An equitable distribution of healthcare use, distributed according to people’s needs instead of ability to pay, is an important goal featuring on many health policy agendas worldwide. However, relatively little is known about the extent to which this principle is violated across socio-economic groups in Sub-Saharan Africa (SSA). The authors ex-amine cross-country comparative micro-data from 18 SSA countries and find that considerable inequalities in healthcare use exist and vary across countries. For almost all countries studied, healthcare utilization is considerably higher among the rich. When decomposing these inequalities wealth is found to be the single most important driver. In 12 of the 18 countries wealth is responsible for more than half of total inequality in the use of care, and in 8 countries wealth even explains more of the inequality than need, education, employment, marital status and urbanicity together. For the richer countries, notably Mauritius, Namibia, South Africa and Swaziland, the contribution of wealth is typical-ly less important. As the bulk of inequality is not related to need for care and poor people use less care because they do not have the ability to pay, healthcare utilization in these countries is to a large extent unfairly distributed. The weak average relationship between need for and use of health care and the potential reporting heterogeneity in self-reported health across socio-economic groups imply that the findings are likely to even underestimate actual inequities in health care.
Equity in Health
Daniel Bausch - interviewed in this paper- has been assisting with patient care during the current Ebola virus disease outbreak in western Africa and – as part of a WHO-led international collaboration – is exploring the possible use of experimental therapies and vaccines. He explains in this paper why this outbreak is different. He notes that the outbreak response had outstripped the available resources. Although personnel were deployed he says "we are all late and it has gotten out of control. It’s too simplistic to lay the blame on one group. There has been a lot of finger pointing at WHO, no one is immune to criticism, but WHO has suffered a loss of personnel and resources. So it’s not only about what we should have done at any particular time, but the whole foundation for an international public health response that has been eroded by the global economic downturn". He further observes that the scale and public profile of this outbreak means that potential vaccines and therapies that were stalled are now being pushed through clinical trials. He argues that if vaccines and drugs are provided in the not too distant future, the problem will change and people will start knocking on the door demanding prevention and treatment, so this is a public health strategy as well, but stemming the outbreak will still depend primarily on the classic strategy of case identification, with isolation and treatment, and contact tracing.
Ebola is also an epidemic, and the causes and conditions of the epidemic are social, economic, and political rather than natural. Outside of these social and economic conditions, the disease would have been contained or even eliminated long before now. The three countries at the centre of the Ebola epidemic are among the most impoverished in the world. The author argues that the permanent legacy of centuries of uninterrupted plunder is chronic and widespread malnutrition, dirt roads, poor or non-existent sanitation, unreliable or non-existent electric power, and one doctor per 100,000 inhabitants. These are the conditions in which an Ebola outbreak becomes an epidemic. For several months after the existence of Ebola was confirmed in the three countries of West Africa, it did not, the author argues, threaten the extraction of wealth from the region, and the first actions were to withdraw many volunteers including those working in health and to suspend flights. As cases were diagnosed in the USA and Europe, the response is reported to have been isolationist, with media spreading fear and speculation. Aid increased, but with limited personnel, except from Cuba. The author argues that West African health workers and volunteers are the ones who have carried out the socially necessary tasks of caring for patients, collecting and burying bodies, and educating the population in prevention and containment measures, despite inadequate safety equipment, serious threats to their own health, inadequate pay, and despite sometimes being ostracised in their own communities.
In August ZMAPP, an untested serum-based therapy in humans, was successfully administered to two American health workers infected with the Ebola virus, who were later declared free from the virus. The public announcement raised hopes for a new front in the fight against the ravaging epidemic. Besides the ethical and equity challenges present in distributing the limited quantity of the experimental therapies, the remarkable survival and first-rate quality of treatments provided to the American patients, as well as the water-tight public health containment measures employed, paint in a very stark manner the contours of divisions in global health, which were already widening before Ebola and have been worsen by the outbreak. The authors argue that an emergency-only response by African countries and the international community would fail to bridge those divisions that will continue in future to manufacture new and remerging epidemics like Ebola at an alarming rate as well as with frightening impact on a global scale. Africa’s endemic diseases like Ebola affect mostly its bottom millions. As such, the patients do not form a viable consumer base enough to motivate pharmaceutical industry to invest in innovative drugs and treatments for them. The WHO has put together a list of 17 neglected poverty-related diseases (NTDs). According to one study, of the about 1,393 new chemical entities introduced between 1975 and 1999, only 16 targeted NTDs.
This supplement explores social determinants of equity in health and highlights differences by socioeconomic status and geographic location, among others. The paper highlights that to reduce health inequalities requires action to reduce socioeconomic and other inequalities. There are other factors that influence health, but these are outweighed by the overwhelming impact of social and economic factors—the material, social, political, and cultural conditions that shape our lives and our behaviours.
