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EQUITY GAUGE PROFILES: SOUTH AFRICA

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Introduction

The Equity Gauge is a national project established to help South Africans measure if their health is improving. It also helps measure if health care is being provided in a way that is fair and equitable. The project is a partnership between South African Legislators and the Health Systems Trust, a Non-Governmental Organisation established in 1992 to support the transformation of the health system. The project is funded by the Henry J. Kaiser Family Foundation (USA) and the Rockefeller Foundation.

Partner Institution

Aims and Objectives

The aim of the "Equity Gauge" is to establish a set of benchmarks by which progress towards equity in health and health care can be monitored over time, and to facilitate its use and application. Specifically, the Gauge seeks to achieve the following objectives:

To define, measure and monitor a core set of indicators for assessing progress towards equity in health and health care provision;
To facilitate the use of information provided in the "Equity Gauge" by national and provincial legislators, and local government representatives, to monitor equity;
To instill the notion of monitoring equity as a key strategy for the promotion of equity among the media and the general population of South Africa;
In addition, legislators are supported with information relating to how the health system functions and the processes followed within government for budgeting and resource allocation;
A subsidiary aim of the gauge is to strengthen the accessibility and quality of health data.

Equity Gauge Contents

Key indicators for the determinants of health, health status, resource allocation (financial, human, drugs) and quality of health care provision are included in the Gauge. Wherever adequate information exists indicators are measured in such a way that they can be used to monitor differences and trends between the public/private sector divide, geographical areas (provinces and districts and rural/urban areas), race, gender and disability.

Sources of Information

The Equity Gauge draws from both primary and secondary data sources. Wherever relevant, up to date information is available this is used. Research is commissioned in areas where no reliable or up to date information exists. For example, following the introduction of the District Health System little information was available regarding infrastructure and quality of care in public sector clinics. A facilities survey covering 10% percent of the country’s clinics and a large proportion of district hospitals was commissioned by HST to address this gap.

Facilitating the Use of the Equity Gauge

A number of strategies have been identified to encourage effective use of information contained in the equity gauge:

Legislators, particularly within provinces are generally poorly resourced with regard to research capacity. With a view to strengthening information and research support to provincial health committees two information officers help identify specific information and research needs of legislators and develop appropriate corrective measures that will enable legislators to deal with information provided to them. Careful attention is given to ensuring that all information produced for legislators is presented in an accessible and inviting format. Material is pre-tested before it is published to ensure its relevance and comprehensibility.
Support is provided to legislators to help them use information from the Equity Gauge and other relevant research. This support comprises workshops and seminars as well as written material on issues of concern to legislators.
In order to increase legislators’ understanding and knowledge of the reality of health care at a District level, visits are arranged for legislators to go to districts to gain a first hand impression of implementation at the primary care level.
Research results are publicised to encourage debate about the issues and promote action where inequity persists. The Equity Gauge works with journalists from TV, radio and newspapers.

Activities of the Project to Date

The whole-hearted involvement on the part of national and provincial legislators indicates that the project has identified a real need and is contributing to meeting that need. Although a formal evaluation of the project is only due to commence at the beginning of 2000 the range of activities undertaken by the project demonstrate that some objectives are already being met.

Workshops

During the developmental phase of the project, an issue that was continually highlighted by legislators was their need for support to enable them to participate effectively in the budget process. One of the first tasks of the project was to develop the curriculum and materials for a workshop to meet this need. To date workshops on the budget process have been organised and run for five of the provincial committees.

Site Visits

A key strategy of the project in empowering legislators to understand the realities of service provision is the arranging of visits for legislators to health districts. Two site visits have already taken place in which national and provincial legislators have been exposed to the impact of inequity on health care provision. Visits are accompanied by a workshop in which legislators have the opportunity to explore possible solutions to problems encountered as well as address policy implications of the findings from the visit. Feedback from participants has indicated that they have made use of the information gleaned on site visits during Parliamentary and Committee discussions.

Reflections on the Project to Date

Legislators are extremely busy. Many provincial legislators sit on more than one committee, and most committee cover more than one area. For example, most provincial standing committees on health also have welfare as part of their remit. In addition, although the legislative agenda is now beginning to level off, until recently the agenda has been extremely full. These factors limit the time available to legislators to participate in training and site visits.

South Africa still has limited data available with which to measure and monitor equity. For example the first ever South African demographic health survey was undertaken in 1998. Much of the data that is available does not enable analysis of equity according to different racial groups or according to gender. While some data allows for comparisons between rural and urban areas, rarely is there information to analyse the situation in peri-urban areas. Additionally the slow process of establishing health districts is inhibiting the development of effective monitoring of resources at the district level.

A major challenge for the project is to develop tools and indicators for monitoring equity in the context of the HIV/AIDS epidemic in South Africa. Many health status indicators will become much worse over the next few years. For example life expectancy dropped from 65 to 55 years between 1995 and 1999. The project is participating in discussions searching for reliable indicators that are sensitive to progress in achieving equity in this environment.

The underlying aim of the project is to provide legislators with information that can assist them in policy formulation. It is not yet clear as to whether legislators will be able to influence the executive branch of government should information from the equity gauge point to the need for policy in conflict with that being pursued by the executive.