Equity in Health

Why language matters: insights and challenges in applying a social determination of health approach in a North-South collaborative research program
Spiegel JM; Breilh J; Yassi A: Globalization and Health 2015, 11(9), 2015

A focus on social determinants of health provides a welcome alternative to the bio-medical illness paradigm. However, the tendency to concentrate on the influence of risk factors related to living and working conditions of individuals, rather than to more broadly examine dynamics of the social processes that affect population health, has triggered critical reaction not only from the Global North but especially from voices the Global South where there is a long history of addressing questions of health equity. In this article, the authors elaborate on how focusing instead on the language of “social determination of health” has led to application of more equity-sensitive approaches to research and related policy and praxis. The authors briefly explore the epistemological and historical roots of epidemiological approaches to health and health equity that have emerged in Latin America to consider its relevance to global discourse. In this region marked by pronounced inequity, context-sensitive concepts such as “collective health” and “critical epidemiology” have been prominent, albeit with limited acknowledgement by the Global North. The authors illustrate attempts to apply a social determination approach (and the “4 S” elements of bio-Security, Sovereignty, Solidarity and Sustainability) in five projects within their research collaboration linking researchers and knowledge users in Ecuador and Canada, in diverse settings (health of healthcare workers; food systems; antibiotic resistance; vector borne disease [dengue]; and social circus with street youth). The authors argue that the language of social determinants lends itself to research that is more reductionist and beckons the development of different skills than would be applied when adopting the language of social determination. They conclude that this language leads to more direct analysis of the systemic factors that drive, promote and reinforce disparities, while at the same time directly considering the emancipatory forces capable of countering negative health impacts. It follows that “reverse innovation” must not only recognise practical solutions being developed in low and middle income countries, but must also build on the strengths of the theoretical-methodological reasoning that has emerged in the South.

Determinants of immunization inequality among urban poor children: evidence from Nairobi’s informal settlements
Egondi T; Oyolola M; Mutua MK; Elung’ata P: International Journal for Equity in Health, 14(24), February 2015

Despite the relentless efforts to reduce infant and child mortality with the introduction of the National Expanded Programmes on Immunization in 1974, major disparities still exist in immunization coverage across different population sub-groups. In Kenya, while the proportion of fully immunized children increased from 57% in 2003 to 77% in 2008–9 at national level and 73% in Nairobi, only 58% of children living in informal settlement areas are fully immunized. This study aimed to determine the degree and determinants of immunization inequality among the urban poor of Nairobi, using data from the Nairobi Cross-Sectional Slum Survey of 2012 on full immunization status among children aged 12–23 months. The wealth index was used as a measure of social economic position for inequality analysis. Immunization inequality was found to be mainly concentrated among children from poor families. Decomposition of the results suggests that 78% of this inequality is largely explained by the mother’s level of education. The author suggests that efforts to reduce this inequality should aim at targeting mothers with low levels of education during immunization campaigns.

Distance decay and persistent health care disparities in South Africa
McLaren ZM; Ardington C; Leibbrandt M: BMC Health Services Research, 14(54), 2014

Access to health care is a particular concern given the important role of poor access in perpetuating poverty and inequality. South Africa has large racial disparities in access despite post-apartheid health policy to increase the number of health facilities, even in remote rural areas. However, even when health services are provided free of charge, monetary and time costs of travel to a local clinic may pose a significant barrier for vulnerable segments of the population, leading to overall poorer health. Using newly available health care utilization data from the first nationally representative panel survey in South Africa, together with administrative geographic data from the Department of Health, the authors use graphical and multivariate regression analysis to investigate the role of distance to the nearest facility on the likelihood of having a health consultation or an attended birth. Ninety percent of South Africans live within 7 km of the nearest public clinic, and two-thirds live less than 2 km away. However, 14% of Black African adults live more than 5 km from the nearest facility, compared to only 4% of Whites, and they are 16 percentage points less likely to report a recent health consultation and 47 percentage points less likely to use private facilities. Racial differentials in the likelihood of having a health consultation or an attended birth persist even after controlling for confounders. The results have two policy implications: minimizing the distance that poor South Africans must travel to obtain health care and improving the quality of care provided in poorer areas will reduce inequality.

Universal Health Coverage Assessment: Zambia
Chitah B; Jonsson D: Global Network for Health Equity (GNHE), June 2015

This document provides a preliminary assessment of the Zambian health system relative to the goal of universal health coverage, with a particular focus on the financing system and related aspects of provision. Zambia is making continuous progress in all the key areas of its health system. However, there are gaps which need to be resolved for the country to be able to realise the goal of universal coverage, including universal financial protection and access to care. First, a more equitable distribution of resources between urban and rural areas is required. Second, resources need to be allocated to promote access to, and utilisation of, health care by the poorer socio-economic groups. The higher consumption of public inpatient health care services by wealthier groups is a striking example of inequitable utilisation, as is the relatively greater levels of government subsidy received by wealthier groups, even for primary health care. Third, the impoverishing effect of out-of-pocket payments exposes poorer households to financial risk, driving households into poverty or further into poverty. This requires reconsideration of public hospital user fees, both in terms of the level of fees and the application of bypass fees (which are charged when patients bypass primary
health care facilities, including because of the severity of their conditions and their proximity to higher-level health facilities). Finally, Zambia’s ambition to introduce social health insurance as a mechanism for improving the pooling and purchasing of services needs to be scrutinised for its possible impacts on equity. The proposed social health insurance scheme would require co-payments and perhaps other contributions, which would increase the financial burden on households. This means that the proposed scheme could effectively run counter to the ambition of attaining universal health coverage. There should be a critical evaluation of the alternative option of simply continuing – and strengthening - the current tax-based financing system.

Improving financial access to health care in the Kisantu district in the Democratic Republic of Congo: acting upon complexity
Stasse S; Vita D; Kimfuta J; da Silveira VC; Bossyns P; Criel B: Global Health Action 8(25480), 5 January 2015, doi: 10.3402/gha.v8.25480

<p>&nbsp;<span lang="EN-US" style="font-size:12.0pt;font-family:
&quot;Gill Sans Light&quot;,&quot;serif&quot;;mso-fareast-font-family:&quot;Arial Unicode MS&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;;mso-bidi-font-family:&quot;Times New Roman&quot;;
mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA">Commercialisation of health care has contributed to widen inequities between the rich and the poor, especially in settings with suboptimal regulatory frameworks of the health sector. Poorly regulated fee-for-service payment systems generate inequity and initiate a vicious circle in which access to quality health care gradually deteriorates. Although the abolition of user fees is high on the international health policy agenda, the sudden removal of user fees may have disrupting effects on the health system and may not be affordable or sustainable in resource-constrained countries, such as the Democratic Republic of Congo. Between 2008 and 2011, the Belgian development aid agency (BTC) launched a set of reforms in the Kisantu district, in the province of Bas Congo, through an action-research process deemed appropriate for the implementation of change within open complex systems such as the Kisantu local health system. Moreover, the entire process contributed to strengthen the stewardship capacity of the Kisantu district management team. The reforms mainly comprised the rationalisation of resources and the regulation of health services financing. Flat fees per episode of disease were introduced as an alternative to fee-for-service payments by patients. A financial subsidy from BTC allowed to reduce the height of the flat fees. The provision of the subsidy was made conditional upon a range of measures to rationalise the use of resources. The results in terms of enhancing people access to quality health care were immediate and substantial. The Kisantu experience demonstrates that a systems approach is essential in addressing complex problems. It provides useful lessons for other districts in the country.</span></p>

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.