude by health workers.
Nothing Positive (Nil)
Sharing of costs with beneficiaries
Capacity building-Staff and community
Increase efficiency in services delivery
Partnerships between various stakeholders
Improvements in health centers i.e. infrastructure.
Formation of Neighbourhood Health Committees (NHCs)
More health centers have been established, bringing Health Centres closer to the people
___
Box & The NEGATIVE elements brought about by the Health Reforms in Zambia
Increased inequalities
Shortages of essential drugs
Exodus of health workers for the countries
Lack of loans and leave benefits
Increased bureaucracy
No or delayed payments for retires
increased abuse of equipment and transport facilities
Poor conditions of service for workers
Poor attitudes by staff
Loss of trained manpower through voluntary separation
Delinkage of staff from Ministry of Health to Boards
None sensitization of the community on the reforms
The poor cannot afford to pay fees at Government HC’s (cost sharing)
Increased corruption at Health Centres (Bribery, Pilfering of drugs by health workers, etc.)
_____ Box 9a: Attempts at Implementing Community Participation can be Frustrating
“I feel that the main stumbling block preventing the top hierarchy in improving community participation
is inaction at the health facility level. As example, if you hold meetings and would like to follow up on
issues as a health centre committee (HCC) chairman, you find that minutes are not available or not
done (by Health Centre staff who serve as the HCC secretariat). Sometimes they tell you that the
minutes have already been forwarded to the District Health authorities. But when you follow up to
check with the district authorities, you are told that there are no minutes from your health centre. At
this point, you do not know whether to report the Health Centre staff (to higher authorities) because
you fear developing bad relations with them. Hence you keep quiet. This frustrates the whole effort,
enthusiasm and concept on community participation”. (Male HCC Chairperson, Chingola).
Box 9b: Attempts at Implementing Community Participation can be Time Consuming and incur
high Opportunity Costs (in terms of other activities and opportunities foregone)
“The issue of minutes depends on the individual effort and commitment of the NHC chairperson. When
minutes are recorded of a meeting, I personally make sure to have them recorded, then I take them to
DHMT offices fortyping and then I make sure I leave a copy behind while also taking a copy with me.
In this way, I ensure that minutes of meetings held are available”. (Female HCC Chairperson,
Chingola).
Annex 2: The Advocacy Pillar SejUafoi^hingo!^^
Advocacy Action
To Develop Convincing & Effective Arguments,
Proposals and Recommendations for the NEED
to reduce inequities in Health & Health Care
Activities to be Undertaken
Groups to be Involved
Health providers
MOH through CBOH;
Sensitize the Community on Equity through Print & Electronic
Media
Intensify and Facilitate on Equity Practices as practical
examples to be followed
Amplify Equity Issues, Offer Support Through Funding of
NGOs (e.g. SFH, WVI, CHEP. Round Tablets)
I Community activities that promote Equity, Carry out their own
Equity in their Health Care Activities & Programmes
Health Providers at Community Level
Traditional Healers; Community Health
Workers; Neighbourhood Health Committees
Non-Health Care Providers, e.g.
Churches,
Schools through the MoE, etc)
Business Communities (e.g. KCM)
Agricultural Workers (e.g. Extension Workers)
Politicians
To Develop Convincing & Effective Arguments, ' Church Leaders. Businessmen & Business
women, NGOs, Politicians, Health Workers
Proposals and Recommendations for the
____
Establishment of an Equity Gauge in the Distrid (includes CHWs, TBAs, NHCs)
Sub-Committee formed in (2) above to form
| To EsTablish Direct Engagement ofPolicy
and Serve as a District Equity Committee (for
I Makers and Decision Makers
Local Policy Decisions on Equity)
Promoting NHC Meetings on Equity, Liase with Community
and Health Care Providers on Equity issues arising
Sensitize the Congregation on Equity
Providing Additional Lessons on the syllabus for Equity,
School Competitions through Debates and the Performing
Arts on Equity Issues.
To Fund Community Activities on Equity
To Put in Place Activities for their Workers to be sensitized on
Equity'
. ,. u,
.
To help spread the messages on Equity in Health through
their programmes I Activities.
