Towards Equity in Health: Some Key Issues Presentation to the Health Portfolio Committee of the National Assembly June 14th 2005 Antoinette Ntuli Director, HealthLink and Chair of the Global Equity Gauge Alliance Co-ordinating Committee

Key Areas of Work Second Equity Gauge: monitoring determinants of health, including health system Treatment Monitor: monitoring and research to improve access to ART HIV Gauge: monitor access to ART through strengthening community empowerment Equitable Distribution of Human Resources for Health: research and policy dialogue within SADC

Socio-economic Determinants of Health Household access to flush toilets between 1996 & 2001 Source: Census 2001, Statistics South Africa, 2003

The Second Equity Gauge Access to flush toilets: Only increased by 1% nationally in five year period Some provinces access is as low as 16% Chronic diarrhoea cited as most difficult condition to deal with by families caring for a member with AIDS Those who are the hardest hit by HIV are also the most underserved in terms of basic services

The Second Equity Gauge Conclusions State’s move from being a ‘provider’ to being an ‘enabler’ can compromise equity objectives Easier and cheaper to provide services in urban areas Cost-recovery paradigm directly linked to outbreak of cholera, use of dangerous energy sources resulting in fires Further Action Strengthen links with Trade and Finance Portfolio committees Participation in SEAPACOH

Treatment Monitor Source: HST HAART Database & NDoH

Treatment Monitor Source: HST HAART Database & NDoH

Treatment Monitor Public sector: est. 52 000 Private sector: est.42 000 Non-profit Sector: est. 12 000 – 50% double counted with public 100 000 out of 750 000 who need ART now are receiving (14%) Key Findings Implementation is most successful where civil society is strong and involved Access to information assists civil society to develop a coherent response Further Action Encourage Provincial openness in activities, strengths and weaknesses Assist development of stronger civil society approach to supporting implementation of the Operational Plan

The HIV Gauge Rationale: foster community participation in health and present picture of urban rural differences Development of a Community based M&E tool (3 languages) for national use. Initial Findings Fear Concerns about continuity of supply Concerns about insufficient resources Stigma Transport costs Food Poverty Generation Gap Access to information

The HIV Gauge National Health Act Further Action Promote community participation in the planning provision and evaluation of health services (s21h and s25(2)t) S 42 Provincial legislation to provide for establishment and functions of clinic committees / community health centre committees (to include community members) Further Action Oversight of Act, specifically enactment of Provincial legislation re: clinic committees Request regular feedback from Provinces on community involvement

Equitable Distribution of HRH Financial Aid from the ‘South’ to the ‘North’ 600 SA Doctors in New Zealand and cost to the country is estimated to be R600m Estimating the cost of training a GP in the SADC Region to be $US60 000, then it can be assumed that there is a reverse subsidy from the developing world of $500m per annum for health personnel alone UNCTAD estimates that US$184,000 is saved in training costs per professional and that US saved US$3.86 billion as a result of importing 21 000 Nigerian doctors Impact is financial and non-financial on donor and recipient countries and on health personnel themselves There are 600 South African doctors registered to practice in New Zealand. The estimated cost to the South African taxpayer is in the region of R600 million (Bundred and Levitt, 2000) The costs of training in the face of depleting government coffers, is prohibitive. In Zimbabwe for example, the cost of training a registered nurse for a 3-year period amounted to US$8,200 in 1998. The annual expenditure on training nurses in Zimbabwe is estimated to be in the region of US$ 2.7 million (USAID, 2003:6) If it cost approximately US60 000 to train a general practitioner in the SADC, then it can be assumed that the developing world is subsidising the developed world to the amount of $500million per year. ( Frommel.newspaper article) Meeus and Sanders – savings over an eight year period

Policy evidence of rich countries planning to utilise HR from South Equitable Distribution of HRH Policy evidence of rich countries planning to utilise HR from South Poor planning - USA will require 1m additional nurses in the next ten years to meet its shortfall and by 2010 a quarter of UK nurses will be over 60 Some evidence that this is a deliberate strategy to acquire “cheap labour”

HRH Flows The flows follow a hierarchy of ‘wealth’ resulting in a global conveyor belt of health personnel moving from the bottom to the top, increasing inequity Urban poor developing country public sector Urban poor developing country private sector Less poor developing country health sector Rich country health sector Rural poor developing country public sector Primary level public sector Secondary and tertiary level public sector Figure 1: Pattern of movement and migration of health personnel

Equitable Distribution of HRH ‘Knock-on’ Costs Negative effect on overall functioning of health systems Loss of institutional memory Unmanaged disease burdens Costs to households of seeking care at higher levels

Equitable Distribution of HRH Key Findings Migration – fuelled by poor retention and globalisation Perverse Subsidies Further Action Support for restitution Push to fulfill Abuja Declaration commitments of 15% Support for Health Workers for improved conditions

Conclusions ‘Back to basics’ – importance of the public sector Increased civil society engagement Ongoing monitoring of equity