Equity in Health

Multimorbidity: a priority for global health research
The Academy of Medical Sciences: AMS, London, 2018.

This report summarises available evidence on multimorbidity and highlights key evidence gaps which must be addressed to better understand the issue, and improve care and outcomes globally. The report calls for a standardised definition and reporting system for multimorbidity. It recommends a need to better understand the trends and patterns of multimorbidity across countries; the determinants of and burden caused by common clusters of conditions and how best to prevent and manage multimorbidity. The report draws on insights from a number of workshops, one of which was held in Johannesburg, South Africa. It raises that many populations in high, middle and low income countries are experiencing multimorbidity on a massive scale but that the available evidence about the burden, determinants, prevention and treatment of patients with multimorbidity is inadequate.

The increasing prevalence of non-communicable diseases in low-middle income countries: the view from Malawi
Gowshall M; Taylor-Robinson: International Journal of General Medicine, 2018(11), 255-264, 2018

As a low-income African country that consistently ranks amongst the world’s poorest nations, Malawi as a case study demonstrates how transition due to societal change and increasing urbanization is often accompanied by a rise in the rate of non-communicable diseases (NCDs). Other factors apart from changing lifestyle factors can explain at least some of this increase, such as the complex relationship between communicable and NCDs and growing environmental, occupational, and cultural pressures. Malawi and other LMIs are struggling to manage the increasing challenge of NCDs, in addition to an already high communicable disease burden. However, the author proposes that health care policy implementation, specific health promotion campaigns, and further epidemiological research may be key to attenuating this impending health crisis, both in Malawi and elsewhere.

WHO Global Ambient Air Quality Database
World Health Organisation: WHO Geneva 2018

More than 80% of people living in urban areas that monitor air pollution are exposed to air quality levels that exceed the World Health Organization (WHO) limits. While all regions of the world are affected, populations in low-income cities are the most impacted. According to the latest air quality database, 97% of cities in low- and middle income countries with more than 100 000 inhabitants do not meet WHO air quality guidelines. However, in high-income countries, that percentage decreases to 49%. In the past two years, the database – now covering more than 4000 cities in 108 countries – has nearly doubled, with more cities measuring air pollution levels and recognizing the associated health impacts. As urban air quality declines, the risk of stroke, heart disease, lung cancer, and chronic and acute respiratory diseases, including asthma, increases for the people who live in them.

Inequalities in health and health risk factors in the Southern African Development Community: evidence from World Health Surveys
Umuhoza S; Ataguba J: International Journal for Equity in Health 17(52), doi: https://doi.org/10.1186/s12939-018-0762-8, 2018

This study investigates inequalities both in poor self-assessed health (SAH) and in the distribution of selected risk factors of ill-health among the adult populations in six SADC countries. Data come from the 2002/04 World Health Survey (WHS) using six SADC countries (Malawi, Mauritius, South Africa, Swaziland, Zambia and Zimbabwe) where the WHS was conducted. Poor SAH is reporting bad or very bad health status. Risk factors such as smoking, heavy drinking, low fruit and vegetable consumption and physical inactivity were considered, as were other environmental factors. Socioeconomic status was assessed using household expenditures. Generally, a pro-poor socioeconomic inequality exists in poor SAH in the six countries. However, this is only significant for South Africa, and marginally significant for Zambia and Zimbabwe. Smoking and inadequate fruit and vegetable consumption were significantly concentrated among the poor. Similarly, the use of biomass energy, unimproved water and sanitation were significantly concentrated among the poor. However, inequalities in heavy drinking and physical inactivity are mixed. Overall, a positive relationship exists between inequalities in ill-health and inequalities in risk factors of ill-health. The authors argue that there is a need for concerted efforts to tackle the significant socioeconomic inequalities in ill-health and health risk factors in the region. With some of the determinants of ill-health lying outside the health sector, inter-sectoral action is required.

