1. 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

2. 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

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

4. 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

5. 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

6. Treatment Monitor
Source: HST HAART Database & NDoH

7. Treatment Monitor
Source: HST HAART Database & NDoH

8. Treatment Monitor Public sector: est. 52 000
Private sector: est
Non-profit Sector: est – 50% double counted with public
out of 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

9. 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

10. 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

11. 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 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$8,200 in The annual expenditure on training nurses in Zimbabwe is estimated to be in the
region of US$ 2.7 million (USAID, 2003:6)
If it cost approximately US 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

12. 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”

13. 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

14. 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

15. 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

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