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.
Equity in Health
This report highlights the ways that the coronavirus pandemic has the potential to lead to an increase in inequality in almost every country at once, the first time this has happened since records began. The virus has exposed, fed off and increased existing inequalities of wealth, gender and race. Over two million people have died, and hundreds of millions of people are being forced into poverty while many of the richest – individuals and corporations – are thriving. Billionaire fortunes returned to their pre-pandemic highs in just nine months, while recovery for the world’s poorest people could take over a decade. While the pandemic has exposed a collective frailty and the inability of a deeply unequal economy to work for all, it has also shown the vital importance of government action to protect health and livelihoods. Transformative policies that seemed unthinkable before the crisis have suddenly been shown to be possible.
The Interim Statement sets out the Commission’s vision and goals, the problems it seeks to ameliorate, and the intellectual foundation for a social determinants approach. In doing so, the Interim Statement is a resource for stakeholders concerned with social determinants of health and health equity, as they build towards a global movement. Recommendations for action, based on the evidence gathered across all the Commission’s work streams, will be made in the Final Report in May 2008.
It is increasingly recognised that different axes of social power relations, such as gender and class, are interrelated, not as additive but as intersecting processes. This paper has reviewed existing research on the intersections between gender and class, and their impacts on health status and access to health care. The review suggests that intersecting stratification processes can significantly alter the impacts of any one dimension of inequality taken by itself. Studies confirm that socio-economic status measures cannot fully account for gender inequalities in health. A number of studies show that both gender and class affect the way in which risk factors are translated into health outcomes, but their intersections can be complex. Other studies indicate that responses to unaffordable health care often vary by the gender and class location of sick individuals and their households. They strongly suggest that economic class should not be analysed by itself, and that apparent class differences can be misinterpreted without gender analysis. Insufficient attention to intersectionality in much of the health literature has significant human costs, because those affected most negatively tend to be those who are poorest and most oppressed by gender and other forms of social inequality. The programme and policy costs are also likely to be high in terms of poorly functioning programmes, and ineffective poverty alleviation and social and health policies.
This study tested the inverse equity hypothesis, which postulates that new health interventions are initially adopted by the wealthy and thus increase inequalities—as population coverage increases, only the poorest will lag behind all other groups. The authors analysed the proportion of births occurring in a health facility by wealth quintile in 286 surveys from 89 low- and middle-income countries (1993–2015) and developed an inequality pattern index. Positive values indicate that inequality is driven by early adoption by the wealthy (top inequality), whereas negative values signal bottom inequality. Absolute inequalities were widest when national coverage was around 50%. At low national coverage levels, top inequality was evident with coverage in the wealthiest quintile taking off rapidly; at 60% or higher national coverage, bottom inequality became the predominant pattern, with the poorest quintile lagging behind. The authors argue that policies need to be tailored to inequality patterns. When top inequalities are present, barriers that limit uptake by most of the population must be identified and addressed. When bottom inequalities exist, interventions must be targeted at specific subgroups that are left behind.
The Lancet Countdown: tracking progress on health and climate change is an international, multidisciplinary research collaboration between academic institutions and practitioners across the world that aims to track the health impacts of climate hazards; health resilience and adaptation; health co-benefits of climate change mitigation; economics and finance; and political and broader engagement. The Lancet Countdown aims to report annually on a series of indicators across these five areas in tandem with existing monitoring processes, such as the UN Sustainable Development Goals and WHO's climate and health country profiles. The indicators will also evolve over time through ongoing collaboration with experts and a range of stakeholders, and be dependent on the emergence of new evidence and knowledge.
An influential policy idea states that reducing inequality is beneficial for improving health in the low and middle income countries (LMICs). The study provides an empirical test of this idea: the authors utilized data collected by the Demographic and Health Surveys between 2000 and 2011 52 LMICs, and examined the relationship between household wealth inequality and two health outcomes: anemia status (of the children and their mothers) and the women' experience of child mortality. Based on multi-level analyses, the authors found that higher levels of household wealth inequality related to worse health, but this effect was strongly reduced when they took into account the level of individuals' wealth. However, even after accounting for the differences between individuals in terms of household wealth and other characteristics, in those LMICs with higher household wealth inequality more women experienced child mortality and more children were tested with anemia. This effect was partially mediated by the country's level and coverage of the health services and infrastructure. Furthermore, we found higher inequality to be related to a larger health gap between the poor and the rich in only one of the three examined samples. The paper concludes that an effective way to improve the health in the LMICs is to increase the wealth among the poor, which in turn also would lead to lower overall inequality and potential investments in public health infrastructure and services.
This article synthesises what is known on equity and tuberculosis (TB) in Malawi and highlights areas for further action and advocacy. Based on a range of published and unpublished reports and analysis of routine data on access to TB services, the authors find that TB cases have increased rapidly from 5,334 in 1985 to 28,000 in 2006. This increase has been attributed to HIV/AIDS; 77 per cent of TB patients are HIV positive. Poor people’s ability to access TB diagnosis services is reduced by the need for repeated visits, long queues and delays in sending results. The costs of seeking care for these people can be up to 240 per cent of monthly income. The paper concludes that the government’s policies to address TB, which are being delivered through the Sector Wide Approach, provide a good opportunity to enhance equity and pro-poor health services. The major challenge is to increase case detection especially amongst poor people. In addition, the Programme needs a prevalence survey which will enable equity monitoring and the development of responsive interventions to promote service access to people with undiagnosed TB.
This paper presents evidence on the potential for social capital to be a protective health resource by mediating the relationship between socioeconomic status and wellbeing of Ghanaian adolescents. A cross-sectional survey involving a randomly selected 2068 adolescents from 15 schools in Ghana was conducted. Relationships were assessed using multivariate regression models. Three measures of familial social capital were found to protect adolescents’ life satisfaction and happiness against the effects of socioeconomic status. There were variations in how socioeconomic status and social capital related to the different dimensions of adolescents’ wellbeing. Social capital was reported to be a significant mechanism through which socioeconomic status impacts the wellbeing of adolescents. The authors suggest that it can be utilised by public health and that the findings show that the role of the family in promoting adolescents’ wellbeing is superior to that of the school.
In most parts of the world, health outcomes among boys and men continue to be substantially worse than among girls and women, yet this gender-based disparity in health has received little national, regional or global acknowledgement or attention from health policy-makers or health-care providers. Including both women and men in efforts to reduce gender inequalities in health as part of the post-2015 sustainable development agenda would improve everyone’s health and well-being. This paper notes that three types of intervention targeting men have emerged in recent years – outreach, partnership and gender transformation – and there is now evidence to support all three approaches. The authors argue that global, regional and national health and development agencies could certainly learn from the success of civil society groups in promoting policies that target men. For example, the South African non-profit organization Sonke Gender Justice successfully pushed the government to add interventions targeting men within South Africa’s national HIV strategic plan. Closing the men’s health gap, it is argued, can benefit men, women and their children.