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INDEPTH HEALTH EQUITY PHASE II WORKSHOP VENUE: La Palm Beach Hotel - Accra Ghana DATE: 6th January - 10th January, 2003
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Report prepared by Ayaga A. Bawah
The workshop began on Monday, January 6, 2003, at 8.30 am. After welcoming the participants and facilitators, the Executive Director (ED) of the INDEPTH-Network, Professor Fred N. Binka, asked both participants and the facilitators to introduce themselves (participants list attached in Appendix). After the introductions, Prof. Binka gave a brief introductory statement enumerating the background to the current workshop on Equity Phase II. He noted that Equity Phase I reports indicated clearly that there were inequalities in health among population groups in Africa and Asia and that the burden of disease and poverty was particularly high among the poorest populations in these areas. There was therefore, the need to move beyond the Phase I work and begin to think of ways to address these issues. He also noted that there was the need to develop a tool that would allow sites to monitor and measure health inequalities in the various countries. After wishing participants useful deliberations, he called on Dr. Bawah to make a presentation on the objectives and expected outcomes of the workshop. Below are the objectives and expected outcomes outlined:
Objectives of Workshop
• Develop a portfolio of intervention research that INDEPTH sites could undertake to reduce health inequalities. This research could help us understand how well interventions reach disadvantaged groups for little is known as to what works in reducing inequalities.
• Some sites are already collecting or are in the process of collecting data to evaluate intra-population group inequalities over time. These could serve as excellent starting points for measuring already existing intervention programs towards the realization of health equity and enhancement for the most deprived population groups in Africa and Asia.
• Provide an avenue for continuous monitoring of health and socio-demographic outcomes and distribution of health infrastructure and/or resources among and within population groups in INDEPTH member sites. This will allow the sites to serve as monitoring centers for progress toward the Millennium Development Goals (MDGs).
• INDEPTH sites are well placed to carry out this kind of research given their unique advantage of monitoring populations over time.
• Develop strategies to manage health inequalities among population groups. For example, how do we manage programs such as micro credit facilities optimally in order to enhance the health status and well-being of vulnerable populations?
• For sites which are already doing some of this work, it would be interesting to evaluate the extent to which set objectives are being achieved and what beneficial lessons could be learnt in order to strengthen work at other sites.
• Finally, to encourage and support sites involved in the network to develop core indicators for collecting data that would allow for the measurement of health and wellbeing of populations within the member sites.
Expected Outcomes • Develop a prototype protocol for understanding health equity. It may be useful to conceive of intervention projects; where sites are already undertaking intervention projects, a protocol could be developed to evaluate their impacts
• Where there are no intervention projects, we could think of ways to implement some intervention projects that could lessen the burden of the poor
• The protocol would indicate core indicators agreed upon by participants. Site- or region-specific modules would also be discussed, especially in cases where a subset of sites from the same geographical or ecological zone agree to have a regional module
• Discuss strategies for developing a wealth indicator which may form the basis for measuring health inequalities among population groups
• Agree upon a timetable for implementing the health equity studies and for evaluating the possible outcomes of interest
After discussion of the objectives and Expected Outcomes, the two facilitators, Dr. Davidson Gwatkin of the World Bank and Dr. Saul Morris from the London School, gave separate presentations. Dave’s presentation was titled “Strategic Options for Future INDEPTH Equity Activities,” focused mainly on interventions and the options that are available to the INDEPTH-Network. His presentation gave insights to research currently going on in different parts of the world on Equity. He articulated clearly the current thinking in this area, and gave examples of what research interventions that have been done and the role the INDEPTH-Network can play in extending the frontiers of such research in order to lesson the burdens of the poor in society.
On the other hand, Saul gave two separate presentations focused mainly on measurement issues and tool development. The first presentation focused on “Measurement of Socio-Economic Status” and the second looked specifically a tool that has been developed by IFPRI/CGAP for measuring socioeconomic status. In the first presentation, he gave an overview of the conceptual difficulties in defining poverty or socioeconomic status and provided insights from different perspectives albeit those of economists and those of sociologists or other social scientists. He noted that because of these conceptual difficulties, it is often difficult to measure poverty or develop an index that will cover all facets of the problem. While recognizing the difficulty of having a comprehensive index that will capture the facets of poverty, he noted that the index developed by IFPRI/CGAP seem to be the most comprehensive so far in the. In the second presentation, he then focused on the IFPRI/CGAP Experience. He listed the input variables that go into developing the index. These range from basic demographic variables such as age and sex, to variables on food security (See Appendix for presentations). He noted the difficulty of collecting data on some of the variables and recommended some modifications for collecting some of data.
Discussing in details of variables included in the IFPRI/CGAP method, Saul noted the conceptual and practical difficulties of collecting information on some of the variables. He recognized the existence of other approaches such as the type the DHS surveys have been using and other non-conventional methods based on socioeconomic status variables. He also mentioned a method being pioneered by the AMMP in Tanzania based on income/expenditure approach. He argued that the method the INDEPTH-Network would ultimately adopt will depend the types of data the sites have or will be in a position to collect and how comprehensive the Network will like its measure to be. While recommending the IFPRI/CGAP approach if a comprehensive index is desired, he also noted that he does not wish to impose on sites a particular approach, especially for those sites that are already in the forefront of index development using alternative approaches, such as for example, the Tanzania case.
