In this paper, the authors investigate the cross-country determinants of health improvements and describe the implications for development policy. The authors argue that making improvements to health need not be expensive. Even very low income countries can make great strides with good technologies and good delivery, but the authors warn that this may take time. They argue that two major factors underlie improved global health outcomes: first,the discovery of cheap technologies that can dramatically improve outcomes; and second, the adoption of these technologies, thanks to the spread of knowledge. Other factors have played a role. Increased income not only allows for improved nutrition, but also helps to improve access to more complex preventative technologies. Institutional development is a second key to the spread of such complex technologies. Nonetheless, evidence of dramatic health improvements even in environments of weak institutions and stagnant incomes suggests that the role of institutional factors may be secondary.
Equity in Health
Despite significant setbacks after the 2008-2009 economic downturn, exacerbated by the food and energy crisis, the United Nations notes that the world is on track to reach poverty-reduction targets, but also notes that progress has been inequitable. According to the United Nations. The number of deaths of children under the age of five declined from 12.4 million in 1990 to 8.1 million in 2009. The largest absolute drops in malaria deaths were in Africa, where 11 countries have reduced malaria cases and deaths by over 50%. New HIV infections are declining steadily, led by sub-Saharan Africa. Between 1995 and 2009, a total of 41 million tuberculosis patients were successfully treated and up to 6 million lives were saved, due to effective international protocols for the treatment of tuberculosis. In contrast, the report notes that progress has been inequitable: the poorest children have made the slowest progress in terms of improved nutrition, poor women and girls remain severely socially disadvantaged, and advances in sanitation often bypass the poor and those living in rural areas.
In this study, monthly pediatric admission data from five Ugandan hospitals and their catchments were gathered retrospectively across 11 years from January 1999 to December 2009. The researchers found that in four out of the five sites under study there was a significant increase in malaria admission rates. At all hospitals, malaria admissions had increased by 47% from 1999. Observed changes in intervention coverage within the catchments of each hospital showed a change in insecticide-treated net coverage from less than 1% in 2000 to 33% by 2009, but this was accompanied by increases in access to nationally recommended drugs at only two of the five hospital areas studied. The authors conclude that their findings show that the reported decline in malaria in Africa is not a universal phenomenon across the continent. More data is needed from a wider range of malaria settings to provide accurate data on progress of the impact of malaria interventions.
Despite widespread implementation of effective multidrug therapy, leprosy has not been eliminated. The authors of this paper report that a third of newly diagnosed patients have nerve damage and might develop disabilities, although the proportion varies according to several factors, including level of self-care. Women who develop leprosy continue to be especially disadvantaged, with rates of late diagnosis and disability remaining high in this subgroup. Leprosy was not a specified disease in the Millennium Development Goals, but improvements in the other areas they cover, such as education and levels of poverty, will help leprosy patients and services, the authors argue. Recommendations for research on diagnosis, treatment, and prevention include further use of molecular analysis of theMycobacterium leprae genome, implementation of BCG vaccination and administration of chemoprophylaxis to household contacts. The authors also suggest development of tools for early diagnosis and detection of infection and nerve damage, and formulation of strategies to manage the chronic complications of leprosy, such as immune-mediated reactions and neuropathy.
A pilot study was conducted in one district of Zambia, in which maternal deaths occurring over a period of twelve months were identified and investigated. Data was collected through in-depth interviews with family, focus group discussions and hospital records. A total of 56 maternal deaths were investigated. Poor communication, existing risk factors, a lack of resources and case management issues were the broad categories under which contributing factors were assigned. Potential high impact actions were related to management of AIDS and pregnancy, human resources, referral mechanisms, birth planning at household level and availability of safe blood. In resource-constrained settings, authors note that the Investigate Maternal Deaths and Act (IMDA) approach promotes the use of existing systems to reduce maternal mortality, thereby strengthening the capacity of local health officers to use data to determine, plan and implement relevant interventions that address local factors contributing to maternal deaths. Monitoring actions taken against the defined recommendations within the routine performance assessment should help ensure sustainability.
