Equity in Health

District Health Barometer 2016/2017, South Africa
Massyn N; Padarath A; Peer N; et al: Health Systems Trust, South Africa, 2017

This 12th edition of the District Health Barometer (DHB) covers 52 districts and includes a total of 47 financial and health indicators, 11 of which are new. This annual publication provides an overview of the performance of public health services in South Africa and has become an important planning and management resource for health service providers, managers, researchers and policy makers in the country. The DHB plays an important role in providing information for district mangers to benchmark their districts against the others in the country and in strengthening the use of data for priority setting and decision making. The Barometer is used as the basis for workshops with district managers which provides an opportunity to engage with the data and collaborate with technical experts on how best to use this information for planning. This edition paints a mixed picture, showing significant gains in some areas while highlighting areas that need further attention. Mortality rates in South Africa increased between 1997 and 2006 and declined thereafter until 2015, mainly due to the HIV epidemic and the roll-out of ARTs. Despite this, HIV and AIDS and associated conditions still stand out as being a leading cause of morbidity, together with cerebrovascular diseases, ischaemic heart disease, diabetes mellitus, road injuries, interpersonal violence and hypertensive heart disease.

Next wave of interventions to reduce under-five mortality in Rwanda: a crosssectional analysis of demographic and health survey data
Amoroso C; Nisingizwe M; Rouleau D; et al: BMC Pediatrics 18(27) doi: 10.1186/s12887-018-0997-y, 2018

This paper reports on a cross-sectional study of 9002 births to 6328 women age 15–49 in the 2010 Rwanda Demographic and Health Survey to identify correlates of under-five mortality in all children under-five, 0–11 months, and 12–59 months. The results indicated that of 14 covariates associated with under-five mortality in bivariate analysis, the following remained associated with under-five mortality in multivariate analysis: household being among the poorest of the poor, child being a twin, mother having 3–4 births in the past 5 years compared to 1–2 births, mother being HIV positive, and mother not using contraceptives compared to using a modern method. Mother experiencing physical or sexual violence in the last 12 months was associated with under-five mortality in children ages 1–4 years. Under five survival was associated with a preceding birth interval 25–50 months compared to 9–24 months, and having a mosquito net. It was concluded that in the past decade, Rwanda rolled out integrated management of childhood illness, near universal coverage of childhood vaccinations, a national community health worker program, and a universal health insurance scheme. The results of the study suggest that Rwanda’s next wave of U5 mortality reduction should target programs in improving neonatal outcomes, poverty reduction, family planning, HIV services, malaria prevention, and prevention of intimate partner violence.

Socioeconomic differential in self-assessment of health and happiness in 5 African countries: Finding from World Value Survey
Adesanya A; Rojas B; Darboe A; et al.,: PLOS One 12(11) doi: https://doi.org/10.1371/ journal.pone.0188281, 2017

This study compared socioeconomic differentials in self-rated health and happiness in five sub-Saharan countries. Using the 2010/2014 World Values Survey, the authors obtained a sample of 9,869 participants of age 16 and above from five sub-Saharan countries. Socioeconomic inequalities were quantified using the concentration index. Poor self-rated health ranges from approximately 9% in Nigeria to 20% in Zimbabwe, whereas unhappiness was lower in Rwanda and higher in South Africa. Poor self-rated health and unhappiness were excessively concentrated among the poorest socioeconomic strata. Although magnitudes differ across countries, however, the major contributor to wealth-related inequality in poor self-rated health is satisfaction with financial situation whereas for unhappiness the major contributors are level of income and satisfaction with financial situation. This study underscores an association between wealth related inequalities and poor self-rated health and unhappiness in the context of sub-Saharan countries. Improving equity in health may be useful in fighting against the unfair distribution of resources. The authors suggest that knowledge about the self-rating of health and happiness can serve as proxy estimates for understanding the distribution of health care access and economic resources for well-being.

Children Count
Children’s Institute, University of Cape Town, 2017

The Children Count website hosts information about children in South Africa: their living conditions, care arrangements, health status, and access to schools and other services. These child-centred statistics are based on the best available national data. The website includes downloadable fact sheets on 40 indicators, as well as an interactive tool that enables you to view tables and graphs for different years and provinces. Children Count / Abantwana Bablulekile is an ongoing data and advocacy project of the Children’s Institute.

The path to longer and healthier lives for all Africans by 2030: the Lancet Commission on the future of health in sub-Saharan Africa
Agyepong I; Sewankambo N; Binagwaho A; et al. Kassebaum: The Lancet 390(10114)p2803–2859, 2017

This Commission was prompted by sub-Saharan Africa's potential to improve health on its own terms, and largely with its own resources. It promotes evidence-based optimism, with caution. Sub-Saharan countries are noted to face difficult development agendas in the decades to come, but also immense opportunities to be acted upon. A key message of this commission is that the opportunities ahead cannot be unlocked with 'more of the same' approaches and by keeping to the current pace. The commission advocates an approach based on people-centred health systems and inspired by progress, which can be adapted in line with each country's specific needs. A comprehensive approach and system-wide changes are required. Broad partnerships beyond the medical and health community are argued to be essential to move the health agenda forward. Without a serious shift in mindsets across all levels of society, all sectors of government, and all institutions it is seen to be difficult to have meaningful and sustainable change. Young people in Africa are observed to be key to bringing about the transformative changes needed to rapidly accelerate efforts to improve health and health equity across sub-Saharan Africa.

