Equity in Health

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.”

Habitat 3: Jean Pierre Elong Mbassi on the importance of cities in implementing the SDGs
Global Goals UN: Quito 19 October 2016

Jean Pierre Elong Mbassi, Secretary-General of United Cities and Local Governments Africa, speaks about how cities help with implementing the Sustainable Development Goals (SDGs), Paris Agreement and more. He noted that it was a positive move to have had the second world assembly of local and regional governments in Quito in the framework of the UN Habitat 3 conference. This was an accomplishment from Habitat 2 when they were not included. This shows that local authorities are not part of the process, and the next step is to bring them around the table with higher level decision making authorities. He argued that without local authorities there is no way to implement global agendas and that if governments and regional bodies listen to cities, the SDGs, climate agendas, and related agreements will stand a significantly better chance of realisation.

Why are maternal health outcomes worse for migrant women in Masindi, Uganda?
Ayiasi R; Mangwi A; Kiiza A; Orach C: Resilient and responsive health systems (RESYST) blog, Makerere University, School of Public Health, September 2016

Globally, 298,000 women die due to pregnancy related causes each year and half of these occur in Africa. In Uganda, maternal mortality has marginally reduced from 526/100,000 to 435/100,000 livebirths between 2001 and 2011. The presence of a skilled attendant during the entire continuum of care for maternal and new born care has great potential to reduce maternal and new born morbidities and mortality. In 2013, an intervention to mobilize communities in Masindi, Uganda for maternal and new born health was introduced and the results showed marked improvement in utilization of maternal health services such as antenatal care and health facility delivery. However, non-indigenous populations were found to use maternal health services less compared to the indigenous populations. The non-indigenous population are mainly from the West Nile region of Arua and Nebbi. These group of people provide a cheap source of labour for the sugar plantation and sugar factory in Kinyala. This study could not adequately explain why migrants were using maternal health services less. The aim of this study was to gain a deeper understanding of internal migrant’s low access and utilisation of maternal and new born care services in Masindi, Uganda. Key barriers to access were identified as lack of financial resources, social beliefs, neglect by health workers, lack of education and lack of male involvement. There are a number of barriers to access to maternity care among migrant women in Masindi, Uganda. These barriers can be addressed at two levels. At the household level, there should be deliberate efforts to engage with men to support their partners during pregnancy and childbirth for example, by saving money and preparing for transport to the health facility in case of antenatal care and delivery. At the district level, there is need for district local managers together with district health managers to create a dialogue platform in which communication barriers and the mistreatment of migrant women can be addressed in the health sector.

2016: Old Challenges, New Hopes
Independent Accountability Panel, September 2016

The Independent Accountability Panel (IAP) inaugural report '2016: Old Challenges, New Hopes' was launched September 18, 2016 in conjunction with the Partnership for Maternal Newborn and Child Health and Countdown to 2030 and formally submitted to the Secretary-General at the Every Woman Every Child high level reception on the 20th September 2016. The report details how inequalities within and between countries are leaving women, children and adolescents at a disadvantage. It argues that more must be done to give every woman, every adolescent, and every child the opportunity to survive and thrive. In a statement at http://tinyurl.com/hadb8np the O’Neill Institute for National and Global Health Law at Georgetown University Law Center endorsed the report noting "The IAP’s report encompasses remedies as a necessary part of an accountability framework, building on the earlier work of the Commission on Information and Accountability and its accountability framework of monitor, review, and act. The inclusion of remedies rounds out a cycle of accountability that is necessary to realize the right to health and other health-related rights, which must extend beyond the traditional emphasis on monitoring and evaluation. This report is intended to help catalyze the use of national, regional, and global accountability mechanisms – and vitally, to ensure that all people, with special attention to the most marginalized, have the resources and respect that empower their ability to access them".