Nicole Valentine

Equity-oriented monitoring in the context of universal health coverage.

As part of the Universal Health Coverage Collection, Ahmad Reza Hosseinpoor and colleagues discuss methodological considerations for equity-oriented monitoring of universal health coverage, and propose recommendations for monitoring and target setting.

Exploring models for the roles of health systems’ responsiveness and social determinants in explaining universal health coverage and health outcomes

Background Intersectoral perspectives of health are present in the rhetoric of the sustainable development goals. Yet its descriptions of systematic approaches for an intersectoral monitoring vision, joining determinants of health, and barriers or facilitators to accessing healthcare services are lacking. Objective To explore models of associations between health outcomes and health service coverage, and health determinants and health systems responsiveness, and thereby to contribute to monitoring, analysis, and assessment approaches informed by an intersectoral vision of health. Design The study is designed as a series of ecological, cross-country regression analyses, covering between 23 and 57 countries with dependent health variables concentrated on the years 2002–2003. Countries cover a range of development contexts. Health outcome and health service coverage dependent variables were derived from World Health Organization (WHO) information sources. Predictor variables representing determinants are derived from the WHO and World Bank databases; variables used for health systems’ responsiveness are derived from the WHO World Health Survey. Responsiveness is a measure of acceptability of health services to the population, complementing financial health protection. