This paper presents a combined historical and contemporary review of the clinical burden of malaria within one of Africa's largest urban settlements, Nairobi, Kenya. The authors conducted a review of historical reported malaria case burdens since 1911 within Nairobi using archived government and city council reports. An audit of 22 randomly selected health facilities within Nairobi was undertaken, including interviews with health workers, and a checklist of commodities and guidelines necessary to diagnose, treat and record malaria. The researchers found that, from the 1930s through to the mid-1960s, malaria incidence declined coincidental with rapid population growth. During this period malaria notification and prevention were a priority for the city council. From 2001-2008 reporting systems for malaria were inadequate to define the extent or distribution of malaria risk within Nairobi. The facilities and health workers included in this study were not universally prepared to treat malaria according to national guidelines or identify foci of risks due to shortages of national first-line drugs, inadequate record keeping and a view among some health workers (17%) that slide negative patients could still have malaria. Combined with historical evidence, there is a strong suggestion that very low risks of locally acquired malaria exist today within Nairobi's city limits and this requires further investigation.
Equity in Health
A draft technical background paper for the World Conference on the Social Determinants of Health October 2011 is being circulated for peer review. It covers the five themes of the Conference, selected to highlight key ways of successfully implementing policies on social determinants. These themes are closely inter-related, reflecting the need for action on social determinants to be undertaken across society: governance to tackle the root causes of health inequities by implementing action on social determinants of health; the role of the health sector, including public health programmes, in reducing health inequities; promoting participation by providing community leadership for action on social determinants; global action on social determinants, especially regarding aligning priorities and stakeholders; and monitoring progress in terms of measurement and analysis to inform policies on social determinants.
The Commission on Social Determinants of Health (CSDH) framework shows how social, economic and political mechanisms give rise to a set of socioeconomic positions, whereby populations are stratified according to income, education, occupation, gender, race/ethnicity and other factors. These socioeconomic positions in turn shape specific determinants of health status (intermediary determinants) reflective of people’s place within social hierarchies; based on their respective social status, individuals experience differences in exposure and vulnerability to health-compromising conditions. The CSDH framework departs from many previous models by conceptualising the health system itself as a social determinant of health (SDH). The role of the health system becomes particularly relevant through the issue of access, which incorporates differences in exposure and vulnerability, and through intersectoral action led from within the health sector. Arguably the single most significant lesson of the CSDH conceptual framework is that interventions and policies to reduce health inequities must not limit themselves to intermediary determinants, but must include policies specifically crafted to tackle the social mechanisms that systematically produce an inequitable distribution of the determinants of health among population groups. To tackle structural, as well as intermediary, determinants requires intersectoral policy approaches.
The 2000s have seen health stand higher than ever on the international development agenda, and stakeholders increasingly acknowledge the inadequacy of health strategies that fail to address the social roots of illness and well-being. Momentum for action on the social dimensions of health is building. Based on the historical survey, four key issue areas are highlighted here, relevant to work on social determinants of health. The first concerns the scope of change and appropriate policy entry points, and the choice between comprehensive and selective primary health care that confronted public health leaders in the 1980s. The work needs evaluation criteria for identifying appropriate policy entry points for different countries/jurisdictions. Potential resistance to social determinants messages can be anticipated from several constituencies, but there are also exceptional political opportunities, including in the global and national processes connected to the MDGs.
According to this article, Africa faces numerous health challenges on the ground, such as lack of skilled health workers and poor social determinants of health, as well as several challenges originating from the global health arena. In global health, idealists who believe that money and technical assistance must be available in sufficient quantities to meet demand are pitted against policy makers who are working with finite resources and competing priorities. The author identifies lack of co-ordination of policies and programmes in Africa as another major obstacle to achieving universal health coverage. In addition, he argues that global health continues to operate on a financing mechanism that strengthens the hand of donor organisations at the expense of host nations and their priorities. Measuring the impact of global health programmes is technically difficult and a massive data gap exists. The author notes lack of participation by target populations in global health initiatives with regard to conceptualisation and design of projects, and their knowledge, attitudes and perceptions of target populations are also seldom included, especially the voices of poor and underserved communities. In Africa and other parts of the developing world, the author argues that global health is evolving from traditional concerns about the spread of infectious diseases to concerns about human security and dignity.
