Equity in Health

World Malaria Report 2016
World Health Organization: WHO Geneva, 2016

The World Malaria Report, published annually by WHO, provides an in-depth analysis of progress and trends in the malaria response at global, regional and country levels. It is the result of a collaborative effort with ministries of health in affected countries and many partners around the world. The 2016 report spotlights a number of positive trends, particularly in sub-Saharan Africa, the region that carries the heaviest malaria burden. It shows that, in many countries, access to disease-reducing measures is expanding at a rapid rate for those most in need. The proportion of the population at risk in sub-Saharan Africa sleeping under an insecticide-treated mosquito net (ITN) or protected by indoor residual spraying (IRS) is estimated to have risen from 37% in 2010 to 57% in 2015. The proportion of the population at risk in sub-Saharan Africa who are infected with malaria parasites is estimated to have declined from 17% in 2010 to 13% in 2015. Further data on malaria prevention, treatment and outcomes are presented.

Patterns and determinants of malaria risk in urban and peri-urban areas of Blantyre, Malawi
Mathanga D; Tembo A; Mzilahowa T; Bauleni A; Mtimaukenena K; Taylor T; Valim C; Walker E; Wilson M: Malaria Journal 15(590), 2016

Although malaria disease in urban and peri-urban areas of sub-Saharan Africa is a growing concern, the patterns and drivers of transmission in these settings remain poorly understood. Factors associated with variation in malaria risk in urban and peri-urban areas were evaluated in this study. A health facility-based, age and location-matched, case–control study of children 6–59 months of age was conducted in four urban and two peri-urban health facilities (HF) of Blantyre city, Malawi. Children with fever who sought care from the same HF were tested for malaria parasites by microscopy and PCR. Those testing positive or negative on both were defined as malaria cases or controls, respectively. A total of 187 cases and 286 controls were studied. In univariate analyses, higher level of education, possession of TV, and electricity in the house were negatively associated with malaria illness; these associations were similar in urban and peri-urban zones. Having travelled in the month before testing was strongly associated with clinical malaria, but only for participants living in the urban zones. Use of long-lasting insecticide nets the previous night was not associated with protection from malaria disease in any setting. In multivariate analyses, electricity in the house, travel within the previous month, and a higher level of education were all associated with decreased odds of malaria disease. Only a limited number of Anopheles mosquitoes were found by aspiration inside the households in the peri-urban areas, and none was collected from the urban households. Travel was the main factor influencing the incidence of malaria illness among residents of urban Blantyre compared with peri-urban areas. Identification and understanding of key mobile demographic groups, their behaviours, and the pattern of parasite dispersal is argued to be critical to the design of more targeted interventions for the urban setting.

Risk of poor development in young children in low-income and middle-income countries: an estimation and analysis at the global, regional, and country level
Lu C; Black M; Richter L: The Lancet 4 (12) e916–e922, 2016

In this paper the authors used 2010 estimates to assess how many children aged younger than 5 years were exposed to stunting or extreme poverty. The authors used country-level prevalence of stunting in children younger than 5 years based on the 2006 Growth Standards proposed by WHO and poverty ratios from the World Bank to estimate children who were either stunted or lived in extreme poverty for 141 low-income and middle-income countries in 2004 and 2010. To avoid counting the same children twice, the authors excluded children jointly exposed to stunting and extreme poverty from children living in extreme poverty. To examine the robustness of estimates, the authors also used moderate poverty measures. The estimated number of children exposed to the two risk factors in low-income and middle-income countries decreased from 279 million in 2004 to 249 million in 2010; and the prevalence of children at risk fell from 51% to 43% globally. Sub-Saharan Africa had the highest prevalence in both years, however.