Represent in Parliament on Equity programmes
Foster Community Participation on Equity issues, Include
equity dimensions in their talks
_________ ___
’ Form the Equity Gauge Sub-Committee that will meet to
formulate an EQUITY GAUGE for Chingola District
Ensure that/monitor implementation of Equity Policies and
Decision Needs
To influence Change of policies detected by situation
/incidents_____
____
To Actively Lob by and Campaign for the Equity
Gauge Activities/ Programmes
District Equity Committees,
NGOs
To Empower People and Disadvantaged
Groups with the Knowledge Necessary forthem
to use in Striving for Greater Equity
Health Care Providers,
DEC (District Equity Committee)
To Carry Out Peaceful Civil Society
Demonstrations in Support for Greater Equity
and the Implementation of Equity Gauge
Activities_____ _ ____________________
Establish an Effective and Strategic
Communication System for the Dissemination of
Information about the Equity Gauge
Any Other Actions You May Think of________
Other Actions 1
Judicial Department
NGOs (WVI, HBCs, CINDI, LIONS, Round
Tablers, etc)
Politicians; Church Leaders; NHCs
District Equity Committee
(Main and Sub-Committees)
Social Welfare Department
Other Actions 2
Other Actions 3
NGOs________________
Department of Social Welfare
Other Actions 4
DEC (District Equity Committees)
Holding meetings with other NGOs, Politicians, Church
Leaders & Business managers (such as Company Directors,
_etc)_______________________________________
Intensify people on good health and health care
Persuade business communities to provide employment to
the local community to sustain their health and health care
through their fair share of wages/ incomes (businesses such
as KCM);
Meetings with Communities for the dissemination of
information on Equity
To follow up Community Health Support Committees, e.g.
KCM (a Mining Company)______
Re-enforce the Rule of Law
Peaceful Society Civil Demonstrations
Fund raising Ventures
Communication committee that should ensure establishment
of an account which they will administer in favour of equity
programmes
To Identify for Needy groups/ areas, such as orphans,
widow/ers, destitute, the physically handicapped, etc
To Hold workshops on Equity_________________ ____
To empower people and disadvantaged groups by providing
them with information about sources of funding according to
their abilities and needs_____________________ _____
To facilitate workshops on Equity,
To serve as Trainer of Trainers on Equity
NHCs = Neighbourhood Health Committees; HBC = Home Based Caregivers; CINDI = Children In Distress; WVI = World Vision International; KCM = Konkola
Copper Mines pic; CHEP = Copperbelt Health Education Project; SFH = Society for Family Health; CBOH = Central Board of Health; MoE = Ministry of Education;
MoH = Ministry of Health
ld Public Participation Pillar (CHOMA Workshop)
Annex 3: The Community an
Community Group
To take
Part?
YES
Policy & Decision
Makers, Senior Public
Office Managers
Elected Representatives YES
(MPs, Councilors, etc)
YES
Donor Agency
Representatives
NGOs and Human Rights YES
Groups
Research & Academic
Institutions
YES
Members of the General
Public
YES
Public Health Workers
Private Health Workers
YES
Role to Play in the Equity Gauge Initiative
~s3U^qfoHuHd^Up^^
with equity considerations (through brochures, circulars and
meetings)______ _ _____ _______ ____ ——
TdvomFr^eOobbFforequityFandsame as above
’■^dvocacyanTFundi^
’^bb^W^i^^
Empower people with knowledge on their rights and equity,
Source funds for equity activities (civic education through
meetings, drama, pamphlejs^pgstersjn^^
------ilbd^ta^
of equity, Make
recommendations for equity, develop convincing proposals for
equity, advocacy and training on equity.
Adroc^ Lobbying for equity, attending workshop campaig
for equity hold peaceful demonstrations for equity ana
involvement in equity activities (through practice & participation)
^^an^re^izTcolnH^eTonlqultfAd^Iefor
equity through talks and practices in care provision, Trair> CHW
to aim for increased coverage foj^asyjccess^seryicgs_ —
ItobiiE^HTSeFsttizec^^
Adv°p^i?
equity through talks and practices in care provision, Provide
affordable health care services--------- -------------------------
Expected Contribution to the Equity
Gauge Activities/ Initiative
____
Funds made available, Equity policies
made, Improved Health Care.
Teoplelensitized^^
culture created, Funds available---------Funds available, People sensitized,
Equity attained
_________ —People sensitized, Funds made available
and Equity attained.
Implementation on equity guided,
Guidelines on equity available;
appropriate updated information on equity
made available; Reliable data on equity
made available.________
Equity awareness created, Sense of sen
worth increased; Sense of ownership of
equity initiative created; Public
involvement in Equity stimulated
_—
Equity gauge activities implemented,
Equity objectives attained.
