Equity in Health

Global mortality variations in patients with heart failure: results from the International Congestive Heart Failure prospective cohort study
Dokainish H; Teo K; Zhu J; et al.,INTER-CHF Investigators: The Lancet Global Health 5(7), e665-e672, 2017

Most data on mortality and prognostic factors in patients with heart failure come from North America and Europe, with little information from other regions. Here, in the International Congestive Heart Failure (INTER-CHF) study, the authors aimed to measure mortality at 1 year in patients with heart failure in Africa, China, India, the Middle East, southeast Asia and South America and to explore demographic, clinical, and socioeconomic variables associated with mortality. The authors enrolled 5823 patients within 1 year with a 98% follow-up. Mortality was highest in Africa (34%) and India (23%), compared to an overall average of 16%. Regional differences persisted after multivariable adjustment. Independent predictors of mortality included cardiac variables and non-cardiac variables (body-mass index, chronic kidney disease, and chronic obstructive pulmonary disease). 46% of mortality risk was explained by multivariable modelling with these variables; however, the remainder was unexplained. Marked regional differences in mortality in patients with heart failure persisted after multivariable adjustment for cardiac and non-cardiac factors. Therefore, variations in mortality between regions could be the result of health-care infrastructure, quality and access, or environmental and genetic factors. Further studies in large, global cohorts are suggested to be needed.

Healthy people and healthy profits? Elaborating a conceptual framework for governing the commercial determinants of non-communicable diseases and identifying options for reducing risk exposure
Buse K; Tanaka S; Hawkes S: Globalisation and Health 13(34), doi: 10.1186/s12992-017-0255-3, 2017

Non-communicable diseases (NCDs) represent a significant threat to human health and well-being, and carry significant implications for economic development and health care and other costs for governments and business, families and individuals. Risks for many of the major NCDs are associated with the production, marketing and consumption of commercially produced food and drink, particularly those containing sugar, salt and transfats (in ultra-processed products), alcohol and tobacco. The problems inherent in primary prevention of NCDs have received relatively little attention from international organisations, national governments and civil society, especially when compared to the attention paid to provision of medical treatment and long-term clinical management. Low political priority may be due in part to the complexity inherent in implementing feasible and acceptable interventions, such as increased taxation or regulation of access, particularly given the need to coordinate action beyond the health sector, and the fact that this brings public health into conflict with the interests of profit-driven food, beverage, alcohol and tobacco industries. The authors use a conceptual framework to review three models of governance of NCD risk: self-regulation by industry; hybrid models of public-private engagement; and public sector regulation. The authors analysed the challenges inherent in each model, and review what was known (or not) about their impact on NCD outcomes. While piecemeal efforts have been established, the authors argued that mechanisms to control the commercial determinants of NCDs are inadequate and efforts at remedial action too limited. The authors set out an agenda to strengthen each of the three governance models, with reforms that will be needed to the global health architecture to consolidate the collective power of diverse stakeholders, its authority to develop and enforce clear measures to address risks, as well as establish monitoring and rights-based accountability systems across all actors to drive measurable, equitable and sustainable progress in reducing the global burden of NCDs.

Equity trends in ownership of insecticide-treated nets in 19 sub-Saharan African countries
Taylor C; Florey L; Ye Y: Bulletin World Health Organisation 95(5) 322–332, 2017

This study examined the change in equity of insecticide-treated net ownership among 19 malaria-endemic countries in sub-Saharan Africa before and after the launch of the Cover The Bed Net Gap initiative. To assess change in equity in ownership of at least one insecticide-treated net by households from different wealth quintiles, the authors used data from Demographic and Health Surveys and Malaria Indicator Surveys. The authors assigned surveys conducted before the launch (2003–2008) as baseline surveys and surveys conducted between 2009–2014 as endpoint surveys and did country-level and pooled multi-country analyses, dividing geographical zones into either low- and intermediate-risk or high-risk. To assess changes in equity, they calculated the Lorenz concentration curve and concentration index (C-index). Out of the 19 countries assessed, 13 countries showed improved equity between baseline and endpoint surveys and two countries showed no changes. Four countries displayed worsened equity, two favouring the poorer households and two favouring the richer. The multi-country pooled analysis showed an improvement in equity. Similar trends were seen in both low- and intermediate-risk and high-risk zones. They conclude that the mass insecticide-treated net distribution campaigns to increase coverage, linked to the launch of the Cover The Bed Net Gap initiative, have led to improvement in coverage of insecticide-treated net ownership across sub-Saharan Africa with significant reduction in inequity among wealth quintiles.

