Equity in Health

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.

Health for All, All for Health: Lessons from the universalisation of health care in emerging economies
United Nations Research Institute for Social Development: Research and Policy Brief 22, UNRISD, Geneva, 2017

This brief summarizes key findings from the UNRISD research project Towards Universal Social Security in Emerging Economies. The project analysed the efforts of selected emerging economies to move towards universal provision of health care. The brief provides a comparative analysis of the political, economic and social drivers of, and constraints on, the extension of health care service for all and draws out the implications for poverty reduction, equity, growth and democracy. The brief identifies the following factors enabling universalisation: facilitating an empowered civil society, working together with government; political will, institutional capacity and political support for reform to create fiscal space for universal health care; democratic mechanisms to build consensus between different interest groups and maintain reform momentum; strategies to reduce resistance in and from the private sector; comprehensive and coherent national framework for health care, with mechanisms to ensure vertical coherence of policies between different levels of government; and tax- financed health care systems. An overarching finding emerges from the successful cases of the universalisation of health care observed in this UNRISD research: they all adopted integrated approaches that can promote synergies between health and non- health sectors; equally the contestation and consensus that reforms for universal health care entailed were not limited to the health sector alone. Health is interconnected with other areas of social, economic and environmental well- being, so the expansion of health care systems must happen alongside efforts to address the determinants of health that lie beyond the health sector.

Progress and priorities for reproductive, maternal, newborn, and child health in Kenya: a Countdown to 2015 country case study
Keats E; Ngugi A; Macharia W; et al.: The Lancet Global Health 5(8) , 2017

Progress in reproductive, maternal, newborn, and child health (RMNCH) in Kenya has been inconsistent over the past two decades, despite the global push to foster accountability, reduce child mortality, and improve maternal health in an equitable manner. This report provides a comprehensive assessment of RMNCH in Kenya from 1990 to 2015, using data from nationally representative Demographic Health Surveys implemented between 1989 and 2014. The authors estimated time trends for key RMNCH indicators, as defined by Countdown to 2015, at both the national and the sub-national level, explored the determinants of change in intervention coverage during the past decade and modelled the effect of intervention scale up by 2030. After an increase in mortality between 1990 and 2003, there was a reversal in all mortality trends from 2003 onwards, although progress was not substantial enough for Kenya to achieve Millennium Development Goal targets 4 or 5. Between 1990 and 2015, maternal mortality declined at half the rate of under-5 mortality, and changes in neonatal mortality were even slower. National-level trends in intervention coverage have improved, although some geographical inequities remain, especially for counties comprising the northeastern, eastern, and northern Rift Valley regions. Disaggregation of intervention coverage by wealth quintile also revealed wide inequities for several health service interventions, such as skilled birth assistance. Maternal literacy and family size were found to be important drivers of positive change in key interventions across the continuum of care. The analysis highlighted the importance of quality of care around birth for maternal and newborn survival, and for targeting poor households and least educated and rural women, through the scale-up of community-level interventions, to improve equity and accelerate progress.

Lifestyle and income-related inequality in health in South Africa
Mukong A; Van Walbeek C; Ross H: International Journal for Equity in Health 16(103), doi: 10.1186/s12939-017-0598-7, 2017

Many low - and middle-income countries are experiencing an epidemiological transition from communicable to non-communicable diseases, imposing both economic and health burdens on their societies. While the prevalence of such diseases varies with socioeconomic status, the inequalities can be exacerbated by lifestyles. This paper explored the contribution of smoking and alcohol consumption to health inequalities, incorporating measures of health directly associated with these lifestyle practices from National Income Dynamic Study panel data for South Africa. The authors found significant smoking-related and income-related inequalities in both self-reported and lifestyle-related ill-health. The results suggest that smoking and alcohol use contribute positively to income-related inequality in health. Smoking participation accounts for up to 7.35% of all measured inequality in health and 3.11% of the inequality in self-reported health. The estimates are generally higher for all measured inequality in health (up to 14.67%) when smoking duration is considered. Alcohol consumption accounts for 27.83% of all measured inequality in health and 3.63% of the inequality in self-reported health. This study provides evidence that inequalities in both self-reported and lifestyle-related ill-health are highly prevalent within smokers and poor people. The authors suggest that policies aimed at reducing tobacco consumption and harmful alcohol will improve health and reduce health inequalities.

