Research for action is best conducted through a participatory approach that enables ownership of the research by the researchers, the communities being researched and those who have the responsibility to implement the findings [18]. Participatory research also has the advantage of the research itself being used as a tool for change through the ongoing process of reflection and action [19, 20]. A participatory approach has therefore been adopted by the Cape Town Equity Gauge. This means that the methods and results are inter-related, and so are presented together in this paper.
All the Cape Town Equity Gauge research was led by the School of Public Health, University of the Western Cape, in collaboration with other stakeholders. Both quantitative and qualitative methods were adopted. The first phase, the collection of measurements across the health subdistricts of Cape Town, used quantitative secondary data to demonstrate the inequities. In the Equity Tools for Managers Project further quantitative work was done, supplemented by qualitative policy analysis to study the constraints to implementing equity. The Water and Sanitation Project was primarily qualitative, using in-depth interviews and focus group discussions. These were used to gain an understanding of the impact of the inequities, in this instance, inadequate sanitation provision.
In the Equity Tools Project, informed consent was obtained from the two participating public sector institutions (City Health and Metro District Health Services) as well as the Provincial Health Department. Senior organizational managers participated in the conceptualization of the Cape Town Equity Gauge and formed part of the Cape Town Equity Gauge Management Task Team which commissioned, and which granted permission for the research within their own organisations. The Water and Sanitation Project, as a community based initiative, worked through the community structures to determine the nature and scope of the research, the issues to be covered in the interviews, and the identification of the sample, which included community members and key officials involved in the Project. Informed consent was given by all respondents and the results were taken back to the community for discussion before the final reports were written.
Phase 1. Initial measurement of health inequities
The first research question posed by the participatory action research team was: Are there significant inequities in health across the health subdistricts of Cape Town?
A series of interactive workshops were held with the primary health care managers between March 2002 and March 2003. The health service partners (City Health and Metro District Health Service) nominated their subdistrict managers to participate in the process of identifying and measuring inequities. Most of the subdistrict managers (16 out of 22) participated actively and consistently in the workshop series. At the first workshop the researchers presented a theoretical understanding of equity as a concept of social justice based on balancing need and resources, and sought to reach consensus with the managers on this definition. From this point on, the role of the researchers became that of facilitators. Managers made decisions by reaching consensus. There were two meetings which were attended by all the subdistrict managers and included their organisational managers for the purposes of report back and further modification of the work.
Health managers were asked to list what they considered to be the various determinants of need for health services in the Cape Town context. They listed a range of indicators which were then grouped into three categories: demographic, health outcomes and underlying socioeconomic determinants. These were then looked at through an 'equity lens' – described by GEGA as moving beyond average measures to examine the differences between the various geographic and social groups. In this instance, the equity lens involved investigating the determinants by disaggregating secondary data to compare the 11 different geographical health subdistricts in Cape Town.
The secondary data used were taken from a wide range of sources, including the 1996 South African Census, health statistics collected by the City Health Department and HIV prevalence projections at the University of Cape Town. To be used, data sets had to be complete, reliable and valid. As can be seen from the graphs, this process provided a clear picture of the gross inequities in the underlying determinants of health [see Additional files 1, 2 and 3] and health outcomes [see Additional files 4, 5 and 6]. It also demonstrated a recurrent pattern of inequity with two health subdistricts, Subdistrict 5 and 7, consistently showing the greatest need for health services.
The initial measurement phase was instrumental in gaining increased support from the organisational and subdistrict managers to the overall Equity Gauge initiative, which set the scene for the collaborative approach that has been central to all areas of work.
Phase 2, Project A. The Equity Tools for Managers Project: the process and the results
This first phase of measurement work convinced organisational and subdistrict managers that inequity was a significant problem in Cape Town. This prompted them to express a desire to address the inequity. This signified a second round in the participatory action research process which asked the following research question: Given the demonstrated inequities in health, does the primary level service allocate resources according to need? Again the managers set the agenda and the role of the researchers from the SOPH was to act as facilitators.
The organisational managers on the Cape Town Equity Gauge Management Task Team requested that the first area of equity research should focus on the primary level health services in Cape Town. Although they recognised that tackling the underlying socioeconomic determinants of health was essential, they felt that they should first address inequities within their own service provision (and this is their area of direct responsibility) before attempting to advocate for change within other sectors.
The subdistrict managers were identified as key to implementation of equity actions, as they have direct responsibility for operationalising policy within the primary level services. They requested assistance in quantifying the inequity in a manner that would enable them to use the control they had over public primary health expenditure. The series of workshops continued. A technical support team was established with specialists invited to participate on the basis of their skills (in public health, health information systems, public sector financing, health policy and planning and health economics) and their familiarity with the Cape Town context. The role of the technical team was limited to specialist advice and the final decision-making power remained with the subdistrict managers. An Equity Measurement Tool was developed to quantify health need in each of the health subdistricts. The technical aspects of this tool are described in detail in a Cape Town Equity Gauge report [21]. Through the process of debate subdistrict managers set criteria for indicators of health need in the Cape Town context. These are shown in Figure 1. They also decided to weight the various indicators of need to create a composite measure of "need for primary level health services". This was then compared with public primary level health expenditure in each health subdistrict. The mismatch between the need for primary level health services and public primary level health expenditure, [as shown in Additional file 7], was dramatic, serving as a powerful source of advocacy. In the Additional file 7, the zero line represents equitable public primary level health expenditure. A bar above the line represents public primary level health expenditure in excess of what is equitable and a bar below the line indicates an expenditure deficit.
