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Enabling universal and equitable access to healthcare for vulnerable people in poor resource settings

Final Report Summary - EQUITABLE (Enabling universal and equitable access to healthcare for vulnerable people in poor resource settings)

Executive Summary:
EquitAble is a four-year collaborative research project comprised of researchers from Ireland, Norway, Namibia, Malawi, South africa, and Sudan. The Project has aimed to produce empirical knowledge on access to healthcare for vulnerable people in resource poor settings in Africa. EquitAble brings together several teams comprised of both leading and upcoming researchers, from two European and four African countries. This strong consortium, with established project management and research credentials, presents a valuable opportunity to provide data to inform crucial policy decisions, as well as building research capacity in this area. EquitAble comprises five Work Packages: WP1: Project Management; WP2: Review and Analysis of Health Policies; WP3: Intensive Qualitative Study; WP4: Extensive Quantitative Study; WP5: Influence Policy & Practice & Dissemination.

Healthcare can be neither universal nor equitable if it is less accessible to some sections of society than it is to others. EquitAble’s focus on activity limitations in Africa has aimed to provide data that is crucial to enable universal and equitable access to healthcare in resource poor areas. The project has aimed to provide the disability sector with data to develop evidence-based advocacy; government ministries with opportunities to implement evidence-based policy decisions; and service providers with data to enact evidence-based practice. However, this project has sought to go beyond making recommendations and producing guidelines; it has aimed to address the process of bridging the evidence-policy-practice gaps, by identifying barriers and facilitators for the implementation of our research findings, thus enabling the project to have a real impact.

EquitAble has:
1. Provided policy, qualitative and quantitative evidence of health service provision, and barriers to it, for persons with disabilities in four African countries - Namibia, Malawi, South Africa, and Sudan - across different regions, groups and contexts.
2. Interfaced with ongoing research on how to get evidence to action in policy and practice.
3. Detailed how the provision of services to persons with disabilities can be used as a probe to evaluate broader health system performance.

Project Context and Objectives:
EquitAble’s primary objectives are to:
1. Conduct an assessment of existing international, European Union and African country-level policies on universal and equitable access to healthcare with particular reference to people with activity limitations.
2. Undertake research into users’ and providers’ perceptions of the facilitators and barriers to equitable and universal access to healthcare in Namibia, Malawi, South Africa, and Sudan.
3. Examine the relationship between access to healthcare services and activity limitations, and other mediating or interacting variables, in Namibia, Malawi, South Africa, and Sudan.
4. Provide test sites for forthcoming measures of activity limitations that have been developed through extensive international consultation.
5. Make recommendations and create guidelines in support of effective and coherent health policy, at both country and international level, that promotes equitable and universal access to healthcare for people with activity limitations.
6. Explore and address barriers to implementing recommendations and guidelines across the four project countries.

EquitAble addresses the Call Topic ‘Universal and equitable access to health care and health financing’, and focuses on healthcare in Africa. While the importance of addressing the health needs of vulnerable groups in low-income countries is increasingly being recognised, there are many challenges with regards to how this should be realized for different categories of vulnerable people. Vulnerable groups are 'social groups who experience limited resources and consequent high relative risk for morbidity and premature mortality' (Flaskerud & Winslow, 1998, p. 69), and this may include women, children, the aged, ethnic minorities, displaced people, people suffering from some illnesses, and people with disabilities. While different groups of vulnerable people present some similar challenges for their equitable access to healthcare, there are also distinctive challenges presented by different vulnerable groups. This project focuses on the challenges that persons with disabilities present to achieving universal and equitable access to healthcare in resource poor settings. In so doing, we have applied the most recent international thinking that conceptualizes disability along a continuum of activity limitations, as described by the International Classification of Functioning, Disability and Health (ICF). The ICF recognises that because everyone experiences some degree of activity limitation during their lifespan, disability is a universal experience and not just one that happens to a minority of the population.

The World Health Report, ‘Working Together for Health’ (WHO, 2006) noted that Africa has the greatest disease burden of any continent but has the poorest health services. The four African countries that are the focus of this proposal each represent distinct challenges in terms of equitable access to health care. These four countries allow us to address how access to the healthcare systems for people with activity limitations can best be promoted in contexts where a large proportion of the population has been displaced (Sudan); where the population is highly dispersed (Namibia); where chronic poverty and high disease burden compete for meagre resources (Malawi); and where, despite relative wealth, universal and equitable access to healthcare is yet to be attained (South Africa). We also explore how activity limitations, across the above contexts, interact with other factors that render people vulnerable to poor access to healthcare, such as age, gender, ethnicity, and so on.