Equity gauge activities implemented,
Equity objectives attained. Quality care
attained
Traditional Healers
YES
Traditional Rulers
(Chiefs, Headmen, etc)
YES
Journalists and the
Media
YES
Trade Unions, Workers’
Committees
YES
Political Party Agents I
Representatives
YES
Artists (like Musicians,
Drama Groups, Painters,
etc)
_______
Other Categories
Churches
Teachers
YES
YES
YES
YES
Attend workshops and participate actively on equity; Participate & Influence people positively for equity;
Sense of ownership developed. Well
contribute to research on equity. Collaborate with health
focused service delivery___________
institutions on equity_________ .— ------------ —rr-r ----- People enlightened, funds made available
Mobilization of communities, Hold meetings on equity, Lobbying
and public participation increased on
and advocating for equity & source for funds
equity._______ ______________
Public awareness on Equity issues and
Publicize Equity Issues and stories; Project equity dimensions in
thinking created and promoted
their writings; help to promote the equity gauge initiative,
generally
________________ ——---- — ------- Equity awareness created; Workers well
Lobbying for Equity in their activities; Advocate for fair work
informed on equity, Equity of access to
conditions; Advocate for medical schemes at work places and
medical servicesimproyed_________
Sensitize their members on equity
— ^Equity awareness created, Equity gauge
”Lobbying Government for equity through legislators (MPs), Local
concepts become non-partisan (Not
Counselors; Incorporate concepts of equity in their manifestos
politicized as such)_________ —
Equity awareness created and sustained
' Entertaining with equity messages in their performances,
in the community.
Publicity and sensitization on equity through songs, drama and
poems. _____ — -----------------Equity awareness created
Educate Communities through Sermons ______ _______
Equity awareness created
~ Educate Communities through Seminars___________ _____
Annex 4: The Measurement Pillar - Some Proposals on Indicators of Value
Incidence and Prevalence of Tuberculosis in Adults (Incidence, prevalence and Case fatality rate
due to TB)
HIV/AIDS amongst the Youth (Number of funerals due to HIV/AIDS; Incidence and prevalence of
orphaned children, Percentage of STDs, Prevalence of abortions among couple and single women,
Availability of mobile voluntary testing)
Safe Motherhood and Maternal Mortality Rates (Number of mothers dying during child birth,
Coverage with TBAs, Skills of TBAs, Infant Mortality among those delivered by TBAs; Attendance
at Antenatal Clinics)
Water and Sanitation (Number of families per well; % Families with rubbish pits; % Families with pit
latrines; Number of bore holes per every 1.5 km)
Utilization of Health Services (Impact due to User fees - Proportion able to pay for medical
schemes, Proportion able to pay for ambulance services, Attendance levels; Time spent waiting for
services at OPD; Access to health care - geographical Spread, facilities per population unit,
distance to nearest health centre, number and frequency of outreach services; Proportion not able
to pay in communities/ villages; Availability of Drugs at health facilities; Staff workloads - staff to
patient ratios)
Morbidity and Mortality Rates (Incidence rates of diseases like Malaria and Measles; Numbers of
People brought in dead at health facilities - Deaths in homes)
Morbidity & Mortality among the 0 - 5 Year olds: (Immunization coverage; Prevalence of Anaemia;
The top 10 diseases in Children)
Literacy & Education: Percent of children IN and OUT of Schools among the school age
population; Percentage able to Read and Write
Utilization of Family Planning Services (Percent attendance at Antenatal Clinics and Percent
Attendance at Post Natal Clinics)
General Socioeconomic Indicators in Society
(Urban: - Poverty level = % poverty, % malnourished; Asset possession (property); Level
of Prostitution, Number of Beggars and Proportion of the disabled in community)
(Rural: - Food Production and Household food security e.g. How many meals per day
eaten; Availability of cultivable land; Proportion of malnourished persons/ children)
(General: - Nutrition Contents of Foods and average Nutrition Intake; Access to transport
services in districts per population unit (Motor vehicles or bicycles)
ENHANCING STAKEHOLDER PARTICIPATION AND
IN HEALTH BUDGET PROCESSES IN ZIMBABWE
I
Institutions: TARSC (Dr Rene Loewenson, Freckson Ropi
Ministry ofHealth and Child Welfare (Dr P Sikhosana)
Other: Mr TZigora
REPORT OF ACTIVITIES
TARSC September 2001
1.
BACKGROUND:
ii.
toSed^r am°n8St key Stakeholders on the goals, mechanisms, principles and
uSI SaUocSon1’^ 'tranSparent ®quity oriented resource ^cation formula to be
SJ of thS JesomS
°UrCeS t0
h6alth SeCt°r and for mo“g
iii.
Jo estabhsh a steering committee of key stakeholders (Govt, Parliament Local
can Sd165’ ‘’I!’618 l° review the technical information and processes involved and that
can widen understanding on equity oriented resource allocation processes
TaS n^sn0?1 Rockefeller Foundation under the Health Equity Gauge project allocated
AIMS OF THE FIRST PHASE
2.
