1. WWW.EQUITABLEPROJECT.ORG PROF. MALCOLM MACLACHLAN EQUITABLE PROJECT MANAGER MLACHLAN@TCDC.IE DR. HASHEEM MANNAN EQUITABLE SENIOR RESEARCH FELLOW MANNANH@TCD.IE MS. JOANNE MCVEIGH EQUITABLE RESEARCHER JMCVEIGH@TCD.IE EquitAble and the EquiFrame manual EquiFrame: A Framework for the Analysis of Human Rights and Vulnerable Groups in Health Policies

2. How Can a University Change the World? The Power of ideas can transform the ideas of Power Frenk, 1995 EquitAble and the EquiFrame manual Policies should be written for all but should be sensitive to different types of need To promote Health for All, focus on equitable health care rather than equal health care Marginalized, discriminated groups bear a disproportionate share of health problems States must recognize specific needs of groups that confront particular challenges through disaggregation of health policies

3. Project EquitAble o FP7 funded, 4-year collaborative research project; researchers from Ireland, Norway, Sudan, Namibia, Malawi & South Africa o Led by Centre for Global Health, Trinity College Dublin o Produce empirical knowledge on health care access for vulnerable people in resource poor settings in Africa o 5 Work Packages:

4. EquiFrame o Novel policy analytical framework; assesses human rights and social inclusion in health policies o Assesses policy content or ‘policy on the books’ o Identifies degree of commitment of a health policy to 21 Core Concepts of human rights and 12 Vulnerable Groups, underpinned by ethos of universal, equitable and accessible health service provision o Particular focus on persons with disabilities (outlined in EquiFrame as a vulnerable group) o 70 health policies analyzed in total o 4 target countries: Sudan, Malawi, Namibia, & South Africa: 51 health policies

5. Impetus Prevailing focus on process of health policy development; A paucity of literature that outlines an analytical framework to analyze ‘policy on the books’ Many health policy practices developed and researched in higher income countries and subsequently transferred to low- and middle-income (LMIC) countries; Variability of context makes generalization problematic EquiFrame: A framework to guide policy analysis in terms of ‘policy on the books’ and doing so from a LMIC perspective

6. Country Profiles Sudan – Large proportion of population displaced Malawi – Chronic poverty and high disease burden compete for meagre resources Namibia – Population highly dispersed South Africa – Despite relative wealth, universal and equitable access to health care not yet attained

7. Development. Literature Searches/ Discussions Initial Ideas Project Meeting Khartoum Draft Framework Consultation Workshops Revised Framework Analysis of 70 Health Policies Results Feedback workshops Conference Presentations EquiFrame Universal, Equitable, Accessible Health Services

8. Core Concepts 1.Non-discrimination 12.Contribution 2.Individualized services 13.Family resource 3.Entitlement 14.Family support 4.Capability based services 15.Cultural responsiveness 5.Participation 16.Accountability 6.Coordination of services 17.Prevention 7.Protection from harm 18.Capacity building 8.Liberty 19.Access 9.Autonomy 20.Quality 10.Privacy 21.Efficiency 11.Integration

9. Vulnerable Groups

10. Core Concept Quality Each Core Concept received a rating of quality of commitment to Core Concept within the given policy document Score on continuum of 1-4: 1. Concept only mentioned 2. Concept mentioned and explained 3. Specific policy actions identified to address Concept 4. Intention to monitor Concept expressed

11. Summary Indices 1. Core Concept Coverage Number of Core Concepts mentioned out of 21 Core Concepts 2. Vulnerable Group Coverage Number of Vulnerable Groups mentioned out of 12 Vulnerable Groups 3. Core Concept Quality Number of Core Concepts rated as 3 or 4 (stating a specific policy action or intention to monitor action) out of 21 Core Concepts 4. Overall Summary Ranking (i) High = policy achieved ≥50% on all of three indices above (ii) Moderate = policy achieved ≥50% on two of three indices above (iii) Low = policy achieved<50% on two or three of three indices above

12. Common Health Policies PolicyMalawiNamibia South Africa Sudan 1HIV AIDS PolicyHighModerateHighLow 2Disability PolicyModerate Low 4Tuberculosis PolicyModerate Low 3Mental HealthModerateHighModerate 5MalariaLow 6National Health policyLow High 7Reproductive Health PolicyLowModerate 8Drug/medication PolicyModerate Low 9Gender Policy High Low EquiFrame: can provide both within and across country comparative analysis of health policies in terms of Core Concepts of human rights and inclusion of Vulnerable Groups

13. Disability Policy PoliciesVG%CC% % of CC quality between 3 to 4 Overall Quality Namibia National Policy on Disability 58%95%43%Moderate South Africa the National Rehabilitation Policy 41%47%19%Low Malawi National Policy On Equalisation Of Opportunities For Persons With Disabilities 17%57%67%Moderate Sudan National Disability policy 42%62%24%Low

14. EquiFrame Findings 51 policies analyzed across Namibia, Sudan, South Africa & Malawi: o Most frequently mentioned Vulnerable Groups across Disability, TB, HIV/AIDS policies: Disabled persons, Suffering from chronic illness, and Youth internal validity of EquiFrame methodology o All Core Concepts mentioned in at least one policy analyzed across project countries construct validity of categories used o 4 countries had policies scored High, Moderate and Low; each country differed in proportion of policies falling in each range o Some very strong policies, serious shortcomings in others & country-specific patterns o Health sectors of each of these states face significant challenges in addressing inequities found to be present within a number of current African health policies

15. Project EquitAble Strategic Impact o Provide better understanding of universal access to health care and provide an invaluable resource for health systems and policy decision makers working to meet universal access to health care, by setting out clear evidence base for proposed actions o First known study to address this wide a range of vulnerability factors within a single data-gathering model Measuring disability in context of other vulnerability factors may assist in disability mainstreaming in public health planning/delivery, and in appreciating that disability frequently interacts with other marginalizing factors to doubly disadvantage people with activity limitations o Collect data from contexts where we have little information Useful for health care systems and disability sectors in Africa & EU aid programmes for developing countries

16. Extensive gap in access to health care between disparate groups in low as well as high-income countries well established Equity in health care is an astute and feasible political aspiration If human rights and social inclusion do not underpin policy formation, it is unlikely that they will be inculcated in service delivery Through its discernment of policy commitment to human rights and vulnerable groups, EquiFrame, devised under Project EquitAble, stands to promote the United Nations directive of ‘health for all’, with its implicit assumption of universal and equitable access to health care. There is nothing more unequal than the equal treatment of unequal people Thomas Jefferson

17. Sources Project website: www.equitableproject.org Manual: Freely downloadable peer reviewed EquiFrame manual, available on project website Papers currently in press: Amin et al. (2011). EquiFrame: a framework for analysis of the inclusion of human rights and vulnerable groups in health policies. Health & Human Rights (in press). Mannan et al. (2011). Core Concepts of human rights and inclusion of vulnerable groups in the disability and rehabilitation policies of Malawi, Namibia, Sudan and South Africa. Journal of Disability Policy Studies (in press).