We conceptualize disability as best represented along a continuum of activity limitations, as the most feasible level of outcome to measure in self-report and observational studies (Washington City Group on Disability Statistics, EUROSTAT and Budapest Initiative). The EquitAble project conceptualises accessibility in terms of the UN Convention on Economic, Civil and Social Rights; as having four principal components: non-discrimination, physical accessibility, economic accessibility and information accessibility. Using this conceptualization, we have undertaken an innovative exploration of the interrelationship between activity limitation and access to healthcare systems. Thus, we were able to make comparative analyses across different contextual challenges, while at the same time incorporating a range of other vulnerability factors that may mediate the relationship between, or interact with, activity limitation and accessibility.
Project Results:
EquitAble undertook policy analysis, intensive ethnographic and extensive household surveys. It has developed a new policy analysis framework - EquiFrame - which will be used to guide all future policy revision and development in Sudan, and which was the guiding framework for the development of Malawi's first National Health Policy. There are currently plans to use EquiFrame in other countries, and it has already been used to evaluate the health-related donor policies of the Governmental aid agencies in Ireland, UK and Norway. EquiFrame evaluates 1) the extent to which 21 Core Concepts of human rights are addressed in policy documents, and 2) coverage of 12 Vulnerable Groups who might benefit from such policies. Using this framework, analysis of 51 policies across Namibia, Malawi, South Africa and Sudan, confirmed the relevance of all Core Concepts and Vulnerable Groups. Further, our analysis has highlighted some very strong policies, serious shortcomings in others, as well as country-specific patterns. More than 10 papers have now being published using EquiFrame; ethnographic work is currently being published and the Consortium has conducted analyses of its unique quantitative data-set of over 32,000 people across 17 sites in Africa.
Potential Impact:
The focus of EquitAble on activity limitations in Africa has provided data that is crucial to enable universal and equitable access to healthcare in resource poor areas. It provides the disability sector with data to develop evidence-based advocacy; government ministries with opportunities to implement evidence-based policy decisions; and service providers with data to enact evidence-based practice. However, this project goes beyond making recommendations and producing guidelines; it addresses the process of bridging the evidence-policy-practice gaps by identifying barriers and facilitators for the implementation of our research findings, thus enabling the project to have a real impact.

The research results arising from EquitAble contributes much needed empirical data and analyses into on-going debates in the field of public health regarding how best to plan interventions that promote access to healthcare and prevent failures in health systems. Such systems-failures, such as multiple drug resistance and exacerbation of health problems, could be cured or prevented with better information and greater accessibility. Finally, this Consortium is committed to disseminating the Project’s findings to a broad range of people with activity limitations and other characteristics that may make them vulnerable to inequitable access to health services. These groups are also traditionally amongst those with whom research results are seldom shared.

List of Websites:

EquitAble Website: www.equitableproject.org
EquiFrame Manual (free-to-download): http://www.global-health.tcd.ie/news/index9.php

Contact us:
Trinity College Dublin, Centre for Global Health (Ireland) [Project Coordinator]:
Prof. Malcolm MacLachlan (Project Manager); email: malcolm.maclachlan@tcd.ie
Dr. Hasheem Mannan (Project Officer); email: mannanh@tcd.ie
Ahfad University for Women (Sudan):
Prof. Mutamad Amin; email: mutamadamin@hotmail.com
Stellenbosch University, Department of Psychology (South Africa):
Prof. Leslie Swartz; email: lswartz@sun.ac.za
Ms. Margie Schneider; email: margie_who@mweb.co.za
Stellenbosch University, Centre for Rehabilitation Studies (South Africa):
Dr. Gubela Mji; email: gumji@sun.ac.za
SINTEF, Global Health and Welfare (Norway):
Prof. Arne H. Eide; email: arne.h.eide@sintef.no
Ms. Stine Hellum Braathen; email: stine.h.braathen@sintef.no
The Secretariat of the African Decade of Persons with Disabilities (South Africa):
Mr. Kudakwashe Dube; email: akdube@samaita.co.za
University of Malawi, Centre for Social Research (Malawi):
Dr. Alister Munthali; email: amunthali@cc.ac.mw
University of Namibia, Multidisciplinary Research and Consultancy Centre (Namibia):
Mr. Gert Van Rooy; email: gvanrooy@unam.na