<p> <span lang="EN-US" style="font-size:12.0pt;font-family:
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mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA">Commercialisation of health care has contributed to widen inequities between the rich and the poor, especially in settings with suboptimal regulatory frameworks of the health sector. Poorly regulated fee-for-service payment systems generate inequity and initiate a vicious circle in which access to quality health care gradually deteriorates. Although the abolition of user fees is high on the international health policy agenda, the sudden removal of user fees may have disrupting effects on the health system and may not be affordable or sustainable in resource-constrained countries, such as the Democratic Republic of Congo. Between 2008 and 2011, the Belgian development aid agency (BTC) launched a set of reforms in the Kisantu district, in the province of Bas Congo, through an action-research process deemed appropriate for the implementation of change within open complex systems such as the Kisantu local health system. Moreover, the entire process contributed to strengthen the stewardship capacity of the Kisantu district management team. The reforms mainly comprised the rationalisation of resources and the regulation of health services financing. Flat fees per episode of disease were introduced as an alternative to fee-for-service payments by patients. A financial subsidy from BTC allowed to reduce the height of the flat fees. The provision of the subsidy was made conditional upon a range of measures to rationalise the use of resources. The results in terms of enhancing people access to quality health care were immediate and substantial. The Kisantu experience demonstrates that a systems approach is essential in addressing complex problems. It provides useful lessons for other districts in the country.</span></p>
Equity in Health
Sub-Saharan Africa is off-track to achieve the Millennium Development Goals (MDGs) for maternal and child health by 2015. Each year 265,000 mothers die due to complications of pregnancy and childbirth, 1,243,000 babies die before they reach one month of age and a further 3,157,000 children die before their fifth birthday. Nevertheless, there is clear evidence demonstrating that progress can be achieved even in low-income countries. This evidence, together with the unprecedented new investments in maternal and child health from continental leaders and increasingly from development partners, offers new hope for the future. Improving health systems and promoting high impact interventions are crucial and require partnerships between scientists, health care providers with government, development partners, policy makers, civil society and communities. Four key actions include: further investment and tracking of resources; equitable implementation of programmes; innovation in research; and using evidence as a basis for health policy and resource allocation.
These two challenge papers were commissioned by DANIDA to address two key questions. First, how has the development challenge changed, and how could it be understood for the future? Second, what are the implications for development agencies and development partnerships? Paper 1 by Andrew Norton, aims to support high-level discussion on the challenges facing global development. He reviews four key challenges: persistent poverty; globalisation and socio-economic transitions; sustainable development in the context of climate change; and human security, violence and conflict. He identifies major potential risks as shocks in the world economy, civil conflict and fragility, long-term resource scarcities and climate change. As a result, policy needs to engage with change, he argues, focusing on the supra-national level to deliver global public goods. Paper 2 by Andrew Rogerson picks up the themes emerging from Paper 1 to address the policy and institutional responses that are needed for inclusive and sustainable development. Like Norton, he calls for collective action within the complex institutional space occupied by many actors, policies and instruments. He further outlines three main options available to development agencies: concentrate on being an efficient disburser of official development assistance (ODA); become brokers and managers of ODA and ODA-like funds; or become deal-makers and brokers across government and internationally.
Whether or not the scale of a society's income inequality is a determinant of population health is still regarded as a controversial issue. We decided to review the evidence and see if we could find a consistent interpretation of both the positive and negative findings. We identified 168 analyses in 155 papers reporting research findings on the association between income distribution and population health, and classified them according to how far their findings supported the hypothesis that greater income differences are associated with lower standards of population health.
Income inequality is widely assumed to be a major contributor to poorer health at national and subnational levels. According to this assumption, the most appropriate policy strategy to improve equity in health is income redistribution. This paper considers reasons why tackling income inequality alone could be an inadequate approach to reducing differences in health across social classes and other population subgroups, and makes the case that universal social programs are critical to reducing inequities in health. A health system oriented around a strong primary care base is an example of such a strategy.