Once health managers understood the financial implications of addressing the health inequities between subdistricts, they raised their next concern which led to the third round of this participatory action research process. While national and provincial tiers of government are able to address inequity by changes in financial allocations to provinces and regions respectively, district health managers face a far more complex task. In health districts, significant changes in expenditure can effectively only be achieved by equitable reallocation of staff, as staff make up 70% of district expenditure. Faced with the magnitude of inequity in health expenditure and the difficulties in reallocating staff, the managers' commitment waned, and they identified a number of obstacles to implementing the equity strategy. At this point in the process, the role of SOPH researchers was questioned by some of the managers who felt under pressure to bring about equity change. They made it clear to the researchers that the role of implementation lay with management and that researchers had no part in this. The researchers agreed to this in principle. However, they argued that the difficulties in implementing equity did not justify denying social justice to communities living in Cape Town. Through a process of debate and boundary-setting, managers agreed that a tool to aid implementation would be helpful. The next research question was: How can equity in health service provision at primary level be achieved without disruption to efficient service delivery? This resulted in the development of an Equity Resource Allocation Tool to assist managers to plan staff allocation in a manner that is equitable. As primary level health services are currently under funded and there are many vacancies the tool was a useful source of advocacy to motivate for increased funding and as a guide to the allocation of new staff as they were appointed. Given the complexity and sensitivity of this task, the managers added various constraining factors (including efficiency, workload norms and the importance of not levelling down to the poorest standards) to equity-motivated staff shifts, which, they argued, were important given their other management mandates.
As part of the ongoing reflective learning process, the constraints were further explored. This was done using an in-depth qualitative health policy analysis study that looked at both the health managers' and the nurses' perceptions of the constraints faced in implementing equitable health care resource policies. Twelve in-depth interviews with organisational and subdistrict managers and 6 focus group discussions with facility-based nurses were done. The methods and results are described in detail in a separate article [22]. The findings showed that, while the legitimacy of equity as a policy goal was broadly accepted, resistance existed to the implementation strategy. In part this was due to role conflict: managers supported equity in terms of their strategic planning responsibilities for Cape Town, but also felt that that they had to secure maximum resources for their own subdistrict and knew that they could be unpopular as line managers with their frontline health workers if they were deployed to under-resourced subdistricts. Nurses, who felt that their main responsibility was to provide a high standard of client care, were also concerned that staff reductions in relatively over-resourced subdistricts would negatively affect the quality of client care offered.
Another key factor contributing to the resistance was a lack of workplace trust between staff and managers resulting from inadequate communication and poor consultation. Nurses were not involved in the decision-making process and they did not believe that the managers considered their well-being.
Where are we now?
Despite these reservations, some equitable reallocation of nurses and environmental health practitioners has been undertaken by the City of Cape Town Health Department.
At the time of writing, an agreement has been reached to repeat the measurements, although this time the analysis would be done primarily by the Health Departments, with the SOPH providing a supporting role. This marks an important landmark in integrating the measurement into mainstream data collection, ensuring sustainability of the process.
Phase 2, Project B. The Water and Sanitation Project: a process of community empowerment and the results
The second example of research to action is a project which was initiated because of the gross inequities in access to basic sanitation demonstrated in Phase 1. It was developed as a community-based initiative in two informal settlements (also referred to as shacks or slum dwellings) in the one of most disadvantaged subdistricts of Cape Town. Amongst the many disadvantages suffered by the residents, is a lack of sanitation within the informal settlements – a City of Cape Town report in late 2003 talked of an average of 105 people per toilet, generally 1 toilet per 7 households where toilets have been provided, with none in other areas. The toilets that did exist were shared 'bucket' toilets which are overused and/or vandalised. Furthermore, because of the high level of unemployment, most people are home during the day, which means these are often the only toilets they have access to. Accompanying the inadequate sanitation are high rates of worm infestation and diarrhoea, which was found by Groenewald et al [23] to be the third highest cause of mortality in under 5 year olds in that particular subdistrict in 2001, after HIV/AIDS and lower respiratory infections.
The Water and Sanitation Project developed a particularly strong emphasis on community empowerment, reflecting the evidence from many countries that, for water and sanitation programmes to be successful, there must be a demand for the facilities by the communities [24]. It grew out of a multisectoral initiative, established in response to a medical officer finding evidence of worm infestation among most of the children in the schools in the informal settlements (96% of 1000 children examined in 12 primary schools). Two main areas of work were focused on as a result of these findings. The first is a health promoting schools initiative, which involves a regular deworming programme, a curriculum development component, and the improvement of the water and sanitation facilities within the schools.