At the end of the discussions, there was unanimity that there is the need to have a comprehensive measure and participants agreed to adopt the IFPRI/CGAP approach with some modifications. Saul indicated that if INDEPTH-Network decides to go along with the IFPRI/CGAP approach, there will be the need for some of the sites to revise the way the type of data. He noted that sites such as Navrongo might have to start collecting data at the household level as opposed to the current situation where data is collected at the compound level. This, he observed may be a major undertaking.
As to whether there was the need to collect information on food security, one of the variables which go into the development of the index, Saul articulated the conceptual arguments for the food security question. He noted that it was the most dynamic variable and reflects transitory variations in income. On the other hand, he recognized the difficulties inherent in collecting information on food security. In the end, the participants agreed that there was the need to collect information on food security with some modifications to the questions. On assets, there was a debate as to whether there was need to ask of value. Eventually, there was an agreement that there was no need to ask about value. It was agreed that sites should pilot test the feasibility of collecting data on clothing ad footwear.
Site specific presentations were also made on ongoing interventions or possible areas of interventions. The presentations focused on the following broad areas…HIV/AIDS, Malaria, Health impact of non-Health Interventions, Community Health Insurance and Safe motherhood. Majority of the presentations rather dwelled on what the sites are doing rather than articulating what could be done or what interventions that are currently going on in their areas or countries that could be modified such that they would be much more pro-poor. Dave urged participants to think creatively about innovative intervention research that could be done. He noted that sites could also think about existing interventions that could be evaluated in order to provide direction for improvement. Can we think of experimenting with new approaches that government officials are thinking of introducing on a large scale that we can try in a pilot scale? Saul noted that it is important to identify who the poor are, which he argued is not a trivial matter, in order to make sure the services are reaching the right people.
On the proposed areas of possible research, it was agreed that the network conduct innovative research to “SHOW HOW WELL INTERVENTIONS COULD BE DESIGNED TO REACH THE POOR OR DISADVANTAGED GROUPS.” These could either be impact or incidence research. In other words, the proposed research could either aim at doing incidence analysis of existing interventions being implemented by government or NGOs, or sites could propose new interventions designed in a controlled manner or evaluate their impact on the poor and other vulnerable groups. Sites could also propose to modify already existing interventions in a research setting to demonstrate how the said intervention could reach the poor better. Preference will be given to proposals in the following five main areas.
Under each of the five main topics, priority will be accorded to areas outlined under each topic.
HIV/AIDS 1. Voluntary Counseling and Treatment 2. Behavioral Change Communication 3. Ante-Retroviral Therapy 4. Condom promotion 5. Family life Education
MALARIA
SAFE MOTHERHOOD
HEALTH IMPACT OF NON-HEALTH INTERVENTIONS
COMMUNITY HEALTH INSURANCE
Returning to the question of food security, which was recognized as one major area of great importance, Dr. Eleuther Mwageni of the Rufiji site shared with the group their experience in research under way in food security at their site. He noted that information is being/to be collected in the following areas:
• Household level information • Consumption – Number of meals per day – Composition of main meal – Source of food • Production • Major Inputs • Land Assets • Issues related to nutrition Other issues he mentioned being considered are relate to contextual issues. Under the contextual issues, he noted the following areas:
– Climatic changes – Markets – Biotic conditions – Cultural events
It was agreed that the proposed research could stratify on the following variables.
1. Gender 2. Race/Ethnicity 3. Socioeconomic position 4. Religion
Any analysis based on socioeconomic position should use standardized methods such as the IFPRI/CGAP method or the Predicted income or expenditures methods based on appropriately selected proxy variables
The last two days of the workshop were focused on a discussion of the phase I reports and strategies to develop these into a Health Equity monograph. The two facilitators who happen to be the reviewers of the first phase reports gave their general comments of the reports and later more focused site-specific discussions were held with the authors. A timetable was agreed upon for finalizing the reports for the monograph. A set of guidelines were also agreed upon for guiding authors to organize the reports into publishable papers.
The meeting was drawn to a close on Friday, January 10, 2003, with an outline of the next steps for Equity Phase II…
The INDEPTH-Secretariat will put up a call first for letters of intent in each of the main areas identified to be followed by calls for full proposals. Proposals would be considered if three or more sites are interested in a particular theme topic. The secretariat will go ahead to put up the call for proposals if enough interest is expressed through the letters of intent by February 3, 2003. Or else, this could be extended to the end of February. The network will attempt to bring together sites with common to dialogue with other implementing agencies or experts in those areas so as to help improve on the design and outcomes of studies. Proposals developed would be reviewed and strategies adopted to fund proposals will be set in motion to get sites to implement the proposed studies. The tool development will be an integral part of the intervention studies. However, a few sites may be assisted to help develop these tools. Funds for these cases will be small funds but still competitive and strategic decisions will have to be made.
Prof. Fred Binka at this stage gave his concluding remarks. He noted that the workshop has been a success and expressed his gratitude to all participants for making it to the workshop despite the short notice. He was particularly thankful to the two facilitators, Dr. Dave Gwatkin and Dr. Saul Morris for agreeing very short notice and at the expense of their busy schedules to come and participate in the workshop. He also expressed his appreciation to Dr. Patrick Naidoo of the Rockefeller Foundation adding “am sure you listened to the deliberations with keen interest and am sure this might generate your interest in some of the areas that we could work together.” Finally, he expressed his appreciation to Dr. A. Bawah (Navrongo) and Titus Tei of the Secretariat for their immense assistance in helping to get everything together.
Appendixes
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