This paper describes the meaning and concepts about a Health Equity Audit. It describes the process of achieving the best results in a Health Equity Audit through a living example of a consortium of three institutions that carried it out in Delhi, in India. The institutions include the Union Ministers of Health in India, the World Health Organization, and the Family Ghulam Nabi. The choice of Delhi was motivated by the fact that India faces the greatest disparity in terms of access to cancer screening and treatment. Delhi represents India’s metropolitan zone with the largest population affected by the inequities of access to health services. Cervical cancer is an area of discussion with a focus on the methodologies adopted to reduce existing inequities of access to smear tests and other treatment facilities.
Heath equity audit is a procedure that looks into the comparative dissemination of health services in relation to the health needs of different groups and geographical locations, and the necessary actions that ensure that the services meet the necessities of the groups in question. The main purpose of carrying out health equity audits is to facilitate efficiency in the distribution and use of health resources. The process is a planning tool for institutions that provide health care in communities. Health equity audits help health institutions and other agencies in reducing inequalities in access to health care. Existing facts and statistics on inequalities in the health sector are used to make crucial decisions on planning, investments, and determining the impact of such inequalities.
Cases that can be identifies as health needs
This is one of the most killer diseases in the world today. The cancer attacks the cervix; a reproductive organ found on the lower side between the uterus and the birth canal. Cervical cancer affects women above the age of 25 hence the age bracket is classified as ‘high risk’. A virus called Human Papillomavirus causes cervical cancer. This is according to research findings of this cancer causing which reveals that it is contracted through sexual intercourse with an infected person. However, not all species of the HPV virus can cause cancer to an infected person. Research by the Center of Disease Control (CDC) in the United States, the virus overwhelms the immune system within a period of two years after infection. The HPV virus, therefore, stays in the body for a long time until it has a cancerous effect on the cells of the cervix. The symptoms of cervical cancer are benign and may not be explicit until the cancer spreads to a critical stage. By the time, the symptoms are severe the cancer will already have spread to other surrounding body tissues. At this stage, treatment is expensive with a fewer chances of survival due to the severe symptoms.
General signs of cervical cancer are, abnormal discharge from the vagina, bleeding or pain during sexual intercourse, blood spots and light bleeding different the normal monthly periods. India records a high prevalence of cervical cancer in the world. Cervical cancer is the only cancer that is preventable. The virus has two vaccines that can prevent it from turning cancerously as long as the infected person takes it early after diagnosis. The high prevalence in India is caused by low awareness about the disease. Health care and cervical smear test initiatives were less until the beginning the twenty first century in 2000. To understand India’s cervical cancer prevalence as a case study, a health audit is the tool of analysis in this article to investigate the distribution of facilities in New Delhi and the education of women about cervical cancer.
Stage 1: Relevant Priorities and Partnerships
A health Equity Audit is a cycle that follows several steps that are part of the entire discussion. The first step in the Health Equity Audit is the re cognition of the major partners that are instrumental in providing statistics about access to health services in a place. The institutions collaborating in this vital initiative are the Union Ministers of Health in India, the World Health Organization, and the Family Ghulam Nabi. These institutions are vital in providing access to information that is useful in analyzing the factors that are responsible for Health inequalities in New Delhi. This consortium comprising the three institutions aims at instituting and implementing measures that can mitigate the prevalence of cervical cancer in India. The government through the Union Minister of India has begun awareness campaigns through regular seminars to sensitize the Indian public about cervical cancer. The campaign involves civic education voluntary smear tests to willing persons after a counseling session.
