Equity in Health

South African Health Review 2016
Padarath A; King J; Mackie E; Casciola J: Health Systems Trust, 2016

The 2016 South African Health Review presents evidence on the current legislative and policy framework guiding healthcare delivery, the challenges that underpin the performance of the health system, on water and food; and on personnel and programmes in the public health system. The report indicates that although tackling HIV targets will be daunting, they are likely to be affordable and cost-effective if implemented in a phased way and if annual increments to Government AIDS budgets are sustained. The report also discusses South Africa’s pharmaceutical pricing and transparency and the concept of and benefit from health research observatories. Finally the report provides a wide range of information on health trends, with a specific focus on the data needed to monitor non-communicable diseases.

Spatial modelling of perinatal mortality in Mchinji, Malawi
Banda M; Kazembe L; Lewycka S; King C; Phiri T; Masache G; Kazembe P; Mwasambo C: Spatial and spatio-temporal epidemiology16, 50-58, 2016

Annual global estimates of perinatal mortality show Malawi among sub-Saharan Africa with the highest rates. Targeted interventions are required to reduce this mortality. This study aimed to quantify small-scale geographical variations in perinatal mortality, and estimate risk factors associated with perinatal mortality in Mchinji district. Factors associated with reduced perinatal mortality were: previous pregnancy; early and consistent use of antenatal care; syphilis test; abdominal examination; pregnancy danger signs advice; skilled birth attendant; normal labour duration; gestation period of at least 9 months; and normal delivery. Perinatal babies whose mothers had a blood test were associated with high probability of dying. Perinatal babies from mothers between 16 and 40 years had reduced prevalence of dying while those aged less than 16 years and greater than 40 years were associated with higher prevalence of dying.

Trends and risk factors for childhood diarrhoea in Sub-Saharan countries (1990 - 2013): Assessing the neighbourhood inequalities.
Bado A; Susuman A; Nebie E: Global Health Action 9(30166), May 2016,

This paper assesses the risk factors of and neighborhood inequalities in diarrhoeal morbidity among under-5 year old children in selected countries in sub-Saharan Africa over the period 1990–2013, using DHS data from selected countries. The findings showed that the proportion of diarrhoeal morbidity among under-5 children varied considerably across the cohorts of birth from 10% to 35%, with increasing inequalities across DHS rounds. The main risk factors were the child’s age, size of the child at birth, the quality of the main floor material, mother’s education and her occupation, type of toilet, and place of residence.

Inequality in disability-free life expectancies among older men and women in six countries with developing economies
Santosa A; Schröders J; Vaezghasemi M; Ng N: Journal of Epidemiology and Community Health, March 2016, doi:10.1136/jech-2015-206640

Evidence on trends and determinants of disability-free life expectancies (DFLEs) are available in high-income countries but less in low and middle-income countries (LMICs). This study examines the levels of and inequalities in life expectancy(LE), disability and DFLE between men and women across different age groups aged 50 years and over in six countries with developing economies. This study utilised the cross-sectional data (n=32 724) from the WHO Study on global AGEing and adult health in China, Ghana, India, Mexico, the Russian Federation and South Africa in 2007–2010. Disability was measured with the activity of daily living instrument.. The disability prevalence ranged from 13% in China to 54% in India. Women were more disadvantaged with higher prevalence of disability across all age groups. Though women had higher LE, their proportion of remaining LE free from disability was lower than men. There are inequalities in the levels of disability and DFLE among men and women in different age groups among people aged over 50 years in these six countries. Countermeasures to decrease intercountry and gender gaps in DFLE, including improvements in health promotion and healthcare distribution, with a gender equity focus, are needed.

