Session 5.3 – Equitable Priority Setting in Developing Countries
Thursday October 30 15:30-17:00
Inequity Among the Poor: Evidence on a Socioeconomic Gradient in Perinatal Mortality and Low Birth Weight in Northeast Tanzania. Challenges for Equitable Priority Setting
(Abstract 0137)Ingrid Holen Olsen1, Rachael Manongi2, Rolv Terje Lie1, Ole Frithjof Norheim1
1University of Bergen, Norway, 2Kilimanjaro Christian Medical Center, Tanzania, United Republic of
Background: Annually 6.3 million children die in the perinatal period and over 20 million are born weighing less than 2500 grams. Perinatal mortality and low birth weight are important causes of disease burden in low-income countries. To be able to reach Millennium Development Goal number four, perinatal mortality and low birth weight need to be addressed. However, more knowledge is needed about the distribution of these health outcomes.
Objective: To quantify the degree of inequality in perinatal mortality and low birth weight in a referral hospital in Northeast Tanzania according to socioeconomic gradient.
Methods: Through the birth registry at Kilimanjaro Christian Medical Center data on perinatal mortality and low birth weight were collected. Additional data on socioeconomic status of the household were collected over a period of four months. The Adult Mortality and Morbidity Projects’ consumption/expenditure per adult equivalent model was used to estimate socioeconomic status. The Concentration index was used to measure social group health inequalities for the two health variables perinatal mortality and low birth weight.
Results: The degree of inequality in perinatal mortality and low birth weight will be reported. The distribution of the health variables according to socioeconomic status is clearly unequal and comparable to other studies.
Policy Implications: The degree of inequality in perinatal mortality and low birth weight highlights two important policy questions:
1. Should women from poor households be targeted for priority interventions in antenatal and obstetric care?
2. Should policies aim at reducing inequalities in socioeconomic status between households?
Fairness in the Selection of Patients for Anti-Retroviral Treatment in Uganda: A Qualitative Study
(Abstract 0059)Neema Sofaer1, Lydia Kapiriri2, Lynn M. Atuyambe3, Erasmus Otolok-Tanga3, Ole Norheim1
1Imperial College, United Kingdom, 2University of Toronto, Canada, 3Makerere University, Uganda, 4University of Bergen, Norway
Objectives: To evaluate the selection of patients for Anti-Retroviral Treatment (ART) in Uganda.
Methods: 39 interviews with 41 adults with various roles in selecting patients for ART in hospitals, NGOs, research centers and the Ugandan Ministry of Health. Five focus groups comprising 47 adult HIV/AIDS patients, mostly on ART, at a hospital and NGO. Selection decisions were evaluated using Accountability for Reasonableness (A4R). A4R considers a decision fair and legitimate if, and only if, those whom it affects can know the decision and its rationale (Publicity), they can consider the rationale relevant (Relevance) and can appeal against the decision (Appeals), and each of these three conditions – Publicity, Relevance and Appeals – is enforced (Enforcement).
Results: Publicity: all patients were told whether, and most were told why, they could (not) receive ART. Institutions employed various means to ensure candidates understood decisions and rationales. Relevance: most rationales could be considered relevant by professionals and patients; a few were of questionable relevance. Appeals: Many patients identified appeals mechanisms, but professionals and patients agreed decisions are unchangeable. Patients deferred to professionals, who endorsed and thought they should enforce criteria. Enforcement: although criteria were enforced, there was insufficient enforcement of Publicity and Relevance, and none of Appeals.
Conclusion: Decisions lack fairness and legitimacy. Effective means for appeals and enforcement should be created. Nonetheless, decisions are fair insofar as they and relevant rationales are communicated, and criteria are applied universally. Such aspects of selection are a benchmark for less transparent or even-handed allocation reported elsewhere.