The partnership has conducted successful Health Equity Audits that will be the guiding strategy in reducing the inequalities in access to cervical cancer in India. In the seminar sessions, the findings of the Health Equity Audits are presented to the public and an annually. The public, therefore, informed about the current state of their regions on cervical cancer. The three institutions have an excellent Health Equity Audit program that has changed the entire state of cervical cancer infections in India. The group has a committee that maintains a database with a guide of interventions that are applied in reducing the continuity of more infection that arise due to ignorance or the absence smear test equipment. One reason why the initiatives of this consortium will pay off is that the disease is preventable without expensive medical interventions such as chemotherapy, radiology, surgery or Hysterectomy. Prevention measures on affordable to most of the populace and can cover a wide geographical area. After the health Equity Audit, n they identify and prioritize needy regions for public awareness, in addition to free vaccinations.
Stage 2: The Healthy Equity Audit Profile in New Delhi
The consortium collected primary data from the regions in Delhi. Data collection was through filling in questionnaires, analyzing formal ministerial reports, journals and interactions from the seminars. Questionnaire distribution targeted main hospitals in Delhi, and individuals filled in during seminars (Morrissey, 2008). The participants in the process were mostly the residents of Delhi, who were identified through the official registry from the Delhi authorities. To reduce the effect of non-response when the sampling groups declined, extra units in the same age bracket replaced them. Hospitals provided important data about past and present cervical cancer diagnoses. Most cases reported from hospitals were severe, and the treatment was only to reduce the symptoms (Pathy, Sinclair & Morely, 2006). There were formal health reports and journals on cervical cancer that circulated in the public that served as sources of secondary information and data the cervical cancer challenge to women in India. Data analysis was through analysis tools such as getting the means, medians, and the percentiles of the population of women affected with cervical cancer in relation to the entire women population in India.
The same methods of analysis applied in every region to determine the regions with a higher prevalence. The information was stored in the database with formal codes that identified the areas in order of the recorded prevalence. The areas with the highest prevalence were given priority in the distribution of smear kits and personnel. Information recording and computation followed a standardized method that linked the rates of prevalence with age groups. A chi -square test was used to get an estimate of the independence of two categorical variables.
The adequate weighting of the respondents who turned out was greatly accounted for in the analysis session.
Cumulative groups based on the age groups were not the only measure but other facets as the socioeconomic status of the group and the education levels of the groups were put under consideration. To analyze the real problem, which is inequalities in access to health care on cervical cancer, relative inequality index was computed with the relative confidence intervals from a prevalence ratio of a linear model derived from a binomial regression. Levels of education of the affected groups were assigned a value from 0 to 1. The values represent the central concern.
Stage 3: Effective Local Actions Initiated By the Consortium
The most partners agreed that the most effective high impact method to reach a large area and narrow the gap of inequalities in the Health Equity Audit was to organize systematic screening programmes and media campaigns about the need for a society to encourage more women to get screened of the HPV virus. This arose from the findings of data analysis that showed a negative relationship between participation in screening and the level. Systematic screening programmes could effectively reduce the inequalities of access to quality screening tests in India. This method increase participation in screening sessions. This method favors women low education because they are the most vulnerable information asymmetry problems on cervical cancer and screening sessions. It also increases the participation of the women who are invited. Systematic screening mitigates on the problems associated with opportunistic screening. Another action that was unanimously supported by the all the three partners in the consortium was to make a proposal to the government of India to adopt systematic screening as a government preventive measure for cervical cancer (Spencer, 2007). This would considerably reduce existing inequalities in accessing screening for women with low incomes and low education.
Stage 4: Local Targets
The group resolved to consider women above the age of 40 as the target group and all women in the low-income social group because the relative inequality index showed the two groups as the most marginalized in the provision of screening services. The former fears the social stigma and the smear process, which require the doctor to examine the birth canal (Sherval & Steward, 2004). The later suffers from information asymmetry due to little access to communication channels that inform the public about free smear test sessions by the government and some non-governmental organizations.