The work to be done in the first phase included
1'
TUti0nal base for the P^ject (contracts with the research co-ordinator
nk< • ?
Wlth C°re ProJect Per$onnel in government and TARSC
2.
Se"”8 “P ““ PrOj“‘
TARSC fOr
3.
4.
5. Assessing theJ current resource allocation formula and system
’
6. Carrying out a survey of stakeholder perceptions of priorities amongst equity indicators
identified from policy review and using this to identify identified priority equity indicators
for resource allocation.
7. Carrying out the literature review for and designing an agreed methodology for the next
stage of analysis of equity indicators for inclusion in resource allocation.
8. Agreeing on a wider steering committee for review of the next phase of the project.
3.
ACTIONS IMPLEMENTED.
All the above actions except items (7) and (8) had been implemented by end June 2001 and the
remaining two items are anticipated to be completed by end September 2001.
The relevant contracts, office support, equipment etc were organized for the project and a review
committee set up including the co-operating institutions. A workplan was prepared and adopted
by this committee. A bank account was opened for the project and separate accounts maintained
for the project. (The TAR.SC audit report for year ending June 2001 has already been sent to
Rockefeller). The interim finance statement covering the period February 1 2001 to June 30 2001
is attached to this report.
Analysis was carried out and a report prepared that identified the current situation, the available
data sources for health-equity indicators and the current resource allocation formula. The report
produced outlined the current situation in Zimbabwe on resource allocation to and within the
public health budget in terms of (I) the institutional framework (ii) the criteria/ factors used in
allocations made (ii) the processes in which these criteria are applied. A report was also prepared
of current policy positions drawing from 5 major policy documents and the major stated policy
goals viz a viz the performance of public health systems, and their relationship with health equity
goals identified.
This summary report was reviewed by the small steering committee set up by the co-operating
institutions and a list of key indicators identified.
A survey was then carried out using a questionnaire that included these indicators to identify
priorities from key stakeholders (health providers, regulatory authorities, health financers,
communities, elected leaders) to identify from stakeholders the benchmarks that they perceived
best measure these objectives.
A sampling frame was defined from key categories of stakeholders involved in health,
representing health providers or purchasers at international, national, provincial and district levels,
from government, non-govemment and private sector, and also representing communities, policy
and elected organizations. A combination of stratified and purposive sampling was used to select
58 representatives from stakeholders.
A questionnaire was designed to solicit stakeholder perceptions on the suitable criteria for the
budget allocation process in the Ministry of Health and Child Welfare. Suggested indicators were
listed under relevant categories and respondents were asked to give a score to each indictor as
measure of the significance of that indicator in allocating resources. The interview method was
used to administer the questionpai^o identified representatives of the stakeholder organizations.
The report of the survey provided information on the perceived priority indicators within the areas
of health needs, ability to meet health needs and health service performance that will be taken
forward into the next stage of the analysis, variation between stakeholders on perceived priority
indicators and perceptions of stakeholders on the current performance of the resource allocation
system.
This information is now being used in three ways:
• To map the current distribution of the identified variables by key dimensions^ identified in the
stakeholder survey as having distributional relevance for equity, viz ggeographical
L T1 1 area, ’urbanrural, level of health sendees and income level (where feasible)
• To apply within the agreed methodology to assess the correlation between variables in order
to identify those with greatest predictive value in health -equity outcomes and to identify
potential single indicators that can be easily applied within the resource allocation formula.
• To apply these identified variables in a resource allocation formula and map the difference in
allocation outcomes against the current formula.
This will be done in the next phase (September - Jan 2002) once the methodology is agreed.
(This work has now been delayed by Mr Ropi’s situation).
In the next phase the steering committee will also be widened and review of the work subject to
wider stakeholder feedback and review, including representatives from MoHCW, MoFinance,
Local govt, Parliament, civil society.
Publications produced to date:
Ropi T, Loewenson R, Sikosana P, Zigora T (2001) Literature review on policies and processes
for inclusion of equity in Health Budget Processes In Zimbabwe. Report prepared under the
Zimbabwe Equity Gauge Project, Training and Research Support Centre (TARSC),
Ministry of Health (MOHCW) and TARSC/ MoHCW/ Equity Gauge Monograph 1/2001
Mbwanda L, Loewenson R, Ropi F, Sikosana P, Zigora T (2001) Stakeholder Views On
Resource Allocations In Health: Report Of A Study On The Perceptions Of Interest Groups On
Priorities For Health Resource Allocation, paper prepared under the Zimbabwe Equity Gauge
Project Ministry of Health (MOHCW) and Training and Research Support Centre (TARSC),
TARSC/ MoHCW/ Equity Gauge Monograph 2/2001
- Media
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