In this study, researchers investigated which alcohol indicator can most effectively detect associations between alcohol use and unsafe sexual behaviour among male sex workers - single-item measures of frequency and patterns of drinking (>=6 drinks on 1 occasion), or the Alcohol Use Disorders Identification Test (AUDIT). A cross-sectional survey in 2008 recruited male sex workers who sell sex to men from 65 venues in Mombasa district, Kenya, similar to a 2006 survey. Information was collected on socio-demographics, substance use, sexual behaviour, violence and STI symptoms. The 442 participants reported a median 2 clients/week, with half using condoms consistently in the last 30 days. Of the approximately 70% of men who drink alcohol, half drink two or more times a week. Binge drinking was common (38.9%). In conclusion, male sex workers have high levels of hazardous and harmful drinking, and require alcohol-reduction interventions, the authors argue. Compared with indicators of drinking frequency or pattern, the AUDIT measure has stronger associations with inconsistent condom use, STI symptoms and sexual violence. Increased use of the AUDIT tool in future studies may assist in delineating with greater precision the explanatory mechanisms which link alcohol use, drinking contexts, sexual behaviours and HIV transmission.
This paper assessed the extent to which the Kenyan health financing system meets the key requirements for universal coverage, including income and risk cross-subsidisation. Recommendations on how to address existing equity challenges and progress towards universal coverage are made. An extensive review of published and gray literature was conducted to identify the sources of health care funds in Kenya. In cases where data were not available at the country level, they were sought from the World Health Organisation website. Each financing mechanism was analysed in respect to key functions namely, revenue generation, pooling and purchasing. The Kenyan health sector relies heavily on out-of-pocket payments. Government funds are mainly allocated through historical incremental approach. The sector is largely underfunded and health care contributions are regressive (i.e. the poor contribute a larger proportion of their income to health care than the rich). Health financing in Kenya is fragmented and there is very limited risk and income cross-subsidisation. The country has made little progress towards achieving international benchmarks including the Abuja target of allocating 15% of government's budget to the health sector. The Kenyan health system is highly inequitable and policies aimed at promoting equity and addressing the needs of the poor and vulnerable have not been successful. Some progress has been made towards addressing equity challenges, but universal coverage will not be achieved unless the country adopts a systemic approach to health financing reforms. Such an approach should be informed by the wider health system goals of equity and efficiency.
Non-communicable diseases (NCD) occur more commonly among people in lower socioeconomic groups. NCDs and poverty are in a vicious cycle, where poverty exposes people to behavioural risk factors for NCDs and, in turn, the resulting NCDs may become an important driver of poverty. Since in poorer countries most health-care costs must be paid by patients out-of-pocket, the cost of health care for NCDs create significant strain on household budgets, particularly for lower-income families. Treatment for diabetes, cancer, cardiovascular diseases and chronic respiratory diseases can be protracted and therefore extremely expensive. Such costs can force families into catastrophic spending and impoverishment. Household spending on NCDs, and on the behavioural risk factors that cause them, translates into less money for necessities such as food and shelter, and for the basic requirement for escaping poverty – education. Each year, an estimated 100 million people are pushed into poverty because they have to pay directly for health services.
Increased control has produced remarkable reductions of malaria in some parts of sub-Saharan Africa, including Rwanda. In the southern highlands, near the district capital of Butare, a combined community- and facility-based survey on Plasmodium infection was conducted early in 2010. In this study, a total of 749 children below five years of age were examined including 545 randomly selected from 24 villages, 103 attending the health centre in charge, and 101 at the referral district hospital. The researchers found that one out of six children under five years of age is infected with malaria. The many asymptomatic infections in the community form a reservoir for transmission of malaria. Risk factors for malaria include low socio-economic status and ineffective self-reported bed net use.
The authors explain how health-care systems are currently facing an increasing burden of chronic disease aggravated by ageing populations, by the continuing risk of infectious diseases and by global pandemics. While the authors welcome the timely present focus on health systems, there are gaps in responding to the burden of chronic disease in developing countries. Discussions to date largely centre on delivering the model of acute-centric care, with some concentration on tackling the weaknesses in the six key components of health systems: service delivery, finance, governance, technologies, workforce, and information; and within the context of universal coverage and equity. Although this approach might be appropriate for acute conditions, and arguably for higher-income countries, the paper argues that it is unaffordable and unsustainable given the increasing burden of chronic disease in low income and middle-income countries. The authors concludes that primary health care approaches might have a better chance of success.