Equity in Health

Maternal mortality: a cross-sectional study in global health
Sajedinejad S, Majdzadeh R, Vedadhir A, Tabatabaei MG, Mohammad K: Globalization and Health, 4 doi:10.1186/s12992-015-0087-y, 2015

Although most of maternal deaths are preventable, maternal mortality reduction programs have not been completely successful. As targeting individuals alone does not seem to be an effective strategy to reduce maternal mortality (Millennium Development Goal 5), the present study sought to reveal the role of many distant macrostructural factors affecting maternal mortality at the global level. After preparing a global dataset, 439 indicators were selected from nearly 1800 indicators based on their relevance and the application of proper inclusion and exclusion criteria. Then Pearson correlation coefficients were computed to assess the relationship between these indicators and maternal mortality. Only indicators with statistically significant correlation more than 0.2, and missing values less than 20% were maintained. Due to the high multicollinearity among the remaining indicators, after missing values analysis and imputation, factor analysis was performed with principal component analysis as the method of extraction. Ten factors were finally extracted and entered into a multiple regression analysis. The findings of this study not only consolidated the results of earlier studies about maternal mortality, but also added new evidence. Education, private sector and trade and governance were found to be the most important macrostructural factors associated with maternal mortality. Employment and labor structure, economic policy and debt, agriculture and food production, private sector infrastructure investment, and health finance were also some other critical factors. These distal factors explained about 65% of the variability in maternal mortality between different countries. Decreasing maternal mortality requires dealing with various factors other than individual determinants including political will, reallocation of national resources (especially health resources) in the governmental sector, education, attention to the expansion of the private sector trade and improving spectrums of governance. In other words, sustainable reduction in maternal mortality (as a development indicator) will depend on long-term planning for multi-faceted development. Moreover, trade, debt, political stability, and strength of legal rights can be affected by elements outside the borders of countries and global determinants. These findings are believed to be beneficial for sustainable development in Post-2015 Development Agenda.

Older people's health in sub-Saharan Africa
Aboderin I, Beard J: The Lancet 385 (9968), 2014

Awareness is growing that the world's population is rapidly ageing. Although much of the related policy debate is about the implications for high-income countries, attention is broadening to less developed settings. Middle-income country populations, in particular, are generally ageing at a much faster rate than was the case for today's high-income countries, and the health of their older populations could be substantially worse. However, little consideration has been given to issues of old age in sub-Saharan Africa, which remains the world's poorest and youngest region.

Why is cancer not a priority in South Africa?
Stefan DC: The South African Medical Journal 105 (2), 2015

Cancer is in the second position on the list of causes of death in South Africa after adding all cancers together. It is expected that cancer will lead the list in the near future. A co-ordinated effort, including a fully functional National Cancer Registry, a National Cancer Control Plan and a new cancer research approach, is argued to be required in order to reduce the burden of cancer.

After Ebola: What next for West Africa’s health systems?
Mcilhone M: African Brains, February 2015

As rates of Ebola infection fall in Guinea, Liberia and Sierra Leone, planning has begun on how to rebuild public health systems and learn lessons from the outbreak. Nobody is declaring victory yet. But in Sierra Leone, the worst-affected country, there were 117 new confirmed cases reported in the week to 18 January, the latest statistics available, compared with 184 the previous week and 248 the week before that. Guinea halved its cases in the week to 18 January – down to 20 – and Liberia held steady at eight. The epidemic is not over until there are zero cases over two incubation periods – the equivalent of 42 days. This article discusses the role of citizen and state, external funders and local community action in addressing the epidemic.

Leaving no one behind: an agenda for equity
Watkins K: Lancet, 384, 9961, 2248–2255, 2014

Shortly before his death, Mahatma Gandhi offered a useful reflection that helps to cut through some of the complexity surrounding debates about equity. “Recall the face of the poorest and the weakest person you may have seen and ask yourself if the step you contemplate is going to be any use to them.” It’s a simple but compelling guide for policy makers concerned with combating extreme inequality. Something of the same spirit underpins the report of the High Level Panel established by the UN Secretary General to make recommendations for the post-2015 development agenda. Going beyond the identification of universal goals, the report calls for “a focus on the poorest and most marginalised” and a commitment to “leave no one behind". This approach is argued to be in-keeping with other work on the post-2015 agenda, including the Global Sustainable Development Report. Far more than the Millennium Development Goals (MDGs)—which were largely neutral on the issue of inequality—the High Level Panel report includes a wide-ranging social justice agenda. If adopted by governments and backed by national policy commitments and a new global partnership, the Panel’s agenda could, the author argues, put exclusion, inequality, and marginalisation at the centre of the post-2015 development framework.