Health as the Pulse of the New Urban Agenda
World Health Organisation: United Nations Conference on Housing and Sustainable Urban Development, 2016

For the Third United Nations Conference on Housing and Sustainable Urban Development, Habitat III agenda for the next 20 years of urban development to succeed, the health of the nearly four billion people who dwell in cities today must be a central concern. Decisions related to urban planning and governance can create or exacerbate major health risks – or they can foster healthier environments and lifestyles, that in turn reduce the risks of both communicable and noncommunicable diseases. The New Urban Agenda adopted at Habitat III, clarifies that health is not only about the provision of health care services, recognising that the shape and form of urban development influences the health of city residents. Those who design, plan, build and govern cities exercise great influence over the basic ingredients of a healthy life, including access to decent housing, clean air and water, nutritious food, safe transport and mobility, opportunities for physical activity, and protection from injury risks and toxic pollutants. Cities that offer these fundamentals can dramatically reduce the incidence and associated costs of a wide range of diseases – from heart disease and stroke, to vector-borne diseases and childhood illnesses – while improving health equity for those most often exposed to such risks, such as children, older people, women, people with disabilities, and the poor. Cities that offer health-enabling environments and coordinated support for healthy lifestyles can ensure that their citizenry are not only healthier and happier, but more economically productive, with far lower costs to both families and societies due to work-related illnesses and injuries. This paper clarifies these and other critically important connections between health and urban policies. It also provides a detailed vision for integrating health into urban planning and governance, and offers practical guidance on health-promoting approaches for those tasked with implementing the New Urban Agenda in the years to come.

Innov8 approach for reviewing national health programmes: Promoting Health Through Life Course
World Health Organisation: Geneva 2016

The Innov8 approach is a resource that supports the operationalisation of the Sustainable Development Goal (SDGs) commitment to “leave no one behind”. Innov8 is an 8-step analytic process undertaken by a multidisciplinary review team. It results in recommendations to improve programme performance through concrete action to address health inequities, support gender equality and the progressive realisation of universal health coverage and the right to health, and address critical social determinants of health. The Innov8 Technical Handbook is a user-friendly resource that includes background readings, country examples and analytical activities to support a programmatic review process. The Technical Handbook will be complemented by the release of a wider set of materials currently under development by WHO as part of the Innov8 resource package.

Trends in Between-Country Health Equity in Sub-Saharan Africa from 1990 to 2011: Improvement, Convergence and Reversal
Jin J; Liang D; Shi L; Huang J: International Journal of Environmental Research and Public Health 13(6), 620; 2016

It is not clear whether between-country health inequity in Sub-Saharan Africa has been reduced over time due to economic development and increased foreign investments. The authors used the World Health Organization’s data about 46 nations in Sub-Saharan Africa to test if under-5 mortality rate (U5MR) and life expectancy (LE) converged or diverged from 1990 to 2011. The authors explored whether the standard deviation of selected health indicators decreased over time (i.e., sigma convergence), and whether the less developed countries moved toward the average level in the group (i.e., beta convergence). The variation of U5MR between countries became smaller from 1990 to 2001. Yet this trend did not continue after 2002. Life expectancy in Africa from 1990–2011 demonstrated a consistent convergence trend, even after controlling for initial differences of country-level factors. The lack of consistent convergence in U5MR partially resulted from the fact that countries with higher U5MR in 1990 eventually performed better than those countries with lower U5MRs in 1990, constituting a reversal in between-country health inequity.

Inequalities in full immunization coverage: trends in low- and middle-income countries
Restrepo-Méndez M; Barros A; Wong K; et al.: Bulletin of the World Health Organisation 94(11) 2016,

This study investigated disparities in full immunisation coverage across and within 86 low- and middle-income countries. In May 2015, using data from the most recent Demographic and Health Surveys and Multiple Indicator Cluster Surveys, the authors investigated inequalities in full immunisation coverage – i.e. one dose of bacille Calmette-Guérin vaccine, one dose of measles vaccine, three doses of vaccine against diphtheria, pertussis and tetanus and three doses of polio vaccine – in 86 low- or middle-income countries. The authors then investigated temporal trends in the level and inequality of such coverage in eight of the countries. In each of the World Health Organisation’s regions, it appeared that about 56–69% of eligible children in the low- and middle-income countries had received full immunisation. However, within each region, the mean recorded level of such coverage varied greatly. In the African Region, for example, it varied from 11.4% in Chad to 90.3% in Rwanda. The authors detected pro-rich inequality in such coverage in 45 of the 83 countries for which the relevant data were available and pro-urban inequality in 35 of the 86 study countries. Among the countries in which the authors investigated coverage trends, Madagascar and Mozambique appeared to have made the greatest progress in improving levels of full immunisation coverage over the last two decades, particularly among the poorest quintiles of their populations. Most low- and middle-income countries are affected by pro-rich and pro-urban inequalities in full immunisation coverage that are not apparent when only national mean values of such coverage are reported.

