Statement by Participants in a November 2001 Bellagio Workshop
Organized by the Rockefeller Foundation in collaboration with the World Bank and the World Health Organization. The growing efforts to combat HIV/AIDS, malaria and tuberculosis have the potential to bring major benefits to the disadvantaged, as well as produce an important reduction in overall disease burden. However, realizing this potential and securing better health among less favored populations will require a determined effort. There is need both to modify the inequitable patterns of disease risks and consequences and to pursue aggressively a more equitable distribution of benefits from programs dealing with HIV/AIDS, malaria and tuberculosis. The evidence base for this conclusion, although not complete, is nonetheless compelling: 1)For HIV: a)Amongst teenagers in Kenya, HIV prevalence in 1999 was five to six times higher for girls than boys. b)Both men and women from a wide range of African countries who have completed secondary school are two to three times more likely to use a condom with a casual sex partner than are those who have not yet finished primary school. 2)For Malaria: a)The proximity of urban slum dwellers to mosquito breeding sites leads to excessive rates of child death from malaria. b)In parts of rural Tanzania, the children from the richest fifth of the population are twice as likely to receive appropriate antimalarial treatment than those from the poorest fifth of the population. 3)For Tuberculosis: a)The cost of transport required to access test results for tuberculosis is 2-3 times the average wage of a day labourer in peri-urban Malawi. b)Poor households in Nairobi spend a disproportionately greater percentage of their household income on TB treatment compared to rich households. c)Prevalence of tuberculosis in the Philippines is 5.5/1,000 amongst the urban poor compared to 3.5/1,000 amongst the urban non-poor. Apart from the inherent concern for such inequalities, other considerations reinforce the need for a sharp focus on inequities. Indeed, where the burden of severe disease is so heavily concentrated among the excluded and marginalized, as in the cases of malaria and tuberculosis, considerable overall reductions can only be achieved by reaching out to these groups. However, there is growing evidence that this is not happening; in the case of HIV/AIDS both HIV behavior change prevention and AIDS treatment programs are beginning to reach the better off in developing countries more rapidly and completely than the poor. In addition, one cannot expect to deal effectively with HIV/AIDS without addressing issues of gender inequalities that play a major role in its spread. If communicable disease programs can move towards effective coverage and treatment of marginalized populations, there will be benefits of reduced residual risk of infection for the entire population. Conversely, low adherence to DOTS therapy for TB may accelerate the emergence of difficult to treat multi-drug resistant tuberculosis. Looking ahead, preparing the ground now for more equitable distribution and access to health care services will help to ensure that new and lower cost technologies, eg: HIV/AIDS, malaria and TB vaccines, drugs and microbicides, attenuate rather than accentuate disparities. The challenge, therefore, is how to integrate equity considerations more effectively into important initiatives for HIV/AIDS, malaria and TB, while maintaining or enhancing the initiatives? capacity to reduce overall disease burden. This workshop reviewed encouraging evidence of several approaches that suggest the potential to go to scale while reaching poor and underserved populations: from integrated, gender-based approaches to TB control and health promotion by non-governmental organizations in Bangladesh, to large-scale condom promotion in Africa, and striking new evidence of the equity-enhancing effects of social marketing for insecticide-treated bednets in Africa. The amelioration of current inequities is the responsibility of everyone concerned with development and health activities at the global, national, and local levels. A particular responsibility resides with those providing and receiving resources for HIV/AIDS, malaria, and TB initiatives in the name of alleviating poverty. They will wish to learn from the experience of the past: that vague, general mission statements about serving the poor are not sufficient. Rather, there is a need for carefully-designed and vigorously-implemented "pro-poor" actions that produce results. Deliberate, concerted and sustained actions are required in the following general areas: 1)Programs must specify distributional goals and objectives, that constitute the basis of rigorous performance management; 2)Resources must be focused geographically and functionally on programs and initiatives that are most likely to achieve maximum health benefits among poor and otherwise marginalized populations; and 3)Greater efforts must be made to ensure the information base for equity-focused performance management and resource allocation. The attached list provides illustrations of the many actions that can be undertaken to work towards greater equity in HIV/AIDS, malaria and TB programs. The organization of the list reflects a conscious effort to avoid an inventory of disease-specific opportunities to redress inequities. The broad areas for engagement are indicative of the imperative to integrate efforts alongside broader health systems development objectives. There is a pressing need to begin implementing these actions as quickly as possible. Initial Actions to Enhance the Equity Dimension of HIV/AIDS, Malaria, and Tuberculosis Programs I. Global Actions 1) Goals: Establishing HIV/AIDS, malaria, and TB goals from an equity perspective in order to focus attention on those groups which are disproportionately infected and affected by these diseases. For example that by 2010 in all of the 22 countries with high TB prevalence, the case detection and DOTs treatment rates are at least as high among the lowest income quintile as among the highest quintile. This approach would greatly benefit the health objectives appearing in documents such as the Millennium Development Goals and the Poverty Reduction Strategy Papers, prepared by country governments for discussion of possible debt relief with the International Monetary Fund and the World Bank. 2) Resource Allocation: Applying clear equity criteria in allocating resources from programs like the Global Fund for AIDS, Tuberculosis, and Malaria, the World Bank, and other international and bilateral funding agencies. This means not only allocating the maximum possible amount of resources to poor countries, but also seeing that those resources flow to poor areas and groups within countries. 