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achieve equity and efficiency in maximizing health outputs: reforms targeting universal ... Key words: Health, equity, efficiency, health maximization, participation.
Malaysian Journal of Public Health Medicine 2013, Vol. 13(1): 64-71

REVIEW FOCUSING HEALTH EQUITY, EFFICIENCY AND HEALTH MAXIMIZATION POLICY REVIEW Thant Z1, Than Mt1, Shamsul BS2, Wai PW3, Htun HN4, Osman Ai5 1

School of Medicine, University Malaysia Sabah, Sabah, Malaysia. Occupational Safety and Health Center, University Malaysia Sabah, Sabah, Malaysia. 3 International Medical University Malaysia, Kuala Lumpur, Malaysia. 4 Canberra Hospital, ACT, Australia. 5 Universiti Kuala Lumpur, Royal College of Medicine, Perak, Malaysia. 2

ABSTRACT With economic growth and significant technological advances in the health sector, many countries have developed aggregate outcomes in terms of both health services and individual well-being. Life expectancy has seen a remarkable increase of more than fifty per cent between 1950 and 2009. Achievement is uneven, however, and some groups are better able to access health services than others. In our review, we explore the need and how to maximize health equity, efficiency and effectiveness. Methodology is the review and web surfing on public health, social science, humanity and development literature. The increasing gap in health inequality, however, calls for further reform of the health system to achieve both equity and efficiency. Health is essential for survival and human capability. Good health enables people to participate in society. A new approach to efficient and cost-effective health service provision is community participation in health development. Participation can increase the skills and knowledge of local people, thus providing opportunities to improve their lives (empowerment). Analysis suggests four functional changes to achieve equity and efficiency in maximizing health outputs: reforms targeting universal coverage to achieve universal access to health; people-centred service delivery through concentrating on health services based on need; public policy change targeting integrated and multi-system health planning; and collective health system and community response to achieve health for all. Key words: Health, equity, efficiency, health maximization, participation.

INTRODUCTION Over the past fifty years, enormous health improvements have occurred in many countries with life expectancy at birth increasing from 46.5 years in 1950-551 to 68 years in 2009 (WHO)2. With economic growth and technological advances in the health sector, many countries have seen aggregate outcomes in health services and individual well-being. Achievement is uneven, however, and some groups are better able to access health services than others. At the same time, the HIV epidemic from 1990 onwards and emerging non-communicable diseases are threatening health development. Moreover, health inequity between and within countries is aggressively worsening. In terms of the HIV epidemic, the most severely affected region is Africa with 22.5 million HIV-infected people, about two-thirds of the total cases recorded3. Similarly, 80% of 36 million NCD deaths have occurred in low and middle income countries4. Uneven economic growth and weak health systems in many geographical areas and inequality among social groups are accelerating existing health problems and further impacting on future health outcomes. In addition, health worker migration and the need for skills

improvement put pressure on the health services in resource-limited countries and regions. The increasing trend of natural disasters and global warming is proving detrimental to the current health services and reducing their achievement. Immediate health action for better outcomes and coordinated responses, a broader agenda than that of current health development, is an urgent matter. According to Sen (1999), health improvement is a basic necessity for human development and democracy5 and the health system needs immediate measures to deliver a universal health services package and reduce health inequity. Globally, people are increasingly impatient with health services' failure to fulfil stated demands and changing needs. On the other hand, health services are struggling with limited resources, skill deficits, and the increasing burden of emerging health problems and ageing populations, and they cannot meet public expectations in many regions. After the foundation of World Health Organization in 1948, health development grew to fulfil the need for health equity and to address disproportionate suffering among poor and