World AIDS Day: Lessons for reversing inequality
Goldring M: Oxfam UK, Global Health Check, December 2016

On World AIDS Day 2016 Mark Goldring Oxfam UK Executive Director reflected on what we have learnt from working to address the inequality challenges of the HIV epidemic. He focuses on 4 lessons. First, that inequality kills. Millions have died because they were too poor to pay the exorbitant prices of medicines and hospital fees. Investing in public health systems to offer free service as the point of use and in affordable medicines are essential to save lives and tackle inequality – both health and economic inequality. The second lesson is that inequality in accessing health services needs to be addressed, especially by overcoming impoverishing costs of care, with women bearing the brunt of this burden. ِِِِThe third less is that access to HIV treatment could not happen without securing adequate financing. The final lesson is that active citizenship – people’s involvement in decision making - is at the heart of the success in the response to HIV and in applying the lessons on addressing inequality.

Area-based units of analysis for strengthening health inequality monitoring
Hosseinpoor A; Bergen N: Bulletin of the World Health Organisation 94(11), 2016

Inequalities in health persist worldwide and one of the starting points for remedial action is collecting data that reveal patterns of inequality. Yet countries have varying capacities for monitoring health inequality. This is due in part to data-related issues such as weaknesses in the health information systems, especially in many low- and middle-income countries; lack of availability or poor quality of health data; and a limited ability to disaggregate data across all health topics within countries. Overcoming these challenges in the long term requires substantial investments in the health information infrastructure. In the short-term, countries need innovative approaches to best harness the potential of their existing data to improve monitoring efforts. In this article the authors make the case for stratifying data at the level of subnational geographical regions, such as provinces, states or districts. The wider use of an area-based unit of analysis as a complementary way to analyse data at the individual or household level has certain practical advantages that are relevant to low- and middle-income countries as well as high-income countries. First, this approach opens up new possibilities concerning the data that can be used for within-country monitoring, in terms of both health data and data about dimensions of inequality. Second, since interventions to reduce inequities are likely to be implemented at the local administrative level, regional monitoring of health inequalities may be a useful tool for benchmarking, with implications for resource allocation, planning and evaluation. Third, area-based measures may provide a more intuitive understanding of health inequalities and may help to identify possible points for intervention. Alongside these advantages, some caution is needed when adopting an area-based unit of analysis. There is the risk of committing a so-called ecological fallacy (i.e. making assumptions about individuals based on population-level patterns, or in this case, erroneously drawing conclusions about the health of individuals using area-based data). In many countries, health inequality monitoring systems could be strengthened by expanding the capacity for, and practice of, area-based health inequality monitoring. Adopting an area-based unit to express health inequality has several merits. Monitoring health inequalities by geographically defined subgroups can help to identify disadvantaged regions that are falling behind in terms of health indicators and to guide improvements in these areas.

The Prevention Gap
UNAIDS: Geneva November 2016

A new report by UNAIDS released prior to World AIDS Day 2016 reveals concerning trends in new HIV infections among adults. The Prevention gap report shows that while significant progress is being made in stopping new HIV infections among children (new HIV infections have declined by more than 70% among children since 2001 and are continuing to decline), the decline in new HIV infections among adults has stalled. The report shows that HIV prevention urgently needs to be scaled up among this age group. The Prevention gap report shows that an estimated 1.9 million adults have become infected with HIV every year for at least the past five years and that new HIV infections among adults are rising in some regions. New HIV infections among adults declined by only 4% in eastern and southern Africa since 2010. The Prevention gap report gives the clear message that HIV prevention efforts need to be increased in order to stay on the Fast-Track to ending AIDS by 2030. “We are sounding the alarm,” said Michel Sidibé, Executive Director of UNAIDS. “The power of prevention is not being realized. If there is a resurgence in new HIV infections now, the epidemic will become impossible to control. The world needs to take urgent and immediate action to close the prevention gap.”