3) Research and Development: Focusing research and development activities on technologies that have the potential to overcome constraints in reaching the neediest groups. Such research development priorities might include: simple and rapid diagnostic tools for malaria, TB, STIs and HIV, new and improved prevention technologies such as microbicides and long-lasting insecticide-treated nets and simplified drug regimes with increased dosing intervals to facilitate long-term adherence (eg: HIV/AIDS and TB). II. Regional, National and Local Actions 1) Performance Management: Developing equity-oriented baseline and progress assessments to monitor the impact of programs, policies, and delivery systems rather than relying solely on simple averages for society as a whole. For example, the impact of primary prevention efforts for HIV can be assessed according to variations in HIV infection, individual knowledge of disease risk factors and access to prevention technologies by level of education, sex, occupation and area of residence. This information can be used as baseline data against which to conduct an impact assessment focused on how well interventions reach the disadvantaged. 2) Targeting Program Resources: Increasing the proportion of total program benefits that go to the excluded and marginalized by promoting interventions that focus on the disadvantaged. These include programs that subsidize access to health products and services for the excluded, outreach services in poor neighborhoods, and behavior change communications that are designed with and for the most marginalized groups. For example, in The Gambia a targeted bednet program resulted in an improvement in health equity; parasitaemia in poor children fell from 63% to 40%, and from 35% to 31% among wealthier children. To meet better the challenges of targeting, the health sector could usefully draw on the techniques employed and experience gained in other development sectors (eg: social-safety nets). 3) Financing: Modifying financing systems to enhance the benefits flowing to disadvantaged groups suffering from HIV/AIDS, malaria and tuberculosis. A range of equity-enhancing financing mechanisms might be considered including: (1) community-based insurance programs that protect poor households from the impoverishing impact of catastrophic illness to an income-earner, (2) social funds to which the poor contribute less and draw greater benefits than the better-off and (3) purchasing instruments such as consumer subsidies, restructured benefit packages and incentive payment plans in favor of the disadvantaged. For example in China, a range of equity-enhancing financing mechanisms have been implemented in the context of health sector reform, using tools of resource mobilization, incentives, and consumer subsidies that assure universal access for TB diagnosis and treatment. 4) Civil Society: Contracting for service delivery with local non-governmental organizations with established records of effectively reaching excluded and marginalized populations. An example is an NGO in Bangladesh that is employing local women as community health workers to extend DOTS treatment to reach rural populations, and especially women, where the government program lacks coverage. Similarly, the establishment of "health equity watchdogs" could help to ensure that marginalized populations are program beneficiaries. For instance, in Cape Town, a group of stakeholders is employing HIV/AIDS as a tracer condition for evidence of the inequitable distribution of health service resources among urban health districts. 5) Leadership and Stewardship: Encouraging the emergence of a new generation of health policy leaders committed to equity and attuned to community conditions. Recognizing policy leaders who take responsibility not only for whether the health initiatives that they operate serve the disadvantaged effectively, but more broadly for whether the disadvantaged are adequately served by the totality of services available -private as well as public- within and beyond the health sector. This would mean ensuring that specific efforts to redress the inequities of these communicable diseases are compatible with broader health systems and development agendas, such as decentralization and poverty alleviation. 6) Research and Analysis: Undertaking research and analysis needed to expand on the existing knowledge base, and to support the design, implementation, and assessment of equity-oriented approaches. Many health information systems have unacceptably low coverage of marginalized groups, potentially masking the magnitude of inequities. Even where data are representative of diverse populations, the absence of group identifiers on survey instruments, eg: income or education level, impairs assessment and monitoring of inequities. In addition, assuming an adequate information base exists, there remains a paucity of evidence on interventions that effectively redress inequities. A good example of better evidence making a difference is seen in Zambia, where the effectiveness of a social marketing strategy for insecticide treated nets targeting poor households was demonstrated through a well-designed intervention study.