Inequalities in health have received considerable attention from health scientists and economists. In South Africa, inequalities exist in socio-economic status (SES) and in access to basic social services and are exacerbated by inequalities in health. While health systems, together with the wider social determinants of health, are relevant in seeking to improve health status and health inequalities, those that need good quality health care too seldom get it. Studies on the burden of ill-health in South Africa have shown consistently that, relative to the wealthy, the poor suffer more from more disease and violence. This paper specifically investigates socio-economic related health inequality in South Africa and seeks to understand how the burden of self-reported illness and disability is distributed and whether this has changed since the early 2000s. The study demonstrates the existence of socio-economic gradients in self-reported ill-health in South Africa. The burden of the major categories of ill-health and disability is greater among lower than higher socio-economic groups. Even non-communicable diseases, which are frequently seen as diseases of affluence, are increasingly being reported by lower socio-economic groups. For instance, the concentration index of flu (and diabetes) declined from about 0.17 (0.10) in 2002 to 0.05 (0.01) in 2008.
Equity in Health
Globally, 12% of women smoke, 22% in developed and 9% in developing countries, according to this article. While smoking has peaked in men and begun a slow decline, it is predicted that by 2025, 20% of women worldwide will be smokers, with so many younger women taking up the habit. Tobacco transnationals minimise the dangers of smoking in powerful advertising that goes round the globe, while health agencies and institutions strive to counter these media messages on shoestring budgets - an astounding asymmetry that endangers the health of millions, the author notes. The author argues that we have to go beyond banning tobacco advertising and ‘demarket’ smoking and counter the positive images that permeate our culture with more sophisticated presentations of the threat to health. Stakeholders also need to create more barriers to tobacco access - in addition to those already banning sales to youngsters and raising cigarette prices - aligning education and legislation for greater effect. And finally, policy makers need to understand more fully the forces that influence people - particularly young women - to start smoking. It is not enough to simply warn people of the dangers of smoking, the article concludes – stronger measures are needed.
The United Nations (UN) High-Level Meeting on Non-communicable Diseases (NCDs) has helped raise awareness about the burden of NCDs, but the authors of this article caution that the real work of preventing and controlling NCDs must begin. They put forward several important steps that must be taken immediately. Governments need to implement the commitments in the Political Declaration that call for acceleration of the Framework Convention on Tobacco Control (FCTC), a global public health treaty focused on reducing the five million deaths per year caused by tobacco use. In addition, national plans to address NCDs need to be developed and NCDs need to be incorporated into the United Nations’ Millennium Development Goals. Clear, effective, and achievable targets to reduce NCDs - developed with input from health experts and civil society - need to be established and monitored by the World Health Organisation. And, importantly, global and national funding needs to be mobilised by governments, the private sector and civil society so that these plans can be effectively implemented, particularly in low- and middle-income countries. Moreover, the global health and development community must commit to greater collaboration across sectors and disease groups. Vertical interventions that target one disease at a time must be folded into comprehensive horizontal health programmes that promote overall health and wellness across the individual’s lifespan.
The World Health Organisation estimates that global warming and trends in rainfall due to human-induced climate change already claim over 150,000 lives annually. Diseases associated with climate change include heart and lung disease due to heat waves, increased spread of infectious diseases, and malnutrition due to crop failures. Sub-Saharan Africa is one of the most vulnerable regions, especially its sprawling cities where the effects of urbanisation aggravate extreme climatic events. More people die from the effects of climate change in Africa than anywhere else. Given the devastating and growing impact of climate change on health, it is ironic that health systems themselves contribute substantially to climate change through their enormous greenhouse gas (GHG) emissions, the authors of this article note. While no data exist for South Africa, estimates from the United Kingdom indicate that the country’s National Health Service contributed 25% of public sector emissions in 2004. The authors emphasise that the parallel policy initiatives of South Africa’s proposed National Health Insurance and ‘Re-engineering Primary Health Care’ initiative could, if thoughtfully implemented, address three crises simultaneously: the health crisis, the employment crisis and the carbon emissions crisis.
In this background paper to the World Conference on the Social Determinants of Health, held in October 2011, the World Health Organisation (WHO) argues that poor progress in the implementation of a social determinants approach reflects in part the inadequacy of governance at the local, national and global levels to address the key problems of the 21st century. WHO proposes a number of priority strategies for action. In terms of governance, WHO argues that governments should build good governance for action on the social determinants of health by implementing collaborative action between sectors (intersectoral action). WHO further recommends that governments should promote participation by: creating the conditions for participation; playing a role as brokers in participation and ensuring representativeness; and facilitating participation by civil society. WHO also considers the role of the health sector in reducing health inequities, arguing that the sector should: execute its role in governance for social determinants; re-orient health care services and public health programmes to reduce inequities; and institutionalise equity into health systems governance. With regard to global action on social determinants, international organisations, non-governmental agencies, bilateral co-operation partners and governments need to align their efforts and priorities for addressing the social determinants of health. Progress also needs to be monitored, as governments should: use measurement and analysis to inform policies and build accountability on social determinants; identify sources, select indicators, collect data, and set targets; move forward despite unavailability of systematic data; and disseminate data on health inequities and social determinants and integrate these data into policy processes.
