Equity in Health

An analysis of the nutrition status of neighboring Indigenous and non-Indigenous populations in Kanungu District, southwestern Uganda: Close proximity, distant health realities
Sauer J; Berrang-Ford L; Patterson K; Donnelly B: Social Science & Medicine 217, 55-64, 2018

This paper analyzed the estimated prevalence, and modeled possible determinants of, moderate acute malnutrition and severe acute malnutrition (SAM) for Indigenous Batwa and non-Indigenous Bakiga of Kanungu District in Southwestern Uganda. The authors characterize possible mechanisms driving differences in malnutrition. Retrospective cross-sectional surveys were administered to 10 Batwa communities and 10 matched Bakiga Local Councils during April of 2014. Individuals were classified as moderate acute malnutrition and SAM based on middle upper-arm circumference for their age-sex strata. Malnutrition is high among Batwa children and adults, with nearly half of Batwa adults and nearly a quarter of Batwa children meeting moderate acute malnutrition criteria. SAM prevalence is lower than moderate acute malnutrition prevalence, with SAM highest among adult Batwa males. SAM prevalence among children was higher for Batwa males compared to Bakiga males. Models that incorporated community ethnicity explained the greatest variance in middle upper-arm circumference values. This research demonstrates inequality in malnutrition between the Indigenous Batwa and non-Indigenous Bakiga of Kanungu District, Uganda, with model results suggesting further investigation into the role of ethnicity as an upstream social determinant of health.

Two decades of antenatal and delivery care in Uganda: a cross-sectional study using Demographic and Health Surveys
Benova L; Dennis M; Lange I; et al: BMC Health Services Research 18(758) 1-14, 2018

The authors present a repeated cross-sectional study using four Uganda Demographic and Health Surveys of evidence on births with ANC, facility delivery, caesarean sections and complete maternal care. The authors assessed socio-economic differentials in these indicators by wealth, education, urban/rural residence, and geographic zone in the 1995 and 2011 surveys. ANC coverage with remained high over the study period but < 50% of women who received any ANC reported 4+ visits. Facility-based delivery care increased slowly, reaching 58% in 2011. While significant inequalities in coverage by wealth, education, residence and geographic zone remained, coverage improved for all indicators among the lowest socio-economic groups of women over time. The private sector market share declined over time to 14% of ANC and 25% of delivery care in 2011. Only 10% of women with 4+ ANC visits and 13% of women delivering in facilities received all measured care components. The Ugandan health system had to cope with more than 30,000 additional births annually between 1991 and 2011. The majority of women in Uganda accessed ANC, but this contact did not result in care of sufficient frequency, content, and continuum of care. Providers in both sectors require quality improvements. The authors suggest that achieving universal health coverage and maternal/newborn SDGs in Uganda requires prioritising poor, less educated and rural women, despite competing priorities for financial and human resources.

Perceptions and experiences related to health and health inequality among rural communities in Jimma Zone, Ethiopia: a rapid qualitative assessment
Bergen N; Mamo A; Asfaw S; et al: International Journal for Equity in Health 17(84) 1-7, 2018

This paper explores community perceptions and experiences related to health and health inequality. The authors conducted 12 focus group discussions and 24 in-depth interviews with community stakeholder groups across six rural sites in Jimma Zone, Ethiopia. Participants described being healthy as being disease free, being able to perform daily activities and being able to pursue broad aspirations. Health inequalities were viewed as community issues, primarily emanating from a lack of knowledge or social exclusion. Poverty was raised as a contributor to poor health that could be overcome through community-level responses. Participants described formal and informal mechanisms for supporting disadvantaged people in form of safety net that provide information and emotional, financial and social support. Understanding community perceptions of health and health inequality can serve as an evidence base for community-level initiatives, including for maternal, new-born and child health.

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(1):52, 1-15, 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 Southern African Development Community (SADC) countries. Generally, a pro-poor socioeconomic inequality exists in poor SAH in the six countries. However, this is only statistically significant for South Africa, and marginally significant for Zambia and Zimbabwe. Smoking and inadequate fruit and vegetable consumption were significantly concentrated among poor people. Similarly, the use of biomass energy, unimproved water and sanitation were significantly concentrated among poor. people 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 for concerted efforts to tackle the significant socioeconomic inequalities in ill-health and health risk factors in the region. Because some of the determinants of ill-health lie outside the health sector, they also indicate that inter-sectoral action is required

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.

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