EQUINET presentations to the Global Health Research Forum, Sep 2005 compiled by EQUINET Secretariat, TARSC September 2005 admin@equinetafrica.org The Network for Equity in Health in east and southern Africa (Equinet) participated in a number of sessions at Forum 9 of the Global Health Research Forum in Mumbai, India, 12-16 September 2005. The theme of the meeting this year was Poverty, equity and health research. The Global Forum’s annual meeting provides the opportunity for presentations and exchange of views on key issues on the global health agenda. Participants from a broad range of constituencies were present: health and development ministries, multilateral and bilateral agencies, research-oriented bodies and universities, NGOs and civil society, the private sector, the media. EQUINET has a substantial programme of research work on equity in health and reported on some of this at the Forum. Papers were presented by Grace Bongololo and Lot Nyirenda on theme work on gender equity in Antiretroviral therapy access; by Di McIntyre and Lucy Gilson on equitable health care financing; Rene Loewenson, Itai Rusike and Memory Zulu on The Impact Of Health Centre Committees On Health outcomes in Zimbabwe and Lucy Gilson, Ermin Erasmus; Peter Kamuzora; TJ Ngulube; Verona Phillips and Vera Scott on applying policy analysis in tackling implementation gaps. Summaries of the information in the papers are presented below and the papers are available from EQUINET. The EQUINET delegates received support from the GHRF and from IDRC for their participation in the Forum. 1. Using Research to promote gender and equity in the provision of Anti-Retrovial Therapy In Malawi Grace Bongololo, Ireen Makwiza, Lot Nyirenda, Bertha Nhlema, Sally Theobald REACH Trust Malawi in collaboration with Southern Africa Regional Network For Equity in Health (EQUINET) This paper explores the importance of using research to promote gender and equity in the provision of anti-retroviral therapy (ART) in Malawi. The purpose of the paper is to highlight the importance of operational research in advocating for programmes that are gender sensitive and can contribute to overall national economic growth and poverty reduction. The paper uses a synthesis of the findings of research in Malawi on how gender roles and relations affect access and adherence to anti-retroviral therapy and to illustrate how these can be used to advocate for more equitable policy and practice. This paper argues for the need to apply a gender equity lens to responses to the HIV epidemic, with a particular focus on ART provision (both access and adherence). Four studies that have been conducted by the REACH Trust on gender and equity considerations in access and adherence to ART are presented and the findings are synthesized. It was found that gender roles and relations intertwine with poverty to affect access and adherence to ART in a complex myriad of ways, even when ART is provided for free. There is a need for quality research to promote attention to gender equity concerns in ART provision and for ongoing responsive monitoring and evaluation to respond quickly to problem areas. If access to ART does not sound the bugle on the need to promote gender and equity then it is difficult to imagine what kind of epidemic it will be. In Malawi we are working with policy makers, practitioners and community members to get the bugle to play. 2. Equitable health care financing and poverty challenges in the African context Di McIntyre, Health Economics Unit, University of Cape Town and Lucy Gilson, Centre for Health Policy, University of the Witwatersrand, EQUINET The paper presented was based on a detailed and critical review of the literature relating to health care financing in the African context. It aims to provide an overview of the equity challenges, particularly in relation to poverty concerns, of current health care financing mechanisms in Africa; provide a brief critical review of major recent developments in health care financing in Africa; and identify key issues in promoting equitable and poverty-reducing health care financing options in the African context. The paper attempts to identify some common trends and challenges, illustrate important issues in relation to particular health care financing options through reference to specific country experience and propose principles and possible actions that require further consideration within each country-specific context. The paper highlights the enormous constraints and challenges that face African countries in relation to health care financing. From the perspective of pursuing financing strategies that will promote equity and alleviate poverty, rather than contribute to further impoverishment of vulnerable households, the following principles are suggested to guide consideration of alternative financing mechanisms within individual country contexts: • The mechanism(s) should provide financial protection, i.e. should ensure that no one who needs health services is denied access due to inability to pay and households’ livelihoods should not be threatened due to the costs of accessing health care. This implies that health care financing contributions or payments should be separated from service utilisation, which requires some form of pre-payment (government taxes and or health insurance). • Health care financing contributions should be distributed according to ability-to-pay. In particular, progressive health care financing mechanisms (i.e. where those with greater ability-to-pay contribute a higher proportion of their income than those with lower incomes) should be prioritised. • Cross-subsidies (from the healthy to the ill and from the wealthy to the poor) in the overall health system should be promoted. This implies that fragmentation between and within individual financing mechanisms should be reduced and that mechanisms should be put in place to allow cross-subsidies across all financing mechanisms. • Mechanisms to ensure that financial resources are translated into universal access to health services should be put in place. This implies that all individuals should be entitled to benefit from health services via one of the funding mechanisms in place, the package of benefits to which they are entitled is explicit, there is active purchasing of services whereby ‘value for money’ is secured, and there is adequate physical access to services to which one is entitled. The paper argues for progressive financing as opposed to proportional financing mechanisms, given the high existing poverty levels and a continual process of further impoverishment due to illness-related costs in Africa. From a practical perspective, the above principles suggest the following actions in relation to health care financing within the African context: • Explicit commitments by African governments to move away from out-of-pocket funding mechanisms, and actively pursuing alternative financing mechanisms to make this a reality. • Urgent efforts to increase the health sector’s share of government resources in line with the existing commitment of African Heads of States in Abuja to a 15% share for health, combined with efforts to increase revenue through improved tax compliance and efficiency within the tax system. • Unconditional cancellation of African governments’ external debt, to allow governments to devote limited tax revenue to health care to achieve the Abuja goal, rather than to debt servicing and repayment. • As health insurance options are most closely aligned with the above principles, along with general tax funding, introducing or expanding insurance mechanisms should be given serious consideration. Critical evaluation of the full range of health insurance options, and creation of a solid evidence base relating to health insurance in the African context, is the greatest research priority relating to health care financing if we are to ensure that health insurance developments promote rather than undermine health system equity in Africa. 