Malaysian Journal of Public Health Medicine 2013, Vol. 13(1): 64-71 marginal populations. In the historical development of health, the following are examples in promoting health equity around the world: universal access to health, primary health care, health for all and people-centred health. Other examples are the Latin American social medicine movement and the People’s Health Movement on the Right to Health which set the broad social vision of the Millennium Development Goals, highlighting the central importance of health, the need for social and participatory action on health, and the core human value of equity in health6-8. Equity means fairness, giving everyone what belongs to them, and recognizing the specific conditions or characteristics of each person or human group regardless of gender, class, religion or age9. Health equity should provide health services fairly for people. Equity in health means that people's needs guide the distribution of opportunity for well-being10. Generally, health services are designed to meet people's need. It is not always easy, however, and there are many barriers to both supply (service provider) and demand (user). Traditional health systems in many countries are providing demand-based specialized clinical services and expensive treatment packages. Furthermore, health needs of poor people have been neglected by reason of lower demand. The lower demand of the poor, however, does not represent lower actual need but is related to the inability to pay for health service utilization or to the inaccessibility of health services because of social, geographical and other structural barriers. Furthermore, health systems paying little attention to equity and social justice will fail to get the best health outcomes for their money. World Health Organization asked for peoplecentred primary health care and health service delivery with better efficiency in health programmes and assessed their impact. World Health Organization in its World Health report 2008 entitled “Primary Health Care, Now More Than Ever” identifies the three most important pitfalls in health provision as11:  Health systems that focus disproportionately on a narrow offer of specialized curative care  Health systems where a command-and-control approach to disease control, focused on shortterm results, is fragmenting service delivery  Health systems where a hands-off or laissezfaire approach to governance has allowed unregulated commercialization of health to flourish.

METHODS The article is a narrative review for health policy and health services. We explore the need for and how to maximize health equity, efficiency and effectiveness. The progress and gaps in universal health development, health equity, effectiveness and efficiency, and community participation and empowerment are identified. The analysis has also been extended to recommend maximization of health outputs. Relevant literature was sought which addresses the review question. A rigorous search plan was necessary, including measures to reduce bias. A literature review and web surfing on public health, social science, humanity and development was done in the following databases: World Health Organization, World Bank, United Nations, PubMed, Medline, EMBASE. After a review of the titles, selected articles between 1960 and 2011 were reviewed. Literature from 1960 to 2011 is needed to understand health equity, efficiency and effectiveness. These principles were very popular in 1960s’ early health development, 1970-80s’ primary health care and 1990-00s’ cost effectiveness scholarly publication. All the studies collected were reviewed, collated, and categorized and reported for all relevant and important findings.

RESULTS AND DISCUSSION Health is essential for human. Considering better aggregate health outcomes and individual wellbeing, we analyse health in poverty reduction and human development, equity in health, efficiency and sustainability in health maximization, and community participation and empowerment. Health for poor is most productive because illpoor will be absent from work and lose income. Equity in health is also important because it possesses both instrumental and intrinsic value. Moreover, people in poor quartiles use fewer health resources than those in rich quartiles. Next, three factors−equity, efficiency and sustainability−in affecting health maximization were explored. Equity and health for poor is productive, however, it costs greatly. Then, efficiency and sustainability need to be considered. Most analysts agree government provision of health as most efficient and equitable. Furthermore, world health organization recommended pooling of health funding and compulsory contribution to pool fund to be efficient and sustainable. Finally, community participation is an aid to cost-

Malaysian Journal of Public Health Medicine 2013, Vol. 13(1): 64-71 effective and sustainable alternative in health development. Community participation enables people to make choices about their own lives so that health needs for communities can be properly identified and health services fairly and efficiently provided. Health in poverty reduction and human development Investing in health for the poor is economically productive. Poor people earn their living from daily labour, and their most important asset is their body. If they are not healthy, they will be unable to work or be underpaid. In most developing countries, poor households and families rely on daily income to survive. They also suffer extreme vulnerability to ill health, economic dislocation, and natural disasters12. For the poor, loss of daily income (because of absence from work owing to illness) is a disaster. First, there will be no more food and no more money for health treatment. Consequently, when ill-health is not properly treated, they will be absent from work and lose income. If they exchange their livelihood and even their home to pay for food and healthcare cost further indebtedness ensues and their children will leave school to work for additional family income. This will have further negative effects because the basic requirements for human development, health and education, will not be met so these children will not be able to obtain well-paid jobs. Finally, they will fall into the poverty trap. Although the poor are more resistant to frequent and minor illness, they are more vulnerable to rare and major illness because they are not easily able to access promotion, prevention and clinical services. In those countries which charge for health services, the poor will not be able to access them. Access by the poor to quality health services is very important. Health and basic education are building blocks for human development and poverty reduction. Globally, there will be poverty and social instability if we do not help the poor to maximize their health. Sachs reports that disease leads to extreme poverty, extreme poverty leads to political instability, political instability leads to state failure, and state failure leads to violence, criminality and even terrorism13. In addition, good health enables people to participate in society, with potentially positive consequences for economic performance14,15. Equity in health Health equity needs to be considered differently from economic development. Equity in health involves the status of both intrinsic and

