Bringing evidence on social determinants of health into health policy in East and Southern

Africa

EQUINET Regional and Tanzania country experiences of the Equity Watch.

Presented at

The First International Stakeholder Meeting INTREC

Outline

• Introduction • Equity Watch – Regional Experiences

• Regional Network for Equity in Health in East and Southern Africa (EQUINET)

• Equity Defined • The Equity Watch

• Equity Watch – Tanzania Experience • The process • Findings • Way forward

The Partnership

• Ministry of Health and Social Welfare, Tanzania (MOHSW) • Josibert Rubona, M&E Unit • Mariam Ally, Health Financing

• Ifakara Health Institute (IHI) • Dr. Yahya Ipuge, Policy Delivery Thematic Group • Kassimu Tani, CONNECT Project

• Regional Network for Equity in Health in East and Southern Africa (EQUINET) • Dr. Rene Loewenson, Training and Research Support Centre (TARSC) • Marie Matsoya, Training and Research Support Centre (TARSC)

• IDRC Canada

UNITED REPUBLIC OF TANZANIA Ministry of Health and Social Welfare

DIRECTORATE OF POLICY AND PLANNING Monitoring and Evaluation Unit

50+ years of health research development

7

IHI Branches and Sentinel Panel of Districts

8

IHI Branches and Sentinel Panel of Districts

Research thematic groups: approx 65 projects

Biomedical scienceimmunology, molecular biology, biotech, etc

Environmental scienceentomology, hydrology, ecology, etc

Interventionstrials, surveillance, bioeffectiveness, etc

Health system sciencematernal health, child health, workforce deployment, etc

Impact evaluationimpact assessment of govt / ngo implementation

Policy translationpublic policy, taking interventions to scale

Operations Knowledge People FinanceOrganisational Support

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Out

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Laboratory discovery / development

Developing ideas to work in practice

Testing in the field

Matching interventions to the real world

Measuring outcomes: did the intervention work

Taking it to scale within reality and public policy

Research Lifecycle

IMPACT!

Regional networking on health equity and the Equity Watch in east and southern Africa

Dr Rene Loewenson Training and Research Support Centre, Regional Network for Equity in Health in East and Southern Africa (EQUINET)

EQUINET

• is a network of professionals, civil society members, policy makers, state officials in east and southern Africa that aims to advance and support health equity and social justice through research, analysis, networking and dialogue

• Formed in 1998, linked to SADC, extended to East Africa in 2003

• Covering 16 countries in ESA

Visit www.equinetafrica.org

Equity (EQUINET DEFINITION)

‘Equity in health implies addressing differences in health status that are unnecessary, avoidable and unfair. Equity-motivated interventions seek to allocate resources preferentially to those with the worst health status. This means understanding and influencing the re-distribution of social and economic resources for equity-oriented interventions, and understanding and informing the power and ability people (and social groups) have to make choices over health inputs and to use these choices towards health.’ EQUINET steering committee, 1998

Equity is advanced when

1. Health has high profile in national goals and values

2. Households access the resources they need for health (the SDH)

3. Health systems are organised for universal coverage and redistribution/ protection

4. People are empowered to claim entitlements, and act on health

5. Countries negotiate and attain greater global justice in the resources for health

2007 EQUINET Regional Analysis of Equity in Health

Gathers and organises evidence on 25 progress markers of contexts; equity in health/ health care, equity in social determinants of health, redistributive health systems; global issues Progress markers reviewed by ECSA M&E Group To promote dialogue on the findings, and implications for policies and actions; To identify monitoring, knowledge and evidence gaps; and To exchange country evidence at regional level on common trends and promising practices.

2010 ECSA/HMC50/R9: Tracking Progress towards the MDGS Noting the 30th and 34th HMC resolutions on ensuring health equity and that it will be difficult and in some cases not possible to achieve the MDGs without reducing health inequalities. Urges Member States to...Report on evidence on health equity and progress in addressing inequalities in health. Directs the Secretariat to...strengthen capacities and measures to monitor and report on progress in addressing inequalities in health.

EVIDENCE FROM • Household surveys post

2000: DHS, MICS, Living Stds measurement survey

• UN databases – WHO, UNAIDS, world Bank, UNESCO, UNICEF, UNDP

• Government reports

• Published studies

• Case studies of promising practice

• Policy dialogue, civil society, community photography

Country Equity Watch and EQUINET Regional Equity Watch

What is measured counts

1. Area and social disaggregations both needed

2. Address gaps: eg MMR, NCDs, district data, health expenditure by level

3. Update progress markers- eg energy, employment as SDH; with key sectors

4. Disaggregate key health system indicators- eg spending by level, drug stockouts

5. Encourage community monitoring

Within ESA countries: • Extremely wide

differentials in maternal and SRH, wider than for most areas of child health services

• Particularly wide at lower levels of overall coverage

For example 1: Differentials post 2000 in (1) births attended by skilled health personnel by wealth and (2) children treated for ARI by area

EQUINET 2012

Public sector: poorest groups benefit more than richer from primary care services; wealthier more from hospitals Faith based: similar to public Private: wealthier benefit more at all levels

For example 2: Benefit incidence studies, South Africa, Kenya, Tanzania, 2010-2012

Makiwa et al 2012; Ataguba and McIntyre, 2012; Chuma et al 2012

Distribution of the benefits of public outpatient services in Tanzania, 2010

…then send them back to the conditions that made them sick?

What good does it do to treat people's illnesses ...

