Equity in Health

Prioritizing action on health inequities in cities: An evaluation of Urban Health Equity Assessment and Response Tool (Urban HEART) in 15 cities from Asia and Africa
Prasad A; Kano M; Dagg K; Mori H; Senkoro H; Ardakani M; Elfeky S; Good S; Engelhardt K; Ross A; Armada F: Social Science & Medicine145, 237–242 November 2015

Following the recommendations of the Commission on Social Determinants of Health (2008), the World Health Organisation (WHO) developed the Urban Health Equity Assessment and Response Tool (HEART) to support local stakeholders in identifying and planning action on health inequities. This report analysed the experiences of cities in implementing Urban HEART to inform how the tool could support local stakeholders better in addressing health inequities. Independent evaluations were conducted in 2011–12 on Urban HEART piloting in 15 cities from seven countries in Asia and Africa: Indonesia, Iran, Kenya, Mongolia, Philippines, Sri Lanka, and Vietnam. Local or national health departments led Urban HEART piloting in 12 of the 15 cities. Improving access to safe water and sanitation was a priority equity-oriented intervention in 12 of the 15 cities, while unemployment was addressed in seven cities. Cities who piloted Urban HEART displayed confidence in its potential by sustaining or scaling up its use within their countries. Engagement of a wider group of stakeholders was more likely to lead to actions for improving health equity. Indicators that were collected were more likely to be acted upon. Quality of data for neighbourhoods within cities was one of the major issues.

Obesity trends and risk factors in the South African adult population
Cois A; Day C: BMC Obesity 2(42), October 2015,

Obesity prevalence is increasing globally and contributes substantially to the burgeoning burden of non-communicable diseases. South Africa is particularly affected by this increasing trend and cross-sectional evidence suggests socioeconomic and behavioural variables as possible drivers. However, no large scale longitudinal study has attempted the direct identification of risk factors for progression towards obesity. This study analysed data on 10,100 South African adults (18 years and over) randomly selected in 2008 and successfully recontacted in 2010 and 2012. Latent Growth Modelling was used to estimate the average rate of change in body mass index (BMI) during the study period, and to identify baseline characteristics associated with different trajectories. The overall rate of change in BMI during the study period was +1.57 kg/m 2 per decade, and it was higher among women than among men. Female gender, younger age, larger waist circumference, white population group and higher household income per capita were baseline characteristics associated with higher rates of change. The association between tobacco use and obesity was complex. Smoking was associated with greater waist circumference at baseline but lower rates of increase in BMI during the study period. Quitting smoking was an independent predictor of BMI increase among subjects with normal weight at baseline. Among subjects with baseline BMI lower than 25 kg/m 2 , rates of changes were higher in rural than urban areas, and inversely related to the frequency of physical exercise. A strong positive trend in BMI remains in South Africa and obesity prevalence is likely to increase. Trends are not homogeneous, and high risk groups (subjects with high socioeconomic status, rural dwellers, young women) and modifiable risk factors (physical inactivity) can be targeted. Subjects quitting smoking should receive additional weight-loss support in order that the numerous health benefits of cessation are not reduced by increasing BMI. Centrally obese subjects should be targeted in campaigns.

Can world’s worst case of inequality be fixed with Pikettian posturing?
Bond P: Pambuzuka News, Issue 745, October 2015

Among the hot ideological wars South Africans wage, the author suggests that none is as violent to the truth as the rejigging of the Gini Coefficient measuring income inequality. (This number is zero if everyone shares income perfectly equally, and one if only a sole person gets it all.) The author suggests that if you measure income prior to state redistribution, South Africa’s Gini – as measured in November 2014 by the World Bank – is 0.77, the highest of any major country. The World Bank’s Pretoria office is reported to claim that the Gini is reduced from 0.77 to 0.59 once all manner of state social spending (social grants, education and health) is included in the calculation. The author projects, however, that the National Development Plan (NDP) will reduce the Gini only from 0.69 (in 2012 measured slightly differently from the Bank) to 0.60, i.e., with the income share earned by the poorest 40 percent rising from 6 to just 10 percent. This, it is noted, will make South Africa's levels of inequality higher than any other major country in the world. Bond indicates that a policy of growth-through-redistribution is needed for the country but that advancing this depends on the balance of political forces more than ideological debates.

