Equity in Health

Engaging with complexity to improve the health of indigenous people: a call for the use of systems thinking to tackle health inequity
Hernández A; Ruano A; Marchal B; San Sebastián M; Flores W: International Journal for Equity in Health 16(26) 2017, doi: 10.1186/s12939-017-0521-2

Indigenous people remain on the margins of society in high, middle and low-income countries, and bear a disproportionate burden of poverty, disease, and mortality compared to the general population. These inequalities have persisted, and in some countries have even worsened, despite the overall improvements in health indicators. The social determinants of health framework has enriched the understanding of the complex conditions that give rise to inequalities in indigenous health, including the structural and socio-political factors, and the intersecting conditions of poverty, social and political exclusion, discrimination and land loss that shape indigenous people’s health. The authors report in this paper the conditions of marginalisation that impact indigenous health from their work in Guatemala and argue for a citizen-led initiative for state accountability for the right to health in rural indigenous municipalities. The authors argue that the challenge of engaging with the conditions underlying inequalities and promoting transformational change means that equity-oriented research and practice in the field of indigenous health requires: engaging power, context-adapted strategies to improve service delivery, and mobilising networks of collective action.

Rheumatology in Africa-challenges and opportunities
Mody G: Arthritis Research & Therapy 19(49), 2017, doi: https://dx.doi.org/10.1186%2Fs13075-017-1259-3

Africa faces many health challenges despite sustained growth and development over the past decade. Contributory factors are the lack of financial resources, an inadequate health professional workforce, a high burden of communicable diseases and an increasing burden of non-communicable diseases. Rheumatology services are limited or non-existent in many parts of sub-Saharan Africa. Over the past decade, partnerships with international academic institutions have resulted in some progress in the training of rheumatologists and health professionals and development of rheumatology services in countries such as Kenya, Nigeria, and Zambia. Basic diagnostic tests, biological agents and arthroplasty are either unavailable or not affordable by the majority of the population. Urbanisation has resulted in a change in the epidemiology of rheumatic diseases with an increase in the prevalence of gout, rheumatoid arthritis, systemic lupus erythematosus, and scleroderma over the past four decades. Future growth of rheumatology services will depend on identifying committed individuals in underserved countries for training and supporting them to educate medical students, physicians, and health professionals in their home countries. The author raises that there is a need to develop models of care using all categories of health workers and identify prevention strategies and cost-effective management programs for low resource settings. Africa affords an opportunity for collaborative research, including genetic and epigenetic studies, to improve regional understanding of many of the rheumatic diseases.

Global Tuberculosis Report 2016
World Health Organisation: WHO, Geneva, 2016

The Global Tuberculosis Report provides a comprehensive and up-to-date assessment of the TB epidemic, and of progress in prevention, diagnosis and treatment of the disease at global, regional and country levels. This global TB report provides an assessment of the TB epidemic and progress in TB diagnosis, treatment and prevention reports, as well as an overview of TB-specific financing and research. It also discusses the broader agenda of universal health coverage, social protection and other SDGs that have an impact on health. Data were available for 202 countries and territories that account for over 99% of the world’s population and TB cases. Six countries accounted for 60% of the new cases: India, Indonesia, China, Nigeria, Pakistan and South Africa. Global progress is argued to depend on major advances in TB prevention and care in these countries. Worldwide, the rate of decline in TB incidence remained at only 1.5% from 2014 to 2015. This needs to accelerate to a 4–5% annual decline by 2020 to reach the first milestones of the End TB Strategy. TB treatment averted 49 million deaths globally between 2000 and 2015, but important diagnostic and treatment gaps persist. US$ 6.6 billion was available for TB care and prevention in low and middle-income countries in 2016, of which 84% was from domestic sources. Nonetheless, national TB programmes in low-income countries continue to rely on international funders for almost 90% of their financing. The report notes that investments in low and middle-income countries fall almost US$ 2 billion short of the US$ 8.3 billion needed in 2016. This annual gap will widen to US$ 6 billion in 2020 if current funding levels do not increase. Despite some progress in the pipeline for new diagnostics, drugs and regimens, and vaccines, TB research and development is also argued to remain severely underfunded.

