In this study, researchers investigated which alcohol indicator can most effectively detect associations between alcohol use and unsafe sexual behaviour among male sex workers - single-item measures of frequency and patterns of drinking (>=6 drinks on 1 occasion), or the Alcohol Use Disorders Identification Test (AUDIT). A cross-sectional survey in 2008 recruited male sex workers who sell sex to men from 65 venues in Mombasa district, Kenya, similar to a 2006 survey. Information was collected on socio-demographics, substance use, sexual behaviour, violence and STI symptoms. The 442 participants reported a median 2 clients/week, with half using condoms consistently in the last 30 days. Of the approximately 70% of men who drink alcohol, half drink two or more times a week. Binge drinking was common (38.9%). In conclusion, male sex workers have high levels of hazardous and harmful drinking, and require alcohol-reduction interventions, the authors argue. Compared with indicators of drinking frequency or pattern, the AUDIT measure has stronger associations with inconsistent condom use, STI symptoms and sexual violence. Increased use of the AUDIT tool in future studies may assist in delineating with greater precision the explanatory mechanisms which link alcohol use, drinking contexts, sexual behaviours and HIV transmission.
Equity in Health
This paper assessed the extent to which the Kenyan health financing system meets the key requirements for universal coverage, including income and risk cross-subsidisation. Recommendations on how to address existing equity challenges and progress towards universal coverage are made. An extensive review of published and gray literature was conducted to identify the sources of health care funds in Kenya. In cases where data were not available at the country level, they were sought from the World Health Organisation website. Each financing mechanism was analysed in respect to key functions namely, revenue generation, pooling and purchasing. The Kenyan health sector relies heavily on out-of-pocket payments. Government funds are mainly allocated through historical incremental approach. The sector is largely underfunded and health care contributions are regressive (i.e. the poor contribute a larger proportion of their income to health care than the rich). Health financing in Kenya is fragmented and there is very limited risk and income cross-subsidisation. The country has made little progress towards achieving international benchmarks including the Abuja target of allocating 15% of government's budget to the health sector. The Kenyan health system is highly inequitable and policies aimed at promoting equity and addressing the needs of the poor and vulnerable have not been successful. Some progress has been made towards addressing equity challenges, but universal coverage will not be achieved unless the country adopts a systemic approach to health financing reforms. Such an approach should be informed by the wider health system goals of equity and efficiency.
Non-communicable diseases (NCD) occur more commonly among people in lower socioeconomic groups. NCDs and poverty are in a vicious cycle, where poverty exposes people to behavioural risk factors for NCDs and, in turn, the resulting NCDs may become an important driver of poverty. Since in poorer countries most health-care costs must be paid by patients out-of-pocket, the cost of health care for NCDs create significant strain on household budgets, particularly for lower-income families. Treatment for diabetes, cancer, cardiovascular diseases and chronic respiratory diseases can be protracted and therefore extremely expensive. Such costs can force families into catastrophic spending and impoverishment. Household spending on NCDs, and on the behavioural risk factors that cause them, translates into less money for necessities such as food and shelter, and for the basic requirement for escaping poverty – education. Each year, an estimated 100 million people are pushed into poverty because they have to pay directly for health services.
Increased control has produced remarkable reductions of malaria in some parts of sub-Saharan Africa, including Rwanda. In the southern highlands, near the district capital of Butare, a combined community- and facility-based survey on Plasmodium infection was conducted early in 2010. In this study, a total of 749 children below five years of age were examined including 545 randomly selected from 24 villages, 103 attending the health centre in charge, and 101 at the referral district hospital. The researchers found that one out of six children under five years of age is infected with malaria. The many asymptomatic infections in the community form a reservoir for transmission of malaria. Risk factors for malaria include low socio-economic status and ineffective self-reported bed net use.
The authors explain how health-care systems are currently facing an increasing burden of chronic disease aggravated by ageing populations, by the continuing risk of infectious diseases and by global pandemics. While the authors welcome the timely present focus on health systems, there are gaps in responding to the burden of chronic disease in developing countries. Discussions to date largely centre on delivering the model of acute-centric care, with some concentration on tackling the weaknesses in the six key components of health systems: service delivery, finance, governance, technologies, workforce, and information; and within the context of universal coverage and equity. Although this approach might be appropriate for acute conditions, and arguably for higher-income countries, the paper argues that it is unaffordable and unsustainable given the increasing burden of chronic disease in low income and middle-income countries. The authors concludes that primary health care approaches might have a better chance of success.
