Kristine Husøy Onarheim

Economic Benefits of Investing in Women’s Health: A Systematic Review

Background Globally, the status of women’s health falls short of its potential. In addition to the deleterious ethical and human rights implications of this deficit, the negative economic impact may also be consequential, but these mechanisms are poorly understood. Building on the literature that highlights health as a driver of economic growth and poverty alleviation, we aim to systematically investigate the broader economic benefits of investing in women’s health. Methods Using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, we systematically reviewed health, gender, and economic literature to identify studies that investigate the impact of women’s health on micro- and macroeconomic outcomes. We developed an extensive search algorithm and conducted searches using 10 unique databases spanning the timeframe 01/01/1970 to 01/04/2013. Articles were included if they reported on economic impacts stemming from changes in women’s health (table of outcome measures included in full review, Table 1). In total, the two lead investigators independently screened 20,832 abstracts and extracted 438 records for full text review. The final review reflects the inclusion of 124 articles. Results The existing literature indicates that healthier women and their children contribute to more productive and better-educated societies. This study documents an extensive literature confirming that women’s health is tied to long-term productivity: the development and economic performance of nations depends, in part, upon how each country protects and promotes the health of women. Providing opportunities for deliberate family planning; healthy mothers before, during, and after childbirth, and the health and productivity of subsequent generations can catalyze a cycle of positive societal development. Conclusions This review highlights the untapped potential of initiatives that aim to address women’s health. Societies that prioritize women’s health will likely have better population health overall, and will remain more productive for generations to come.

Prioritizing child health interventions in Ethiopia: modeling impact on child mortality, life expectancy and inequality in age at death.

Background The fourth Millennium Development Goal calls for a two-thirds reduction in under-5 mortality between 1990 and 2015. Under-5 mortality rate is declining, but many countries are still far from achieving the goal. Effective child health interventions that could reduce child mortality exist, but national decision-makers lack contextual information for priority setting in their respective resource-constrained settings. We estimate the potential health impact of increasing coverage of 14 selected health interventions on child mortality in Ethiopia (2011–2015). We also explore the impact on life expectancy and inequality in the age of death (Ginihealth). Methods and Findings We used the Lives Saved Tool to estimate potential impact of scaling-up 14 health interventions in Ethiopia (2011–2015). Interventions are scaled-up to 1) government target levels, 2) 90% coverage and 3) 90% coverage of the five interventions with the highest impact. Under-5 mortality rate, neonatal mortality rate and deaths averted are primary outcome measures. We used modified life tables to estimate impact on life expectancy at birth and inequality in the age of death (Ginihealth). Under-5 mortality rate declines from 101.0 in 2011 to 68.8, 42.1 and 56.7 per 1000 live births under these three scenarios. Prioritizing child health would also increase life expectancy at birth from expected 60.5 years in 2015 to 62.5, 64.2 and 63.4 years and reduce inequality in age of death (Ginihealth) substantially from 0.24 to 0.21, 0.18 and 0.19. Conclusions The Millennium Development Goal for child health is reachable in Ethiopia. Prioritizing child health would also increase total life expectancy at birth and reduce inequality in age of death substantially (Ginihealth).

Impact of a peer-counseling intervention on breastfeeding practices in different socioeconomic strata: results from the equity analysis of the PROMISE-EBF trial in Uganda

Background Undernutrition is highly prevalent among infants in Uganda. Optimal infant feeding practices may improve nutritional status, health, and survival among children. Objective Our study evaluates the socioeconomic distribution of exclusive breastfeeding (EBF) and growth outcomes among infants included in a trial, which promoted EBF by peer counselors in Uganda. Design Twenty-four clusters comprising one to two communities in Uganda were randomized into intervention and control arms, including 765 mother-infant pairs (PROMISE-EBF trial, 200608, ClinicalTrials.gov no. NCT00397150). Intervention clusters received the promotion of EBF by peer counselors in addition to standard care. Breastfeeding and growth outcomes were compared according to wealth quintiles and intervention/control arms. Socioeconomic inequality in breastfeeding and growth outcomes were measured using the concentration index 12 and 24 weeks postpartum. We used the decomposition of the concentration index to identify factors contributing to growth inequality at 24 weeks. Results EBF was significantly concentrated among the poorest in the intervention group at 24 weeks postpartum, concentration index −0.060. The control group showed a concentration of breastfeeding among the richest part of the population, although not statistically significant. Stunting, wasting, and underweight were similarly significantly concentrated among the poorest in the intervention group and the total population at 24 weeks, but showing non-significant concentrations for the control group. Conclusion This study shows that EBF can be successfully promoted among the poor. In addition, socioeconomic inequality in growth outcomes starts early in infancy, but the breastfeeding intervention was not strong enough to counteract this influence.Background Undernutrition is highly prevalent among infants in Uganda. Optimal infant feeding practices may improve nutritional status, health, and survival among children. Objective Our study evaluates the socioeconomic distribution of exclusive breastfeeding (EBF) and growth outcomes among infants included in a trial, which promoted EBF by peer counselors in Uganda. Design Twenty-four clusters comprising one to two communities in Uganda were randomized into intervention and control arms, including 765 mother-infant pairs (PROMISE-EBF trial, 200608, ClinicalTrials.gov no. NCT00397150). Intervention clusters received the promotion of EBF by peer counselors in addition to standard care. Breastfeeding and growth outcomes were compared according to wealth quintiles and intervention/control arms. Socioeconomic inequality in breastfeeding and growth outcomes were measured using the concentration index 12 and 24 weeks postpartum. We used the decomposition of the concentration index to identify factors contributing to growth inequality at 24 weeks. Results EBF was significantly concentrated among the poorest in the intervention group at 24 weeks postpartum, concentration index -0.060. The control group showed a concentration of breastfeeding among the richest part of the population, although not statistically significant. Stunting, wasting, and underweight were similarly significantly concentrated among the poorest in the intervention group and the total population at 24 weeks, but showing non-significant concentrations for the control group. Conclusion This study shows that EBF can be successfully promoted among the poor. In addition, socioeconomic inequality in growth outcomes starts early in infancy, but the breastfeeding intervention was not strong enough to counteract this influence.

