Equity in Health

Progress and priorities for reproductive, maternal, newborn, and child health in Kenya: a Countdown to 2015 country case study
Keats E; Ngugi A; Macharia W; et al.: The Lancet Global Health 5(8) , 2017

Progress in reproductive, maternal, newborn, and child health (RMNCH) in Kenya has been inconsistent over the past two decades, despite the global push to foster accountability, reduce child mortality, and improve maternal health in an equitable manner. This report provides a comprehensive assessment of RMNCH in Kenya from 1990 to 2015, using data from nationally representative Demographic Health Surveys implemented between 1989 and 2014. The authors estimated time trends for key RMNCH indicators, as defined by Countdown to 2015, at both the national and the sub-national level, explored the determinants of change in intervention coverage during the past decade and modelled the effect of intervention scale up by 2030. After an increase in mortality between 1990 and 2003, there was a reversal in all mortality trends from 2003 onwards, although progress was not substantial enough for Kenya to achieve Millennium Development Goal targets 4 or 5. Between 1990 and 2015, maternal mortality declined at half the rate of under-5 mortality, and changes in neonatal mortality were even slower. National-level trends in intervention coverage have improved, although some geographical inequities remain, especially for counties comprising the northeastern, eastern, and northern Rift Valley regions. Disaggregation of intervention coverage by wealth quintile also revealed wide inequities for several health service interventions, such as skilled birth assistance. Maternal literacy and family size were found to be important drivers of positive change in key interventions across the continuum of care. The analysis highlighted the importance of quality of care around birth for maternal and newborn survival, and for targeting poor households and least educated and rural women, through the scale-up of community-level interventions, to improve equity and accelerate progress.

Lifestyle and income-related inequality in health in South Africa
Mukong A; Van Walbeek C; Ross H: International Journal for Equity in Health 16(103), doi: 10.1186/s12939-017-0598-7, 2017

Many low - and middle-income countries are experiencing an epidemiological transition from communicable to non-communicable diseases, imposing both economic and health burdens on their societies. While the prevalence of such diseases varies with socioeconomic status, the inequalities can be exacerbated by lifestyles. This paper explored the contribution of smoking and alcohol consumption to health inequalities, incorporating measures of health directly associated with these lifestyle practices from National Income Dynamic Study panel data for South Africa. The authors found significant smoking-related and income-related inequalities in both self-reported and lifestyle-related ill-health. The results suggest that smoking and alcohol use contribute positively to income-related inequality in health. Smoking participation accounts for up to 7.35% of all measured inequality in health and 3.11% of the inequality in self-reported health. The estimates are generally higher for all measured inequality in health (up to 14.67%) when smoking duration is considered. Alcohol consumption accounts for 27.83% of all measured inequality in health and 3.63% of the inequality in self-reported health. This study provides evidence that inequalities in both self-reported and lifestyle-related ill-health are highly prevalent within smokers and poor people. The authors suggest that policies aimed at reducing tobacco consumption and harmful alcohol will improve health and reduce health inequalities.

Measurement and decomposition of socioeconomic inequality in single and multimorbidity in older adults in China and Ghana: results from the WHO study on global AGEing and adult health
Kunna R; Sebastian M; Williams J: International Journal for Equity in Health 16(79), doi: 10.1186/s12939-017-0578-y, 2017

There is a need for country-specific evidence of NCD inequalities in developing countries where populations are ageing rapidly amid economic and social change. The study measures and decomposes socioeconomic inequality in single and multiple NCD morbidity in adults aged 50 and over in China and Ghana, using data from the World Health Organisation Study on Global AGEing and Adult Health 2007–2010. In China, the prevalence of single and multiple NCD morbidity was 64.7% and 53.4%, compared with 65.9% and 55.5% respectively in Ghana. Inequalities were significant and more highly concentrated among the poor in China. In Ghana inequalities were significant and more highly concentrated among the rich. In China, rural residence contributed most to inequality in single morbidity (36.4%) and the wealth quintiles contributed most to inequality in multi morbidity (39.0%). In Ghana, the wealth quintiles contributed 24.5% to inequality in single morbidity and body mass index contributed 16.2% to the inequality in multi- morbidity. The country comparison reflects different stages of economic development and social change in China and Ghana. More studies of this type are needed to inform policy-makers about the patterning of socioeconomic inequalities in health, particularly in developing countries undergoing rapid epidemiological and demographic transitions.

