GEGA Activities
Secretariat

After a bit of a hiatus, the GEGA Newsletter is back, mainly to do to the addition of Qamar Mahmood as the new GEGA Assistant Coordinator. Qamar will be providing support in various areas of the Secretariat's work, and we are very grateful to have him!

GEGA and Equinet recently sponsored a workshop, in cooperation with the Southern African Development Community, on Parliamentary Alliances for Health Equity, which brought together Parliamentarians as well as groups supporting health equity and parliamentary processes to discuss priority equity issues and develop plans for working together to strengthen health equity. Participants of the project include representatives from the South Africa, Zambia, Zimbabwe, and Kenya Equity Gauges, as well as representatives from Malawi and Tanzania. One of the outcomes of the workshop was a set of resolutions regarding the role of parliaments in promoting health equity as well as the need to safeguard health by forming coalitions at the regional level (the resolutions, as well as the workshop program and report of the meeting are available here). We are currently discussing possible areas of follow up work and how co-operation between parliaments and professional and civic resources within Equinet / GEGA and within parliament support agencies can support such work.

The World Health Organisation has established a Health Metrics Network. The purpose of the Network is to strengthen the quality, sustainability, integration, and usefulness of health information systems within countries, including for sub-national analysis. The Network includes a Task Force on Integrating Equity into Health Information Systems, and Lexi Bambas, Coordinator of GEGA, has been asked to coordinate the work of this Task Force. She will be taking on this responsibility in addition to her primary work coordinating GEGA. This is an excellent opportunity for promoting GEGA's goal of establishing equity-sensitive information systems within countries, and is expected to directly contribute to our own efforts and to strengthen our long-term potential to support pro-equity policy around the world.

The GEGA produced booklet The Equity Gauge: Concepts, Principles, and Guidelines is available at www.gega.org.za. The booklet serves as a primer for anyone interested in developing an Equity Gauge.

Training: The University of the Western Cape (Cape Town Gauge) and the Chile Gauge will be offering courses related to health equity analysis and promotion during their Summer Schools in January. Chile's courses will be more oriented toward middle and high-level decision-makers, while the Cape Town courses will be targeted to researchers and health workers. More information, including the specific courses being offered, will be available soon on the GEGA webpage.

Gauges

Ecuador Equity Gauge
At the University of Cuenca's international meeting on health research and promotion, the Ecuador Gauge presented the results of its project on Monitoring and building health equity at the local level, which was well received and parts of which were published by the university. In August, Aldes, which leads the Gauge, launched its webpage at www.aldesecuador.com (in Spanish). The page includes information on Aldes' actions and projects; results of the equity monitoring initiatives of the Gauge, a bibliography on themes of equity, development and health; a discussion forum on equity; and an electronic bulletin. The Gauge has secured a community-based coordination and action committee in El Tambo to promote women's health, especially in relation to effective implementation of the legally guaranteed universal access to maternity care. The Gauge is forming an alliance with the National Advisory Council of Women, the National University of Loja, PAHO and UNFPA to monitor inequities in sexual and reproductive health and look at the possibility of pushing social mobilization for access to health services. In October, the Gauge will present a CD with geographic information (GIS) on health inequalities in El Tambo. The Leadership School of Molleturo is working well with 25 participants; they have created a space for coordinating work with the Democracy and Development Group working at the national level.

Bangladesh Equity Gauge
Findings from BHEW survey presented at Bangladesh Institute of Development Studies Findings from a cross sectional survey carried out during the first half of 2002 by BHEW in collaboration with BRAC Health Watch were presented at a seminar at the Bangladesh Institute of Development Studies on June 14th. The survey conducted in early 2002 covered 11 rural sites (2220 households); urban Dhaka (201 households); and Bandarban - of Chittagong Hill Tracts (201households). A repeat survey is presently underway. A one week course on poverty measurement was organised by the Poverty and Health Programme of ICDDR,B and BHEW. A second paper in the Equity Watch Paper Series was published, entitled: Inequalities in the Utilisation of Safe Deivery Services: Barriers to reducing Maternal Mortality. The Equity Dialogue-a newsletter which is a joint initiative of the BHEW and the Poverty and Health Programme of ICDDR,B to provide a forum for exchanges on equity issues-is being published and is available at www.icddrb.org.