instrumental value. Income inequality, on the other hand, has only instrumental value16. According to the S. Anand (2002), health is regarded as critical because it primarily affects the person's well-being and is a prerequisite to his/her functioning as an agent16. Inequality in health is an indicator of inequality in terms of basic freedom and the opportunities that people can enjoy throughout their lives. Economists often assert that income incentives are needed to elicit effort, skill, and enterprise. Income and economic assets can be distributed proportionately according to the capability of people. In contrast, health and basic necessities should be distributed less unequally regardless of people's ability to pay17. Health is more essential than income as money cannot be used if one is ill. Health is a direct manifestation of a person's well-being and it enables them to survive and to pursue what they value. The following paraphrases illustrate this; (Sen 1999) health contributes to a person's basic capability to function5, (United Nations Human Development Report 1996) basic needs such as health and education are at the forefront in promoting human well-being18, (Berlin 1969) positive freedom19, and (Rawls 1971) equality of opportunity to obtain primary goods such as health, education, etc., which means reduction of inequality in health is a direct requirement for justice20. Virginia and Sandra (2008) define equity in health care from a broader perspective; it is an ethical imperative not only because of the intrinsic worth of good health, or the value that society places on good health, but because, without good health, people would be unable to enjoy life’s other sources of happiness9. Investing in universal health development is more effective than income. Anand suggested aversion to inequality in health is likely to be greater value than aversion to inequality in income16. Equality in opportunity may lead us to be more averse to twofold infant mortality between groups than to twofold difference in adult or old age mortality rates, and concerned about disability in health (physical or mental) that prevents a person being mobile or gaining employment16. Further analysis of inter-group inequality in health would allow us to understand groups that are at high risk of or suffering particularly poor health. In general, people in poor quartiles use fewer health resources than those in rich quartiles. Gwatkin et al. (2004) reported that in low-income and middle-income countries, public money for health care tends to go to services that wealthy people use more than poor people21. Furthermore, early healthcare reforms

Malaysian Journal of Public Health Medicine 2013, Vol. 13(1): 64-71 incorporating a user fee and cost-sharing in developing countries showed less opportunity for the poor. Stephen et al. (1999) reported that once cost-sharing has been put into place, there is a tendency to maximize revenues by granting very few exemptions to poor people22. This is supported by other studies; (D Collins et al., 1996) government health facilities grant fee waivers for poverty below a certain, very low threshold23. Health systems need further reform in terms of allocation of resources and diversion of necessary expenditure to the neediest population. Reforms in the past 20 years which require payment at the point of use are limiting healthcare utility. Out-of-pocket expenditure for health care deters poorer people from using services, leading to untreated morbidity24. In two independent reports, such expenditure is shown to have a negative impact on human development: (Whitehead et al., 2001) further impoverishment or (Gottlieb 2000) bankruptcy25,26. Furthermore, (Xu et al., 2007) study reported that ‘The larger the proportion of health care that is paid out of pocket, the larger the proportion of households that are faced with catastrophic health expenditures’27. Equity, efficiency and sustainability in maximizing health Costing in health services is important in terms of decisions on investment and expenditure. Health systems around the world are selecting highly cost-effective programmes for funding prioritization. Those with the greatest need will be accorded less priority, however, because they live in less affluent areas with poorer health infrastructure. In general, investing in health services in more populated areas is more productive in terms of health outputs than in less populated rural areas. Health systems around the world can generally cover half to three-quarters of the population but beyond this costs rise exponentially. As regards cost-effectiveness, the World Bank (World Development Report 1994) recommended two packages for greater value; a public health package (AIDS prevention, immunization, schoolbased health services, nutrition, control of tobacco and alcohol) and essential clinical services (pregnancy-related maternal health, control of TB and sexually transmitted diseases, family planning, care of child-diarrhoea, acute respiratory infection, acute malnutrition, measles, malaria) to achieve high DALY (disability-adjusted life-year) gain28. The packages omit, however, elderly health, noncommunicable disease and other communicable diseases because they calculate cost per DALY gain without measuring individual health needs