One year into the Zika outbreak: how an obscure disease became a global health emergency
World Health Organisation: Geneva, May 2016

By May 2016, tests conducted at Brazil’s national reference laboratory conclusively identified that a new mosquito-borne disease - Zika- had indeed arrived in the Americas, though no one knew what that might mean. Although the re-profiling of Zika from a benign disease to a global health emergency stimulated a flurry of research, the disease remains poorly understood at levels ranging from its virology and epidemiology to the clinical spectrum of complications it can cause. No one can answer questions about further international spread with certainty, though theories abound. As the virus has been detected in parts of Asia and Africa for several decades, some level of endemicity is assumed, though no one knows whether presence of the virus over time has resulted in widespread or low-level immune protection or possibly no protection at all. In April 2016, researchers in Ecuador and the northeastern part of Brazil reported the detection of Zika in monkeys, suggesting a new transmission cycle that could allow the virus to persist. In Brazil, the virus detected in monkeys was identical to the one circulating in humans. Researchers at a government laboratory in Mexico reported detection of the Zika virus in female Aedes albopictus mosquitoes collected in the wild, as opposed to experimentally infected – a first for the western hemisphere. As the mosquito can survive the winter in temperate climates, its ability to carry the Zika virus could expand the map of areas at risk of Zika virus transmission.

Our future: a Lancet commission on adolescent health and wellbeing
The Lancet Commission: 11 May 2016

Decades of neglect and chronic underinvestment have had serious detrimental effects on the health and wellbeing of adolescents aged 10–24 years, according to a major new Lancet Commission on adolescent health and wellbeing. Two-thirds of young people are growing up in countries where preventable and treatable health problems like HIV, early pregnancy, unsafe sex, depression, injury, and violence remain a daily threat to their health, wellbeing, and life chances. Evidence shows that behaviours that start in adolescence can determine health and wellbeing for a lifetime. Adolescents today also face new challenges, including rising levels of obesity and mental health disorders, high unemployment, and the risk of radicalisation. Adolescent health and wellbeing is also a key driver of a wide range of the Sustainable Development Goals on health, nutrition, education, gender, equality and food security, and the costs of inaction are enormous, warn the authors. While efforts to improve the health of children under 5 have led to major improvements in younger ages, the leading causes of death for young people aged 10-24 years have changed remarkably little from 1990 to 2013, with road injuries, self-harm, violence, and tuberculosis remaining in the top five. Maternal disorders were the leading cause of death in young women in 2013, responsible for 17% of deaths in women aged 20–24 years and 11.5% in girls aged 15–19 years. The leading risk factors for death in young people aged 10–14 years have not changed in the past 23 years, with unsafe water, unsafe sanitation, and handwashing remaining in the top three. Diarrheal and intestinal diseases are still responsible for 12% of deaths in 10–14 year old girls. Injuries, mental health conditions, common infectious diseases, and sexual and reproductive health problems are the dominant health problems in young people. The two main contributors to health loss worldwide for both sexes are mental health disorders and road injuries.

Risk factors affecting child cognitive development: a summary of nutrition, environment, and maternal–child interaction indicators for sub-Saharan Africa
Ford N; Stein A: Journal of Developmental Origins of Health and Disease 7(2) pp 197-217

An estimated 200 million children worldwide fail to meet their development potential due to poverty, poor health and unstimulating environments. Missing developmental milestones has lasting effects on adult human capital. Africa has a large burden of risk factors for poor child development. This paper identifies the scope for improvement at the country level in three domains – nutrition, environment, and mother–child interactions. It uses nationally representative data from large-scale surveys, data repositories and country reports from 2000 to 2014. Overall, there was heterogeneity in performance across domains, suggesting that each country faces distinct challenges in addressing risk factors for poor child development. Data were lacking for many indicators, especially in the mother–child interaction domain. The authors argue that there is a need to improve routine collection of high-quality, country-level indicators relevant to child development to assess risk and track progress.