In this study, monthly pediatric admission data from five Ugandan hospitals and their catchments were gathered retrospectively across 11 years from January 1999 to December 2009. The researchers found that in four out of the five sites under study there was a significant increase in malaria admission rates. At all hospitals, malaria admissions had increased by 47% from 1999. Observed changes in intervention coverage within the catchments of each hospital showed a change in insecticide-treated net coverage from less than 1% in 2000 to 33% by 2009, but this was accompanied by increases in access to nationally recommended drugs at only two of the five hospital areas studied. The authors conclude that their findings show that the reported decline in malaria in Africa is not a universal phenomenon across the continent. More data is needed from a wider range of malaria settings to provide accurate data on progress of the impact of malaria interventions.
This article notes that almost 400 million of the world's indigenous people have low standards of health. This poor health is associated with poverty, malnutrition, overcrowding, poor hygiene, environmental contamination, and prevalent infections. The authors argue that this precarious situation is aggravated by inadequate clinical care and health promotion, and poor disease prevention services. As indigenous groups move from traditional to transitional and modern lifestyles, they are rapidly acquiring lifestyle diseases, such as obesity, cardiovascular disease, and type 2 diabetes, and physical, social, and mental disorders linked to misuse of alcohol and of other drugs. To correct these inequities, the authors recommend increased awareness, political commitment, and recognition rather than governmental denial and neglect of these serious and complex problems. Additionally, the authors recommend that indigenous people should be encouraged, trained, and enabled to become increasingly involved in overcoming these challenges.
This second article on the health of indigenous people delves into the underlying causes of health disparities between indigenous and non-indigenous people, providing an indigenous perspective to understanding these inequalities. The authors present a snapshot of the many research publications about indigenous health, with the aim to provide clinicians with a framework to better understand such matters. By applying this lens, placed in context for each patient, the authors argue that more culturally appropriate ways to interact with, to assess, and to treat indigenous peoples shall be promoted. The topics covered in this article include indigenous notions of health and identity; mental health and addictions; urbanisation and environmental stresses; whole health and healing; and reconciliation.
In this policy brief, the authors highlight worsening income inequalities between and within countries in recent decades, while noting that gender inequalities are narrowing at a snail’s pace. They argue that increases in inequality are partly due to the neglect of policy instruments to promote equality of outcome in favour of approaches that claim to create equality of opportunity. Current social discontent and distrust of government highlight the urgency of addressing inequality head-on: reducing inequality should be should be high on the post-2015 development agenda and should be seen as a goal in itself. It should also be reflected in other goals. The authors recommend that development targets should be set for within-country inequalities, including inequalities across regions, gender, ethnicity and income status. Proposed targets and indicators could include: inequality expressed in terms of the top and bottom deciles/ventiles; wages vs. profits (functional distribution of income); gender-based wage gaps; other labour market indicators, such as median wage, existence of minimum wage, percentage of labour force with social protection (female, male); and female/male ratio of unpaid work.
The analysis in this paper illustrates that the child survival picture – in terms of rate and inequality – varies in the developing world, highlighting the importance of differentiated child survival strategies between middle- and low-income countries. In many countries, reductions in child mortality among poorer households have been smaller than for the higher income groups. Once child mortality is concentrated among lower income groups – as is the case in many middle-income countries – major efforts to reduce child mortality should be equalising, but these require a focus on systematic interventions rather than ‘quick win’ strategies. On the other hand, under-five mortality in low-income countries is usually high not only among the poorest quintile, but in the bottom 40–60% of the population, suggesting the need for more comprehensive strategies to reduce under-five mortality across a broader spectrum of the population.
The paper argues that neonatal mortality tends to fall more slowly than under-five mortality, since reducing it needs longer-term and relatively more expensive interventions associated with functioning health systems. This indicates that while there are quick wins that can help improve child survival, middle-income countries (and low-income ones that have relatively low child mortality rates) need to focus more on reducing neonatal deaths.