Africa is confronted by a heavy burden of communicable and non-communicable diseases. Cost-effective interventions that can prevent the disease burden exist but coverage is too low due to health systems weaknesses. This editorial reviews the challenges related to leadership and governance; health workforce; medical products, vaccines and technologies; information; financing; and services delivery. It also provides an overview of the orientations provided by the WHO Regional Committee for Africa for overcoming those challenges. It cautions that it might not be possible to adequately implement those orientations without a concerted fight against corruption, sustained domestic and external investment in social sectors, and enabling macroeconomic and political (i.e. internally secure) environment.
Using South Africa's annual mortality and population estimates data, the authors of this study calculated lung cancer age-standardised mortality rates for the period 1995 to 2006. Lung cancer caused 52,217 deaths during the study period. There were 4,525 deaths for the most recent year (2006), with men accounting for 67% of deaths. For the entire South African population, the age-standardised mortality rate of 24.3 per 100,000 persons in 1995 was similar to the rate of 23.8 per 100,000 persons in 2006. Overall, there was no significant decline in lung cancer mortality in South Africa from 1995 to 2006. In men, there was a statistically non-significant annual decline of 0.21 deaths per 100,000 persons. Despite this promising trend, the authors caution that the increasing rate in women is a public health concern that warrants intervention. Smoking intervention policies and programmes need to be strengthened to further reduce lung cancer mortality in men and to address the increasing rates in women.
In this study, the author reviews a range of health inequalities, across social class, gender, wealth and within and between countries. He tentatively identifies pathways of causality in each case, and makes judgments about whether or not each inequality is unjust. Health inequalities that come from medical innovation are among the most benign, he argues. The author emphasises the importance of early life inequalities, and of trying to moderate the link between parental and child circumstances. He argues that racial inequalities in health are unjust and add to injustices in other domains. The vast inequalities in health between rich and poor countries are neither just nor unjust, nor are they easily addressable. The author concludes that there are grounds to be concerned about the rapid expansion in inequality at the very top of the income distribution: this is not only an injustice in itself, but it poses a risk of spawning other injustices, in education, in health, and in governance.
In this paper, three categories of social inclusion policies are reviewed – cash-transfers, free social services and specific institutional arrangements for programme integration – in six selected countries, including Botswana, Mozambique, South Africa and Zimbabwe. The authors highlight the impact of these policies on health inequities. They identify crosscutting benefits, such as poverty alleviation, notably among vulnerable children and youths, improved economic opportunities for disadvantaged households, reduction in access barriers to social services, and improved nutrition intake. However, they caution that the impact of these benefits, and hence the policies, on health status can only be inferred. A major weakness of most policies was the lack of a monitoring and evaluation system. The authors call on governments of sub-Saharan African countries to conduct research to measure health inequities and design social policies that address the constraints identified in the research. They also call for support for a strong movement by civil society to address health inequities and to hold governments accountable for improving health and reducing inequities.
According to this paper, Zambia’s Millennium Development Goal (MDG) progress reports of 2003 and 2005 show that it is unlikely that Zambia will achieve even half of its MDG goals, despite laudable political commitment and some advances made towards achieving universal primary education, gender equality, improvement of child health and management of the HIV and AIDS epidemic. The authors of this paper argue that Zambia’s health systems have been weakened by a high disease burden and high mortality rates, natural and man-made environmental threats and some negative effects of globalisation such as major external debt, low world prices for commodities and the human resource ‘brain drain’. They urge for the government to put its political promises into action, and offer some tried-and-tested strategies and ‘quick wins’ that have been proven to produce high positive impact in the short term.