Suchergebnisse

The international conference 'Closing the gap in a generation: health equity through action on the social determinants of health', November 2008 (1) was a global call to action – a call to develop and implement public policies, private sector responsibility and social action that put health equity as a central goal. Over the course of two days politicians, senior public servants, leaders of international organisations, civil society activists and academics, fromall regions of the world, discussed the issues, conclusions and recommendations made by the Commission on Social Determinants of Health (CSDH)(2). The CSDH was set up in 2005 by the World Health Organization (WHO) as a major global effort to address health inequity between and within countries (3). Its final report was presented to Dr Margaret Chan, Director General of WHO in August 2008. Here we describe the key issues debated at the November conference and outline a global research, training and policy agenda for health equity.

The international conference 'Closing the gap in a generation: health equity through action on the social determinants of health', November 2008 (1) was a global call to action – a call to develop and implement public policies, private sector responsibility and social action that put health equity as a central goal. Over the course of two days politicians, senior public servants, leaders of international organisations, civil society activists and academics, fromall regions of the world, discussed the issues, conclusions and recommendations made by the Commission on Social Determinants of Health (CSDH)(2). The CSDH was set up in 2005 by the World Health Organization (WHO) as a major global effort to address health inequity between and within countries (3). Its final report was presented to Dr Margaret Chan, Director General of WHO in August 2008. Here we describe the key issues debated at the November conference and outline a global research, training and policy agenda for health equity.

BACKGROUND: Low-income and middle-income countries have introduced different health insurance schemes over the past decades, but whether different schemes are associated with different neonatal outcomes is yet unknown. We examined the association between the health insurance coverage scheme and neonatal mortality in Colombia. METHODS: We used Colombian national vital registration data, including all live births (2 506 920) and neonatal deaths (17 712) between 2008 and 2011. We used Poisson regression models to examine the association between health insurance coverage and the neonatal mortality rate (NMR), distinguishing between women insured via the contributory scheme (40% of births, financed through payroll and employer's contributions), government subsidised insurance (47%) and the uninsured (11%). RESULTS: NMR was lower among babies born to mothers in the contributory scheme (6.13/1000) than in the subsidised scheme (7.69/1000) or the uninsured (8.38/1000). Controlling for socioeconomic and demographic factors, NMRs remained higher for those in the subsidised scheme (OR 1.09, 95% CI 1.05 to 1.14) and the uninsured (OR 1.16, 95% CI 1.10 to 1.23) compared to those in the contributory scheme. These differences increased in models that additionally controlled for caesarean section (C-section) delivery. This increase was due to the higher fraction of C-section deliveries among women in the contributory scheme (49%, compared to 34% for the subsidised scheme and 28% for the uninsured). CONCLUSIONS: Health insurance through the contributory system is associated with lower neonatal mortality than insurance through the subsidised system or lack of insurance. Universal health insurance may not be sufficient to close the gap in newborn mortality between socioeconomic groups.

Entrenched poor health and health inequity are important public health problems. Conventionally, solutions to such problems originate from the health care sector, a conception reinforced by the dominant biomedical imagination of health. By contrast, attention to the social determinants of health has recently been given new force in the fight against health inequity. The health care sector is a vital determinant of health in itself and a key resource in improving health in an equitable manner. Actors in the health care sector must recognize and reverse the sector's propensity to generate health inequity. The sector must also strengthen its role in working with other sectors of government to act collectively on the deep-rooted causes of poor and inequitable health.

Purpose: Cash transfer interventions broadly improve the lives of the vulnerable, making them exceedingly popular. However, evidence of impacts on mental health is limited, particularly for conditional cash transfer (CCT) programs. We examined the impacts of Tanzania's government-run CCT program on depressive symptoms of youth aged 14–28. Methods: We utilized cluster randomized controlled trial data of 84 communities (48 intervention; 36 control). The intervention administered bimonthly CCTs to eligible households, while control communities were assigned to delayed intervention. The analysis included youth with measurements of depression (10-item Centre for Epidemiological Studies Depression Scale) at baseline and 18 months later. We determined impacts using analysis of covariance models, adjusting for youth characteristics (including baseline depression), district-level fixed effects, and community-level random effects. Differential effects by sex and baseline social support were also estimated. Results: Although no evidence was found to suggest that the intervention impacted depressive symptoms among the full sample (n = 880) (effect −.20, 95% confidence interval [CI] −.88 to .48, p = .562), subsample results indicated that depressive symptoms were reduced 1.5 points among males (95% CI −2.56 to −.04, p = .007) and increased 1.1 points among females (95% CI .11–2.09, p = .029). Females 18+ years old (effect 1.55, 95% CI .27–2.83, p = .018) and females with children (effect 1.32, 95% CI −.13 to 2.78, p = .074) drove this negative impact. Social support did not moderate impacts. Conclusions: Despite no overall intervention effects, results suggest that receiving a CCT has differential effects on mental health by sex. Although males benefited from the intervention, conditions which rely on stereotypically female roles may result in negative consequences among women.

