Jeanette Vega

Socioeconomic inequality in malnutrition in developing countries

OBJECTIVE The objectives of this study were to report on socioeconomic inequality in childhood malnutrition in the developing world, to provide evidence for an association between socioeconomic inequality and the average level of malnutrition, and to draw attention to different patterns of socioeconomic inequality in malnutrition. METHODS Both stunting and wasting were measured using new WHO child growth standards. Socioeconomic status was estimated by principal component analysis using a set of household assets and living conditions. Socioeconomic inequality was measured using an alternative concentration index that avoids problems with dependence on the mean level of malnutrition. FINDINGS In almost all countries investigated, stunting and wasting disproportionately affected the poor. However, socioeconomic inequality in wasting was limited and was not significant in about one third of countries. After correcting for the concentration indexs dependence on mean malnutrition, there was no clear association between average stunting and socioeconomic inequality. The latter showed different patterns, which were termed mass deprivation, queuing and exclusion. Although average levels of malnutrition were higher with the new WHO reference standards, estimates of socioeconomic inequality were largely unaffected by changing the growth standards. CONCLUSION Socioeconomic inequality in childhood malnutrition existed throughout the developing world, and was not related to the average malnutrition rate. Failure to tackle this inequality is a cause of social injustice. Moreover, reducing the overall rate of malnutrition does not necessarily lead to a reduction in inequality. Policies should, therefore, take into account the distribution of childhood malnutrition across all socioeconomic groups.

Malnutrition and the disproportional burden on the poor: the case of Ghana

BackgroundMalnutrition is a major public health and development concern in the developing world and in poor communities within these regions. Understanding the nature and determinants of socioeconomic inequality in malnutrition is essential in contemplating the health of populations in developing countries and in targeting resources appropriately to raise the health of the poor and most vulnerable groups.MethodsThis paper uses a concentration index to summarize inequality in childrens height-for-age z-scores in Ghana across the entire socioeconomic distribution and decomposes this inequality into different contributing factors. Data is used from the Ghana 2003 Demographic and Health Survey.ResultsThe results show that malnutrition is related to poverty, maternal education, health care and family planning and regional characteristics. Socioeconomic inequality in malnutrition is mainly associated with poverty, health care use and regional disparities. Although average malnutrition is higher using the new growth standards recently released by the World Health Organization, socioeconomic inequality and the associated factors are robust to the change of reference population.ConclusionChild malnutrition in Ghana is a multisectoral problem. The factors associated with average malnutrition rates are not necessarily the same as those associated with socioeconomic inequality in malnutrition.

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.

Strengthening health information systems to address health equity challenges.

Special studies and isolated initiatives over the past several decades in low-, middle- and high-income countries have consistently shown inequalities in health among socioeconomic groups and by gender, race or ethnicity, geographical area and other measures associated with social advantage. Significant health inequalities linked to social (dis)advantage rather than to inherent biological differences are generally considered unfair or inequitable. Such health inequities are the main object of health development efforts, including global targets such as the Millennium Development Goals, which require monitoring to evaluate progress. However, most national health information systems (HIS) lack key information needed to assess and address health inequities, namely, reliable, longitudinal and representative data linking measures of health with measures of social status or advantage at the individual or small-area level. Without empirical documentation and monitoring of such inequities, as well as country-level capacity to use this information for effective planning and monitoring of progress in response to interventions, movement towards equity is unlikely to occur. This paper reviews core information requirements and potential databases and proposes short-term and longer term strategies for strengthening the capabilities of HIS for the analysis of health equity and discusses HIS-related entry points for supporting a culture of equity-oriented decision-making and policy development.

Tackling health inequalities: new approaches in public policy

That social and environmental factors account for a substantial portion of health inequalities between and within countries has long been recognized (1). Much less is understood about how these determinants can be tackled. A multi-sectoral approach to policy design and implementation is urgently needed to confront persisting infectious epidemics and rising noncommunicable disease burdens in developing countries.The mainstream policy response to socially determined health inequali-ties is “pro-poor” strategies: interven-tions targeted on low-income groups. While often important, such strategies are insufficient, as they focus only on a specific population subset defined by income level. In countries characterized by pervasive widespread deprivation, access to health-enabling conditions and a broad scaling-up of health services are required (2). Factors other than income powerfully shape the social hierarchy that determines chances to be healthy. Pro-poor approaches limit interven-tion to the end of the social production chain that creates health or sickness: they tend to leave untouched the core social processes that generate health inequities, including gender and ethnicity (3).Genuinely pro-equity health policy is needed, considering not only income but all “systematic disparities in health between more and less advantaged social groups” (4) and intervening on the social factors that influence health. The pro-equity agenda demands an evolu-tion in the delivery of clinical services, in health information systems, and in the relationship between the health sector and other policy areas.A few countries have moved to-wards a pro-equity approach. Sweden’s new national public health policy, for example, focuses on “determinants of health mainly at the societal level”. Government departments and social sectors — including education, trans-port, environmental protection and labour policy — assume explicit respon-sibility for improving population health

Priority-setting for achieving universal health coverage.

Abstract Governments in low- and middle-income countries are legitimizing the implementation of universal health coverage (UHC), following a United Nation’s resolution on UHC in 2012 and its reinforcement in the sustainable development goals set in 2015. UHC will differ in each country depending on country contexts and needs, as well as demand and supply in health care. Therefore, fundamental issues such as objectives, users and cost–effectiveness of UHC have been raised by policy-makers and stakeholders. While priority-setting is done on a daily basis by health authorities – implicitly or explicitly – it has not been made clear how priority-setting for UHC should be conducted. We provide justification for explicit health priority-setting and guidance to countries on how to set priorities for UHC.

Social Determinants of Health, the United Nations Commission of

This article is reproduced from the previous edition, volume 6, pp. 64–68,