Almost 100 million people a year forced to choose between food and healthcare
Bowman V: The Guardian, UK, December 2017

The author raises that almost 100 million people are pushed into extreme poverty each year because of debts accrued through healthcare expenses. Citing a report, published by the World Health Organization and the World Bank, she highlights that the poorest and most vulnerable people are routinely forced to choose between healthcare and other necessities for their household, including food and education, subsisting on $1.90 (£1.40) a day. Researchers found that more than 122 million people around the world are forced to live on $3.10 a day, the benchmark for “moderate poverty”, due to healthcare expenditure. Since 2000, this number is reported to have increased by 1.5% a year. She cites Timothy Evans, senior director of health, nutrition and population at the World Bank Group: “Universal healthcare coverage is not just about better health. The reality is that as long as millions of people are being impoverished by health expenses, we will not reach our collective sustainable development goal of ending extreme poverty by 2030.”

Mapping under-5 and neonatal mortality in Africa, 2000–15: a baseline analysis for the Sustainable Development Goals
Golding N; Burstein R; Longbottom J; et al: The Lancet 390(10108)2171-2182, 2017

This study aimed to generate high-resolution estimates of under-5 and neonatal all-cause mortality across 46 countries in Africa. The authors assembled 235 geographically resolved household survey and census data sources on child deaths to produce estimates of under-5 and neonatal mortality at a resolution of 5 × 5 km grid cells across 46 African countries for 2000, 2005, 2010, and 2015. Amid improving child survival in Africa, there was substantial heterogeneity in absolute levels of under-5 and neonatal mortality in 2015, as well as the annualised rates of decline achieved from 2000 to 2015. Subnational areas in countries such as Botswana, Rwanda, and Ethiopia recorded some of the largest decreases in child mortality rates since 2000, positioning them well to achieve SDG targets by 2030 or earlier. Yet these places were the exception for Africa, since many areas, particularly in central and western Africa, must reduce under-5 mortality rates by at least 8.8% per year, between 2015 and 2030, to achieve the SDG 3.2 target for under-5 mortality by 2030. In the absence of unprecedented political commitment, financial support, and medical advances, the viability of SDG 3.2 achievement in Africa is argued to be precarious at best.

The Lancet Countdown: Tracking Progress on Health and Climate Change
Watts, Nick et al.: The Lancet , 389 (10074 ), 1151 - 1164, 2017

The Lancet Countdown: tracking progress on health and climate change is an international, multidisciplinary research collaboration between academic institutions and practitioners across the world that aims to track the health impacts of climate hazards; health resilience and adaptation; health co-benefits of climate change mitigation; economics and finance; and political and broader engagement. The Lancet Countdown aims to report annually on a series of indicators across these five areas in tandem with existing monitoring processes, such as the UN Sustainable Development Goals and WHO's climate and health country profiles. The indicators will also evolve over time through ongoing collaboration with experts and a range of stakeholders, and be dependent on the emergence of new evidence and knowledge.

Noncommunicable Diseases Progress Monitor 2017
World Health Organization: WHO, Geneva, 2017

In May 2015 the World Health Organization published a Technical Note on its 2017 reporting to the United Nations General Assembly on the progress achieved in the implementation of national commitments included in the 2011 UN Political Declaration and the 2014 UN Outcome Document on NCDs. The Technical Note was updated in September 2017 to ensure alignment with the updated set of WHO ‘best-buys’ and other recommended interventions for the prevention and control of non communicable diseases that was endorsed by the World Health Assembly in May 2017. The Progress Monitor provides data on the 19 indicators on progress in NCDs and their control and management for all of WHO’s 194 Member States. The indicators include setting time-bound targets to reduce NCD deaths; developing all-of-government policies to address NCDs; implementing key tobacco demand reduction measures, measures to reduce harmful use of alcohol and unhealthy diets and promote physical activity; and strengthening health systems through primary health care and universal health coverage.

What 115 years of data tells us about Africa’s battle with malaria past and present
Snow B: The conversation, October 2017

The author reports on efforts in the last 21 years tracking down malaria survey reports done across Africa. The greatest challenge was that they were mostly hidden in old government archives or curated by the World Health Organisation. Their final report covers over 50,000 surveys dating back 115 years. This is the largest repository containing information on over 7.8 million blood tests for malaria. They analysed malaria infection prevalence for each of 520 administrative units across countries south of the Sahara and Madagascar for 16 time periods. The study suggests that the prevalence of malaria infection in sub-Saharan Africa today is at the lowest point since 1900. The biggest historical reduction in malaria coincided with the introduction of new tools to fight malaria. After the Second World War, the discovery of DDT for indoor spraying and chloroquine drugs made a difference in treating malaria. In 2005 the rolling out of insecticide treated bed nets and new antimalarial drugs, led to a further drop of malaria cases. The lowest periods of malaria prevalence were evident when the international community abandoned specific malaria control investment in Africa, during the late 1960s, through the 1970s and early 1980s. The gains made after 2005 are also reported to have stalled since 2010. Declining malaria funding, insecticide and drug resistance are the obvious threats to the elimination of malaria in Africa. The authors observe from the evidence that the malaria map in Africa might shrink a bit at the margins but that middle belt isn’t going anywhere in our lifetimes with what we have at our disposal now – bed nets and drugs. When insecticide and drug resistance becomes established, they argue that unless we have new classes of both drugs and insecticides or a natural period of drought, malaria will revert in large parts of Africa to what it was in the 1990s, another perfect storm.

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