AFRO-NETS> Greater Equity in the Fight against HIV/AIDS, Malaria, and Tuberculosis

[Hilary Brown <hbrown@rockfound.org>]

Greater Equity in the Fight against HIV/AIDS, Malaria, and Tuberculosis
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I am writing to request that a statement emerging from a workshop ti-
tled, "Working towards Greater Equity in the Fight against HIV/AIDS, 
Malaria and Tuberculosis" be posted. This workshop was organized by 
the Rockefeller Foundation, in collaboration with the World Bank and 
the World Health Organization. The impetus for this workshop grew out 
of the recent heightened attention to HIV/AIDS, malaria and tubercu-
losis and the mobilization of dedicated programs and financial re-
sources to control these diseases. The discussions of the workshop 
focused on the need to both modify the inequitable patterns of dis-
ease risks and consequences and to pursue aggressively a more equita-
ble distribution of benefits from programs working to fight these 
three diseases. 

Kind regards, 
Hilary Brown 
The Rockefeller Foundation 
Program Coordinator 
mailto:hbrown@rockfound.org


--
WORKING TOWARD GREATER EQUITY IN THE FIGHT AGAINST HIV/AIDS, MALARIA, 
AND TUBERCULOSIS

Statement by Participants in a November 2001 Bellagio Workshop

Organized by the Rockefeller Foundation in collaboration with the 
World Bank and the World Health Organization


The growing efforts to combat HIV/AIDS, malaria and tuberculosis have 
the potential to bring major benefits to the disadvantaged, as well 
as produce an important reduction in overall disease burden. However, 
realizing this potential and securing better health among less fa-
vored populations will require a determined effort. There is need 
both to modify the inequitable patterns of disease risks and conse-
quences and to pursue aggressively a more equitable distribution of 
benefits from programs dealing with HIV/AIDS, malaria and tuberculo-
sis. 

The evidence base for this conclusion, although not complete, is 
nonetheless compelling: 

For HIV:
* Amongst teenagers in Kenya, HIV prevalence in 1999 was five to six
  times higher for girls than boys. 
* Both men and women from a wide range of African countries who have
  completed secondary school are two to three times more likely to
  use a condom with a casual sex partner than are those who have not
  yet finished primary school.

For Malaria:
* The proximity of urban slum dwellers to mosquito breeding sites
  leads to excessive rates of child death from malaria.
* In parts of rural Tanzania, the children from the richest fifth of
  the population are twice as likely to receive appropriate antima-
  larial treatment than those from the poorest fifth of the popula-
  tion.

For Tuberculosis:
* The cost of transport required to access test results for tubercu-
  losis is 2-3 times the average wage of a day labourer in peri-urban
  Malawi. 
* Poor households in Nairobi spend a disproportionately greater per-
  centage of their household income on TB treatment compared to rich
  households.
* Prevalence of tuberculosis in the Philippines is 5.5/1,000 amongst
  the urban poor compared to 3.5/1,000 amongst the urban non-poor. 

Apart from the inherent concern for such inequalities, other consid-
erations reinforce the need for a sharp focus on inequities. Indeed, 
where the burden of severe disease is so heavily concentrated among 
the excluded and marginalized, as in the cases of malaria and tuber-
culosis, considerable overall reductions can only be achieved by 
reaching out to these groups. However, there is growing evidence that 
this is not happening; in the case of HIV/AIDS both HIV behaviour 
change prevention and AIDS treatment programs are beginning to reach 
the better off in developing countries more rapidly and completely 
than the poor. In addition, one cannot expect to deal effectively 
with HIV/AIDS without addressing issues of gender inequalities that 
play a major role in its spread. If communicable disease programs can 
move towards effective coverage and treatment of marginalized popula-
tions, there will be benefits of reduced residual risk of infection 
for the entire population. Conversely, low adherence to DOTS therapy 
for TB may accelerate the emergence of difficult to treat multi-drug 
resistant tuberculosis. Looking ahead, preparing the ground now for 
more equitable distribution and access to health care services will 
help to ensure that new and lower cost technologies, eg: HIV/AIDS, 
malaria and TB vaccines, drugs and microbicides, attenuate rather 
than accentuate disparities. 

The challenge, therefore, is how to integrate equity considerations 
more effectively into important initiatives for HIV/AIDS, malaria and 
TB, while maintaining or enhancing the initiatives? capacity to re-
duce overall disease burden. This workshop reviewed encouraging evi-
dence of several approaches that suggest the potential to go to scale 
while reaching poor and underserved populations: from integrated, 
gender-based approaches to TB control and health promotion by non-
governmental organizations in Bangladesh, to large-scale condom pro-
motion in Africa, and striking new evidence of the equity-enhancing 
effects of social marketing for insecticide-treated bednets in Af-
rica. 

The amelioration of current inequities is the responsibility of eve-
ryone concerned with development and health activities at the global, 
national, and local levels. A particular responsibility resides with 
those providing and receiving resources for HIV/AIDS, malaria, and TB 
initiatives in the name of alleviating poverty. They will wish to 
learn from the experience of the past: that vague, general mission 
statements about serving the poor are not sufficient. Rather, there 
is a need for carefully-designed and vigorously-implemented ?pro-
poor? actions that produce results. Deliberate, concerted and sus-
tained actions are required in the following general areas:

* Programs must specify distributional goals and objectives, that
  constitute the basis of rigorous performance management;
* Resources must be focused geographically and functionally on pro-
  grams and initiatives that are most likely to achieve maximum
  health benefits among poor and otherwise marginalized populations;
  and
* Greater efforts must be made to ensure the information base for 
  equity-focused performance management and resource allocation.