HEALTH ministers in the Southern African Development Community (SADC) have agreed to collaborate in the event of an outbreak of Ebola in the region. The ministers held an extra ordinary meeting in Johannesburg in August to plan a coherent response should the Ebola outbreak in West Africa spread to other regions of the continent as feared. There has not been a reported case of Ebola in the SADC region but there is a risk. People travel frequently between Southern and West African countries. Among other things, the SADC ministers agreed to organise cross-border consultations to facilitate the exchange of information, and to strengthen surveillance of the virus. They agreed to commit additional financial resources, but proposed a regional fund for emergency situations as a long-term solution. South Africa was chosen as the centre of excellence in Ebola laboratory diagnosis in the region. It is expected to help with the training of health professionals treating infected individuals.
In most parts of the world, health outcomes among boys and men continue to be substantially worse than among girls and women, yet this gender-based disparity in health has received little national, regional or global acknowledgement or attention from health policy-makers or health-care providers. Including both women and men in efforts to reduce gender inequalities in health as part of the post-2015 sustainable development agenda would improve everyone’s health and well-being. This paper notes that three types of intervention targeting men have emerged in recent years – outreach, partnership and gender transformation – and there is now evidence to support all three approaches. The authors argue that global, regional and national health and development agencies could certainly learn from the success of civil society groups in promoting policies that target men. For example, the South African non-profit organization Sonke Gender Justice successfully pushed the government to add interventions targeting men within South Africa’s national HIV strategic plan. Closing the men’s health gap, it is argued, can benefit men, women and their children.
The UN working group charged with outlining a proposed set of sustainable development goals (SDGs) adopted an outcome document on Saturday. The recommended goals will now be sent to the UN General Assembly for consideration as part of the discussions around the post-2015 development agenda. The final 23-page document maintains the 17 goals outlined in a revised “zero draft” – released by the working group’s co-chairs in early July to serve as a basis for this final meeting – with 169 targets. Sixty-two of these can be classed as “means of implementation,” (MoI) or the methods to achieve each goal. During the closing plenary on Saturday morning, the working group co-chairs said that while they were happy with their efforts in steering participants towards an outcome document, they recognised the final product was not flawless. Another year of discussion is likely as the UN General Assembly reflects upon the proposed goals. The document does not yet contain indicators for measuring progress towards each goal and target, which was part of the working group’s original mandate. The eventual addition of indicators at a later stage may prove a useful opportunity to clarify some of the proposed targets and further work will likely be undertaken in this area.
The 2014 Human Development Report— Sustaining Progress: Reducing Vulnerabilities and Building Resilience—looks at two concepts which are both interconnected and immensely important to securing human development progress. As successive Human Development Reports (HDRs) have shown, most people in most countries have been doing steadily better in human development. Advances in technology, education and incomes hold ever-greater promise for longer, healthier, more secure lives. But there is also a widespread sense of precariousness in the world today—in livelihoods, in personal security, in the environment and in global politics. High achievements on critical aspects of human development, such as health and nutrition, can quickly be undermined by a natural disaster or economic slump. Theft and assault can leave people physically and psychologically impoverished. Corruption and unresponsive state institutions can leave those in need of assistance without recourse. Based on analysis of the available evidence, the Report makes a number of important recommendations for achieving a world which addresses vulnerabilities and builds resilience to future shocks. It calls for universal access to basic social services, especially health and education; stronger social protection, including unemployment insurance and pensions; and a commitment to full employment, recognizing that the value of employment extends far beyond the income it generates. It examines the importance of responsive and fair institutions and increased social cohesion for building community-level resilience and for reducing the potential for conflict to break out.
With many MDG targets already met on reducing poverty, increasing access to improved drinking water sources, improving the lives of slum dwellers and achieving gender parity in primary school, The Millennium Development Goals Report 2014, says many more targets are within reach by their 2015 target date. If trends continue, the world will surpass MDG targets on malaria, tuberculosis and access to HIV treatment, and the hunger target looks within reach. Other targets, such as access to technologies, reduction of average tariffs, debt relief, and growing political participation by women, show great progress. The MDG report is based on comprehensive official statistics and provides the most up-to-date summary of all Goals and their targets at global and regional levels, with additional national statistics available online. Results show that concentrated efforts to achieve MDG targets by national governments, the international community, civil society and the private sector are working to lift people out of extreme poverty and improve their futures. It notes that much greater effort and investment will be needed to alter inadequate sanitation facilities. High dropout rates remain a barrier to universal primary education. Despite considerable advancements in recent years, the report says reliable statistics for monitoring development remain inadequate in many countries, but better statistical reporting on the MDGs has led to real results.