Zambia’s drive to eliminate malaria faces challenges
Loewenberg S: Bulletin of the World Health Organisation 96(5) 302–303, 2018

Zambia is one of eight southern African countries aiming to eliminate malaria in the next few years. Zambia has switched from the goal of its malaria control from reducing the number of cases to a very low level to elimination, defined as reducing the number of indigenous cases to zero. Supporters of the elimination agenda point to the success of the Maldives and Sri Lanka, which received World Health Organization certification for malaria elimination in 2015 and 2016, respectively. Some parts of Zambia such as the Southern Province have made huge progress in reducing the burden of malaria, but the country has not yet achieved overall control. Challenges include shortages of medicines, supplies and health workers with adequate training and supervision at the community level. However, community health workers are unpaid volunteers, leading to high turnover. While Zambia remains heavily dependent on external funding for its malaria elimination efforts, critics have questioned whether the disease can be successfully tackled without building stronger health systems first. Officials are worried by the challenge of mosquito resistance to insecticides and recent evidence this may be increasing, especially resistance to pyrethroids, the only insecticide class WHO recommends for use in insecticide-treated nets.

Botswana: A model for harnessing Africa’s demographic dividend?
Onabanjo J: Pambazuka News, April 2018

On 16 March 2018, Botswana became one of a dozen countries in East and Southern Africa that have launched its national demographic dividend study. A demographic dividend is not only contingent on a rapid decline in fertility and mortality. It also requires strategic investments in promoting equality, health and family planning, education and skills development, and job creation. When countries harness the demographic dividend, their young people are argued to become more empowered, healthier, better educated and have more equal access to opportunities. At the launch of Botswana’s demographic dividend report, President Mokgweetsi EK Masisi acknowledged “the right investments have to be made in Botswana for us to tap into the potential and skills of young people. Our return on investments isn’t commensurate with the expectations we have for Botswana.” The author argues that this is a golden moment for Botswana and other African countries to reprioritise their investments and tap into the potential of their young people – and for Botswana to plan for its second demographic dividend.

A fuzzy set qualitative comparative analysis of 131 countries: which configuration of the structural conditions can explain health better?
Paykani T; Rafiey H; Sajjadi H: International Journal for Equity in Health 17(10) doi: https://doi.org/10.1186/s12939-018-0724-1, 2018.

In this study, following the World Health Organization Commission On Social Determinants of Health (CSDH) approach the authors aimed to unravel complexity and answer the kinds of questions that are outside the scope of conventional variable-oriented approach. A fuzzy-set qualitative comparative analysis of 131 countries was conducted to examine the configurational effects of five macro-level structural conditions on life expectancy at birth. The potential causal conditions were level of country wealth, income inequality, quality of governance, education, and health system. The data collected from different international data sources were recorded during 2004–2015. The analysis indicated a configuration of conditions including high level of governance, education, wealth, and affluent health system to be consistently sufficient for high life expectancy. The configurations linked to high life expectancy were not the opposite of those associated with low life expectancy and the authors identified areas for further research.

The Inverse Equity Hypothesis: Analyses of Institutional Deliveries in 286 National Surveys
Victora C; Joseph G; Silva I; et al: American Journal of Public Health 108(4) 464-471, 2018

This study tested the inverse equity hypothesis, which postulates that new health interventions are initially adopted by the wealthy and thus increase inequalities—as population coverage increases, only the poorest will lag behind all other groups. The authors analysed the proportion of births occurring in a health facility by wealth quintile in 286 surveys from 89 low- and middle-income countries (1993–2015) and developed an inequality pattern index. Positive values indicate that inequality is driven by early adoption by the wealthy (top inequality), whereas negative values signal bottom inequality. Absolute inequalities were widest when national coverage was around 50%. At low national coverage levels, top inequality was evident with coverage in the wealthiest quintile taking off rapidly; at 60% or higher national coverage, bottom inequality became the predominant pattern, with the poorest quintile lagging behind. The authors argue that policies need to be tailored to inequality patterns. When top inequalities are present, barriers that limit uptake by most of the population must be identified and addressed. When bottom inequalities exist, interventions must be targeted at specific subgroups that are left behind.

UN aims to eliminate yellow fever epidemics in Africa by 2026
Times LIVE, Reuters, April 2018

Nearly 1 billion people in Africa will be vaccinated against yellow fever by 2026 in an ambitious United Nations campaign to eliminate epidemics of the deadly disease on the continent. The mosquito-borne viral disease is a major killer in Africa, where it can spread fast in highly populated areas with devastating consequences. "With one injection we can protect a person for life against this dangerous pathogen," said Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization (WHO) at the programme's launch in Nigeria, a priority target country. A major vaccination campaign in Angola and Congo in 2016 brought one of the worst outbreaks of the disease in decades under control after more than 400 people died. The vaccination programme is a joint venture by the WHO, UNICEF, the GAVI global vaccine alliance and more than 50 health partners.

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.