This latest edition of Roll Back Malaria’s (RBM) global progress report indicates that all but four of the 46 African region countries still have ongoing malaria transmission. Four countries in southern Africa (Botswana, Namibia, South Africa and Swaziland) share a common goal of eliminating malaria by 2015. They were joined by their four northern neighbours (Angola, Mozambique, Zambia and Zimbabwe) in 2009, to form the sub-regional malaria elimination initiative known as the Elimination Eight (E8). Another four countries in Africa (Gambia, Rwanda, São Tomé and Principe, and Madagascar) have secured Global Fund grants to prepare for elimination. The long-term cost benefit of elimination still needs to be sufficiently documented, RMB notes, in order to facilitate the required policy and financing commitments. Success is accumulating, however, and the evidence base guiding local, national, regional and global action is growing quickly. Future investment in new malaria control tools and in socio-economic development that will support malaria control and communities broadly will be essential, RBM argues. With strong human capacity, continued investment, evidence-based programming and continued partnership, achieving the ambitious Roll Back Malaria 2015 targets, including elimination in at least eight to ten countries is still possible, the report concludes.
In the three years since ‘Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health’ was published by the World Health Organisation (WHO), the global financial crisis has deepened and the steps put in place to deal with the crisis have had worse impacts on the poor and relatively disadvantaged, while bad governance nationally and globally persists, and measures to mitigate climate change have served to increase health inequity. Despite the dissenters who claim that social determinants are not the concern of WHO, specialists across WHO used evidence-based research to show that action on social determinants of health was fundamental to disease control programmes. The author of this article suggests that the global community can still make great progress towards closing the health gap by improving the social determinants of health and by ensuring equity for every child from the start, as well as ensuring healthier environments, fair employment and decent work, social protection across the life course and universal health care. But to make progress, the global community must also deal with inequity in power, money and resources – the social injustice that is killing on a grand scale.
In this editorial, the author argues that a comprehensive response to Non Communicable Diseases (NCDs) not only calls for systemic changes in our physical and social environments. It also demands that we focus on equitable and universal access to prevention, diagnosis, and treatment, as well as on improving the quality of life of those living with NCDs. The interconnections between policies in agriculture, education, environment, transportation, labor, trade, finance, and health run deep and their contribution to NCDs is as yet underappreciated. Thus, the response to NCDs requires an intersectoral approach – which includes civil society - that embeds health in policies across the board. Stakeholders need to educate and focus public interest, as well as that of government and industry, on the positive value of health and well-being. This will require a social movement and maximising the use of social media to generate more consumer demand for healthier products and healthier environments.
The global obesity epidemic has been escalating for four decades, yet sustained prevention efforts have barely begun. Forecasts suggest that high rates of obesity will affect future population health and economics. The authors of this study identify several cost-effective policies that governments should prioritise for implementation. Systems science provides a framework for organising the complexity of forces driving the obesity epidemic and has important implications for policy makers. Many parties (such as governments, international organisations, the private sector, and civil society) need to contribute complementary actions in a coordinated approach. Priority actions include policies to improve the food and built environments, cross-cutting actions (such as leadership, healthy public policies, and monitoring), and much greater funding for prevention programmes. Increased investment in population obesity monitoring would improve the accuracy of forecasts and evaluations. The integration of actions within existing systems into both health and non-health sectors (trade, agriculture, transport, urban planning, and development) can greatly increase the influence and sustainability of policies. The authors call for a sustained worldwide effort to monitor, prevent, and control obesity.
Rather than call for a new ‘mega-fund’ for NCDs, the author of this article argues that we need to use the growing focus on NCDS to build a global social movement for Universal Health Coverage (UHC) to address all health needs according to national and local epidemiology and priorities. The UHC movement calls on nations to reform their health plans and financing structures toward access to essential diagnostics, prevention, and treatment for all. Strong equitable health systems are the tipping point for universal health coverage. As demographics change and people with communicable diseases live long enough to develop chronic diseases, a responsive, performance-driven, integrated health systems approach will have the greatest health impact. A strong health system grounded in UHC, working to address NCDs must: be coordinated and integrated to reach people who may otherwise go undetected; deliver integrated care and include all players in the health system; have strong information systems and an educated health workforce; and support local private sector health providers.