A TOOL FOR MONITORING EQUITY IN HEALTH AND HEALTH CARE IN SOUTH AFRICA

1. A TOOL FOR MONITORING EQUITY IN HEALTH AND HEALTH CARE IN SOUTH AFRICA

2. What is Equity ? • Equity has a number of different dimensions and interpretations. Attempting to identify one single definition limits understanding • Equity is not equality, but “fair shares” and “fair opportunities” in distribution of resources • Needy groups should receive preferential treatment for resources

3. Contextualising Equity in Health and Health Care in South Africa • Constitution and policies of government commit the country to a national goal of “equity and equality” • Health policies target the poor, especially rural women and children through: • Increasing access to integrated health care services • Distributing health personnel in an equitable manner • Establishing equity oriented health care financing policies

4. Political Arrangements • South Africa has a National Assembly and National Council of provinces and a provincial parliament in each of the nine provinces • State resources are in the hands of a powerful Executive Branch which has control over the development of policies, systems and programmes • Legislative branch of government (in national and provincial parliaments) with oversight function for monitoring policy development and implementation, but has limited technical support • Oversight role of legislators is critical for attainment of equity

5. Health Systems Trust • Health Systems Trust is an independent organ of civil society which supports the development of an equitable and comprehensive health care system • HST seeks to strengthen capacity of legislators and has entered into a partnership with legislators in both national and provincial parliaments in the form of a project called the Equity Gauge

6. Development of the Equity Gauge • A workshop in 1997, supported by the Kaiser Family Foundation, bringing together top level policy makers, laid the groundwork • Importance of being able to measure progress towards equity as a prerequisite for promoting equity • Following on from Manila a series of meetings and workshops were held in South Africa bringing together legislators and local and international health systems experts. These meetings resulted in: • A formal endorsement by legislators of their role in monitoring equity • Identification of the information required of legislators • A greater understanding of their support needs

7. The Equity Gauge • Aims and Objectives • The Equity Gauge seeks to: • establish a set of benchmarks or indicators by which progress towards equity can be monitored over time • facilitate the use and application of information on equity • instill the notion of monitoring equity, as a key strategy for the promotion of equity, among the media and South African Population • strengthen the accessibility and quality of health data and information

8. Activities of the Project Site Visits Two site visits (each accompanied by a workshop) in which national and provincial legislators were exposed to the impact of inequity upon health care provision Workshops Development of curriculum and materials for the budget process – workshops run in six of the nine provinces Project Materials “Equity Gauge” – measurement of key indicators Budget Process Booklet 1998 and 1999 South African Health Reviews focussed on equity General Support In other activities such as public hearings on pieces of legislation that parliamentarians have to review Publicity Coverage of research information on equity issues on TV, radio and newspapers

9. Reflections on the Project to Date • Partnership • Project developed in conjunction with legislators • Steering Committee chaired by the chair of the National Assembly Portfolio Committee on Health, with representation from four of the key national committees and three of the nine provincial health committees • Partnership enables project to understand and focus on issues that are of priority to legislators • Facilitates media publicity e.g. when SAHR was launched earlier this year in parliament • Partnership has led to active participation by legislators at national and provincial level

10. Focus • Legislators are extremely busy – most provincial legislators sit on at least two and sometimes three committees – over the past few years there has been a huge legislative burden imposed by the need to overturn pre 1994 legislation • External events often result in legislators having to respond to issues at short notice with planned activities being postponed • Project thus needs to align activities with priorities of legislators – eg budget process and site visits

11. Information • Limited data due to inadequate information systems • Outcome of improved equity is improved health status for the most vulnerable – yet health outcome indicators are slow to respond to change (danger of loss of momentum) • HIV/AIDS epidemic in SA means that many health status indicators will worsen over the next few years even if there is improvement in equity of resource distribution

12. Health System • Slow process of establishing districts • Implications of transformation of local government • General • Will legislators be able to influence the executive branch should information from the Equity Gauge point to the need for policy in conflict with that being pursued by the Executive? • Dynamics of an NGO that relies on soft funding

13. Future • Local Government – eg need to bring Local Councillors on Board • Local advocacy project • HIV/AIDS