Towards universal health coverage for reproductive health services in Ethiopia: two policy recommendations

Reproductive health services are crucial for maternal and child health, but universal health coverage is still not within reach in most societies. Ethiopia’s goal of universal health coverage promises access to all necessary services for everyone while providing protection against financial risk. When moving towards universal health coverage, health plans and policies require contextualized knowledge about baseline indicators and their distributions. To understand more about the factors that explain coverage, we study the relationship between socioeconomic and geographic factors and the use of reproductive health services in Ethiopia, and further explore inequalities in reproductive health coverage. Based on these findings, we discuss the normative implications of these findings for health policy. Using population-level data from the Ethiopian Demographic and Health Survey (2011) in a multivariate logistic model, we find that family planning and use of antenatal care are associated with higher wealth, higher education and being employed. Skilled attendance at birth is associated with higher wealth, higher education, and urban location. There is large variation between Addis Ababa (the capital) and other administrative regions. Concentration indices show substantial inequalities in the use of reproductive health services. Decomposition of the concentration indices indicates that difference in wealth is the most important explanatory factor for inequality in reproductive health coverage, but other factors, such as urban setting and previous health care use, are also associated with inequalities. When aiming for universal health coverage, this study shows that different socioeconomic factors as well as health-sector factors should be addressed. Our study re-confirms the importance of a broader approach to reproductive health, and in particular the importance of inequality in wealth and geography. Poor, non-educated, non-employed women in rural areas are multidimensionally worse off. The needs of these women should be addressed through elimination of out-of-pocket costs and revision of the formula for resource allocation between regions as Ethiopia moves towards universal health coverage.

Ethics capacity building in low-income countries: Ethiopia as a case study

Ethical dilemmas are part of everyday clinical practice, and doctors worldwide must make value-based decisions. In low-income countries with very limited resources, healthcare personnel and policymakers face ethical challenges. Ethiopian policies aim to improve the ethical decision-making competence of healthcare personnel. But what are the dilemmas experienced by Ethiopian doctors and how can training and professional development equip them to deal with the ethical challenges they face? In this text, we illustrate ethical challenges that doctors experience in a resource-constrained health and welfare system. Our discussion is based upon our own empirical data from Ethiopia, our experience as healthcare workers in low-income countries, as well as relevant literature. We will describe the challenges and opportunities that lie in education, guidance and facilitation of ethical decision-making in a low-income country like Ethiopia.

Newborn health benefits or financial risk protection? An ethical analysis of a real-life dilemma in a setting without universal health coverage

Introduction High healthcare costs make illness precarious for both patients and their families’ economic situation. Despite the recent focus on the interconnection between health and financial risk at the systemic level, the ethical conflict between concerns for potential health benefits and financial risk protection at the household level in a low-income setting is less understood. Methods Using a seven-step ethical analysis, we examine a real-life dilemma faced by families and health workers at the micro level in Ethiopia and analyse the acceptability of limiting treatment for an ill newborn to protect against financial risk. We assess available evidence and ethical issues at stake and discuss the dilemma with respect to three priority setting criteria: health maximisation, priority to the worse-off and financial risk protection. Results Giving priority to health maximisation and extra priority to the worse-off suggests, in this particular case, that limiting treatment is not acceptable even if the total well-being gain from reduced financial risk is taken into account. Our conclusion depends on the facts of the case and the relative weight assigned to these criteria. However, there are problematic aspects with the premise of this dilemma. The most affected parties—the newborn, family members and health worker—cannot make free choices about whether to limit treatment or not, and we thereby accept deprivations of people’s substantive freedoms. Conclusion In settings where healthcare is financed largely out-of-pocket, families and health workers face tragic trade-offs. As countries move towards universal health coverage, financial risk protection for high-priority services is necessary to promote fairness, improve health and reduce poverty.