The attached list provides illustrations of the many actions that can 
be undertaken to work towards greater equity in HIV/AIDS, malaria and 
TB programs. The organization of the list reflects a conscious effort 
to avoid an inventory of disease-specific opportunities to redress 
inequities. The broad areas for engagement are indicative of the im-
perative to integrate efforts alongside broader health systems devel-
opment objectives. There is a pressing need to begin implementing 
these actions as quickly as possible.

--
Initial Actions to Enhance the Equity Dimension of HIV/AIDS, Malaria, 
and Tuberculosis Programs

Global Actions

Goals: 
Establishing HIV/AIDS, malaria, and TB goals from an equity perspec-
tive in order to focus attention on those groups which are dispropor-
tionately infected and affected by these diseases. For example that 
by 2010 in all of the 22 countries with high TB prevalence, the case 
detection and DOTs treatment rates are at least as high among the 
lowest income quintile as among the highest quintile. This approach 
would greatly benefit the health objectives appearing in documents 
such as the Millennium Development Goals and the Poverty Reduction 
Strategy Papers, prepared by country governments for discussion of 
possible debt relief with the International Monetary Fund and the 
World Bank. 

Resource Allocation: 
Applying clear equity criteria in allocating resources from programs 
like the Global Fund for AIDS, Tuberculosis, and Malaria, the World 
Bank, and other international and bilateral funding agencies. This 
means not only allocating the maximum possible amount of resources to 
poor countries, but also seeing that those resources flow to poor ar-
eas and groups within countries.

Research and Development: 
Focusing research and development activities on technologies that 
have the potential to overcome constraints in reaching the neediest 
groups. Such research development priorities might include: simple 
and rapid diagnostic tools for malaria, TB, STIs and HIV, new and im-
proved prevention technologies such as microbicides and long-lasting 
insecticide-treated nets and simplified drug regimes with increased 
dosing intervals to facilitate long-term adherence (e.g. HIV/AIDS 
and TB). 

Regional, National and Local Actions

Performance Management: 
Developing equity-oriented baseline and progress assessments to moni-
tor the impact of programs, policies, and delivery systems rather 
than relying solely on simple averages for society as a whole. For 
example, the impact of primary prevention efforts for HIV can be as-
sessed according to variations in HIV infection, individual knowledge 
of disease risk factors and access to prevention technologies by 
level of education, sex, occupation and area of residence. This in-
formation can be used as baseline data against which to conduct an 
impact assessment focused on how well interventions reach the disad-
vantaged.

Targeting Program Resources: 
Increasing the proportion of total program benefits that go to the 
excluded and marginalized by promoting interventions that focus on 
the disadvantaged. These include programs that subsidize access to 
health products and services for the excluded, outreach services in 
poor neighborhoods, and behaviour change communications that are de-
signed with and for the most marginalized groups. For example, in The 
Gambia a targeted bednet program resulted in an improvement in health 
equity; parasitaemia in poor children fell from 63% to 40%, and from 
35% to 31% among wealthier children. To meet better the challenges of 
targeting, the health sector could usefully draw on the techniques 
employed and experience gained in other development sectors (e.g.: 
social-safety nets).

Financing: 
Modifying financing systems to enhance the benefits flowing to disad-
vantaged groups suffering from HIV/AIDS, malaria and tuberculosis. A 
range of equity-enhancing financing mechanisms might be considered 
including: (1) community-based insurance programs that protect poor 
households from the impoverishing impact of catastrophic illness to 
an income-earner, (2) social funds to which the poor contribute less 
and draw greater benefits than the better-off and (3) purchasing in-
struments such as consumer subsidies, restructured benefit packages 
and incentive payment plans in favor of the disadvantaged. For exam-
ple in China, a range of equity-enhancing financing mechanisms have 
been implemented in the context of health sector reform, using tools 
of resource mobilization, incentives, and consumer subsidies that as-
sure universal access for TB diagnosis and treatment.

Civil Society: 
Contracting for service delivery with local non-governmental organi-
zations with established records of effectively reaching excluded and 
marginalized populations. An example is an NGO in Bangladesh that is 
employing local women as community health workers to extend DOTS 
treatment to reach rural populations, and especially women, where the 
government program lacks coverage. Similarly, the establishment of 
?health equity watchdogs? could help to ensure that marginalized 
populations are program beneficiaries. For instance, in Cape Town, a 
group of stakeholders is employing HIV/AIDS as a tracer condition for 
evidence of the inequitable distribution of health service resources 
among urban health districts. 

Leadership and Stewardship: 
Encouraging the emergence of a new generation of health policy lead-
ers committed to equity and attuned to community conditions. Recog-
nizing policy leaders who take responsibility not only for whether 
the health initiatives that they operate serve the disadvantaged ef-
fectively, but more broadly for whether the disadvantaged are ade-
quately served by the totality of services available -private as well 
as public- within and beyond the health sector. This would mean en-
suring that specific efforts to redress the inequities of these com-
municable diseases are compatible with broader health systems and de-
velopment agendas, such as decentralization and poverty alleviation. 

Research and Analysis: 
Undertaking research and analysis needed to expand on the existing 
knowledge base, and to support the design, implementation, and as-
sessment of equity-oriented approaches. Many health information sys-
tems have unacceptably low coverage of marginalized groups, poten-
tially masking the magnitude of inequities. Even where data are rep-
resentative of diverse populations, the absence of group identifiers 
on survey instruments, e.g. income or education level, impairs as-
sessment and monitoring of inequities. In addition, assuming an ade-
quate information base exists, there remains a paucity of evidence on 
interventions that effectively redress inequities. A good example of 
better evidence making a difference is seen in Zambia, where the ef-
fectiveness of a social marketing strategy for insecticide treated 
nets targeting poor households was demonstrated through a well-
designed intervention study.

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