For example 3: Differentials in social determinants that underlie inequalities in health

Poor progress and 2-3 fold urban –rural differentials in access to safe water and sanitation

Positive gains in primary education Inequity in ECEC - only 2 in 5 children, high inequalities, high private provisioning, low public funding

EQUINET 2012; Mutazu 2012

2011 Zambia Equity Watch: The budget allocation to agriculture rose

from 4% to 8% between 2002 and 2007, with improvements on rural nutrition and reduced rural: urban differentials in the period;

Malawi spending averaged 13% 2004-2007. Food poverty fell from 45% to 29% in the period.

Survey evidence of gains to food production and household nutrition from investment in smallholder, women farmers

All 8 African countries that met the CAADP target of 10% in 2004-2007 achieved reductions in food poverty

Follow up of Equity Watch Work in countries 1. Widen ownership within MoH, across health

stakeholders, multi-sectoral steering gp 2. Institutionalise EW work –annually using routine

data; periodically using household surveys; linked to planning and with regular review

3. Specific areas of policy tracking, eg -ZAMBIA: Track resource support for and implementation of PHC and “health post” policy -MOZAMBIQUE: Equity in resource allocation= RA and gap analysis -ZIMBABWE: UHC: EHB and Domestic health financing -UGANDA: OOP and Catastrophic spending

4. Follow up on evidence gaps identified – eg district and within area inequalities, health system surveys and data disaggregations

Eg: 2012 ECSA DJCC recommendation on •health financing, organization and integration of services for equitable allocation of human and financial resources and commodities to frontline and community health services for women and children •Undertake deliberate actions and efforts to close the gap in MNCH between the worst and best performing areas and groups. •Track and report on progress in closing inequalities in health towards 2015 and in the post 2015 development goals.

Follow up of Equity Watch Work regionally • Capacity building on equity analysis - eg Regional

workshop in April 2012; training in BIA, FIA • Regional monitoring: ECSA M+E, Regional Equity

Watch, with UNICEF, WHO AFRO • Regional exchange and dialogue on evidence

Tanzania country experiences of the Equity Watch A collaboration between • Ministry of Health and

Social Welfare • Ifakara Health Institute • EQUINET-TARSC

Tanzania Equity Watch –The process (1)

• Implemented by in country personnel • Gathering data, analysis and presentation (Ifakara Health Institute) • Peer review and approval (Ministry of Health and Social Welfare) • Stakeholder Peer review meeting (public, private and civil society) • Endorsement by Minister for Health and Social Welfare • Dissemination and post-publication dialogue

• Available secondary data in the public domain as sources of evidence. • Demographic and household surveys • Routine data and official reports • National Surveys (HDSS, SPD) • Published (peer reviewed) and grey literature

• EQUINET technical support

Tanzania Equity Watch –The process (2)

• Data Quality Limitations –same as in sources of evidence • Lack of district disaggregation • Inconsistent definitions across time • Incomplete reporting • Lack of robust data verification process for routine health information

• EQUINET framework allows comparison with other ESA countries

Equity watch Tanzania 2012: Progress and Actions needed

• A consistent policy commitment to health equity, but not reflected in the constitution

• Beyond primary enrolment, need to boost quality of education, affordable transition from primary to secondary and widen access to pre-school

• More investment to improve coverage of safe water and sanitation

• Address availability and access barriers to increase antenatal visits, HIV services and assisted deliveries

• Intensify delivery of policy focus on community and primary health care level to enhance equity

• Special focus on poorly serviced regions

• Enhance effectiveness of waiver and exemption mechanisms

• Invest in community participation

Equity In Health

Equity In Health

• Consistent policy commitment to health equity

• Low levels of income inequality

• Declining infant and child mortality rates & rural-urban inequalities

• Access to HIV services and youth sexual behavior

Equity In Health

• Right to health not enshrined in the constitution

• Off track in poverty reduction targets

• Static gini coefficient and widening urban income inequality

• Child under-nutrition has not improved

• Geographical and social difference in service coverage

Household Access to resources for Health

• Improved enrolment rate and gender parity in primary and secondary education

• Wage as share of GDP has risen

• Agricultural spending has risen

• Some decline in cost barriers for use of health services

Household Access to resources for Health

• Shortfalls in quality of education in rural households

• Inadequate pre-schools and cost barriers

• Little progress in access to safe water and sanitation with worsening urban coverage

• Small decline in earning disparities between men and women

Household Access to resources for Health

• Agricultural spending below 10% AU target

• Limited investment in agricultural technology, training for small holder and women farmers

• Large-scale foreign land acquision for biofuels

• Availability, social and cost factors are barriers for service uptake

Redistributive Health Systems • Health as share of

government spending and share of GDP

• Government health expenditure per capita increased to almost US$ 60 (PPP)

• Public spending and prepayment schemes have reduced out of pocket payments

• Essential Health benefits package defined, costed and included in health plans

• Policy support for public participation in health service provision

• waivers and exemption not effectively implemented

• Low coverage of prepayment schemes especially in rural areas

• Severe staff shortages in health facilities and training institutions

• Medicine stock outs undermine access

• Inadequate investment to guide roles of health committee members

A just return from the Global Economy

A just return from the Global Economy

• Debt relief initiatives with benefit to health and education

• TRIPS flexibilities provided for by law

• Tanzania has health attaché` in Geneva but influence in global diplomacy is unclear

• External debt rising after 2008-reducing resources for health or SDH

• Administrative, political and capacity barriers limit the full use of TRIPS flexibilities

• Tanzania has not committed its health services to GATS

• No bilateral agreements to manage health worker migration

Way Forward

• A dissemination meeting planned to involve all stakeholders (public, private, civil society) • Make Policy recommendations for follow up action –joint ownership of

recommendations • Discuss and agree options to institutionalise Equity Watch in Tanzania • Inter sectoral approach for Equity Watch • Recommendations for further priority research and studies to address

gaps • Consider Equity and SDH as indicators for Universal Coverage in in post

2015 (MDG) era.

THANK YOU