and population health. Thus, policy targeting cost per DALY gain could merely mimic health equity within a population. Sustainability was another concern in international health programming and participation29. Different health care system approaches have been used in different countries. Among them, the three most common systems are direct government provision and through social security system, insurance system and third party payment (private payment, user fee, costsharing, community group or user group health funding). Most analysts agree that government provision and social security funding are more equitable and efficient than an insurance system (as for example in the United States of America) and third party payment or user payment (most prevalent in developing countries). The World Health Organization suggested the pooling of health funding as the best option, such as the social security system in Europe and the 30 baht health care scheme in Thailand. Similarly, the following are also recommended by the World Health Organization; proportion of population too poor to contribute subsidized through revenue, and compulsory contribution to pool fund to get enough funding and avoid rich and less risky to be opt out30. In addition, multiple pools, each with their own administrations and information systems, are also inefficient and make it difficult to achieve equity. On the other hand, private sectors in health services are focused on private benefit and costeffectiveness. Health is a public good, however, and social benefit beyond individual gain will not be achieved by the private sector. Health promotion to the community may not be provided by the private sector and communicable disease control related to environmental measures may be excluded too. Government support in such matters is essential and immediate cessation of uncontrolled commercialization in health services may need to be balance against population need. Conversely, public-private partnership has been used in some health programmes when the private sector can increase coverage: e.g. treatment of tuberculosis. Equity, efficiency and sustainability are interconnected. Inequities in health related to the social conditions that lead to illness are the main cause of health need. Furthermore, they are particularly common among socially disadvantaged populations which require health systems to be more responsive to population needs. Health programmes should rather expand coverage to the population in greatest need. In the interest of health equity, attention should be

Malaysian Journal of Public Health Medicine 2013, Vol. 13(1): 64-71 focused on community needs and demand. Graham and Kelly (2004) emphasize the importance of local needs, suggesting the goal of tackling health inequalities can be adapted to local needs and community priorities, enabling broad coalitions of support to be mobilized31. Similarly, empowering the community to manage their health needs through a primary health care approach using a mechanism most appropriate to their context and the available resources will be more efficient and sustainable. Furthermore, the central role of national health systems in addressing health inequities is essential. A country's health system must be supported by a mechanism whereby it is adequately resourced, functions well, and is accessible to all. Appropriately configured and managed health systems provide a vehicle to improve people’s lives, protecting them from the vulnerability of sickness, generating a sense of security, and building social cohesion within society; they can ensure that all groups benefit from socioeconomic development and they can generate the political support needed to sustain them32. On the thirtieth anniversary of primary health care in 2008, WHO explored four strategic reforms to improve equity and efficiency in healthcare services11. These were coverage reform and service delivery reform concerned with health service provision and public policy reform and leadership reform related to ministerial and national-international coordination. The reforms were targeted at more efficient and universal health services as follows:  Universal coverage reforms contribute to health equity and universal access to health.  Service delivery reforms re-organize health services around people’s needs and expectations while producing better outcomes.  Public policy reforms secure healthier communities by strengthening national and transnational public health interventions.  Leadership reforms replace disproportionate reliance on command and control with participatory leadership within the health system. To be more efficient and cost-effective, health improvement should be comprehensive and holistic. As regards comprehensiveness, access to health promotion will be limited for a society which has no basic education. Human resource development and technological advancement are also important to the quality of health services and further maximization of health output is essential.

Community participation and empowerment in promoting health A new approach to efficient and cost-effective health service provision is community participation in health development. Initially, community participation was introduced as a tool for developing community resources. Later, it became a tool for empowering communities to foster sustainable development. Morgan (2001) defined community participation as a utilitarian effort on the part of donors or governments to use community resources (land, labour and money) to offset the costs of providing services or an empowerment tool through which local communities take responsibility for diagnosing and working to solve their own health and development problems33. In historical health development, community participation shifted from a medically directed approach to a local people-led approach, notably moving from the compliance model or marginal participation to a collaborative model or substantial participation and finally to a community control model or structural participation. Robert Chambers (2007) described the development of three participation models for health: Rapid Rural Appraisal (1970s), Participatory Rural Appraisal (1990s) and Participatory Learning Action (2000s)34. Methodologically, Rapid Rural Appraisal was led by scientists to make a need assessment by asking local people to participate in providing information, Participatory Rural Appraisal got local people themselves to collect and analyse information, and Participatory Learning Action used a range of methods including mapping, ranking, flow charts, problem identification and prioritization enabling local people to express and enhance their knowledge and take action. Recently, community participation became an important mainstream agenda item as reflected by the World Bank's (1996) definition of community participation as a process through which stakeholders influence and share control over development initiatives and the decisions and resources which affect them35. Community participation creates a ‘social learning’ process whereby professionals and local people learn from each other and build working partnerships for sustainable improvements36,37. Furthermore, community participation enhances social justice and promotion of democracy. It is now an essential element of community health and other development programmes sponsored by NGOs and international donors. In community participation, health programmes are designed through active community participation or community empowerment. In this approach, working together and developing local capacity (training and skills development) is essential. In general,