3. The Impact Of Health Centre Committees On Health outcomes in Zimbabwe Dr Rene Loewenson, Training and Research Support Centre, Itai Rusike, Community Working Group on Health and Memory Zulu Training and Research Support Centre This paper presented a study that sought to analyse and better understand the relationship between health centre committees in Zimbabwe as a mechanism for participation in health and specific health system outcomes, including representation of community interests in health planning and management at health centre level; provision of and access to primary health care services and community health knowledge and health seeking behaviour. A Case-Control study design was used, with four case sites with health centre committees and control sites selected in the same districts where there are no health center committees with sufficient distance between catchment areas to avoid spillover of results. This paper reports on the findings from the cross sectional community surveys OF 1006 respondents carried out in February 2003 and the health information system analyses. The study shows that public sector clinics are the primary source of health care for communities in Zimbabwe, but are not well resourced in terms of basic supplies and staffing. Health Centre Committees appear from the study findings to be associated with improved health resources at clinic level and improved performance of the primary health care services.. Communities in areas with HCCs had a better knowledge of the organization of their health services from the indicators assessed, making services more transparent to them. There was also evidence of improved links between communities and health workers in these areas. The study suggests an association between HCCs and improved health outcomes, even in the highly under-resourced situation of poor communities and poorly resourced clinics. The evidence, supported by the mechanisms of community resource mobilisation, information outreach and social actions around health, indicate that HCCs play a positive role within health systems. They provide evidence of roles for community participation beyond dialogue and consultation. This positive contribution of HCCs to health outcomes calls for greater attention to strengthening these structures as an important component of primary health care and of the health system generally. The finding cited in the literature review that these structures often lack formal recognition, are weakly resourced and poorly trained for their roles is thus an area to be addressed, to strengthen the health system. It may be argued that the strengthening of HCCs as a vehicle of community participation is thus deeply bound with the strengthening of the PHC and primary care level of the health system. There are clear signals in this study of the virtuous cycles of positive health outcome between HCCs and performing clinics. This calls for greater investments in policy, practice and resource plans to strengthen this base for health systems performance. 4. Applying Policy Analysis in Tackling Implementation Gaps Prof. Lucy Gilson, Centre for Health Policy, University of Wiwatersrand (lucy.gilson@nhls.ac.za; lgilson@iafrica.com) with Ermin Erasmus; Peter Kamuzora; TJ Ngulube; Verona Phillips; Vera Scott; EQUINET The paper demonstrates how examining the influence of process and power over policy implementation generates critical insights for future policy and practice. Given that equity-oriented policy change often does not achieve its goals, and can even have unwanted consequences, simply identifying which policies or programmes to invest in is a weak basis for such change. Instead, it is important to understand what factors underlie the process of change within health systems, and so influence whether policies intended to promote equitable health systems are implemented effectively. Policy change, particularly that which is equity-oriented, always involves challenges to the current practices of individuals and organisations and so is often be blocked by resistance and opposition. Understanding how such factors play out in particular contexts and policy environments, and considering how to manage contestation between ideas and actors, is necessary in thinking about how to strengthen implementation practices in pursuit of equity goals. The paper provides an overview of the nature of the research to be conducted; outlines several studies of policy implementation conducted in various African countries and focusing on different policy issues, but all applying conceptual approaches derived from the field of policy analysis; and concludes with specific insights about how this type of research can support equity-oriented policy change within health systems. The studies cover the reasons for low enrolment into the community health fund in Tanzania; key obstacles to the re-allocation of heath personnel in order to achieve more equitable distribution across areas within Cape, Town, South Africa; power imbalances within the Zambian process of priority setting and budgeting for primary health care; and the discourses surrounding the implementation of public private interactions within the South African health system. Taken together the studies emphasise the importance of actively constructing the support required to sustain the implementation of policies. A good evidence base will not by itself bring about implementation and political will is neither a personality characteristic nor an inherent feature of some types of states. Instead, support for equity-promoting policy change has to be built among the range of actors influencing health policy implementation. The studies, and wider reflection on relevant theoretical perspectives, also provide support for three specific suggestions about how to build this support. These are • developing the values, understandings and meanings that can sustain support for equity-oriented policies within the health sector • enhancing the legitimacy of new interventions and policies in the eyes of those responsible for implementation, and • building the combination of software and hardware that sustains equity-promoting health systems. Software elements include items such as the values, understandings, meanings, discourse and legitimacy that, as discussed, can promote resistance to, or underpin support for, policy change. Hardware elements, meanwhile, encompass the legal frameworks, financing mechanisms and organisational structures that frame service delivery practices. Overall, the complex work of managing rather than imposing policy change cannot be avoided, a task that implementation theorists increasingly refer to as the task of governance.