Zambia Equity Gauge
The Zambia Gauge will launch its activities at the national level October 19-23. The Gauge has been working in four districts in the country, and building a strong relationship with the Parliamentary Portfolio Committee on Health and Welfare. This activity will generate additional public attention to the issues, and help solidify an effective cooperative base for supporting the work.

Cape Town Equity Gauge
With the current measurement activities nearing completion, the focus of the Cape Town Equity Gauge has shifted more towards advocacy and community participation. These activities have taken place concurrently at various levels and include the following. Stronger links are being made with the major city-wide community based forums. This has been through both formal and informal interactions, with members of the Equity Gauge team presenting work at community based forums, and community based members joining the Equity Gauge structures. Funding has been secured to undertake policy analysis research into two aspects of the Equity Gauge activities: the implementation resources in primary health care, and nurse workloads, also in primary health care. These studies should play a significant role in the understanding of how and why decisions are made, including the existence and impact of resistance to change. The first of these programmes began in August 2003. An advocacy short course was held as part of the School of Public Health Winter School programme. This included an analysis of the policy process and its relationship to advocacy, and a step-by-step approach to developing an advocacy campaign. Community members involved in the Equity Gauge activities received sponsorship to attend the course, and equity gauge work areas were used as 'case studies' for the course. Finally, work on the violence tracer condition is now underway, with the collection and analysis of data on male mortality across the different health districts. Activities on the other tracer conditions, that is diarrhoea/worm infestation and HIV/AIDS/TB continues to develop.

South Africa Equity Gauge
The South Africa Gauge recently provided an analysis of the National Health Bill, and made a presentation to the parliament, which was well received. The Gauge has started working with communities and doing work on empowering communities to become involved in their health care system. Recently, HST's Strategic Vision was revisited and the organisation will concentrate on priority diseases - HIV/AIDS, tuberculosis and Sexually-Transmitted Infections - in its future work. The South Africa Gauge's HIV and Rural Gauges are designed to chronicle and identify key aspects of the health system that can be/need to be changed in order to contribute to improving critical health inequities with the long term view to developing core equity targets for the health system. The HIV Gauge, designed to paint a qualitative and quantitative picture of the provision of HIV-related services in a small number of purposively selected sub-districts. Through its focus on human resources the rural gauge will provide detailed insights designed to assist with redressing the most significant determinant of inequity, health professionals. Understanding the challenges of putting in place treatments and addressing these diseases will help ensure equitable methods are adopted. An electronic database containing key health and health system indicators has been established and will be regularly updated and expanded. This database is available at www.hst.org.za/indic. Soul City(www.soulcity.org.za), a dynamic and innovative multi-media health promotion and social change project, has decided to include inequity in health care delivery as one of the four topics for its seventh series. The key messages will focus on community empowerment and strategies communities can adopt to push for improved equity in access to and quality of care.

Tools for Action, Advocacy, and Community Empowerment

Training Modules on Health Research for Policy, Action and Practice. Version 1.1, June 2003. The Collaborative Training Programme is supported and coordinated by: WHO Alliance for Health Policy and Systems Research; Council on Health Research for Development; Global Forum for Health Research ; INCLEN Trust. The goal of this programme is to support strategies to increase the impact of health research on policy, programmes and practice through training and institutional development. The modules focus on practical experience and best practices regarding 1) priority-setting in health research (6 training units); 2) knowledge management (5 training units); 3) advocacy and leadership (5 training units). The modules are designed in a flexible manner and are tailored to the needs and interests of diverse constituencies. They are intended for a diverse set of countries and development situations and their content will be found to be methodologically sound, well tested and of the highest quality and relevance. Many people interested in increasing the impact of health research will benefit from the modules. In particular, research managers, policy analysts within ministries of health and research and continuing education officers may find that training in these subject areas will be a valuable investment. Contact Information: Miguel Gonzalez-Block, Alliance for Health Policy and Systems Research, World Health Organization, 20 avenue Appia, CH 1211 Geneva 27, Switzerland blockm@who.int

Anthology of Health Communication Materials From HABIT: Vol.6 No. 6 2003. Full document available at: http://www.comminit.com/mahealthanthol/sld-7327.html. Many of the materials are available in Spanish as well as English. The Anthology of Health Communication Materials was collected by the Communication Initiative, a partnership of organizations including UNICEF, PANOS and the Rockefeller Foundation that works on communication projects related to international development. The anthology was commissioned by the Pan American Health Organization in 2002. Research about the importance of health communication is piling up, while resources to help practitioners wade through what works and what doesn't are much scarcer. This month's spotlight falls on a Web site with a peer-reviewed list of health communication materials ranging from academic texts to CD-ROM sets. A team of health communications experts reviewed the final list of 61 materials with an eye toward those products with proven success in the field. Topics include health issues among children and adolescents, gender, HIV/AIDS, reproductive health and family planning, health worker training materials and even tips for promoting health initiatives to the media. Each listing briefly describes the materials and their original audience, and provides information on how to purchase or links to download the materials for free.

