LONDON CONSENSUS BUILDING FORUM
"New Methodology: Analysing Health Equity Gaps"
June 12, 2012 • London, England
The Forum was established to give participants the opportunity to consider methodological issues in equity gap analysis.
> Professor Chris Heginbotham facilitated the forum and introduced the participants. He emphasized the richness of existing resources, especially those from the various WHO initiatives, and a number of key papers prepared by academics over the preceding decade. Intra-country equity can be measured on three levels:
- Macro – 'top down': largely the impact of government policies on the determinants of health equity (such as the Gradient approach of EuroHealthNet);
- Meso – 'middle level': based on analysis of a large area (e.g. region or city) disease or condition indicators (e.g. UrbanHEART)
- Micro – 'bottom up': engaging communities in describing the way that health is provided for them (GHEF) and assisting in obtaining appropriate access or other equity measure.
Dr. Mazen Kherallah
The Forum noted the WHO Commission on Social Determinants of health conclusions:
- health equity to become a marker of government performance;
- health equity impact assessments should be undertaken of major global, regional and bilateral economic agreements;
- strengthening of public sector leadership in the provision of essential health-related goods/services and control of health-damaging commodities is needed;
- gender equity to be promoted through enforced legislation and a gender equity unit to be created and financed;
- the economic contribution of housework, care work, and voluntary work to be included in national accounts;
- all groups in society to be empowered through fair representation in decision-making;
- civil society to be enabled to organize and act in a manner that promotes and realizes the political and social rights affecting health equity.
From this list GHEF has the resources and commitment to undertake limited-scope research, advocacy and capacity building. Deciding on the scope of the GHEF program is critical.
> Dr. Tayeb Alhafez described the consensus building forum history and the work done in Montana on mental health as a result of an earlier forum. Dr Alhafez talked about the problems of suicide in Montana and the initiative that he and GHEF have taken to mitigate the problem, in particular engaging young people in media production as one of a number of solutions that young people create for themselves.
> Dr. Eduardo Missoni provided an introductory presentation on Global Health, defined equity in health and laid out the role of health diplomacy and governance for health. His presentation demonstrated both his own experience and the latent opportunities for GHEF. He demonstrated both the size of the problem and extent of GHEF's expertise. Global Health is an emerging area for interdisciplinary studies, research and practice that considers the effects of globalization on health – understood in the comprehensive meaning of a complete state of physical, mental and social well-being – and the achievement of equity in health for all people worldwide, emphasizing transnational health issues, determinants and solutions, and their interactions with national and local systems. Dr. Missoni explained the difference between health inequalities and health inequities:
- Inequalities in health describe the differences in health between groups independent of any assessment of their fairness.
- Inequities refer to a subset of inequalities that are deemed unfair.
Unfairness invokes assessments of whether inequalities are avoidable, and ideas of distributive justice as applied to health. Health outcomes are linked to factors such as gender, education, living environment (urban/rural), income, ethnicity, social status and conditions, employment and work conditions, as well as economic and social policies. Health outcomes are directly related to socio-economic inequality as demonstrated by Wilkinson and Pickett in their seminal work published in 2009. The fundamental step a country can take to promote health equity is to move towards universal coverage with: universal access to the full range of personal and non-personal health services they need, with social health protection; and pooling pre-paid contributions collected on the basis of ability to pay, and using these funds to ensure that services are available, accessible and produce quality care for those who need them, without exposing them to the risk of catastrophic expenditures.
A paradigmatic shift toward a more caring and equitable society requires substantial reorientation of policies at the national level, and citizens' engagement at the community level. Global interdependence and the unavoidable interactions between global forces and national systems requires rethinking and reorganization of global health governance into Global Governance for health and civil society engagement at the global level.
> Chris Brookes, Director of Programmes and Partnership at Health Action Partnerships International (HAPI) gave an overview of international developments in health inequalities and spoke about the Marmot Review and the importance of tackling the social determinants of health.
> Helen Bingley, president of Abaseen Foundation, UK, gave an inspiring update on the foundation's work in north-west Pakistan over the past fifteen years and offered GHEF the opportunity to have a closer look at their research and capacity building models in order to replicate them in different settings and disadvantaged communities. She described the country and the challenges it offers to health agencies. For example:
- Average life expectancy: 65 years; UK: 78 years
- Average per capita income: US$ 1,085; UK: US$ 69,560
- Percentage of people not meeting daily food needs: 22.5% living below national poverty line
- Women dying in childbirth: 320 per 100,000 live births UK: 13 per 100,000
- Children dying before age 5: 94 per 1,000 live births UK: 6 per 1,000
- Percentage of people with access to safe, clean water: 66 %
- 1 of 4 countries where polio is endemic
- Hepatitis and Malaria is endemic and has 6th highest rate of TB in the world
- Emerging diseases – HIV, Avian Flu, SARS
Abaseen started work in health but has now expanded to education, research and humanitarian relief. The Foundation works through local communities in the UK and in Pakistan, especially in the Federally Administered Tribal Areas (FATA). A research program with UCLan, the University of Northumbria, and the University of Peshawar is considering in particular nutrition and malnutrition because of the increased incidence of child deaths, stunted growth, reduced learning ability and productivity as an adult. Maternal and child health is another important research area working closely with UNICEF and the Wellcome Trust. One key issue for Abaseen is whether the Jirga system can be used as a vehicle to improve mother and child health. GHEF and the Abaseen Foundation have similar or related objectives and GHEF may be able to learn from Abaseen's experience.
> Participants split into three groups and discussed three different research topics in an attempt to reach consensus of the methodology of Equity Gap Analysis. Although there was no consensus reached during the forum, it became obvious that incorporating media and communications into research methodology would provide both a higher yield and a set of achievable research topics. The most important lessons from this part of the Forum were (1) that the Foundation has limited resources which must therefore be targeted carefully, and (2) that health inequalities or inequities exist in many forms in every country; if GHEF is to be successful it must decide on which subjects to tackle either in each country separately or on a multi-country basis. If the former option is considered appropriate, then each country involved should tackle one of the critical priorities discussed as part of a wider program; if the latter option is chosen, GHEF members must agree on one limited but nonetheless hopefully achievable and effective intervention. GHEF requires useful and acceptable tool(s) to undertake equity gap analysis, with comparable, commensurable and measureable indicators that enable GHEF and other agencies to make steady progress; and make changes that achieve improvements in (i.e. reduce) equity gaps. In summary, GHEF needs to undertake research and analysis engaging the communities affected, in order to:
- understand the implications of political decisions, health systems and social policies;
- draw conclusions from the data on the extent of equity problems;
- identify socio-political solutions to social determinants of health and health systems discrimination.
> The forum was concluded by introducing the idea of Syrian International Coalition for Health by Dr. Mazen Kherallah, MD, FCCP and president of the Middle East Critical Care Assembly. He concluded his valuable presentation with two key goals:
- Our initial goal is to strengthen emergency responses by developing a strategy that addresses healthcare delivery at the country and field levels; and
- During and post-crisis the coalition aims to provide healthcare leadership by ensuring sound coordination and evidence-based action;
And three main objectives: coordination and communication, healthcare delivery for displaced populations, and transition from relief to development through strategic health care planning.
A fruitful discussion about the immediate need took place, and the participants as well as the board members of the Foundation supported this important initiative and agreed to host it within the Foundation.
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