Did Equity of Reproductive and Maternal Health Service Coverage Increase during the MDG Era? An Analysis of Trends and Determinants across 74 Low- and Middle-Income Countries
Alkenbrack S; Chaitkin M; Zeng W; Couture T; Sharma S: PLoS ONE 10(9), September 2015, doi:10.1371/journal.pone.0134905

Despite widespread gains toward the 5th Millennium Development Goal (MDG), pro-rich inequalities in reproductive health (RH) and maternal health (MH) are pervasive throughout the world. This study explores how equity of service coverage differs across countries, and explores what policy factors are associated with a country’s progress, or lack thereof, toward more equitable RH and MH service coverage. The authors used RH and MH service coverage data from Demographic and Health Surveys (DHS) for 74 countries to examine trends in equity between countries and over time from 1990 to 2014 in both relative and absolute equity. Relative equity for the coverage of RH and MH services has continually increased across all countries over the past quarter century; however, inequities in coverage persist, in some countries more than others. Multivariate analysis shows that higher education and greater political commitment (measured as the share of government spending allocated to health) were significantly associated with higher equity of service coverage. Neither country income, i.e., GDP per capita, nor better governance were significantly associated with equity.

Global, regional, and national levels and trends in under-5 mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Inter-agency Group for Child Mortality Estimation
You D; Hug L; MA; Ejdemyr S; Idele P; Hogan D; Mathers C; Gerland P; Rou New J; Alkema L; The Lancet, September 2015, doi: http://dx.doi.org/10.1016/S0140-6736(15)00120-8

In 2000, world leaders agreed on the Millennium Development Goals (MDGs). MDG 4 called for a two-thirds reduction in the under-5 mortality rate between 1990 and 2015. The authors aimed to estimate levels and trends in under-5 mortality for 195 countries from 1990 to 2015 to assess MDG 4 achievement and then intended to project how various post-2015 targets and observed rates of change will affect the burden of under-5 deaths from 2016 to 2030. To provide insights into the global and regional burden of under-5 deaths associated with post-2015 targets, the authors constructed five scenario-based projections for under-5 mortality from 2016 to 2030 and estimated national, regional, and global under-5 mortality rates up to 2030 for each scenario. The global under-5 mortality rate has fallen from 90·6 deaths per 1000 livebirths (90% uncertainty interval 89·3–92·2) in 1990 to 42·5 (40·9–45·6) in 2015. The global under-5 mortality rate reduced by 53% (50–55%) in the past 25 years and therefore missed the MDG 4 target. Based on point estimates, two regions—east Asia and the Pacific, and Latin America and the Caribbean—achieved the MDG 4 target. 62 countries achieved the MDG 4 target, of which 24 were low-income and lower-middle income countries. Between 2016 and 2030, 94·4 million children are projected to die before the age of 5 years if the 2015 mortality rate remains constant in each country, and 68·8 million would die if each country continues to reduce its mortality rate at the pace estimated from 2000 to 2015. If all countries achieve the Sustainable Development Goal of an under-5 mortality rate of 25 or fewer deaths per 1000 livebirths by 2030, the authors project 56·0 million deaths by 2030. About two-thirds of all sub-Saharan African countries need to accelerate progress to achieve this target. Despite substantial progress in reducing child mortality, concerted efforts remain necessary to avoid preventable under-5 deaths in the coming years and to accelerate progress in improving child survival further. Urgent actions are needed most in the regions and countries with high under-5 mortality rates, particularly those in sub-Saharan Africa and south Asia.

Albinism in Africa: a medical and social emergency
Brilliant M: International Health 7(4): 223-225, 2015

People with albinism (PWA) face a variety of medical and social problems, ranging from poor vision and skin cancer to murder for their body parts for witchcraft in East Africa. PWAs are reported to face enormous challenges in East Africa. They have very poor, uncorrectable vision and, as a result, they are disadvantaged in schools and in employment opportunities. At best, the authors report, they are discriminated against; at worst, they are hunted and often killed for their body parts for witchcraft use. If they survive these attacks, they are very likely to develop skin cancer that is most often untreated, leading to a preventable premature death. However, awareness and activism can help PWAs to lead more normal lives by addressing their medical and social needs. Above all, the authors urge people to make efforts to stop atrocities against PWA.