Malaysian Journal of Public Health Medicine 2013, Vol. 13(1): 64-71 people seek solutions to problems when they have been involved in the process. Moreover, participation can increase the skills and knowledge of local people, thus providing opportunities to improve their lives (empowerment). Empowerment can provide opportunity enable people to make choices about their own lives so that health needs for communities can be properly identified and health services fairly and efficiently provided. Although individuals are at the centre of empowerment, Marmot (2007) argued for three interconnected dimensions, material, psychosocial, and political, reflecting the importance of empowerment among individuals, nations, institutions, and communities32. He stressed that every nation should empower people in all three dimensions individually and in society as a whole. Advancement in medicine is essential for health improvement. This alone will rarely be sufficient, however. In order to maximize utilization and modest treatment outcome, there is a need to empower individuals, communities, and whole countries. There is rigorous evidence of the importance of community empowerment through participatory health improvement: e.g. ‘A Partnership Plan to Improve the Health of the Public’ (Zahner et al., 2005); community participation and empowerment at the heart of effective health promotion (Heritage and Dooris, 2009); the Ottawa Charter for Health Promotion (World Health Organization, 1996), which gives priority to increasing community capacity and empowering individuals; and the Jakarta Declaration (World Health Organization, 1998)3841 . In conclusion, to achieve maximum health output in an efficient way, there must be community empowerment at all levels, individual, community and society. The study also has limitation. Health equity and efficiency are subjective and unable to easily compare in nominal term. Moreover, health infrastructure and disease burden are uneven both within and between countries. Nevertheless, the study review and reported most comprehensively.

The four parameters discussed—health for poor, health equity, efficiency and sustainability, and community participation—are important in maximizing health development. As a possible solution to those problems, i.e. achieving maximum health improvement with equitable distribution within the population, the following four functional changes are recommended for consideration.  Reforms targeting universal coverage; development of appropriate technology, human resource capacity for health services and community participation to achieve universal access to health.  People-centred service delivery: health services directed away from professional command towards people’s needs and expectations while producing better outcomes.  Public policy change; integrated health planning. Health at the centre of country development with multi-ministerial support and strengthening of national and transnational public health interventions including national policies in non-health ministries covering healthy environment, healthy city and infrastructure, healthy food, healthy lifestyle and sports development, etc.  Health system and collective community response for total health; improve health system performance through community empowerment; the community should be selfaware of health problems, seek a solution and participate in the whole process.

ACKNOWLEDGEMENT I fully acknowledge support of Professor Dr D. Kamarudin D. Mudin - School of Medicine, University Malaysia Sabah in his fullest support to my writing.

REFERENCES 1.

Moser K, Shkolnikov V, Leon D A. World mortality 1950-2000, divergence replace convergence from late 1980s. Bulletin of World Health Organization 2005; 83 (3): 202-9.

2.

World Health Organization. Life expectancy, Global Health Observatory (GHO) 2010. Available from http: www.who.int/gho/mortality_burden_disease /life_tables/en/ (access between April and September 2011).

CONCLUSION Given the disparity in health improvement between countries and emerging health problems, the world needs better design of health services to achieve equity and efficiency. On the other hand, limited resources and prioritization in health funding are unavoidable.

Malaysian Journal of Public Health Medicine 2013, Vol. 13(1): 64-71 3.

4.

UNAIDS. Global Report, UNAIDS report on the global aids epidemic 2010. Available from: http://www.unaids.org/en/media/unaids/co ntentassets/documents/unaidspublication/2 010/20101123_globalreport_en.pdf (access between April and September 2011). WHO. Global status report on noncommunicable diseases 2010. Available from: http://whqlibdoc.who.int/publications/2011 /9789240686458_eng.pdf (access between April and September 2011).

5.

Sen A. Development as Freedom. Oxford University Press: Oxford, 1999.

6.

United Nations. The right to the highest attainable standard of health: .08/11/2000. E/C.12/2000/4. (General Comments). Available from: http://www.unhchr.ch/tbs/doc.nsf/%28sym bol%29/E.C.12.2000.4.En (access between May and August 2011).

7.

Tajer D. Latin American social medicine roots, development during the 1990s, and current challenges. American Journal of Public Health 2003; 93(12): 2023-7.

8.

United Nations. United Nation Millennium Development Goals, 2010. Available from http: www.who.int/topics/millennium_developme nt_goals/en/ (access between March and July 2011).

9.

Virginia LRS, Sandra TS. Equity in Health Care. Cuad. Bioét 2008; 19(2ª): 355-68.

