The South African Equity Gauge

What is equity?

Inequities in health refer to those differences in health that are unfair, unacceptable and avoidable. Equity is not the same as equality. Equality implies providing the same level of services to everyone regardless of the need they have for the service. Equity on the other hand requires that a greatest share of resources is targeted towards meeting the needs of those who are most disadvantaged and vulnerable.

What is an Equity Gauge?

An Equity Gauge actively monitors and addresses inequity in health and health care. Rather than simply describing or passively monitoring selected indicators, the Gauge seeks to develop a set of concrete actions. These actions are designed to lead to real and sustained change in moving towards equity. Since many of these indicators and actions cut across many different sectors, it is not a typical health research project and is not limited to actions in the public health domain.

An Equity Gauge Project is based on a on a three-tier model of assessment and monitoring, advocacy and community empowerment. The assessment and monitoring tier include ‘identifying context and processes that contribute to health inequities and tracking selected inequities over time in relation to those contexts'. The advocacy pillar involves using information strategically and acting to change policies to improve the lives of disadvantaged people. The third tier, community empowerment involves a ‘bottom up developmental approach and moves away from the notion of poor and disadvantaged groups as passive beneficiaries.

The Health Systems Trust (HST) established the South African Equity Gauge project in January 1999 in partnership with national and provincial parliamentarians to provide technical support to the government. The nature of its work has evolved since then and the project is now built on a three-pillar model which consists of:

• Research and monitoring - This pillar measures and describes inequities in health care using a specific set of indicators
• Advocacy and public participation - This pillar promotes the use of information by different groups, all of whom are working towards the same goal: equity in health care
• Community empowerment - This pillar strives to get communities into a position where they can enact change themselves rather than remain passive observers.

To that end, the South African Equity Gauge is not merely a measurement of equity in the country but is a set of actions and initiatives to facilitate equity.

Each of the three pillars can be incorporated at any time and do not follow a linear process.

Some Activities of the Project

While the work of the South African Equity Gauge continues to be guided and informed by the 3 ‘pillars' of an Equity Gauge, the project has consciously sought to strengthen the community empowerment arm of its work and has aimed to integrate all pillars of its work into it mini-projects.

The HIV Gauge project is designed to facilitate community participation in health care delivery and to develop local responses to overcome weaknesses in health systems. The HIV Gauge has been conceptualised as a mini-equity gauge, in that all three pillars are represented in the project. Unlike traditional equity gauges, where the monitoring and assessment sometimes represents the more ‘technical, academic' aspect of the project, the monitoring and assessment aspect of the HIV gauge is represented in the community based M&E tool. The findings reflected by the tool will then be used by the community to engage in advocacy at local and policy-making levels.

The monitoring and assessment aspect of the HIV Gauge is represented by the community based Monitoring and Evaluation tool which evaluates the presence or absence of key services and resources from a supply and demand side that impact on the uptake of HIV/AIDS and ARV services. The findings arising out of the tool will then be used by the community to engage in advocacy at local and policy-making levels.

The overarching goal of the project is to develop community capacity to monitor, evaluate and facilitate the provision and delivery of HIV related services in their local areas, and to provide assistance to communities in developing strategic plans for action to address shortcomings that might be identified. In the longer term the project aims, through strengthening community engagement with HIV and AIDS services to improve access to care and reduce the burden of disease on South Africa's most vulnerable and disadvantaged communities

Clinic committees are responsible for administering the monitoring tool and for spearheading further activities arising out of the findings of the tool. The project intends to assist communities and clinic staff to both develop local solutions to the obstacles impeding take up of HIV/ARV services and to mount local advocacy initiatives aimed at decision and policy makers to address the broader systemic issues that are hampering effective service delivery and treatment.  The project promotes the building of partnerships between the community and the clinic staff as an effective method of improving health care delivery at local levels.