Mortality risks in children aged 5–14 years in low-income and middle-income countries: a systematic empirical analysis
Hill K; Zimmerman L; Jamison D: The Lancet Global Health, 3: e609–16, 2015

Health priorities since the UN Millennium Declaration have focused strongly on children younger than 5 years. The health of older children (age 5–9 years) and younger adolescents (age 10–14 years) has been neglected until recently, especially in low-income and middle-income countries, and mortality measures for these age groups have often been derived from overly flexible models. The authors report global and regional empirical mortality estimates for children aged 5–14 years in low-income and middle-income countries, and compare them with ones from existing models, using birth-history data from a 25-year period from 1986 of Demographic and Health Surveys programme for 84 World Bank low-income and middle-income countries, and data about household deaths in China from their 1990 and 2010 censuses. The mean risk of a child dying at age 5–14 years in low-income and middle-income countries is about 19% of the risk of dying between birth and age 5 years (12% at age 5–9 plus 7% at age 10–14). According to their estimates, the total number of deaths at ages 5–14 years in low-income and middle-income regions fell from about 2·4 million in 1990 to about 1·5 million in 2010. From estimates the authors concluded there to have been 200 000 (16%) more deaths at ages 5–14 than in the UN report; however, the estimates exceeded GBD estimates by more than 700 000 (87%). The average annual rate of decline in mortality at age 5–9 years (about 3%) slightly exceeded that for ages 0–4 years (2·8%), but progress has been slower for age 10–14 years (about 2%). Their analysis suggests that mortality risks nowadays in the age range 5–14 years in low-income and middle-income countries are rather higher (relative to mortality in children younger than 5 years) than would be expected on the basis of historical evidence. The authors argue that global policy emphasis on reduction of mortality in children younger than 5 years should be broadened to include older children and adolescents.

Tanzania's Countdown to 2015: an analysis of two decades of progress and gaps for reproductive, maternal, newborn, and child health, to inform priorities for post-2015
Afnan-Holmes H; Magoma M; John T; Levira F; Msemo G; Armstrong C; Martínez-Álvarez M; Kerber K; Kihinga C; Makuwani A; Rusibamayila N; Hussein A; Lawn J; Tanzanian Countdown Country Case Study Group: The Lancet Global Health 3(7) e396–e409, 2015

Tanzania is on track to meet Millennium Development Goal (MDG) 4 for child survival, but is making insufficient progress for newborn survival and maternal health (MDG 5) and family planning. To understand this mixed progress and to identify priorities for the post-2015 era, Tanzania was selected as a Countdown to 2015 case study. The authors analysed progress made in Tanzania between 1990 and 2014 in maternal, newborn, and child mortality, and unmet need for family planning, in which they used a health systems evaluation framework to assess coverage and equity of interventions along the continuum of care, health systems, policies and investments, while also considering contextual change (eg, economic and educational). In the past two decades, Tanzania's population has doubled in size, necessitating a doubling of health and social services to maintain coverage. Trends along the continuum of care varied, with preventive child health services reaching high coverage (≥85%) and equity (socioeconomic status difference 13–14%), but lower coverage and wider inequities for child curative services (71% coverage, socioeconomic status difference 36%), facility delivery (52% coverage, socioeconomic status difference 56%), and family planning (46% coverage, socioeconomic status difference 22%). Mixed progress in reproductive, maternal, newborn, and child health in Tanzania were found to indicate a complex interplay of political prioritisation, health financing, and consistent implementation.

Inequalities in health: definitions, concepts, and theories
Arcaya M; Arcaya A; Subramanian S: Global Health Action 8 (27106), June 2015

This article defines and distinguishes between unavoidable health inequalities and unjust and preventable health inequities. The authors describe the dimensions along which health inequalities are commonly examined, including across the global population, between countries or states, and within geographies, by socially relevant groupings such as race/ethnicity, gender, education, caste, income, occupation, and more. Different theories attempt to explain group-level differences in health, including psychosocial, material deprivation, health behaviour, environmental, and selection explanations. Concepts of relative versus absolute; dose–response versus threshold; composition versus context; place versus space; the life course perspective on health; causal pathways to health; conditional health effects; and group-level versus individual differences are vital in understanding health inequalities. The authors close by reflecting on what conditions make health inequalities unjust, and consider the merits of policies that prioritise the elimination of health disparities versus those that focus on raising the overall standard of health in a population.

Global evidence on inequities in rural health protection: New data on rural deficits in health coverage for 174 countries
Scheil-Adlung X: International Labour Office, ESS Document No. 47, Geneva, 2015

While inequities in health protection are increasingly recognized as an important issue in current policy debates on universal health coverage (UHC) and in the post-2015 agenda, the rural/urban divide is largely ignored. This paper presents global estimates on rural/urban disparities in access to health-care services. The report uses proxy indicators to assess key dimensions of coverage and access involving the core principles of universality and equity. Based on the results of the estimates, policy options are discussed to close the gaps in a multi-sectoral approach addressing issues and their root causes both within and beyond the health sector.

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