Angelica Sousa

Socioeconomic inequality in infant mortality in Iran and across its provinces

OBJECTIVE To measure the socioeconomic inequality in infant mortality in Iran (the Islamic Republic of Iran). METHODS We analysed data from the provincially representative Demographic and Health Survey, which was done in Iran in 2000. We used a dichotomous hierarchical ordered probit model to develop an indicator of socioeconomic status of households. We assessed the inequality in infant mortality by using the odds ratio of infant mortality between the lowest and highest socioeconomic quintiles at both the provincial and national levels, and the concentration index, an inequality measure based on the entire socioeconomic distribution. RESULTS We found a decreasing trend in the infant mortality rate in relation to socioeconomic quintiles. The poorest to richest odds ratio was 2.34 (95% CI = 1.78-3.09). The concentration index of infant mortality in Iran was -0.1789 (95% CI = -0.2193--0.1386). Furthermore, the inequality of infant mortality between the lowest and highest quintiles was significant and favoured the better-off in most of the provinces. However, this inequality varied between provinces. CONCLUSION Socioeconomic inequality in infant mortality favours the better-off in the country as a whole and in most of its provinces, but the degree of this inequality varies between the provinces. As well as its national average, it is important to consider the provincial distribution of this indicator of population health.

Sub-national assessment of inequality trends in neonatal and child mortality in Brazil.

ObjectiveBrazils large socioeconomic inequalities together with the increase in neonatal mortality jeopardize the MDG-4 child mortality target by 2015. We measured inequality trends in neonatal and under five mortality across municipalities characterized by their socio-economic status in a period where major pro poor policies were implemented in Brazil to infer whether policies and interventions in newborn and child health have been successful in reaching the poor as well as the better off.MethodsUsing data from the 5,507 municipalities in 1991 and 2000, we developed accurate estimates of neonatal mortality at municipality level and used these data to investigate inequality trends in neonatal and under five mortality across municipalities characterized by socio-economic status.ResultsChild health policies and interventions have been more effective in reaching the better off than the worst off. Reduction of under five mortality at national level has been achieved by reducing the level of under five mortality among the better off. Poor municipalities suffer from worse newborn and child health than richer municipalities and the poor/rich gaps have increased.ConclusionOur analysis highlights the importance of monitoring progress on MDGs at sub-national level and measuring inequality gaps to accurately target health and inter-sectoral policies. Further efforts are required to improve the measurement and monitoring of trends in neonatal and under five mortality at sub-national level, particularly in developing countries and countries with large socioeconomic inequalities.

Exploring the determinants of unsafe abortion: improving the evidence base in Mexico

BACKGROUND Despite the realized importance of unsafe abortion as a global health problem, reliable data are difficult to obtain, especially in countries where abortion is illegal. Estimates for most developing countries are based on limited and incomplete sources of data. In Mexico, studies have been undertaken to improve estimates of induced abortion but the determinants of unsafe abortion have not been explored. METHODS We analysed data from the 2006 Mexican National Demographic Survey. The sample comprises 14 859 reported pregnancies in women between 15 and 55 years old, of which 966 report having had an abortion in the 5 years preceding the survey. We use logistic regression to explore the relationship between unsafe abortion and various socio-economic and demographic characteristics. FINDINGS We estimate that 44% of abortions have been induced and 16.5% of those were unsafe. We find three variables to be positively and significantly associated with the probability of having an induced abortion: (1) whether the woman reported that the pregnancy was mistimed (OR = 4.5, 95% CI = 1.95-10.95); (2) whether the woman reported that the pregnancy was unwanted (OR = 2.86, 95% CI = -1.40-5.88); and (3) if the woman had three or more children at the time of the abortion (OR = 3.73, 95% CI = 1.20-11.65). There is a steep socio-economic gradient in the probability of having an unsafe abortion: poorer women are more likely to have an unsafe abortion than richer women (OR = 2.48, 95% CI = 1.09-5.63); women with 6-9 years of education (OR = 0.30, 95% CI = 0.11-0.81) and with more than 13 years of education are less likely to have an unsafe abortion (OR = 0.065, 95% CI = 0.01-0.43), and women with indigenous origin are more likely to have an unsafe abortion (OR = 5.44, 95% CI = 1.91-15.51). Thus, the probability for poor women with less than 5 years of education and indigenous origin is nine times higher compared with rich, educated and not indigenous women. We also find marked geographical inequities as women living in the poorest states have a higher risk of having an unsafe abortion. INTERPRETATION This analysis has explored the determinants of unsafe abortion and has demonstrated that there are large socio-economic and geographical inequities in unsafe abortions in Mexico. Further efforts are required to improve the measurement and monitoring of trends in unsafe abortions in developing countries.

A comprehensive health labour market framework for universal health coverage.