The second initiative, the focus of this paper, was the community based Water and Sanitation Project. This was initially established to target one of the determinants of diarrhoea – inadequate sanitation – through a pilot of dry sanitation toilets (toilets that are not connected to the sewage system). A participatory approach was adopted, working closely with the local communities as part of a multisectoral programme. This was led by a community-based Sanitation Task Team comprised of representatives from the informal settlement street committees, officials from the local government, and the Cape Town Equity Gauge/SOPH researcher. Site visits to see toilets in operation informed the decision about which toilets to pilot; the community representatives, through their street committees, decided on the twenty households that would test the toilets, using their local knowledge and judgement about candidates that they believed would remain committed to the Project; and Task Team members were involved in the installation of the toilets. The monitoring of the dry sanitation toilets was the responsibility of the City of Cape Town Health and Water Services Departments, and, apart from some minor maintenance problems which were easily remediable, they were found to work well. Assessing the acceptability of the toilets by the community was the responsibility of the Cape Town Equity Gauge. This was an important component of the study as there was initial resistance to the pilot as the sanitation provision was not the water-borne toilets that the community aspired to. A first set of in-depth interviews was held with representatives from the twenty households before the toilets were installed, for their perception on the current situation vis-à-vis the lack of sanitation in the informal settlements, and its impact on their health. A second set of interviews was undertaken after they had been using the toilets for between nine months and one year, for their view on the acceptability of the toilets and their feasibility for the informal settlements. Additional interviews with 10 key officials directly and indirectly involved in the pilot provided the professional perspective. The content analysis of the interviews showed that there was general acceptance of the toilets by the householders [25]. The main reason for their satisfaction was the fact that they did not have to share the toilets. This meant that the toilets were not overused, and the owners could keep them clean. The following quote sums up the views of the community respondents:
"It's unlike the first toilets whereby people were unable to enter and use them because of such things like the dirtiness. We enter these toilets as if you are entering the house ..."
The officials' comments supported the communities' assessment that dry sanitation could be a viable option for the informal settlements.
An important contributing factor was the role of the community members of the Task Team. As they were neighbours of the householders, they were trusted to have the interest of the community as their priority. They and the key officials had also spent a considerable amount of time with the householders explaining the technology and providing practical support.
The initial Task Team had been set up with a specific focus, and its membership of street committee representatives was appropriate for that focus. However, after some time, the structure was challenged for not being representative of the wider community of the subdistrict. This led to the establishment of a new, comprehensive community forum, the Water and Sanitation Forum, which has an extended remit to cover the whole district and all aspects of water and sanitation. This marked an important stage in the development of the Water and Sanitation Project, as it gained the recognition of the community establishment of the subdistrict. The Cape Town Equity Gauge took on the responsibility of building the capacity of the Forum members, to support them in their various roles. This included team building skills to work with (and at the same time challenge) public sector officials, and awareness-raising on issues of health and sanitation. Two focus group discussions, one with the Forum's Executive Committee and one with general members, were undertaken approximately two years after the Forum was established to assess its achievements and to note its limitations [26]. The strength of the Forum was seen as the commitment of members, and their desire to take the knowledge they had gained out into the wider community. However, two important concerns were noted. The first was what the Forum members described as limited commitment by the City of Cape Town, which was restricting their capacity to work for change.
All of these things we talk about need support from the municipality....if the municipality could hear us then something might happen.
The second concern, which was linked to the first, was the lack of funds to cover the expenses of the Forum. Funding had been allocated for community support, but due to bureaucratic procedures and differences in priorities between the community and the City of Cape Town, these funds did not materialise. This has been a significant problem for community members who are largely unemployed.
The problems ...were coming to the meetings penniless hoping that you will get money [to cover transport] once you were there....then told that the money has not yet been received.
Where are we now?
The success of the initial dry sanitation pilot resulted in an extended pilot programme, this time led by the council. 70 more toilets were installed. However, these had shared use (four households per toilet), and the Forum members were not involved in the decisions about their distribution. This led to overuse of some units, which the technology could not sustain, while others remained unused due to unresolved tensions about who should have access to them. The second phase of the pilot was therefore considered to be unsuccessful, and dry sanitation has not been introduced into the area.
The Forum continued to meet despite the constraints. This was largely due to the commitment of its members, and sense of being able to make a contribution to their communities. As one Forum member noted
... this has not dampened our spirit. When we look around and see people doing what we have taught them it's encouraging.
This commitment was rewarded, as Forum members were invited to participate in the provincial and local government diarrhoea prevention programmes as the legitimate community representatives. In addition, the Cape Town Equity Gauge initiated a community action programme in 2006 which involved training Forum members to establish and run health clubs in the community. These initiatives were aimed at assisting the Forum members to achieve their objective of taking water and sanitation concerns into the community, as educators in their communities, and as advocates for improved water and sanitation provision. However, due to the limited capacity of the local and provincial governments to support the Forum and a lack of funding, its membership has dwindled, meetings are intermittent, and this has impacted on its ability to take forward the intended outreach programme. The remaining Forum members, however, remain committed and determined to continue the programme, despite these constraints.