South Africa is increasingly focused on reducing maternal mortality. Documenting variation in access to maternal health services across one of the most inequitable nations could assist in re-direction of resources.
This analysis drew on a population-based household survey that used multistage-stratified sampling. Women, who in the past two years were pregnant (1113) or had a child (1304), completed questionnaires and HIV testing. Distribution of access to maternal health services and health status across socio-economic, education and other population groups was assessed using weighted data. The survey found that the poorest women had near universal antenatal care coverage (ANC), but only 39.6% attended before 20 weeks gestation; this figure was 2.7-fold higher in the wealthiest quartile (95%CI adjusted odds ratio = 1.2–6.1). Women in rural-formal areas had lowest ANC coverage (89.7%), percentage completing four ANC visits (79.7%) and only 84.0% were offered HIV testing. Testing levels were highest among the poorest quartile (90.1% in past two years), but 10% of women above 40 or with low education had never tested. Skilled birth attendant coverage (overall 95.3%) was lowest in the poorest quartile (91.4%) and rural formal areas (85.6%). Around two thirds of the wealthiest quartile, of white and of formally-employed women had a doctor at childbirth, 11-fold higher than the poorest quartile. Overall, only 44.4% of pregnancies were planned, 31.7% of HIV-infected women and 68.1% of the wealthiest quartile. Self-reported health status also declined considerably with each drop in quartile, education level or age group. Aside from early ANC attendance and deficiencies in care in rural-formal areas, inequalities in utilisation of services were mostly small, with some measures even highest among the poorest. Considerably larger differences were noted in maternal health status across population groups. This may reflect differences between these groups in quality of care received, HIV infection and in social determinants of health.
Equity in Health
Very little is known about socioeconomic related inequalities in multi-morbidity, especially in developing countries. Traditionally, studies on health inequalities have mainly focused on a single disease condition or different conditions in isolation. This paper examines socioeconomic inequality in multi-morbidity in illness and disability in South
Africa between 2005 and 2008. Data were drawn from the 2005, 2006, 2007, and 2008 rounds of the nationally representative annual South African General Household Surveys. Indirectly standardised concentration indices were used to assess socioeconomic inequality. A proxy index of socioeconomic status was constructed, for each year, using a selected set
of variables that are available in all the GHS rounds. Multi-morbidity in illness and disability were constructed using data on nine illnesses and six disabilities contained in the GHS. Multi-morbidity was found to affect a substantial number of South Africans. Most often, based on the nine illness conditions and six disability conditions considered, multi-morbidity in illness and multi-morbidity in disability were each found to
involve only two conditions. In 2008 in South Africa, the multi-morbidity that affected the greatest number of individuals combined high blood pressure with at least one other illness. Between 2005 and 2008, multi-morbidity in illness and disability was more prevalent among poor people; in disabilities this is yet more consistent. While there is a dearth of information on the socioeconomic distribution of multi-morbidity in many
developing countries, the paper shows that its distribution in South Africa indicates that the poor bear a greater burden of multi-morbidity. The author argues that, given the high burden and skewed socioeconomic distribution of multi-morbidity, there is a need to design policies to address this situation, and surveys that specifically assess multi-morbidity.
This editorial considers the neonatal deaths occurring in South Africa that are due to limited availability of intensive care beds or inadequate referral systems and problematic transport systems. The editor proposes simple, cost-effective preventative measures to decrease the mortality rate outside of tertiary care centres, including resuscitation training of primary health care providers, breastfeeding and kangaroo mother care (KMC) programmes, using polyethylene wrappings for neonates less than 1200g and increasing the number of neonatal beds available and the number of staff to care for these patients. Community education programmes on healthy pregnancies are proposed to improve help-seeking behaviour, improve clinic attendance and increase awareness of the benefits of free interventions, such as breastfeeding and KMC. While many other countries in the region have reduced their maternal mortality, South Africa has made limited progress. The authors call on government to prioritise the implementation of sustainable measures to improve neonatal mortality, and ultimately reducing under-5 mortality.
This outcome statement summarises views from stakeholders from a total of 53 African countries, represented by governments, Regional Economic Communities, civil society organisations including youth and women’s organisations, parliamentarians, academic institutions and the private sector. Noting the relatively slow progress made by African countries towards the Millennium Development Goals (MDGs) and recognising the capacity deficits and disabling initial conditions prevailing in a number of countries, participants unanimously agreed that the post-2015 development agenda should: 1. Emphasise inclusive economic growth and structural transformation. 2. Re-orient the development paradigm away from externally-driven initiatives toward domestically- inspired and funded initiatives that are grounded in national ownership. 3. Prioritise equity and social inclusion and measure progress in terms of both the availability and quality of service delivery. 4. Pay greater attention to vulnerable groups such as women, children, youth, the elderly, people with disabilities, displaced persons 5. Take into account the initial conditions of nation states and recognise the efforts countries have made towards achieving the goals as opposed to exclusively measuring how far they fall short of global targets. 6. Incorporate the Rio+20 outcomes and the outcomes of Africa-wide initiatives, national and regional consultations as well as UN forums such as ICPD +20. 7. Focus on development enablers as well as development outcomes.