Mortality among twins and singletons in sub-Saharan Africa between 1995 and 2014: a pooled analysis of data from 90 Demographic and Health Surveys in 30 countries
Monden C; Smits J: The Lancet Global Health 5(7), e673-e679, 2017

Sub-Saharan Africa has the world's highest under-5 and neonatal mortality rates as well as the highest naturally occurring twin rates. Twin pregnancies carry high risk for children and mothers. Under-5 mortality has declined in sub-Saharan Africa over the last decades. It is unknown whether twins have shared in this reduction. The authors pooled data from 90 Demographic and Health Surveys for 30 sub-Saharan Africa countries on births reported between 1995 and 2014 to address this question. Under-5 mortality among twins declined from 327 per 1000 live births in 1995–2001 to 213 in 2009–14. This decline of 35% was less steep than the 51% reduction among singletons. Twins account for an increasing share of under-5 deaths in sub-Saharan Africa: currently 11% of under-5 mortality and 15% of neonatal mortality. Excess twin mortality cannot be explained by common risk factors for under-5 mortality, including birth-weight. The difference with singletons was especially stark for neonatal mortality and 52% of women pregnant with twins reported receiving medical assistance at birth. The authors note that an alarming one-fifth of twins in the region dies before age 5 years, three times the mortality rate among singletons. Twins account for a substantial and growing share of under-5 and neonatal mortality, but they are largely neglected in the literature. They argue that co-ordinated action is required to improve the situation of this extremely vulnerable group.

The State of the World’s Children 2016: A fair chance for every child
United Nations Children's Fund: UNICEF, New York, 2016

Based on current trends, 69 million children under five will die from mostly preventable causes, 167 million children will live in poverty, and 750 million women will have been married as children by 2030, the target date for the Sustainable Development Goals – unless the world focuses more on the plight of its most disadvantaged children, according to a UNICEF report released today. The State of the World’s Children, UNICEF’s annual flagship report, paints a stark picture of what is in store for the world’s poorest children if governments, funders, businesses and international organisations do not accelerate efforts to address their needs. The publication argues that progress for the most disadvantaged children is not only a moral, but also a strategic imperative. Stakeholders must have an obvious choice to make: invest in accelerated progress for the children being left behind, or face the consequences of a far more divided world by 2030. At the start of a new development agenda, the report concludes with a set of recommendations to help chart the course towards a more equitable world.

Early menarche: A systematic review of its effect on sexual and reproductive health in low- and middle-income countries
Ibitoye M; Choi C; Lee G; Sommer M: PLOS One, doi: https://doi.org/10.1371/journal.pone.0178884, 2017

Adolescent girls aged 15–19 bear a disproportionate burden of negative sexual and reproductive health outcomes in low- and middle-income countries. The authors conducted this systematic review to better understand whether and how early menarche is associated with various negative sexual and reproductive health outcomes in low- and middle-income countries and the implications of such associations. They systematically searched eight health and social sciences databases for peer-reviewed literature on menarche and sexual and reproductive health in low- and middle-income countries. The authors’ review of the minimal existing literature (with 24 papers included) showed that early menarche is associated with early sexual initiation, early pregnancy and some sexually transmitted infections in low- and middle-income countries, as has been observed in high-income countries. Early menarche is also associated with early marriage–an association that may have particularly important implications for countries with high child marriage rates. Early age at menarche may be an important factor affecting the sexual and reproductive health of adolescent girls and young women in low- and middle-income countries. Given the association of early menarche with early marriage, the authors propose that ongoing efforts to reduce child marriage may benefit from targeting efforts to early maturing girls.

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.