How Have Global Health Initiatives Impacted on Health Equity?

From the journal Promotion & Education, Vol. 15, No. 1, 19-23 (2008), this 6-page review examines the impact of Global Health Initiatives (GHIs) on health equity, focusing on low- and middle-income countries. It is a summary of a literature review commissioned by the World Health Organization (WHO) Commission on the Social Determinants of Health. The review focuses on gender equity in three GHIs; the US President's Emergency Plan For AIDS Relief (PEPFAR), the World Bank's Multi-country AIDS Programme (MAP), and the Global Fund to Fight AIDS, TB, and Malaria. The review finds that the GHIs have impact on health equity, including gender equity, through programme formulation and implementation, but they have failed to address the drivers of inequity and have had difficulties in harmonising activities at a country level. Recommendations, as stated in the review, include "a call for equity-sensitive targets, the collection of gender-disaggregated data, the use of policy-making processes for empowerment, programmes that explicitly address causes of health inequity and impact assessments of interventions' effect on social inequities."


As stated here, "socio-economic inequalities increase people’s risk of HIV infection, and once infected, they act as barriers to treatment, care, and support for people living with and affected by HIV/AIDS....By focusing on their [GHIs'] strategies with regard to gender equity, this paper suggests that GHIs have an impact through their policies and programmes, and through the processes that govern their policy design and implementation. PEPFAR’s policy to ensure equitable access to ART for women serves as an example. It has directly resulted in gender-equitable access to such treatment. The Global Fund’s Country Coordination Mechanisms have shown the potential of this process to empower women, by providing new political spaces and by acknowledging their importance in the political process." Examples of ensuring equitable access to healthcare included in the review are adjusting a facility's hours to ensure that female farmers have access to its service, or that mobile male workers, such as truckers, know where to access service. However, as stated in the review, the GHI models studied fall short, in policies and funding, of addressing underlying social inequities that determine access to health care, such as poor access by women to economic resources and their experiences of sexual violence.


While GHIs have the advantage of country-level structures and country-level policy and communication to 'harmonise' policies and operational guidelines, as well as maximise resource use, ensuring the inclusion of gender equity was a challenge, as reported here, for the top-down structure of PEPFAR and for the bottom-up structure of the World Bank. However, the Global Fund has used policy-making (linked to funding) as an empowerment tool for country-led programming, making inroads in gender equity.


The report states that desegregation of monitoring and evaluation (M&E) data by gender has been weak due to country-led M&E efforts. Thus, "strengthening countries’ systems capacity to monitor outcomes and impact will require more joined-up action by the WHO (as the normative [United Nations] UN agency) and the World Bank (as the agency with a particular remit for country systems strengthening)," coupled with GHI support.


Specific recommendations include:

1. Address explicitly the causes of gender inequities in access to health.
2. Assess interventions’ impacts on social inequities.
3. Include measurements that are sensitive to gender and other inequities when deciding targets.
4. Enhance the uniform collection of gender-disaggregated data.
5. Use policy-making processes for empowerment.
6. Address GHI impacts on health systems and human resources.
7. Harmonise to build on comparative advantage.
8. Integrate social equity in access to health in other development policies.
9. Monitor and evaluate GHIs’ impact on social equity.