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Int J Epidemiol. 1992 Dec;21(6):1043-9.

Surveillance for equity in primary health care: policy implications from international experience.

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  • 1School of Hygiene and Public Health, Johns Hopkins University, Baltimore, MD 21202.


Experience around the world shows that health agencies can promote community-based surveillance for equity to focus low-cost interventions on priority needs. Social inequities which have seemed intractable can be resolved if care responds directly to demonstrated need. The concept of promoting equity as a basic principle of primary health care has an interesting psychological twist. The ethical imperative of equity can strengthen services when linked with the practical management tool of surveillance. Moral conviction in applying this social justice norm can facilitate action which is made efficient by the realism of statistically based methods of surveillance. If international agencies condition their aid on surveillance for equity their assistance will more likely go to those in greatest need. This is a more efficient and effective way of tracking their money than the previous tendency to set up vertical programmes which generally have poor sustainability. Surveillance helps mobilize political will and community participation by providing practical data for local, district and national decision-makers. The many field demonstrations of successful surveillance for equity tend to have been brushed off by development experts who say they are difficult to replicate nationally. The Model County Project in China shows how a systematic extension process can test procedures in experimental areas and adapt them for general implementation. Surveillance can help bureaucracies maintain capacity for flexible and prompt response as decentralization promotes decision-making by local units which are held responsible for meeting equity targets. Surveillance for equity provides a mechanism to ensure such accountability.


Epidemiological methods of surveillance allow public health officials to use equity indicators (fertility, mortality, and causes of death) to improve health care for the poor, thereby achieving an effective and efficient primary health care system and a moral objective. The indicators should be simple and measurable. Each community is responsible for monitoring its members and should begin with registering all families. Simple retrospective verbal autopsy methods should be used initially. Continuous data collection (e.g., rapid assessment procedures and simple demographic surveys) should monitor high risk subgroups. Surveillance provides feedback so health workers and community leaders can discuss how to address health problems. Interventions should be simple and inexpensive and attack only priority demonstrated needs. Development specialists have discredited many field demonstrations of successful surveillance for equity, claiming they cannot be reproduced at the national level. The Model County Project in China is an example of how ideological commitment to equity can improve health care. Between the early 1960s and late 1970s, it used barefoot doctors to monitor the health of and provide health care to neighbors. Local health cooperatives and the barefoot doctors promoted preventive measures and equitable distribution of food. The Project's activities resulted in a sizable reduction of infant mortality (275-50). In the 1980s, however, China shifted to privatization which reversed the earlier priority of equity. It has since realized the effects of this shift and now reemphasizes equity. In the Punjab, India, village-based auxiliary nurse-midwives conducted effective continuous epidemiological surveillance, focusing on the most needy families, and provided health care. This Narangwal Project improved both equity and cost effectiveness. Other effective surveillance projects were in rural Haiti (affiliated with the Schweitzer Hospital), the Kakamega Project in Kenya, and in Jamkhed, India.

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