This paper presents a combined historical and contemporary review of the clinical burden of malaria within one of Africa's largest urban settlements, Nairobi, Kenya. The authors conducted a review of historical reported malaria case burdens since 1911 within Nairobi using archived government and city council reports. An audit of 22 randomly selected health facilities within Nairobi was undertaken, including interviews with health workers, and a checklist of commodities and guidelines necessary to diagnose, treat and record malaria. The researchers found that, from the 1930s through to the mid-1960s, malaria incidence declined coincidental with rapid population growth. During this period malaria notification and prevention were a priority for the city council. From 2001-2008 reporting systems for malaria were inadequate to define the extent or distribution of malaria risk within Nairobi. The facilities and health workers included in this study were not universally prepared to treat malaria according to national guidelines or identify foci of risks due to shortages of national first-line drugs, inadequate record keeping and a view among some health workers (17%) that slide negative patients could still have malaria. Combined with historical evidence, there is a strong suggestion that very low risks of locally acquired malaria exist today within Nairobi's city limits and this requires further investigation.
A draft technical background paper for the World Conference on the Social Determinants of Health October 2011 is being circulated for peer review. It covers the five themes of the Conference, selected to highlight key ways of successfully implementing policies on social determinants. These themes are closely inter-related, reflecting the need for action on social determinants to be undertaken across society: governance to tackle the root causes of health inequities by implementing action on social determinants of health; the role of the health sector, including public health programmes, in reducing health inequities; promoting participation by providing community leadership for action on social determinants; global action on social determinants, especially regarding aligning priorities and stakeholders; and monitoring progress in terms of measurement and analysis to inform policies on social determinants.
The Commission on Social Determinants of Health (CSDH) framework shows how social, economic and political mechanisms give rise to a set of socioeconomic positions, whereby populations are stratified according to income, education, occupation, gender, race/ethnicity and other factors. These socioeconomic positions in turn shape specific determinants of health status (intermediary determinants) reflective of people’s place within social hierarchies; based on their respective social status, individuals experience differences in exposure and vulnerability to health-compromising conditions. The CSDH framework departs from many previous models by conceptualising the health system itself as a social determinant of health (SDH). The role of the health system becomes particularly relevant through the issue of access, which incorporates differences in exposure and vulnerability, and through intersectoral action led from within the health sector. Arguably the single most significant lesson of the CSDH conceptual framework is that interventions and policies to reduce health inequities must not limit themselves to intermediary determinants, but must include policies specifically crafted to tackle the social mechanisms that systematically produce an inequitable distribution of the determinants of health among population groups. To tackle structural, as well as intermediary, determinants requires intersectoral policy approaches.
The 2000s have seen health stand higher than ever on the international development agenda, and stakeholders increasingly acknowledge the inadequacy of health strategies that fail to address the social roots of illness and well-being. Momentum for action on the social dimensions of health is building. Based on the historical survey, four key issue areas are highlighted here, relevant to work on social determinants of health. The first concerns the scope of change and appropriate policy entry points, and the choice between comprehensive and selective primary health care that confronted public health leaders in the 1980s. The work needs evaluation criteria for identifying appropriate policy entry points for different countries/jurisdictions. Potential resistance to social determinants messages can be anticipated from several constituencies, but there are also exceptional political opportunities, including in the global and national processes connected to the MDGs.
According to this article, Africa faces numerous health challenges on the ground, such as lack of skilled health workers and poor social determinants of health, as well as several challenges originating from the global health arena. In global health, idealists who believe that money and technical assistance must be available in sufficient quantities to meet demand are pitted against policy makers who are working with finite resources and competing priorities. The author identifies lack of co-ordination of policies and programmes in Africa as another major obstacle to achieving universal health coverage. In addition, he argues that global health continues to operate on a financing mechanism that strengthens the hand of donor organisations at the expense of host nations and their priorities. Measuring the impact of global health programmes is technically difficult and a massive data gap exists. The author notes lack of participation by target populations in global health initiatives with regard to conceptualisation and design of projects, and their knowledge, attitudes and perceptions of target populations are also seldom included, especially the voices of poor and underserved communities. In Africa and other parts of the developing world, the author argues that global health is evolving from traditional concerns about the spread of infectious diseases to concerns about human security and dignity.