The impact of multi-morbidity on disability among older adults in South Africa: do hypertension and socio-demographic characteristics matter?
Waterhouse P; van der Wielen N; Banda P; Channon A: International Journal Equity Health 16(62), 2017, doi: 10.1186/s12939-017-0537-7

This study in South Africa investigated the association between multi-morbidity and disability among older adults; and whether hypertension (both diagnosed and undiagnosed) mediates this relationship. The authors consider whether the impact of the multi-morbidity on disability varies by socio-demographic characteristics. Data were drawn from Wave 1 (2007-08) of the South African Study on Global Ageing and Adult Health. Disability was measured using the 12-item World Health Organisation Disability Assessment Schedule (WHODAS) 2.0. Nearly half of the respondents had a hypertensive blood pressure when measured during the interview, but had not been previously diagnosed. A further third self-reported they had been told by a health professional they had hypertension. The logistic regression showed in comparison to those with no chronic conditions, those with one or two or more had significantly higher odds of severe disability. Hypertension was insignificant and did not change the direction or size of the effect of the multi-morbidity measure substantially. The interactions between number of chronic conditions with wealth were significant. The diagnosis of multiple chronic conditions, can be used to identify those most at risk of severe disability and to prioritise limited resources for such individuals for preventative, rehabilitative and palliative care.

Socioeconomic status and non-communicable disease behavioural risk factors in low-income and lower-middle-income countries: a systematic review
Allen L; Williams J; Townsend N; Mikkelsen B; Roberts N; Foster C; Wickramasinghe K: The Lancet Global Health, 5(3), 2017

This study aimed to review evidence on the association between socioeconomic status and harmful use of alcohol, tobacco use, unhealthy diets, and physical inactivity within low-income and lower-middle-income countries (LLMICs). The authors searched 13 electronic databases, grey literature, and reference lists for primary research published between Jan 1, 1990, and June 30, 2015. They used a piloted version of the Cochrane Effective Practice and Organisation of Care Group data collection checklist to extract relevant data at the household and individual level from the included full text studies including study type, methods, outcomes, and results. Low socioeconomic groups were found to have a significantly higher prevalence of tobacco and alcohol use than high socioeconomic groups. These groups also consumed less fruit, vegetables, fish, and fibre than those of higher socioeconomic status. Groups at higher socioeconomic status were found to be less physically active and to consume more fats, salt, and processed food than individuals of low socioeconomic status. Despite significant heterogeneity in exposure and outcome measures, the evidence shows that behavioural risk factors are affected by socioeconomic position within LLMICs.

The Second National Burden of Disease Study for South Africa: Cause of death profile Report, 1997 – 2012
Msemburi W; Pillay-van Wyk V; Dorrington RE et al: South African Medical Research Council: Cape town, 2016

This report estimates consistent and coherent cause-specific death rates for the period 1997–2012 and identifies the leading causes of death and premature mortality for South Africa, taking into consideration and adjusting for the data deficiencies. The report used the methodology of the Global Burden of Disease Study 2005 in secondary analysis of data obtained from Statistics South Africa (Stats SA), the Injury Mortality Survey 2009 (IMS) and National Injury Surveillance System 2000 (NIMSS). For the non-communicable diseases, there was an increasing trend in numbers over the whole period while the trends for communicable disease combined with maternal causes, perinatal conditions and nutritional deficiencies, remained fairly stable between 1997 and 2009, decreasing slightly thereafter. HIV/AIDS and TB increased between 1997 and 2006, where it peaked at 687 deaths per 100,000 population and then decreased steadily each subsequent year. The report points to a considerable burden from non-communicable diseases and concerning signs of an increase in diabetes mortality. The authors say that efforts targeting prevention and management of non-communicable diseases and their risk factors need to be scaled up.

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.