The linkage between the socio-economic inequality and HIV outcomes was analysed using data from a population-based household survey that employed multistage-stratified sampling, to help refocus attention on how HIV is linked to inequalities. A socio-economic index (SEI) score, derived using multiple correspondence analysis of measures of ownership of durable assets, was used to generate three SEI groups: Low (poorest), Middle, and Upper (no so poor). Distribution of HIV outcomes (i.e. HIV prevalence, access to HIV/AIDS information, level of stigma towards HIV/AIDS, perceived HIV risk and sexual behaviour) across the SEI groups, and other background characteristics was assessed using weighted data. Univariate and multivariate logistic regression was used to assess the covariates of the HIV outcomes across the socio-economic groups. More women than men were found in the poor SEI. HIV prevalence was highest among the poor and declined as SEI increased. Individuals in the upper SEI reported higher frequency of HIV testing compared to the low SEI. Only 21% of those in poor SEI had good access to HIV/AIDS information compared to 80% in the upper SEI. A higher percentage of the poor had a stigmatizing attitude towards HIV/AIDS and personal HIV risk perception compared to those in the upper SEI. Our findings underline the disproportionate burden of HIV disease and HIV fear among the poor and vulnerable in South Africa, who are further disadvantaged by lack of access to HIV information and HIV and AIDS services.
Equity in Health
South Africa is increasingly focused on reducing maternal mortality and documenting variation in access to maternal health services across one of is argued to assist in re-direction of resources. Analysis draws on a population-based household survey that used multistage-stratified sampling. Women, who in the past two years were pregnant (1113) or had a child (1304), completed questionnaires and HIV testing. Distribution of access to maternal health services and health status across socio-economic, education and other population groups was assessed using weighted data. Poorest women had near universal antenatal care coverage (ANC), but only 40% attended before 20 weeks gestation; higher in the wealthiest quartile. Women in rural-formal areas had lowest ANC coverage, completion of four ANC visits and share offered HIV testing. Testing levels were highest among the poorest quartile, but 10% of women above 40 or with low education had never tested. Skilled birth attendant coverage was lowest in the poorest quartile and rural formal areas. Around two thirds of the wealthiest quartile, of white and of formally-employed women had a doctor at childbirth, 11-fold higher than the poorest quartile. Self-reported health status declined considerably with each drop in quartile, education level or age group.
Action on the social determinants of health is considered a necessary approach to improving health equity. Case studies of intersectoral action are available, however there is limited information about the impact of intersectoral action on the social determinants of health and health equity. Search and retrieval of literature published between 2001 and 2011 was conducted in 6 databases. 17 articles of varied methodological quality met the inclusion criteria. One systematic review investigating partnership interventions found mixed and limited impacts on health outcomes. Primary studies evaluating the impact of upstream and midstream interventions showed mixed effects. Downstream interventions were generally moderately effective in increasing the availability and use of services by marginalized communities. The literature evaluating the impact of intersectoral action on health equity is limited. The included studies identified reveal a moderate to no effect on the social determinants of health. The evidence on the impact of intersectoral action on health equity is even more limited. The lack of evidence should not be interpreted as a lack of effect. Rigorous evaluations of intersectoral action are needed to strengthen the evidence base of this public health practice.
This paper offers two unique contributions to existing global and regional frameworks on multisectoral action on NCDs and their social determinants. The first is a typology of multisectoral action that highlights three general categories of possible action outside the health sector: expanding delivery platforms; NCD-specific actions on social determinants; and NCD-sensitive actions on social determinants. This paper’s second contribution is a framework that outlines more specific areas and opportunities for actors outside the health sector to take action on the social determinants of NCDs. The framework has two parts. The first describes opportunities for NCD-specific and NCD-sensitive actions across the policy and programme lifecycle. The second part describes opportunities to create an enabling environment that promotes multisectoral action. Actors outside the health sector are uniquely positioned to help build political will, enabling legal frameworks, enforcement mechanisms and effective governance structures that are multisectoral and participatory – all anchored in a human rights-based approach.
The East African community (EAC) partner states have been urged to re-focus monitoring and achieving of the Millennium Development Goals (MDGS) as the set deadline 2015 draws near. According to Tanzanian vice-president Dr. Mohammed Gharib Bilal, there is need for constant monitoring of MDGs by EAC partner states especially THE ‘shelter for all’ goal as an important agenda in social - economic development. Gharib addressed a two-day East African Legislative Assembly (EALA) conference on MDGs in Arusha Tanzania. He told the conference that Tanzania had taken measures aimed at addressing the challenges of unplanned settlement and slums in the urban population and was undertaking a study with the United Nations-Habitat. Legislators must re-focus their oversight activities in the development agenda, he argued: they should not only be critical of their governments but must stress what has been achieved, where the failures are and the reasons whether they resulted from inadequate resources or misplaced priorities.
South Africa is increasingly focused on reducing maternal mortality. Documenting variation in access to maternal health services across one of the most inequitable nations could assist in re-direction of resources.