In many developed and developing countries, progress towards attaining UHC is hindered by the lack of a health workforce large enough and with the proper skills to deliver quality services to the entire population. Several factors accentuate the problems associated with health worker shortages, especially in low- and middle-income countries: maldistribution and migration of the workforce, inappropriate training, poor supervision, unregulated dual practice, imbalances in skill-mix composition, and reduced productivity and performance.1 Such problems are, however, not limited to low- and middle-income countries; many high-income countries are likely to face severe shortages of health workers because of budget cuts for social services resulting from the global economic downturn. The ageing of the population puts further pressure on health systems by increasing the demand for health care. Moreover, the changing dynamics of workforce migration, such as the increased exodus of workers from one developing country to another, pose a challenge for global health labour markets.2

Monitoring Inequalities in the Health Workforce: The Case Study of Brazil 1991–2005

Introduction Both the quantity and the distribution of health workers in a country are fundamental for assuring equitable access to health services. Using the case of Brazil, we measure changes in inequalities in the distribution of the health workforce and account for the sources of inequalities at sub-national level to identify whether policies have been effective in decreasing inequalities and increasing the density of health workers in the poorest areas between 1991 and 2005. Methods With data from Datasus 2005 and the 1991 and 2000 Census we measure the Gini and the Theil T across the 4,267 Brazilian Minimum Comparable Areas (MCA) for 1991, 2000 and 2005 to investigate changes in inequalities in the densities of physicians; nurse professionals; nurse associates; and community health workers by states, poverty quintiles and urban-rural stratum to account for the sources of inequalities. Results We find that inequalities have increased over time and that physicians and nurse professionals are the categories of health workers, which are more unequally distributed across MCA. The poorest states experience the highest shortage of health workers (below the national average) and have the highest inequalities in the distribution of physicians plus nurse professionals (above the national average) in the three years. Most of the staff in poor areas are unskilled health workers. Most of the overall inequalities in the distribution of health workers across MCA are due to inequalities within states, poverty quintiles and rural-urban stratum. Discussion This study highlights some critical issues in terms of the geographical distribution of health workers, which are accessible to the poor and the new methods have given new insights to identify critical geographical areas in Brazil. Eliminating the gap in the health workforce would require policies and interventions to be conducted at the state level focused in poor and rural areas.

Reducing inequities in neonatal mortality through adequate supply of health workers: evidence from newborn health in Brazil.

Introduction Progress towards the MDG targets on maternal and child mortality is hindered worldwide by large differentials between poor and rich populations. Using the case of Brazil, we investigate the extent to which policies and interventions seeking to increase the accessibility of health services among the poor have been effective in decreasing neonatal mortality. Methods With a panel data set for the 4,267 Minimum Comparable Areas (MCA) in Brazil in 1991 and 2000, we use a fixed effect regression model to evaluate the effect of the provision of physicians, nurse professionals, nurse associates and community health workers on neonatal mortality for poor and non-poor areas. We additionally forecasted the neonatal mortality rate in 2005. Results We find that the provision of health workers is particularly important for neonatal mortality in poor areas. Physicians and especially nurse professionals have been essential in decreasing neonatal mortality: an increase of one nurse professional per 1000 population is associated with a 3.8% reduction in neonatal mortality while an increase of one physician per 1000 population is associated with a 2.3% reduction in neonatal mortality. We also find that nurse associates are less important for neonatal mortality (estimated reduction effect of 1.2% ) and that community health workers are not important particularly among the poor. Differences in the provision of health workers explain a large proportion of neonatal mortality. Discussion In this paper, we show new evidence to inform decision making on maternal and newborn health. Reductions in neonatal mortality in Brazil have been hampered by the unequal distribution of health workers between poor and non-poor areas. Thus, special attention to a more equitable health system is required to allocate the resources in order to improve the health of poor and ensure equitable access to health services to the entire population.

Health labour market policies in support of universal health coverage: a comprehensive analysis in four African countries

BackgroundProgress toward universal health coverage in many low- and middle-income countries is hindered by the lack of an adequate health workforce that can deliver quality services accessible to the entire population.MethodsWe used a health labour market framework to investigate the key indicators of the dynamics of the health labour market in Cameroon, Kenya, Sudan, and Zambia, and identified the main policies implemented in these countries in the past ten years to address shortages and maldistribution of health workers.ResultsDespite increased availability of health workers in the four countries, major shortages and maldistribution persist. Several factors aggravate these problems, including migration, an aging workforce, and imbalances in skill mix composition.ConclusionsIn this paper, we provide new evidence to inform decision-making for health workforce planning and analysis in low- and middle-income countries. Partial health workforce policies are not sufficient to address these issues. It is crucial to perform a comprehensive analysis in order to understand the dynamics of the health labour market and develop effective polices to address health workforce shortages and maldistribution as part of efforts to attain universal health coverage.