The objective of this study was to investigate the underlying circumstances of maternal deaths in Botswana. Fifty-six case notes from the 80 reported maternal deaths in 2010 were reviewed. Five clinicians reviewed each case independently and then together to achieve a consensus on diagnosis and underlying cause(s) of death. Results indicated that 60% of deaths occurred in Botswana’s two referral hospitals. Cases in which death had direct obstetric causes were fewer than cases in which cause of death was indirect. The main direct causes were haemorrhage (39%), hypertension (22%), and pregnancy-related sepsis (13%). Thirty-six (64%) deaths were in HIV-positive women, of whom 21 (58%) were receiving antiretroviral (ARV) therapy. Nineteen (34%) deaths were attributable to HIV, including 4 from complications of ARVs. Twenty-nine (52%) deaths were in the postnatal period, 19 (66%) of these in the first week. Case-note review revealed several opportunities for improved quality of care, such as: better teamwork, communication and supportive supervision of health professionals; better supply management; and joint management between HIV and obstetric clinicians. The authors argue that integrating HIV management into maternal healthcare is essential to reduce maternal deaths in the region, alongside greater efforts to improve quality of care to avoid direct and indirect causes of death.
In this paper the author described age- and sex-specific rates of child homicide in South Africa. A cross-sectional mortuary-based study was conducted in a sample of 38 medico-legal laboratories operating in 2009. Child homicide data were collected from mortuary files, autopsy reports and police interviews. Findings showed an estimated 1,018 child homicides occurred in 2009, or 5.5 homicides per 100,000 children under 18 years. The homicide rate was much higher in boys than in girls. Child abuse and neglect had preceded nearly half of all homicides, but three times more often among girls than among boys. In children aged 15 to 17 years, the homicide rate among boys was nearly five times higher than among girls. South Africa’s child homicide rate is more than twice the global estimate. Since a background of child abuse and neglect is common, the authors recommend that parenting skills should be a key part of primary prevention efforts.
Universal health coverage has been set as a possible umbrella goal for health in the post-2015 development agenda. In this editorial, the authors discuss the relationship between universal coverage and universal access. They argue that addressing the broader social determinants of health will also improve access to health services; differences in access in particular will be ameliorated by reducing poverty and income inequalities. These actions alone, however, will not guarantee that all people obtain the health services they need. Even if the services exist and people have access to them, they might not use them. Universal health coverage cannot be attained unless both health services and financial risk protection systems are accessible, affordable and acceptable. In turn, universal access, although necessary, is not sufficient. Coverage builds on access by ensuring actual receipt of services. Thus, universal health coverage and universal access to health services are complementary ideas. Without universal access, universal health coverage becomes an unreachable goal.
In this paper, the author examines the problems and prospects for including meaningful indicators of equity into the city based regional planning efforts unfolding around the globe. The central focus of the paper is on the challenges that environmental justice (EJ) activists face as they attempt to frame the problem of equity in ways that the general public would see as not only informative, but compelling. After reviewing examples of successful efforts to reframe debates about equity, the author concludes with a discussion of a set of EJ concerns and indicators that have the greatest potential for capturing public attention and commitment despite mounting resistance to the use of redistributive policies in support of sustainability goals.
A United Nations Economic and Social Council (ECOSOC) panel discussion on universal health coverage (UHC) on 3 July 2013 highlighted the importance of science, technology and innovation for achieving UHC, especially in the context of the post-2015 development agenda. Speakers discussed the meaning and scope of UHC as well as the financing and promotion of UHC in various country contexts. World Health Organisation Director General Margaret Chan pointed to political commitment, investment, clear policy goals and tracking mechanisms as necessary conditions for UHC, but also emphasised state ownership in developing and implementing UHC. She argued that each state should develop its own healthcare system according to the needs of its population. She said that no major breakthrough, such as the introduction of vaccines, is possible without innovation; however, innovation has become expensive, at the cost of access for most people. On the matter of social innovation Chan remarked that often innovation is thought of as sophisticated science, but looking forward, the future of healthcare should be people-centred, integrated and based on primary healthcare and prevention.
This report outlines five main goals for the post 2015 agenda: ending poverty by 2030; promote gender quality; improve access to quality education, water and sanitation; promote good governance; and build strong effective institutions. It posits five transformative shifts as crucial for achieving all five goals: leave no one behind; put sustainable development at the core; transform economies for jobs and inclusive growth; build peace and effective, open and accountable institutions for all, and forge a new global partnership. Like the Millennium Development Goals, the report suggests that targets would not be binding, but should be monitored closely. The indicators that track them should be disaggregated to ensure no one is left behind and targets should only be considered ‘achieved’ if they are met for all relevant income and social groups. The Panel recommends that any new goals should be accompanied by an independent and rigorous monitoring system, with regular opportunities to report on progress and shortcomings at a high political level. It also calls for a data revolution for sustainable development, with a new international initiative to improve the quality of statistics and information available to citizens.