The current economic recession has caused striking levels of unemployment, underemployment, and job insecurity globally. The International Labour Organization (ILO) estimated that the number of unemployed people was 212 million in 2009, and it projects the global unemployment rate in 2010 to be 6.5%, with a confidence interval ranging from 6.1% to 7%. In rich countries in the Organization for Economic Co-operation and Development more than 57 million people, or 10%, are unemployed in 2010, the current unemployment rate in Spain is 20%, and in the United States the rate is around 10% using conservative estimates. The ILO has predicted that the impact of the economic crisis on vulnerable employment is likely to have increased the number of working poor—those living on $1.25 (£0.80; €0.90) a day—by 215 million workers between 2008 and 2009, and that in 2009 there were between 1.48 and 1.59 billion vulnerable workers worldwide. These developments will increase global health inequalities, and inequalities between social classes within countries, because unemployment and underemployment cluster among lower income countries and workers. In this article we explore the relation between unemployment, poor working conditions, and health, and argue that governments and public health agencies should recognise that fair employment conditions should be regarded as a human right.

The current economic recession has caused striking levels of unemployment, underemployment, and job insecurity globally. The International Labour Organization (ILO) estimated that the number of unemployed people was 212 million in 2009, and it projects the global unemployment rate in 2010 to be 6.5%, with a confidence interval ranging from 6.1% to 7%. In rich countries in the Organization for Economic Co-operation and Development more than 57 million people, or 10%, are unemployed in 2010, the current unemployment rate in Spain is 20%, and in the United States the rate is around 10% using conservative estimates. The ILO has predicted that the impact of the economic crisis on vulnerable employment is likely to have increased the number of working poor—those living on $1.25 (£0.80; €0.90) a day—by 215 million workers between 2008 and 2009, and that in 2009 there were between 1.48 and 1.59 billion vulnerable workers worldwide. These developments will increase global health inequalities, and inequalities between social classes within countries, because unemployment and underemployment cluster among lower income countries and workers. In this article we explore the relation between unemployment, poor working conditions, and health, and argue that governments and public health agencies should recognise that fair employment conditions should be regarded as a human right.

Background: Tribal peoples are among the most marginalised groups worldwide. Evidence on birth outcomes in these groups is scant. We describe inequalities in Stillbirth Rate (SBR), Neonatal Mortality Rate (NMR), and uptake of maternal and newborn health services between tribal and less disadvantaged groups in eastern India, and examine the contribution of poverty and education to these inequalities. Methods: We used data from a demographic surveillance system covering a 1 million population in Jharkhand State (March 2017 – August 2019) to describe SBR, NMR, and service uptake. We used logistic regression analysis combined with Stata's adjrr-command to estimate absolute and relative inequalities by caste/tribe (comparing Particularly Vulnerable Tribal Groups (PVTG) and other Scheduled Tribes (ST) with the less marginalised Other Backward Class (OBC)/none, using the Indian government classification), and by maternal education and household wealth. Results: PVTGs had a higher NMR (59/1000) than OBC/none (31/1000) (rate ratio (RR): 1.92, 95%CI: 1.55–2.38). This was partly explained by wealth and education, but inequalities remained large after adjustment (adjusted RR: 1.59, 95%CI: 1.28–1.98). NMR was also higher among other STs (44/1000), but disparities were smaller (RR: 1.47, 95%CI: 1.23–1.75). There was a systematic gradient in NMR by maternal education and household wealth. SBRs were only higher in poorer groups (RR poorest vs. least poor :1.56, 95%CI: 1.14–2.13). Uptake of facility-based services was low among PVTGs (e.g. institutional birth: 25% vs. 69% in OBC/none) and among poorer and less educated women. However, 65% of PVTG women with an institutional birth used a maternity vehicle vs. 34% among OBC/none. Visits from frontline workers (Accredited Social Health Activists [ASHAs]) were similar across groups, and ASHA accompaniment of institutional births was similar across caste/tribe groups, and higher among poorer and less educated women. Attendance in participatory women's groups was similar across ...