10. WHO. Health Promotion Glossary. Geneva: World Health Organization, 1998. 11. World Health Organization. The world health report 2008: primary health care now more than ever. Geneva: World Health Organization, 2008. 12. The World Bank. World Development Report 2001: attacking poverty. Washington: The World Bank, 2001. 13. Sachs J D. Health in the developing world achieving the Millennium Development Goals, Bulletin of the World Health Organization 2004; 82(12): 947-9. 14. Sachs J D. Macroeconomics and health: investing in health for economic

development. Geneva: Organization, 2001.

World

Health

15. Mackenbach JP, Meerding WJ, Kunst AE. Economic implications of health inequalities in the European Union. European Commission: Netherland, 2007. 16. Anand S. Concern for Equity in Health. Journal of Epidemiology Community Health 2002; 56: 485-7. 17. Tobin J. On limiting the domain of inequity. The Journal of Law and Economics 1970; 13: 263-77. 18. United Nations Development Programme. Human Development Report 1996. Oxford University Press: New York, 1996. 19. Berlin I. Four essays on Liberty. Oxford University Press: Oxford, 1969. 20. Rawls J A. Theory of Justice. Harvard University Press: Harvard, 1971. 21. Gwatkin DR, Bhuiya A, Victora CG. Making health systems more equitable. Lancet 2004; 364: 1273-80. 22. Stephen J F, Clifford W K, Anne M. Why the poor pay more household curative expenditures in rural Sierra Leone. International Journal of Health Planning and Management 1999; 14: 179-99. 23. Collins D, Quick J D, Musau S N, Kraushaar D, Hussein I M. The fall and rise of cost sharing in Kenya, the impact of phased implementation. Health Policy And Planning 1996; 11(1): 52-63. 24. Palmer N, Mueller DH, Gilson L, Mills A, Haines A. Health financing to promote access in low income settings—how much do we know? Lancet 2004; 364: 1365-70. 25. Whitehead M, Dahlgren G, Evans T. Equity and health sector reforms, can low-income countries escape the medical poverty trap. Lancet 2001; 358: 833-6. 26. Gottlieb S. Medical bills account for 40% of bankruptcies. BMJ 2000; 320: 1295. 27. Ke X, David B E, Guidio C, Ana MAR, Philip M, Timothy E. Protecting households from catastrophic health spending. Health Affair 2007; 26 (4): 972-83.

Malaysian Journal of Public Health Medicine 2013, Vol. 13(1): 64-71 28. The World Bank. World Development Report 1993: investing in health. Washington: The World Bank, 1993.

40. WHO. Milestones in health promotion: Ottawa charter for health promotion 1986. Geneva: World Health Organization, 2009.

29. Anne LaFond. Sustaining Primary Health Care. Save the Children Fund: London, 1995.

41. WHO. Milestones in health promotion: Jakarta declaration on health promotion into the 21st century 1997. Geneva: World Health Organization, 2009.

30. WHO. World Health Report 2010: health system financing, the path to universal coverage. Geneva: World Health Organization, 2010. 31. NHS UK Health Development Agency Report Health Inequality, concepts, frameworks and Policy, 2004. 32. Marmot M. Achieving health equity- from root causes to fair outcomes. Lancet 2007; 370: 1153-63. 33. Morgan L M. Community participation in health, perpetual allure, persistent challenges. Health Policy And Planning 2001; 16(3): 221-30. 34. Robert C. From PRA to PLA and pluralism, practice and theory. Institute of Development Studies at the University of Sussex: Brighton, 2007. 35. The World Bank. Reflections from the Participation Sourcebook. 1996. Available from: http:www.wds.worldbank.org/external/defa ult/WDSContentServer/WDSP/IB/2003/12/30 /000160016_ 20031230144215/Rendered/PDF/273850sdn2 50see0also018201.pdf) (access between April and September 2011). 36. Rafkin S B. Paradigm loss-toward a new understanding of community participation in health programmes. Acta Tropica 1996; 61: 79-92. 37. Rafkin SB, Muller F and Bichmann W. Primary health care in measuring participation. Social Science Medicine 1998; 26: 931-40. 38. Zahner S J, Kaiser B, Kapelke-Dale J. Local partnerships for community assessment and planning. Journal of Public Health Management & Practice 2005; 11(5): 460-4. 39. Heritage Z, Dooris M. Community participation and empowerment in healthy cities. Health Promotion International 2009; 24(S1): i45-i55.