Trends in socioeconomic disparities in a rapid under-five mortality transition: a longitudinal study in the United Republic of Tanzania
Kanté A; Nathan R; Jackson E; Levira F; Helleringer S; Masanja H; Phillips J: Bulletin of the World Health Organisation 94(4), 233-308

This study explored trends in socioeconomic disparities and under-five mortality rates in rural parts of the United Republic of Tanzania between 2000 and 2011. The authors used longitudinal data on births, deaths, migrations, maternal educational attainment and household characteristics from the Ifakara and Rufiji health and demographic surveillance systems. They estimated hazard ratios (HR) for associations between mortality and maternal educational attainment or relative household wealth, using Cox hazard regression models. The under-five mortality rate declined in Ifakara from 132.7 deaths per 1000 live births in 2000 to 66.2 in 2011 and in Rufiji from 118.4 deaths per 1000 live births in 2000 to 76.2 in 2011. Combining both sites, in 2000–2001, the risk of dying for children of uneducated mothers was 1.44 times higher than for children of mothers who had received education beyond primary school and in 2010–2011, the HR was 1.18. In contrast, mortality disparities between richest and poorest quintiles worsened in Rufiji, from 1.20 in 2000–2001 to 1.48 in 2010–2011, while in Ifakara, disparities narrowed from 1.30 to 1.15 in the same period. While childhood survival has improved, mortality disparities still persist. The authors thus argue for policies and programmes that both reduce child mortality and address socioeconomic disparities.

Equity in Maternal Health in South Africa: Analysis of Health Service Access and Health Status in a National Household Survey
Wabiri N; Chersich M; Zuma K; Blaauw D; Goudge J; Dwane N: PLoS One 8(9), 2013

South Africa is increasingly focused on reducing maternal mortality. Documenting variation in access to maternal health services across one of the most inequitable nations could assist in re-direction of resources. This analysis draws on a population-based household survey that used multistage-stratified sampling. Women, who in the past two years were pregnant (1113) or had a child (1304), completed questionnaires and HIV testing. Poorest women had near universal antenatal care coverage (ANC), but only 39.6% attended before 20 weeks gestation; this figure was 2.7-fold higher in the wealthiest quartile. Women in rural-formal areas had lowest ANC coverage (89.7%), percentage completing four ANC visits (79.7%) and only 84.0% were offered HIV testing. Testing levels were highest among the poorest quartile (90.1% in past two years), but 10% of women above 40 or with low education had never tested. Skilled birth attendant coverage (overall 95.3%) was lowest in the poorest quartile (91.4%) and rural formal areas (85.6%). Around two thirds of the wealthiest quartile, of white and of formally-employed women had a doctor at childbirth, 11-fold higher than the poorest quartile. Overall, only 44.4% of pregnancies were planned, 31.7% of HIV-infected women and 68.1% of the wealthiest quartile. Self-reported health status also declined considerably with each drop in quartile, education level or age group. Aside from early ANC attendance and deficiencies in care in rural-formal areas, inequalities in utilisation of services were mostly small, with some measures even highest among the poorest. Considerably larger differences were noted in maternal health status across population groups. This may reflect differences between these groups in quality of care received, HIV infection and in social determinants of health.

Health Equity: The Key for Transformational Change
Garay J; Kelley N; Chiriboga D: Editorial Nacional de Salud y Seguridad Social (EDNASSS), Costa Rica, 2015

The authors of this paper, drawing also on experience in primary health care in Zimbabwe, developed a "healthy, feasible and sustainable (HFS)" model utilising trends in readily available data from 1960s onwards in detailed tables, figures and maps and identifying specific countries which fit the criteria of the model. They also identify countries and population subgroups affected by inequity, with practical insights to eliminate global health inequities. They quantify the cost of bridging the global health equity gap, and outline mechanisms to finance the necessary interventions through a binding global redistribution system. This is compared with what is considered to be an outdated, arbitrary and inefficient international cooperation model. The approach considers global levels of poverty and excessive global accumulation, which abuses natural resources in such a way as to deprive current and future generations from the access they deserve, making reference to the concept of inter-generational equity. The online book discusses the difference between equity and equality, the global burden of health equity, the minimum income threshold for dignity, the maximum threshold of income above which excessive accumulation or hoarding occurs, and how resource hoarding is directly linked to the burden of health equity; while also proposing a holistic health index, including healthy life expectancy by gender, the happiness index, and life-years lost of others due to the hoarding effect and to exhausting effect. The methodology provides tools to defend the right to health for all by supporting the development of binding instruments linked to concrete health standards attainable through a financially sustainable mechanism.

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