INTRODUCTION: The WHO recommends community mobilisation with women's groups practising participatory learning and action (PLA) to improve neonatal survival in high-mortality settings. This intervention has not been evaluated at scale with government frontline workers. METHODS: We did a pragmatic cluster non-randomised controlled trial of women's groups practising PLA scaled up by government front-line workers in Jharkhand, eastern India. Groups prioritised maternal and newborn health problems, identified strategies to address them, implemented the strategies and evaluated progress. Intervention coverage and quality were tracked state-wide. Births and deaths to women of reproductive age were monitored in six of Jharkhand's 24 districts: three purposively allocated to an early intervention start (2017) and three to a delayed start (2019). We monitored vital events prospectively in 100 purposively selected units of 10 000 population each, during baseline (1 March 2017–31 August 2017) and evaluation periods (1 September 2017–31 August 2019). The primary outcome was neonatal mortality. RESULTS: We identified 51 949 deliveries and conducted interviews for 48 589 (93.5%). At baseline, neonatal mortality rates (NMR) were 36.9 per 1000 livebirths in the early arm and 39.2 in the delayed arm. Over 24 months of intervention, the NMR was 29.1 in the early arm and 39.2 in the delayed arm, corresponding to a 24% reduction in neonatal mortality (adjusted OR (AOR) 0.76, 95% CI 0.59 to 0.98), including 26% among the most deprived (AOR 0.74, 95% CI 0.57 to 0.95). Twenty of Jharkhand's 24 districts achieved adequate meeting coverage and quality. In these 20 districts, the intervention saved an estimated 11 803 newborn lives (min: 1026–max: 20 527) over 42 months, and cost 41 international dollars per life year saved. CONCLUSION: Participatory women's groups scaled up by the Indian public health system reduced neonatal mortality equitably in a largely rural state and were highly cost-effective, warranting scale-up in other ...

Introduction The WHO recommends community mobilisation with women's groups practising participatory learning and action (PLA) to improve neonatal survival in high-mortality settings. This intervention has not been evaluated at scale with government frontline workers. Methods We did a pragmatic cluster non-randomised controlled trial of women's groups practising PLA scaled up by government front-line workers in Jharkhand, eastern India. Groups prioritised maternal and newborn health problems, identified strategies to address them, implemented the strategies and evaluated progress. Intervention coverage and quality were tracked state-wide. Births and deaths to women of reproductive age were monitored in six of Jharkhand's 24 districts: Three purposively allocated to an early intervention start (2017) and three to a delayed start (2019). We monitored vital events prospectively in 100 purposively selected units of 10 000 population each, during baseline (1 March 2017-31 August 2017) and evaluation periods (1 September 2017-31 August 2019). The primary outcome was neonatal mortality. Results We identified 51 949 deliveries and conducted interviews for 48 589 (93.5%). At baseline, neonatal mortality rates (NMR) were 36.9 per 1000 livebirths in the early arm and 39.2 in the delayed arm. Over 24 months of intervention, the NMR was 29.1 in the early arm and 39.2 in the delayed arm, corresponding to a 24% reduction in neonatal mortality (adjusted OR (AOR) 0.76, 95% CI 0.59 to 0.98), including 26% among the most deprived (AOR 0.74, 95% CI 0.57 to 0.95). Twenty of Jharkhand's 24 districts achieved adequate meeting coverage and quality. In these 20 districts, the intervention saved an estimated 11 803 newborn lives (min: 1026-max: 20 527) over 42 months, and cost 41 international dollars per life year saved. Conclusion Participatory women's groups scaled up by the Indian public health system reduced neonatal mortality equitably in a largely rural state and were highly cost-effective, warranting scale-up in other ...