However, the target groups are only for treatment purpose but screening was open for all women willing to participate. After the screening process, the target groups are a priority on vaccination because of their higher risk of contracting HPV. Women in household below the national poverty average of India were another special target group. Official Statistics indicated that 58% of women who lived below the poverty level live in the rural areas. Rural areas around Delhi would be a target group for the same reason (Hirschmann, 2010). The consortium through the World Health Organization added other measures that would improve girl-child education in Delhi and the entire country. This was sighted a long -term measure that would reduce the risk of prevalence. The more educated a girl child gets, the faster they acquire information about the health matters. Therefore, Public information about cervical cancer would be more effective to due to a sensitized public.
Stage 5: Investments in Cancer Infrastructure
Currently cervical cancer screening remains an elusive problem in India. The resources for this service are meager with most screening centers concentrated in urban centers. This locks out rural regions from the service yet they are the most vulnerable. Even though there are great efforts by the government to provide affordable treatment to cervical cancer patients, the measures only target curative options, which may not be good for the next generations and the vulnerable groups. With the statistic at hand, the consortiums agreed to invest more resources in building cervical cancer centers. Personnel employed by the World Health Organization would manage the centers. Modern equipment that can effectively carry out Colposcopy after the Pap smear test would be installed at the center. Colposcopy is a diagnostic method useful in the diagnosis and assessment of cervical intraepithelial neoplasia and the preclinical invasive cancer.
The process allows for the magnified visualization of the site where cervical carcinogenesis takes place. The equipments will allow specialists to take a direct biopsy and delineate the extent of lesions on the cervix for women who test positively of cervical cancer. This will facilitate prompt interventions hence reducing the number of resulting from late diagnosis. The WHO resolved through a collaboration paper that it would fully act on the recommendations of the Health Equity Audit to better the health of Indian women.
Another area to invest in is training medical personnel to disseminate skills about in areas with medical personnel disparities. Most of the medical personnel in Delhi and the entire India have little skills to carry important procedures such as the Colposcopy and treating cervical intraepithelial neoplasia (Almendral, 2001). This would be done through specific research and demonstration projects. The process is vital detection and prevention of cervical cancer. The trained personnel are expected to channel their services in target regions and persons at high risk of contracting HPV.
The last and most important aspect that would receive investments according to the recommendations is the acquisition and availing of vaccines in the remote and most vulnerable regions. This measure is relevant for women who test negative of HPV. Regions where healthcare resources are scarce would receive more investments. Secondary prevention measures also received heavy investments and allocation of resources (Cancer Advances in Focus: Cervical Cancer, 2010). HPV vaccination is a fundamental prevention approach that will have a considerable result on the incidence of cervical precancer. Invasive cancers such cervical cancer needs periodical assessments for both vaccinated and unvaccinated women. This was the justification for the heavy investment in secondary preventive measures such as acquiring the vaccine and providing it at an affordable price to low income groups.
Stage 6: Progress and Impacts Against Targets
After a decade, the level of prevalence has significantly reduced especially among the target groups. Rural awareness has increased the number of women participating in screening sessions. Statistics from the ministry of health indicate an increase of about 47% of smear test participations. Education and income disparity are no longer the impediments to accessing cervical cancer treatment. The media has played a major role on keeping the public informed about the commissioning services offered by the consortium. However, the challenges of commissioning still slow the progress of expanding services delivery to remote areas. More investments in infrastructure could improve the possibility of realizing the consortium’s main goal.
Challenges to Commissioning Service
The challenges that affect the implementation of actions that would reduce inequalities in accessing cervical cancer screening and screening are related to clinical governance. Some of these challenges may have an impact on patient care. Policy makers will in laying the ground for the implementation of new measures. Currently, there is a lack of central attention among policy makers in the central government to recognize the differences between populations based programmes that require centralized oversight and personal health services, which require a more decentralized environment for providing policy formulation and competition.