This analysis drew on a population-based household survey that used multistage-stratified sampling. Women, who in the past two years were pregnant (1113) or had a child (1304), completed questionnaires and HIV testing. Distribution of access to maternal health services and health status across socio-economic, education and other population groups was assessed using weighted data. The survey found that the poorest women had near universal antenatal care coverage (ANC), but only 39.6% attended before 20 weeks gestation; this figure was 2.7-fold higher in the wealthiest quartile (95%CI adjusted odds ratio = 1.2–6.1). Women in rural-formal areas had lowest ANC coverage (89.7%), percentage completing four ANC visits (79.7%) and only 84.0% were offered HIV testing. Testing levels were highest among the poorest quartile (90.1% in past two years), but 10% of women above 40 or with low education had never tested. Skilled birth attendant coverage (overall 95.3%) was lowest in the poorest quartile (91.4%) and rural formal areas (85.6%). Around two thirds of the wealthiest quartile, of white and of formally-employed women had a doctor at childbirth, 11-fold higher than the poorest quartile. Overall, only 44.4% of pregnancies were planned, 31.7% of HIV-infected women and 68.1% of the wealthiest quartile. Self-reported health status also declined considerably with each drop in quartile, education level or age group. Aside from early ANC attendance and deficiencies in care in rural-formal areas, inequalities in utilisation of services were mostly small, with some measures even highest among the poorest. Considerably larger differences were noted in maternal health status across population groups. This may reflect differences between these groups in quality of care received, HIV infection and in social determinants of health.
Very little is known about socioeconomic related inequalities in multi-morbidity, especially in developing countries. Traditionally, studies on health inequalities have mainly focused on a single disease condition or different conditions in isolation. This paper examines socioeconomic inequality in multi-morbidity in illness and disability in South
Africa between 2005 and 2008. Data were drawn from the 2005, 2006, 2007, and 2008 rounds of the nationally representative annual South African General Household Surveys. Indirectly standardised concentration indices were used to assess socioeconomic inequality. A proxy index of socioeconomic status was constructed, for each year, using a selected set
of variables that are available in all the GHS rounds. Multi-morbidity in illness and disability were constructed using data on nine illnesses and six disabilities contained in the GHS. Multi-morbidity was found to affect a substantial number of South Africans. Most often, based on the nine illness conditions and six disability conditions considered, multi-morbidity in illness and multi-morbidity in disability were each found to
involve only two conditions. In 2008 in South Africa, the multi-morbidity that affected the greatest number of individuals combined high blood pressure with at least one other illness. Between 2005 and 2008, multi-morbidity in illness and disability was more prevalent among poor people; in disabilities this is yet more consistent. While there is a dearth of information on the socioeconomic distribution of multi-morbidity in many
developing countries, the paper shows that its distribution in South Africa indicates that the poor bear a greater burden of multi-morbidity. The author argues that, given the high burden and skewed socioeconomic distribution of multi-morbidity, there is a need to design policies to address this situation, and surveys that specifically assess multi-morbidity.
This editorial considers the neonatal deaths occurring in South Africa that are due to limited availability of intensive care beds or inadequate referral systems and problematic transport systems. The editor proposes simple, cost-effective preventative measures to decrease the mortality rate outside of tertiary care centres, including resuscitation training of primary health care providers, breastfeeding and kangaroo mother care (KMC) programmes, using polyethylene wrappings for neonates less than 1200g and increasing the number of neonatal beds available and the number of staff to care for these patients. Community education programmes on healthy pregnancies are proposed to improve help-seeking behaviour, improve clinic attendance and increase awareness of the benefits of free interventions, such as breastfeeding and KMC. While many other countries in the region have reduced their maternal mortality, South Africa has made limited progress. The authors call on government to prioritise the implementation of sustainable measures to improve neonatal mortality, and ultimately reducing under-5 mortality.
This outcome statement summarises views from stakeholders from a total of 53 African countries, represented by governments, Regional Economic Communities, civil society organisations including youth and women’s organisations, parliamentarians, academic institutions and the private sector. Noting the relatively slow progress made by African countries towards the Millennium Development Goals (MDGs) and recognising the capacity deficits and disabling initial conditions prevailing in a number of countries, participants unanimously agreed that the post-2015 development agenda should: 1. Emphasise inclusive economic growth and structural transformation. 2. Re-orient the development paradigm away from externally-driven initiatives toward domestically- inspired and funded initiatives that are grounded in national ownership. 3. Prioritise equity and social inclusion and measure progress in terms of both the availability and quality of service delivery. 4. Pay greater attention to vulnerable groups such as women, children, youth, the elderly, people with disabilities, displaced persons 5. Take into account the initial conditions of nation states and recognise the efforts countries have made towards achieving the goals as opposed to exclusively measuring how far they fall short of global targets. 6. Incorporate the Rio+20 outcomes and the outcomes of Africa-wide initiatives, national and regional consultations as well as UN forums such as ICPD +20. 7. Focus on development enablers as well as development outcomes.
The objective of this study was to investigate the underlying circumstances of maternal deaths in Botswana. Fifty-six case notes from the 80 reported maternal deaths in 2010 were reviewed. Five clinicians reviewed each case independently and then together to achieve a consensus on diagnosis and underlying cause(s) of death. Results indicated that 60% of deaths occurred in Botswana’s two referral hospitals. Cases in which death had direct obstetric causes were fewer than cases in which cause of death was indirect. The main direct causes were haemorrhage (39%), hypertension (22%), and pregnancy-related sepsis (13%). Thirty-six (64%) deaths were in HIV-positive women, of whom 21 (58%) were receiving antiretroviral (ARV) therapy. Nineteen (34%) deaths were attributable to HIV, including 4 from complications of ARVs. Twenty-nine (52%) deaths were in the postnatal period, 19 (66%) of these in the first week. Case-note review revealed several opportunities for improved quality of care, such as: better teamwork, communication and supportive supervision of health professionals; better supply management; and joint management between HIV and obstetric clinicians. The authors argue that integrating HIV management into maternal healthcare is essential to reduce maternal deaths in the region, alongside greater efforts to improve quality of care to avoid direct and indirect causes of death.