Trends in obesity and diabetes across Africa from 1980 to 2014: an analysis of pooled population-based studies
NCD Risk Factor Collaboration (NCD-RisC) – Africa Working Group: International Journal of Epidemiology dyx078, doi: https://doi.org/10.1093/ije/dyx078, June 2017

The 2016 Dar Es Salaam Call to Action on Diabetes and Other non-communicable diseases (NCDs) advocates national multi-sectoral NCD strategies and action plans based on available data and information from countries of sub-Saharan Africa and beyond. The authors estimated trends from 1980 to 2014 in age-standardised mean body mass index (BMI) and diabetes prevalence in these countries, in order to assess the co-progression and assist policy formulation. They pooled data from African and worldwide population-based studies which measured height, weight and biomarkers to assess diabetes status in adults aged ≥ 18 years. African data came from 245 population-based surveys (1.2 million participants) for BMI and 76 surveys (182 000 participants) for diabetes prevalence estimates. The age-standardised mean BMI increased from 21.0 kg/m2 to 23.0 kg/m2 in men, and from 21.9 kg/m2 to 24.9 kg/m2 in women. The age-standardised prevalence of diabetes increased from 3.4% to 8.5% in men, and from 4.1% to 8.9% in women. Estimates in northern and southern regions were mostly higher than the global average; those in central, eastern and western regions were lower than global averages. A positive association was observed between mean BMI and diabetes prevalence in both sexes in 1980 and 2014. These estimates, based on limited data sources, confirm the rapidly increasing burden of diabetes in Africa. This rise is being driven, at least in part, by increasing adiposity, with regional variations in observed trends. African countries’ efforts to prevent and control diabetes and obesity should integrate the setting up of reliable monitoring systems, consistent with the World Health Organisation’s Global Monitoring System Framework.

Engaging with complexity to improve the health of indigenous people: a call for the use of systems thinking to tackle health inequity
Hernández A; Ruano A; Marchal B; San Sebastián M; Flores W: International Journal for Equity in Health 16(26) 2017, doi: 10.1186/s12939-017-0521-2

Indigenous people remain on the margins of society in high, middle and low-income countries, and bear a disproportionate burden of poverty, disease, and mortality compared to the general population. These inequalities have persisted, and in some countries have even worsened, despite the overall improvements in health indicators. The social determinants of health framework has enriched the understanding of the complex conditions that give rise to inequalities in indigenous health, including the structural and socio-political factors, and the intersecting conditions of poverty, social and political exclusion, discrimination and land loss that shape indigenous people’s health. The authors report in this paper the conditions of marginalisation that impact indigenous health from their work in Guatemala and argue for a citizen-led initiative for state accountability for the right to health in rural indigenous municipalities. The authors argue that the challenge of engaging with the conditions underlying inequalities and promoting transformational change means that equity-oriented research and practice in the field of indigenous health requires: engaging power, context-adapted strategies to improve service delivery, and mobilising networks of collective action.

Rheumatology in Africa-challenges and opportunities
Mody G: Arthritis Research & Therapy 19(49), 2017, doi: https://dx.doi.org/10.1186%2Fs13075-017-1259-3

Africa faces many health challenges despite sustained growth and development over the past decade. Contributory factors are the lack of financial resources, an inadequate health professional workforce, a high burden of communicable diseases and an increasing burden of non-communicable diseases. Rheumatology services are limited or non-existent in many parts of sub-Saharan Africa. Over the past decade, partnerships with international academic institutions have resulted in some progress in the training of rheumatologists and health professionals and development of rheumatology services in countries such as Kenya, Nigeria, and Zambia. Basic diagnostic tests, biological agents and arthroplasty are either unavailable or not affordable by the majority of the population. Urbanisation has resulted in a change in the epidemiology of rheumatic diseases with an increase in the prevalence of gout, rheumatoid arthritis, systemic lupus erythematosus, and scleroderma over the past four decades. Future growth of rheumatology services will depend on identifying committed individuals in underserved countries for training and supporting them to educate medical students, physicians, and health professionals in their home countries. The author raises that there is a need to develop models of care using all categories of health workers and identify prevention strategies and cost-effective management programs for low resource settings. Africa affords an opportunity for collaborative research, including genetic and epigenetic studies, to improve regional understanding of many of the rheumatic diseases.

