Monitoring systems require strengthening to attribute the Non communicable disease (NCD) burden and deaths in low and middle-income countries (LMICs). Data from health and demographic surveillance systems (HDSS) can contribute towards this goal. Between 2003 and 2010, 15,228 deaths in adults aged 15 years (y) and older were identified retrospectively using the HDSS census and verbal autopsy in rural western Kenya. 37% were ascribed to NCDs, 60% to communicable diseases (CDs), 3% to injuries, and <1% maternal causes. Median age at death for NCDs was 66y and 71y for females and males, respectively, with 43% of NCD deaths occurring prematurely among adults aged below 65y. NCD deaths were mainly attributed to cancers (35%) and cardio-vascular diseases (CVDs; 29%). The proportionate mortality from NCDs rose from 35% in 2003 to 45% in 2010. While overall annual mortality rates (MRs) for NCDs fell, cancer-specific MRs rose from 200 to 262 per 100,000 population, mainly due to increasing deaths in adults aged 65y and older, and to respiratory neoplasms in all age groups. NCDs constitute a significant proportion of deaths in rural western Kenya. Evidence of the increasing contribution of NCDs to overall mortality supports international recommendations to introduce or enhance prevention, screening, diagnosis and treatment programmes in LMICs.
Equity in Health
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.
The African continent is currently in the midst of simultaneously unfolding and highly significant demographic, economic, technological, environmental, urban and socio-political transitions. Africa’s economic performance is promising, with booming cities supporting growing middle classes and creating sizable consumer markets. But despite significant overall growth, not all of Africa performs well. The continent continues to suffer under very rapid urban growth accompanied by massive urban poverty and many other social problems. These seem to indicate that the development trajectories followed by African nations since post-independence may not be able to deliver on the aspirations of broad based human development and prosperity for all. This report, therefore, argues for a bold re-imagining of prevailing models in order to steer the ongoing transitions towards greater sustainability based on a thorough review of all available options. That is especially the case since the already daunting urban challenges in Africa are now being exacerbated by the new vulnerabilities and threats associated with climate and environmental change.
South Africa remains one of the most unequal societies in the world. In its third South Africa Economic Update in 2012, the World Bank pointed out that the potential for economic growth has been held back by industrial concentration, skills shortages, labour market rigidities and chronically low savings and investment rates. The bank further stated that the economic growth has also been highly uneven in distribution and this continues to perpetuate inequality and economic exclusion. Despite this, the country is making some strides in tackling the socioeconomic ills faced by its poor majority. In this paper the author week’s writes that economic growth usually leads to increasing levels of inequality in developing countries. He notes, however, that as economies develop, larger portions of their populations move from agriculture into other sectors of the economy and their skills base expand to a point where inequality falls. He warns that there are no quick and easy solutions to South Africa’s inequality problem, adding that without substantive improvements in the human capital of the poor, income inequality will remain unacceptably wide.
The ongoing outbreak of human Ebola virus in West Africa, the largest and most extensive recorded, began in forest villages across four districts in southeastern Guinea as early as December 2013. The authors argue that the shifts in land use in Guinée forestière where the virus originated are also connected to government policies promoting neoliberal structural adjustment that, alongside divesting public health infrastructure, opened domestic food production to global capital with Ebola’s latest spillover arising due to massive expansion in the land allocated to corporate production of oil palm, taking over farmland, and bringing a a variety of disturbance-associated fruit bats attracted to oil palm plantations into more direct contact with informal pickers and contract farmers. Deforestation, including from oil palm planting, changes foraging behavior of the bat and expands interfaces among bats, humans and livestock. The authors suggest that deforestation, de-development, population mobility, peri-urbanization, cycle migration, and an inadequate health system that failed to recognize and isolate cases may have contributed, and that the the present outbreak signals the need to characterise the ecosystems on which humanity must routinely be reminded it depends.