Neglected tropical disease and emerging infectious disease: An analysis of the history, promise and constraints of two worldviews
Jackson Y, Stephenson N: Global Public Health 9(9), 2014

Emerging infectious diseases (EIDs) and neglected tropical diseases (NTDs) are medical terms referring to a group of diseases, yet they are simultaneously socio-political constructs (EID and NTD). When viewed as such, public health interest in EID has been criticised as prioritising free market, Global North interests. This paper asks if the recent turn to NTD, which directs attention and resources to ‘the bottom billion’ of the world's population, addresses the limitations of focusing on EID. Our approach involves comparing the specific socio-political framing, or ‘worldview’ of NTD, with that of EID. We examine the distinct history, rationales, morals, political and economic tensions and loci of power entailed in each worldview. This analysis suggests that efforts to foreground NTD constitute a site where humanitarian and biomedical industry actors and actions are increasingly blurred. We examine whether the NTD worldview constitutes a break with or a new version of a free market approach to global health, and whether it reworks or solidifies paternalistic Global North–South relations. We consider some of the limits of work on NTD to date, suggesting that although the NTD worldview does not escape the neo-colonial history of global health, it can actualise it under a different form.

The Ebola epidemic: a transformative moment for global health
Hill SR, Bero L, McColl G, Roughead E: Bulletin of the World Health Organization 93 (1), January 2014

The devastating effects of the current epidemic of Ebola virus disease in western Africa have put the global health response in acute focus. The index case is believed to have been a 2-year-old child in Guéckédou, Guinea, who died in December 2013. By late February 2014, Guinea, Liberia and Sierra Leone were in the midst of a full-blown and complex global health emergency. The response by multilateral and humanitarian organizations has been laudable and – at times – heroic. Much of the worst affected region is recovering from civil conflicts. This region is characterized by weak systems of government and health-care delivery, high rates of illiteracy, poverty and distrust of the government and extreme population mobility across porous, artificial boundaries. A more coordinated, strategic and proactive response is urgently needed.

Deaths Ascribed to Non-Communicable Diseases among Rural Kenyan Adults Are Proportionately Increasing: Evidence from a Health and Demographic Surveillance System, 2003–2010
Phillips-Howard PA, Laserson KF, Amek N, Beynon CM, Angell SY, Khagayi S, Byass P, Hamel MJ, van Eijk AM, Zielinski-Gutierrez E, Slutsker L, De Cock KM, Vulule J, Odhiambo FO: PLoS ONE 9(11), November 2014

Monitoring systems require strengthening to attribute the Non communicable disease (NCD) burden and deaths in low and middle-income countries (LMICs). Data from health and demographic surveillance systems (HDSS) can contribute towards this goal. Between 2003 and 2010, 15,228 deaths in adults aged 15 years (y) and older were identified retrospectively using the HDSS census and verbal autopsy in rural western Kenya. 37% were ascribed to NCDs, 60% to communicable diseases (CDs), 3% to injuries, and <1% maternal causes. Median age at death for NCDs was 66y and 71y for females and males, respectively, with 43% of NCD deaths occurring prematurely among adults aged below 65y. NCD deaths were mainly attributed to cancers (35%) and cardio-vascular diseases (CVDs; 29%). The proportionate mortality from NCDs rose from 35% in 2003 to 45% in 2010. While overall annual mortality rates (MRs) for NCDs fell, cancer-specific MRs rose from 200 to 262 per 100,000 population, mainly due to increasing deaths in adults aged 65y and older, and to respiratory neoplasms in all age groups. NCDs constitute a significant proportion of deaths in rural western Kenya. Evidence of the increasing contribution of NCDs to overall mortality supports international recommendations to introduce or enhance prevention, screening, diagnosis and treatment programmes in LMICs.

The Link between Inequality and Population Health in Low and Middle Income Countries: Policy Myth or Social Reality?
Van Deurzen I, van Oorschot W, van Ingen E: PLoS ONE 9(12), 11 December 2014

An influential policy idea states that reducing inequality is beneficial for improving health in the low and middle income countries (LMICs). The study provides an empirical test of this idea: the authors utilized data collected by the Demographic and Health Surveys between 2000 and 2011 52 LMICs, and examined the relationship between household wealth inequality and two health outcomes: anemia status (of the children and their mothers) and the women' experience of child mortality. Based on multi-level analyses, the authors found that higher levels of household wealth inequality related to worse health, but this effect was strongly reduced when they took into account the level of individuals' wealth. However, even after accounting for the differences between individuals in terms of household wealth and other characteristics, in those LMICs with higher household wealth inequality more women experienced child mortality and more children were tested with anemia. This effect was partially mediated by the country's level and coverage of the health services and infrastructure. Furthermore, we found higher inequality to be related to a larger health gap between the poor and the rich in only one of the three examined samples. The paper concludes that an effective way to improve the health in the LMICs is to increase the wealth among the poor, which in turn also would lead to lower overall inequality and potential investments in public health infrastructure and services.

The State of African Cities 2014
UN Habitat, 13 March 2014

The African continent is currently in the midst of simultaneously unfolding and highly significant demographic, economic, technological, environmental, urban and socio-political transitions. Africa’s economic performance is promising, with booming cities supporting growing middle classes and creating sizable consumer markets. But despite significant overall growth, not all of Africa performs well. The continent continues to suffer under very rapid urban growth accompanied by massive urban poverty and many other social problems. These seem to indicate that the development trajectories followed by African nations since post-independence may not be able to deliver on the aspirations of broad based human development and prosperity for all. This report, therefore, argues for a bold re-imagining of prevailing models in order to steer the ongoing transitions towards greater sustainability based on a thorough review of all available options. That is especially the case since the already daunting urban challenges in Africa are now being exacerbated by the new vulnerabilities and threats associated with climate and environmental change.