The Gap Between Policy and Implementation in the Provision of New Malaria Drugs in Tanzania: Implication of Social Justice in the Provision of Health Care
(Abstract 0128)Emmanuel Makundi1, Ole Frithjof Norheim1
1Department of Public Health and Primary Health Care- University of Bergen, Norway, 2Centre for International Health- University of Bergen, Norway, 3National Institute for Medical Research, Tanzania, United Republic of
Background: Artemisin based Combination Therapies (ACTs) for the treatment of malaria was recommended and introduced in Tanzania in 2007. ACTs seem to be the best hope for malaria treatment as they are the most efficient anti-malarias available now. However, the cost of new drugs is high compared to other previously used therapies. There have been few studies showing whether poor people in malaria-endemic resource poor settings can access and afford such drugs.
Objectives: To describe the current process of allocating ACTs in Tanzania, and evaluate it according to accessibility and affordability criteria.
Methods: A case study involving data collection through in-depth interviews. Mbarali district was selected on a basis a typical Tanzanian district implementing malaria interventions. Study population included policy makers, health workers and mothers of children under five years of age who have just suffered from malaria in the past one year. Data was analysed thematically according to the themes of access and affordability.
Findings: A majority of poor women at household levels described barriers to access and reported that they could not afford the new drugs for their children even though such drugs are already subsidised at public facilities at Tshs 2400 per dose. The same drugs cost Tshs 12,000 at private drugs shops.
Policy Implications: High prices of ACTs, even when subsidized, act as impediments to access for poor people in malaria-endemic resource poor settings. The paper discusses whether equitable priority setting requires other ways of introducing this treatment modality in Tanzania.
Response to Accountable Priority Setting for Trust in Health Systems
(Abstract 0151)Yeri Kombe1, James Muttunga1, Isaac Nyamongo2, Onyango Ouma2, Peter Kamuzora3, Leonard Mboera4, Elisabeth Shayo4, Benedict Ndawi5, Gavin Silwamba6, Charles Michelo6, Thabale Ngulube7, Mary Tuba7, Anna-Karin Hurtig8, Bruno Marchal9, Astrid Blystad10, Knut Fylkesnes10, Jens Byskov11, Paul Bloch11, Oystein Olsen11, Douglas Martin12
1Centre for Public Health Research, Kenya Medical Research Institute, Kenya, 2Institute of African Studies, University of Nairobi, Kenya, 3Institute of Development Studies, University of Dar Es Salaam, Tanzania, United Republic of, 4National Institute for Medical Research, Tanzania, United Republic of, 5Primary Health Care Institute, Tanzania, United Republic of, 6Department of Community Medicine, University of Zambia, Zambia, 7Institute of Economic and Social Research, University of Zambia, Zambia, 8International School of Public Health, University of Umea, Sweden, 9Institute for Tropical Medicine, Belgium, 10Centre for International Health, University of Bergen, Norway, 11DBL-Centre for Health Research and Development, University of Copenhagen, Denmark, 12Joint Centre for Bioethics, University of Toronto, Canada
Efforts to improve health sector performance in resource poor countries have not yet been satisfactory and adequate and sustainable improvements of health outcomes have not been shown. Current priority setting in health systems do not equip decision makers to address a broader range of values that are of concern to all partners in health development and not least to the populations concerned.
The objectives of the study are to describe and evaluate district-level priority setting, to develop and implement improvement strategies guided by an explicit ethical framework and to measure the effect on quality, equity and trust within selected disease and programme interventions and services, within general care and on health systems management.
Accountability for Reasonableness (AFR) is a framework for legitimate and fair priority setting that provides decision makers with an explicit tool to identify and consider a wide range of relevant values, and priority setting decisions as necessary compromises between partners.
REACT is the title acronym for a 5 year intervention and action research study testing the application and effects of the AFR approach in one district in Tanzania, Kenya and Zambia. Qualitative and quantitative methods are applied in an action research design.
The project baseline surveys indicate both a strong need and a high willingness for change in the study districts. An increasing range of actors including the communities are becoming involved.
Results are expected to lead to changes in policies for priority setting in health systems.