The monitoring and evaluation tool is available in English, Zulu and Xhosa.(Adobe Acrobat PDF files)

Understanding Challenges to Effective Community Participation
The Equity Gauge Project, together with the Population Council is involved in a study to understand the barriers and challenges to effective community participation in the rollout of HIV/AIDS treatment and care services.  The goal of the project is to collect data on the barriers and challenges to the use of services and on the involvement of community organisations in the rollout of ARV for use in the design and implementation of appropriate interventions. The project seeks to improve understanding of the context of public health utilisation including obstacles to the use of ART and entry points to treatment such as VCT and DOTS. Additionally, the project aims to assess the role that community based organisations can play in the implementation of the government's plan for ART rollout.   The project is based in two sites in KwaZulu- Natal and a further two sites in the Limpopo Province .

Soul City
The Equity Gauge team has been working with Soul City on their forthcoming series which will be focussing on equity and community participation in health care. Key messages focus on Community Empowerment and strategies that the community can adopt to advocate for improved equity in access to and quality of care. Some of the suggested strategies, based firmly within a human rights model, draw from community empowerment work that the Equity Gauge is doing at local level with communities and clinic committees, in particular the HIV Gauge.

The team was responsible for proposing the topic to Soul City , compiling a literature review on the subject, participating in message design workshops and providing consultant input on both the radio and television series.

Global Public Private Partnerships in Health
Given the rapid increase in the number of Global Public Private Partnerships questions have been raised regarding the desirability, sustainability, effectiveness and impact of such partnerships. Attention has been given to assessing how far these entities strengthen the right to health in countries where their activities are located, the appropriateness of these interventions and the effect of such initiatives on the overall health system. In order to shed more light on these issues, the Equity Gauge undertook a review of the Stop TB Partnership in South Africa . This was part of a multi- country study funded by WEMOS which sought to augment the existing body of knowledge on Global Public Private Initiatives (GPPIs) in Health with the aim of generating a set of country-based evidence relating to the effect of GPPIs on health policies and health systems.

Technical Support
The project provides technical support to a variety of organisations and bodies such as the national and provincial Portfolio Committees on Health, NGOs, research institutions and media houses.

Contributing to Regional Activities

• In response to needs expressed by the Zambian Gauge, an exchange visit in which Zambian members of the Health Portfolio committee met with their South African counterparts was organised and ongoing support is being provided by the South African Equity Gauge project to Zambia . This work is now feeding into a region-wide process intended to strengthen the role that Parliaments can play in promoting equity.
• The South African Equity Gauge project was the driving force behind the formation of the Global Equity Gauge Alliance (GEGA), a partnership between 12 equity gauges from different countries around the world.
• The South African Equity Gauge is an active member of the African Chapter of GEGA and Continuing Work

PUBLICATIONS AND PRESENTATIONS

• Barr D, Padarath A, Sait L (2005) The Stop TB Partnership In South Africa : a Review Durban : Health Systems Trust.
• Barron P, Day C, Loveday M, Monticelli F. The District Health Barometer Year 1. January-December 2004. Durban: Health Systems Trust; 2005.
• Padarath A, Ntuli A The Brain Drain in South Africa in Harvard Health Policy Review vol. 5 no. 2, 2004.
• Padarath A, Ntuli A, Berthiaume L. (2004) Human Resources In Ijumba P, Day C Ntuli A. editors. South African Health Review 2003/4. Durban : Health Systems Trust.
• Khosa S, Ntuli A, Padarath A. (2004) The Second Equity Gauge: Monitoring fairness in access to basic services essential for health. Durban : Health Systems Trust.
• Stewart R, Padarath A, Bamford L. (2004) Providing Antiretroviral Treatment in southern Africa : a literature review. Durban : Health Systems Trust.
• Padarath A, Chamberlain C, McCoy D et al (2003) Health Personnel in Southern Africa: Confronting Maldistribution and Brain Drain, Equinet Discussion Paper no 3, Equinet
• Ntuli A, Ijumba P, Padarath A. (2003) HIV/AIDS and health sector responses in South Africa – Treatment, Access and Equity: Balancing the Act, Equinet.
• Padarath A, Berthiaume B (2003) Health Care: A Right and a Responsibility, Literature Review commissioned by Soul City.
• Ntuli A, Khosa S, McCoy D. The Equity Gauge Durban : Health Systems Trust, 1999

Keywords	This Item is associated with the Following Keywords: Equity.
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