Equity and the child health Millennium Development Goal: the role of pro-poor health policies.
ABSTRACT There are substantial disparities in mortality between rich and poor children in developing countries. As a result, there is a call for explicitly pro-poor health programming in efforts to reach the child health Millennium Development Goals.
To estimate the contribution made by pro-poor health policy to reduction in wealth disparities in under-5 mortality.
An ecological, cross-sectional analysis was performed using Demographic and Health Survey data from 47 developing countries. Multivariate analysis was used to estimate the association between government health expenditure, the wealth distribution of two essential child health services (concentration indices of immunisation and treatment for acute respiratory infection) and aggregate under-5 mortality, as well as two measures of poor-rich equity in mortality outcomes-the quintile ratio and the concentration index of under-5 mortality-while confounders were controlled for.
Lower concentration (more pro-poor) indices for immunisation and treatment for acute respiratory infection were found to be associated with a reduction in inequity in under-5 mortality to the benefit of the poor. Government health expenditures were associated with lower overall national mortality reductions but had no effect on equity of mortality outcomes.
Redistributive health policies that promote pro-poor distribution of health services may reduce the gap in under-5 mortality between rich and poor in low-income and middle-income countries. To ensure that the poor gain from the current efforts to reach the Millennium Development Goals, essential child health services should explicitly target the poor. Failing that, the gains from these services will tend to accrue to the wealthier children in countries, magnifying inequalities in mortality.
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ABSTRACT: Global health equity strategists have previously focused much on differences across countries. At first glance, the global health gap in health status appears to result primarily from disparities between the developing and developed regions. We examine how much of this disparity could be attributed to within-country disparities in developing nations. We used data from Demographic and Health Surveys conducted between 1995 and 2010 in 67 developing countries. Using a population attributable risk approach, we computed the proportion of global under-five mortality gap and the absolute under-five deaths that would be reduced if the under-five mortality rate in each of these 67 countries was lowered to the level of the top 10% economic group in each country. As a sensitivity check, we also conducted comparable calculations replacing the top 10% with the top 5% and with the top 20%. In 2007, approximately 6.6 million under-five deaths were observed in the 67 countries used in the analysis. This could be reduced to only 600,000 deaths if these countries had the same under-five mortality rate as developed countries. If the under-five mortality rate in developing countries was lowered to the rate among the top 10% economic group in those same each of these countries, under-five deaths would be reduced to 3.7 million. This corresponds to a 48% reduction in the global mortality gap and 2.9 million under-five deaths averted. Using cutoff points of top 5% and top 20% economic groups showed reduction of 37% and 56% respectively in the global mortality gap. With these cutoff points, respectively 2.3 and 3.4 million deaths would be averted. Under-five mortality disparities within developing countries account for roughly half of the global gap between developed and developing countries. Thus, within-country inequities deserve as much consideration as do inequalities between the world's developing and developed regions.BMC Public Health 03/2014; 14(1):216. · 2.32 Impact Factor
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ABSTRACT: Rabies remains a major public health threat in many parts of the world and is responsible for an estimated 55,000 human deaths annually. The burden of rabies is estimated to be around US$20 million in Africa, with the highest financial expenditure being the cost of post-exposure prophylaxis (PEP). However, these calculations may be substantial underestimates because the costs to households of coping with endemic rabies have not been investigated. We therefore aimed to estimate the household costs, health-seeking behaviour, coping strategies, and outcomes of exposure to rabies in rural and urban communities in Tanzania. Extensive investigative interviews were used to estimate the incidence of human deaths and bite exposures. Questionnaires with bite victims and their families were used to investigate health-seeking behaviour and costs (medical and non-medical costs) associated with exposure to rabies. We calculated that an average patient in rural Tanzania, where most people live on less than US$1 per day, would need to spend over US$100 to complete WHO recommended PEP schedules. High costs and frequent shortages of PEP led to poor compliance with PEP regimens, delays in presentation to health facilities, and increased risk of death. The true costs of obtaining PEP were twice as high as those previously reported from Africa and should be considered in re-evaluations of the burden of rabies.PLoS Neglected Tropical Diseases 11/2013; 7(11):e2510. · 4.49 Impact Factor
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ABSTRACT: Epidemiology is the study of the causes and distributions of diseases in human populations so that we may identify ways to prevent and control disease. Although this definition broadly serves us well, I suggest that in recent decades, our discipline's robust interest in identifying causes has come at the expense of a more rigorous engagement with the second part of our vision for ourselves-the intent for us to intervene-and that this approach threatens to diminish our field's relevance. I argue here for a consequentialist epidemiology, a formalization and recalibration of the philosophical foundations of our discipline. I discuss how epidemiology is, at its core, more comfortably a consequentialist, as opposed to a deontological, discipline. A more consequentialist approach to epidemiology has several implications. It clarifies our research priorities, offers a perspective on the place of novel epidemiologic approaches and a metric to evaluate the utility of new methods, elevates the importance of global health and considerations about equity to the discipline, brings into sharp focus our engagement in implementation and translational science, and has implications for how we teach our students. I intend this article to be a provocation that can help clarify our disciplinary intentions.American journal of epidemiology 09/2013; · 4.98 Impact Factor