Measurement and decomposition of socioeconomic inequality in single and multimorbidity in older adults in China and Ghana: results from the WHO study on global AGEing and adult health
Kunna R; Sebastian M; Williams J: International Journal for Equity in Health 16(79), doi: 10.1186/s12939-017-0578-y, 2017

There is a need for country-specific evidence of NCD inequalities in developing countries where populations are ageing rapidly amid economic and social change. The study measures and decomposes socioeconomic inequality in single and multiple NCD morbidity in adults aged 50 and over in China and Ghana, using data from the World Health Organisation Study on Global AGEing and Adult Health 2007–2010. In China, the prevalence of single and multiple NCD morbidity was 64.7% and 53.4%, compared with 65.9% and 55.5% respectively in Ghana. Inequalities were significant and more highly concentrated among the poor in China. In Ghana inequalities were significant and more highly concentrated among the rich. In China, rural residence contributed most to inequality in single morbidity (36.4%) and the wealth quintiles contributed most to inequality in multi morbidity (39.0%). In Ghana, the wealth quintiles contributed 24.5% to inequality in single morbidity and body mass index contributed 16.2% to the inequality in multi- morbidity. The country comparison reflects different stages of economic development and social change in China and Ghana. More studies of this type are needed to inform policy-makers about the patterning of socioeconomic inequalities in health, particularly in developing countries undergoing rapid epidemiological and demographic transitions.

Mortality among twins and singletons in sub-Saharan Africa between 1995 and 2014: a pooled analysis of data from 90 Demographic and Health Surveys in 30 countries
Monden C; Smits J: The Lancet Global Health 5(7), e673-e679, 2017

Sub-Saharan Africa has the world's highest under-5 and neonatal mortality rates as well as the highest naturally occurring twin rates. Twin pregnancies carry high risk for children and mothers. Under-5 mortality has declined in sub-Saharan Africa over the last decades. It is unknown whether twins have shared in this reduction. The authors pooled data from 90 Demographic and Health Surveys for 30 sub-Saharan Africa countries on births reported between 1995 and 2014 to address this question. Under-5 mortality among twins declined from 327 per 1000 live births in 1995–2001 to 213 in 2009–14. This decline of 35% was less steep than the 51% reduction among singletons. Twins account for an increasing share of under-5 deaths in sub-Saharan Africa: currently 11% of under-5 mortality and 15% of neonatal mortality. Excess twin mortality cannot be explained by common risk factors for under-5 mortality, including birth-weight. The difference with singletons was especially stark for neonatal mortality and 52% of women pregnant with twins reported receiving medical assistance at birth. The authors note that an alarming one-fifth of twins in the region dies before age 5 years, three times the mortality rate among singletons. Twins account for a substantial and growing share of under-5 and neonatal mortality, but they are largely neglected in the literature. They argue that co-ordinated action is required to improve the situation of this extremely vulnerable group.

The State of the World’s Children 2016: A fair chance for every child
United Nations Children's Fund: UNICEF, New York, 2016

Based on current trends, 69 million children under five will die from mostly preventable causes, 167 million children will live in poverty, and 750 million women will have been married as children by 2030, the target date for the Sustainable Development Goals – unless the world focuses more on the plight of its most disadvantaged children, according to a UNICEF report released today. The State of the World’s Children, UNICEF’s annual flagship report, paints a stark picture of what is in store for the world’s poorest children if governments, funders, businesses and international organisations do not accelerate efforts to address their needs. The publication argues that progress for the most disadvantaged children is not only a moral, but also a strategic imperative. Stakeholders must have an obvious choice to make: invest in accelerated progress for the children being left behind, or face the consequences of a far more divided world by 2030. At the start of a new development agenda, the report concludes with a set of recommendations to help chart the course towards a more equitable world.

Early menarche: A systematic review of its effect on sexual and reproductive health in low- and middle-income countries
Ibitoye M; Choi C; Lee G; Sommer M: PLOS One, doi: https://doi.org/10.1371/journal.pone.0178884, 2017

Adolescent girls aged 15–19 bear a disproportionate burden of negative sexual and reproductive health outcomes in low- and middle-income countries. The authors conducted this systematic review to better understand whether and how early menarche is associated with various negative sexual and reproductive health outcomes in low- and middle-income countries and the implications of such associations. They systematically searched eight health and social sciences databases for peer-reviewed literature on menarche and sexual and reproductive health in low- and middle-income countries. The authors’ review of the minimal existing literature (with 24 papers included) showed that early menarche is associated with early sexual initiation, early pregnancy and some sexually transmitted infections in low- and middle-income countries, as has been observed in high-income countries. Early menarche is also associated with early marriage–an association that may have particularly important implications for countries with high child marriage rates. Early age at menarche may be an important factor affecting the sexual and reproductive health of adolescent girls and young women in low- and middle-income countries. Given the association of early menarche with early marriage, the authors propose that ongoing efforts to reduce child marriage may benefit from targeting efforts to early maturing girls.