Towards universal health coverage: including undocumented migrants

As countries throughout the world move towards universal health coverage, the obligation to realise the right to health for undocumented migrants has often been overlooked. With unprecedented millions on the move – including refugees, asylum seekers, internally displaced persons, and returnees – undocumented migrants represent a uniquely vulnerable subgroup, experiencing particular barriers to health related to their background as well as insecure living and working conditions. Their legal status under national law often restricts access to, and affordability of, healthcare services. While striving to ensure health for all, national governments face challenging priority setting dilemmas in deciding: who to include, which services to provide, and how to cover out-of-pocket expenses. Building on comparative experiences in Norway, Thailand and the United States – which reflect varied approaches to achieving universal health coverage – we assess whether these national approaches provide rights-based access to affordable essential healthcare services for undocumented migrants. To meet the shared Sustainable Development Goal on universal health coverage, the right to health must be realised for all persons – including undocumented migrants. To ensure universal health coverage in accordance with the right to health, governments must evaluate laws, regulations, policies and practices to evaluate: whether undocumented migrants are included, to which services they have access, and if these services are affordable. Achieving universal health coverage for everyone will require rights-based support for undocumented migrants.

Global health financing: Priority to poor people or poor countries?

Global health initiatives have long focused on the health of poor people in poor countries. Changes in demographic, economic, and health patterns challenge our understanding about where to direct our attention. Most of the world’s poor now live in middle-income countries. How should this affect the distribution of development assistance for health? Should we give priority to poor people or poor countries?

Towards universal health coverage for undocumented migrants

ANDREA MELBERG E-mail: andrea.melberg@uib.no Andrea Melberg (born 1989) is a medical doctor and a PhD fellow at the Department of Global Public Health and Primary Care, University of Bergen. She works as a volunteer for the healthcare centre for undocumented migrants in Bergen and is a member of the organisation’s board of directors. The author has completed the ICMJE form and reports no conflicts of interest.

Young people have a new vision for essential medicines

The struggle to secure equitable access to aff ordable, quality medicines transcends national borders and affects patients of all ages. Young people are inheriting an inequitable and dysfunctional system that often fails to deliver life-saving drugs. These systemic deficits range from the present research and development system that is unable to meet population health needs, to stringent intellectual property protections restricting access and innovation, and to weak health systems that render medicine service delivery and use inadequate. Being less bound by the interests of existing institutions, young people have a unique role in analysing and advocating for transformative policies to ensure access to medicines. They should be partners in shaping and implementing a sustainable system that serves everyone. Well designed youth policies and strategies give young people the means to collaborate in shaping their own future within healthy and resilient societies. The National Strategy for Young Australians, for example, recognises the potential of young people to address the problems of climate change, terrorism, ageing societies, and health infrastructure. Indeed, young people can contribute to addressing many more systemic social issues. The reorientation of sectoral policies and strategies to engage the next generation in advancing access to services and drugs for non-communicable diseases, along with other challenges in the sustainable development agenda, is long overdue. Young people should be equipped with the critical thinking skills to overcome barriers to equitable access, aff ordability, availability, and quality of pharmaceutical products. For young researchers, many institutions offer workshops and universities run courses on intellectual property considerations and technology transfer, with a patentable discovery as an aim and commercial licensing as the only option. Greater knowledge and awareness of social responsibility licensing and research and development models, including the concept of delinkage, should also be readily accessible. Universities Allied for Essential Medicines and the Young Professionals Chronic Disease Network have used a decentralised approach to education by providing such information, but formal incorporation of this content into academic institutions could reap substantial benefi ts. The UN Major Group for Children and Youth (MGCY), mandated by UN resolutions for civil society engagement in high-level decision making, was virtually absent in the recent UN Secretary General’s HighLevel Panel on Access to Medicines (HLPAM). Awareness needs to be raised among young people about the process in HLPAM and how it is linked to the Sustainable Development Goals. There should be opportunities for engagement at local or regional levels to ensure that the global policy discourse translates into realisation of access locally. An opportunity will arise at the proposed Youth Gateway Initiative, which is to be co-convened by the UN’s Office of the Secretary General’s Envoy on Youth and MGCY. The Lancet Youth Commission on Essential Medicine Policies, was formed in March, 2015, as an independent commission complementing the work of the Lancet Commission on Essential Medicine Policies. As a global team of young professionals from diverse backgrounds, we will be releasing a report in the coming months that seeks to provide evidencebased policy recommendations and raise awareness, not only to describe what is known, but also to elaborate on what principles and long-term solutions are needed to achieve equitable access. We seek accountability from those who wield power to make decisions that will aff ect us all. Next year will mark the 40-year anniversary of the revolutionary WHO Essential Medicine List. Noting that young people comprise nearly a quarter of the world’s population, yet are underrepresented in decisionmaking bodies, we recommend a more inclusive approach, especially in the formulation of policies to tackle inequities in access to drugs. By challenging the present systems, we are hopeful that our call for a new reality will be heard, and that the world will be set by the example of devoted and forward-looking policy makers.