An equitable distribution of healthcare use, distributed according to people’s needs instead of ability to pay, is an important goal featuring on many health policy agendas worldwide. However, relatively little is known about the extent to which this principle is violated across socio-economic groups in Sub-Saharan Africa (SSA). The authors ex-amine cross-country comparative micro-data from 18 SSA countries and find that considerable inequalities in healthcare use exist and vary across countries. For almost all countries studied, healthcare utilization is considerably higher among the rich. When decomposing these inequalities wealth is found to be the single most important driver. In 12 of the 18 countries wealth is responsible for more than half of total inequality in the use of care, and in 8 countries wealth even explains more of the inequality than need, education, employment, marital status and urbanicity together. For the richer countries, notably Mauritius, Namibia, South Africa and Swaziland, the contribution of wealth is typical-ly less important. As the bulk of inequality is not related to need for care and poor people use less care because they do not have the ability to pay, healthcare utilization in these countries is to a large extent unfairly distributed. The weak average relationship between need for and use of health care and the potential reporting heterogeneity in self-reported health across socio-economic groups imply that the findings are likely to even underestimate actual inequities in health care.
Daniel Bausch - interviewed in this paper- has been assisting with patient care during the current Ebola virus disease outbreak in western Africa and – as part of a WHO-led international collaboration – is exploring the possible use of experimental therapies and vaccines. He explains in this paper why this outbreak is different. He notes that the outbreak response had outstripped the available resources. Although personnel were deployed he says "we are all late and it has gotten out of control. It’s too simplistic to lay the blame on one group. There has been a lot of finger pointing at WHO, no one is immune to criticism, but WHO has suffered a loss of personnel and resources. So it’s not only about what we should have done at any particular time, but the whole foundation for an international public health response that has been eroded by the global economic downturn". He further observes that the scale and public profile of this outbreak means that potential vaccines and therapies that were stalled are now being pushed through clinical trials. He argues that if vaccines and drugs are provided in the not too distant future, the problem will change and people will start knocking on the door demanding prevention and treatment, so this is a public health strategy as well, but stemming the outbreak will still depend primarily on the classic strategy of case identification, with isolation and treatment, and contact tracing.
Ebola is also an epidemic, and the causes and conditions of the epidemic are social, economic, and political rather than natural. Outside of these social and economic conditions, the disease would have been contained or even eliminated long before now. The three countries at the centre of the Ebola epidemic are among the most impoverished in the world. The author argues that the permanent legacy of centuries of uninterrupted plunder is chronic and widespread malnutrition, dirt roads, poor or non-existent sanitation, unreliable or non-existent electric power, and one doctor per 100,000 inhabitants. These are the conditions in which an Ebola outbreak becomes an epidemic. For several months after the existence of Ebola was confirmed in the three countries of West Africa, it did not, the author argues, threaten the extraction of wealth from the region, and the first actions were to withdraw many volunteers including those working in health and to suspend flights. As cases were diagnosed in the USA and Europe, the response is reported to have been isolationist, with media spreading fear and speculation. Aid increased, but with limited personnel, except from Cuba. The author argues that West African health workers and volunteers are the ones who have carried out the socially necessary tasks of caring for patients, collecting and burying bodies, and educating the population in prevention and containment measures, despite inadequate safety equipment, serious threats to their own health, inadequate pay, and despite sometimes being ostracised in their own communities.
In August ZMAPP, an untested serum-based therapy in humans, was successfully administered to two American health workers infected with the Ebola virus, who were later declared free from the virus. The public announcement raised hopes for a new front in the fight against the ravaging epidemic. Besides the ethical and equity challenges present in distributing the limited quantity of the experimental therapies, the remarkable survival and first-rate quality of treatments provided to the American patients, as well as the water-tight public health containment measures employed, paint in a very stark manner the contours of divisions in global health, which were already widening before Ebola and have been worsen by the outbreak. The authors argue that an emergency-only response by African countries and the international community would fail to bridge those divisions that will continue in future to manufacture new and remerging epidemics like Ebola at an alarming rate as well as with frightening impact on a global scale. Africa’s endemic diseases like Ebola affect mostly its bottom millions. As such, the patients do not form a viable consumer base enough to motivate pharmaceutical industry to invest in innovative drugs and treatments for them. The WHO has put together a list of 17 neglected poverty-related diseases (NTDs). According to one study, of the about 1,393 new chemical entities introduced between 1975 and 1999, only 16 targeted NTDs.
This supplement explores social determinants of equity in health and highlights differences by socioeconomic status and geographic location, among others. The paper highlights that to reduce health inequalities requires action to reduce socioeconomic and other inequalities. There are other factors that influence health, but these are outweighed by the overwhelming impact of social and economic factors—the material, social, political, and cultural conditions that shape our lives and our behaviours.