Global Tuberculosis Report 2016
World Health Organisation: WHO, Geneva, 2016

The Global Tuberculosis Report provides a comprehensive and up-to-date assessment of the TB epidemic, and of progress in prevention, diagnosis and treatment of the disease at global, regional and country levels. This global TB report provides an assessment of the TB epidemic and progress in TB diagnosis, treatment and prevention reports, as well as an overview of TB-specific financing and research. It also discusses the broader agenda of universal health coverage, social protection and other SDGs that have an impact on health. Data were available for 202 countries and territories that account for over 99% of the world’s population and TB cases. Six countries accounted for 60% of the new cases: India, Indonesia, China, Nigeria, Pakistan and South Africa. Global progress is argued to depend on major advances in TB prevention and care in these countries. Worldwide, the rate of decline in TB incidence remained at only 1.5% from 2014 to 2015. This needs to accelerate to a 4–5% annual decline by 2020 to reach the first milestones of the End TB Strategy. TB treatment averted 49 million deaths globally between 2000 and 2015, but important diagnostic and treatment gaps persist. US$ 6.6 billion was available for TB care and prevention in low and middle-income countries in 2016, of which 84% was from domestic sources. Nonetheless, national TB programmes in low-income countries continue to rely on international funders for almost 90% of their financing. The report notes that investments in low and middle-income countries fall almost US$ 2 billion short of the US$ 8.3 billion needed in 2016. This annual gap will widen to US$ 6 billion in 2020 if current funding levels do not increase. Despite some progress in the pipeline for new diagnostics, drugs and regimens, and vaccines, TB research and development is also argued to remain severely underfunded.

The impact of multi-morbidity on disability among older adults in South Africa: do hypertension and socio-demographic characteristics matter?
Waterhouse P; van der Wielen N; Banda P; Channon A: International Journal Equity Health 16(62), 2017, doi: 10.1186/s12939-017-0537-7

This study in South Africa investigated the association between multi-morbidity and disability among older adults; and whether hypertension (both diagnosed and undiagnosed) mediates this relationship. The authors consider whether the impact of the multi-morbidity on disability varies by socio-demographic characteristics. Data were drawn from Wave 1 (2007-08) of the South African Study on Global Ageing and Adult Health. Disability was measured using the 12-item World Health Organisation Disability Assessment Schedule (WHODAS) 2.0. Nearly half of the respondents had a hypertensive blood pressure when measured during the interview, but had not been previously diagnosed. A further third self-reported they had been told by a health professional they had hypertension. The logistic regression showed in comparison to those with no chronic conditions, those with one or two or more had significantly higher odds of severe disability. Hypertension was insignificant and did not change the direction or size of the effect of the multi-morbidity measure substantially. The interactions between number of chronic conditions with wealth were significant. The diagnosis of multiple chronic conditions, can be used to identify those most at risk of severe disability and to prioritise limited resources for such individuals for preventative, rehabilitative and palliative care.

Socioeconomic status and non-communicable disease behavioural risk factors in low-income and lower-middle-income countries: a systematic review
Allen L; Williams J; Townsend N; Mikkelsen B; Roberts N; Foster C; Wickramasinghe K: The Lancet Global Health, 5(3), 2017

This study aimed to review evidence on the association between socioeconomic status and harmful use of alcohol, tobacco use, unhealthy diets, and physical inactivity within low-income and lower-middle-income countries (LLMICs). The authors searched 13 electronic databases, grey literature, and reference lists for primary research published between Jan 1, 1990, and June 30, 2015. They used a piloted version of the Cochrane Effective Practice and Organisation of Care Group data collection checklist to extract relevant data at the household and individual level from the included full text studies including study type, methods, outcomes, and results. Low socioeconomic groups were found to have a significantly higher prevalence of tobacco and alcohol use than high socioeconomic groups. These groups also consumed less fruit, vegetables, fish, and fibre than those of higher socioeconomic status. Groups at higher socioeconomic status were found to be less physically active and to consume more fats, salt, and processed food than individuals of low socioeconomic status. Despite significant heterogeneity in exposure and outcome measures, the evidence shows that behavioural risk factors are affected by socioeconomic position within LLMICs.

The Second National Burden of Disease Study for South Africa: Cause of death profile Report, 1997 – 2012
Msemburi W; Pillay-van Wyk V; Dorrington RE et al: South African Medical Research Council: Cape town, 2016

This report estimates consistent and coherent cause-specific death rates for the period 1997–2012 and identifies the leading causes of death and premature mortality for South Africa, taking into consideration and adjusting for the data deficiencies. The report used the methodology of the Global Burden of Disease Study 2005 in secondary analysis of data obtained from Statistics South Africa (Stats SA), the Injury Mortality Survey 2009 (IMS) and National Injury Surveillance System 2000 (NIMSS). For the non-communicable diseases, there was an increasing trend in numbers over the whole period while the trends for communicable disease combined with maternal causes, perinatal conditions and nutritional deficiencies, remained fairly stable between 1997 and 2009, decreasing slightly thereafter. HIV/AIDS and TB increased between 1997 and 2006, where it peaked at 687 deaths per 100,000 population and then decreased steadily each subsequent year. The report points to a considerable burden from non-communicable diseases and concerning signs of an increase in diabetes mortality. The authors say that efforts targeting prevention and management of non-communicable diseases and their risk factors need to be scaled up.