Articles

Several publications from the Bangladesh Equity Gauge are now available in the "Documents" and "Bangladesh Gauge" sections of the GEGA webpage, including The Equity Dialogue newsletter; the BHEW Brochure; the document "Who is vaccinated in Bangladesh? The immunization divide" and a summary of the paper; and "The Bibliographical Alert: Health, Poverty, and Equity," published quarterly by BHEW and compiled by conducting searches of the Internet and popular databases such as Popline and Medline.

An especially illustrative document on identifying equity indicators, entitled "Improving and Monitoring the Equity of Health Care Provision: A Discussion of the Selection of Indicators," by David McCoy and Lucy Gilson, is available in A Travelling Seminar on the Attainability and Affordability of Equity in Health Care Provision - Workshop Proceedings, pg 66-79.

Is inequality in Africa really different? Branko Milanovic, May 2003. World Bank, Development Research Group. Available online as PDF file [44p.] at:
http://www.worldbank.org/research/inequality/pdf/africa.pdf. ".....High inequality in Africa is something of a paradox: Africa should be a low-inequality continent according to the Kuznets hypothesis (because African countries are poor and agriculture-based), and also because land (the main asset) is widely shared. Our hypothesis is that African inequality is politically determined. Yet in the empirical analysis, despite the introduction of several political variables, there is still an inequality-increasing "Africa effect" linked to ethnic fractionalization. The politics however may work through ethnic fractionalization which provides an easy and secure basis for formation of political groups. Although this is a plausible explanation, it is not fully satisfactory and is criticized in the concluding section...."

Who Would Gain most from Efforts to Reach the Millennium Development Goals for Health? An Inquiry into the Possibility of Progress that Fails to Reach the Poor. Davidson Gwatkin. Principal Health and Poverty Specialist. The World Bank, 2002. Available online as PDF file [4.6 MB] at: http://poverty.worldbank.org/files/13920_gwatkin1202.pdf. "This paper is an inquiry into the possibility of progress toward the MDGs targets for health that does not significantly benefit the disadvantaged people whom the MDGs are intended to serve. The MDGs health targets, unlike most other prominent MDGs targets, are stated in terms of improvement in societal averages rather than in terms of gains among poor groups within societies...The inquiry begins by examining the implications of two alternative scenarios for progress: a "top-down" scenario, with gains highly concentrated among the better-off; and a converse "bottom-up" scenario, under which gains flow primarily to the poor. Quantitative illustrations for typical countries in Latin America and the Caribbean, South and Southeast Asia, and Sub-Saharan Africa indicate that the amount of benefit accruing to the poor would vary greatly according to the scenario folllowed. The second part of the inquiry examines the plausibility of the two scenarios. The conclusion is that, while the "pure" top-down scenario is unlikely, some approximation of it is considerably less improbable than a bottom-up scenario. The implication is that special efforts will be required to ensure that health and development initiatives reach poor people if they are to gain significantly from progress toward the Millennium Development Goals MDGs health targets....."

Has Improved Availability of Health Expenditure Data Contributed to Evidence-Based Policy making? Country Experiences with National Health Accounts. Susan De, Tania Dmytraczenko, Derick Brinkerhoff, Marie Tien. Technical Report No.022 - May 2003. The Partners for Health Reformplus Project. Abt Associates Inc. Bethesda, MD USA. Available online as PDF file [56p.] at: http://www.phrplus.org/Pubs/Tech022_fin.pdf. "National Health Accounts (NHA) is a tool designed to inform the health policy process by providing policymakers with valuable information on the distribution of health funds within the system. NHA was introduced and implemented in a number of middle - and low-income countries in the mid- to late 1990s. This study sets out to determine if NHAs has actually met its principal goal of contributing to evidence-based policymaking. The paper examines the policy impact of National Health Accounts NHA in 21 developing countries from the Latin America and the Caribbean region, East and Southern Africa, the Middle East and North Africa, and the Asia Pacific region. The study describes how policymakers have used National Health Accounts and assesses the various factors and influences that determine the extent to which NHAs impact the policy process......"