The absence of information systems and quality control processes, and the inattention of the government to the work force have had a negative impact on the perspective of the public to the health profession (Johnson, 2001). Today, cervical screening is provided regional agencies in India with many flaws in the public registry. Unfortunately, the authorities depend on the registry in making public appeals for cancer screening. Many patients may miss out of the audit programme if the consortium relied on the registries. The institutions will have to find some better means to get information about people it begins the commissioning process. An update of the registry will be vital in this case.
The health system in India is changing expeditiously in technical, social and economic terms. Some of the changes are fanning more challenges and tensions in the sector making implementation of the health audit recommendations a difficult task. This is an extra cost to the service providers of extra health services such as the target by the institutions in the consortium. Commissioning all the programmes needs to have environment equity in the distribution of health services, low medical tariffs on health products, streamlined insurance patents, a stable financial system, and equitable distribution of insurance premium among patients. Such conditions will enable the government and the private sector to cushion the target groups in the audit from harsh conditions they may not afford to finance. India falls short of these requirements making it a great challenge for the institutions to commission intervention services for the target regions (Dickerson, 2008). It is important to make the cost of insurance affordable so that many patients are under insurance cover. The World health organization will be tasked to apply for permissions to allow it bypass some national restrictions on the importation of drugs. Commissioning of these services may be construed to be permanent, and the governments may fail to actively take its part in cervical cancer screening and prevention.
Commissioners ought to have a high level of technical and managerial skills because of the nature and complexity of health services. It is difficult to define medical services such as cancer screening in absolute contractual terms (Cervical cancer (Rev. Mar. 2009. ed.). (2009). All of the services will largely depend on the professional discretion of trained clinicians rather than contractual relationships. Therefore, this requires the institutions to do a comprehensive training programme that will equip the new clinicians with the right skills that can deliver the right results.
Challenges associated with health economics are likely to arise. Cancer screening and treatment and other health services are intractable transactions. The would be difficult for the consortium to decide on contracting suppliers through negotiations between them and the sellers of vaccines and other equipment or chose to use integrated systems with a strict budget that can open loopholes for corruption by commissioners and the suppliers of equipment. However, there will be a lesser challenge if the consortium decides to use the traditional suppliers of the World Health Organization. Procurement challenges in the Indian society are bureaucratic and delay the process of service delivery to target groups.
An imbalance between commissioners and provider s is likely to occur. Commissioners may not negotiate on equal terms with service providers within the existing financial constraints. This would compel the consortium to adopt an integrated system rather than those based on commissioner/provider combination (Israel, 2013). Services providers will have to adopt accurate performance measures and the data standardization by incorporating more skills through training. Issues of transparency are a public challenge in India. Compliance with the conventional measures to reduce inefficiencies may hurt service delivery.
To provide value based commissioning on cervical cancer, many health-based values may be part of the wider culture of patients and service users. Understanding those cultures is necessary to ensure that everyone and especially the minority groups and cultures get their deserved attention on screening and treatment. Values of a community are written in many ways, but there are normative are normative statements that affirm how things ought to be. These values may affect participation if they are dealt with professionally. For successful commissioning to take place, it is important for providers to observe aspects that a community in a particular region observes as cultural practices. They should exploit recognized group, community, and population values with which to develop a picture of the community in relation to cervical cancer screening and testing ( Barr & Dowding, 2012). They must seek the best ways to offer care to cervical cancer patients while giving due weight to the values expressed in the community. Doing so will create a working environment between commissioners and patients. To succeed in providing value –based commissioning of cervical cancer that is acceptable to all patients in the community, commissioners have a responsibility to adjust their meet cultural needs. This challenge is common in a cultural society such as India (Schultz & Schultz, H.2004).
- Almendral, A. C. (2001). Cervical cancer. Berlin: Springer-Verlag.
- Barr, J., & Dowding, L. (2012). Leadership in health care (2nd ed.). Los Angeles: SAGE.
- Cancer Advances in Focus: Cervical Cancer.. (2010). Bethesda, Md.: U.S> Department of Health and Human Services, National Institutes of Health, National Cancer Institute.