An Annotated Bibliography on Policy Processes. Jos Mooij, Veronica de Vos. Policy Processes: Working Paper 221 - July 2003. Overseas Development Institute, London, UK. Available online as PDF file at: http://www.odi.org.uk/publications/working_papers/wp221.pdf. "The term 'policy process' is based on the notion that policies are formulated and implemented in particular social and historical contexts, and that these contexts matter - for which issues are put on the policy agenda, for the shape of policies and policy institutions, for budget allocations, for the implementation process and for the outcome of the policies. The idea of 'policy process' stands opposed to that of 'policy as prescription', which assumes that policies are the result of a rational process of problem identification by a benevolent agency (usually the state). While the 'policy as prescription' approach is still important - both in much of the public administration literature as well as in the heads of many policy-makers - there is a fast expanding body of literature that analyses, explains or conceptualises the process dimensions of policy. This literature is a blend of political science, sociology and anthropology. It does not assume that policies are 'natural phenomena' or 'automatic solutions' resulting from particular social problems and it does not privilege the state as an actor fundamentally different from other social actors. The why, how and by whom questions are treated as empirical questions; it is only concrete empirical research that can generate the answers. It is this body of literature that is included in this bibliography......"

Applying an equity lens to child health and mortality: more of the same is
not enough. Cesar G Victora, Universidade Federal de Pelotas, Pelotas, Brazil; Adam Wagstaff, University of Sussex, Falmer, Brighton, UK , The World Bank; Davidson Gwatkin, Mariam Claeson, The World Bank, Washington, DC, USA; Joanna Armstrong Schellenberg, London School of Hygiene and Tropical Medicine, London, UK, Ifakara Health Research and Development Centre, Tanzania; Jean-Pierre Habicht, Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA. Lancet 2003: 362: 233-41 - Volume 362, Number 9379 - 19 July 2003. Available online at: http://www.thelancet.com/journal/vol362/iss9379/full/llan.362.9379.child_survival.26472.1. "Gaps in child mortality between rich and poor countries are unacceptably wide and in some areas are becoming wider, as are the gaps between wealthy and poor children within most countries. Poor children are more likely than their better-off peers to be exposed to health risks, and they have less resistance to disease because of undernutrition and other hazards typical in poor communities. These inequities are compounded by reduced access to preventive and curative interventions. Even public subsidies for health frequently benefit rich people more than poor people. Experience and evidence about how to reach poor populations are growing, albeit largely through small-scale case studies. Successful approaches include those that improve geographic access to health interventions in poor communities, subsidised health care and health inputs, and social marketing. Targeting of health interventions to poor people and ensuring universal coverage are promising approaches for improvement of equity, but both have limitations that necessitate planning for child survival and effective delivery at national level and below. Regular monitoring of inequities and use of the resulting information for education, advocacy, and increased accountability among the general public and decision makers is urgently needed, but will not be sufficient. Equity must be a priority in the design of child survival interventions and delivery strategies, and mechanisms to ensure accountability at national and international levels must be developed....." Also available in this issue are:
Why do poor children die earlier? ;
Can policy makers reduce child survival gaps? ;
Translating knowledge into action at national and subnational levels ;
Increasing coverage in poor communities with child survival interventions ;
Improvement of accountability ;
The challenge at international level

Interventions in the Social Environment to Improve Community Health:
A Systematic Review. From the US Task Force on Community Preventive Services. Published in the American Journal of Preventive Medicine in April 2003. Available at: http://www.thecommunityguide.org/social. "Social determinants of health are societal conditions that affect health and can potentially be altered by social and health policies and programs. Three broad categories of social determinants are social institutions - including cultural and religious institutions, economic systems, and political structures; surroundings - including neighborhoods, workplaces, towns, cities, and built environments; and social relationships - including position in social hierarchy, differential treatment of social groups, and social networks. The Task Force on Community Preventive Services has conducted systematic reviews of interventions that address social determinants of health disparities: comprehensive early childhood development programs; affordable family housing in safe neighborhood environments; and culturally and linguistically competent healthcare systems. These reviews show that interventions to increase these social resources in neighborhoods and communities have a measurable impact on community health outcomes...."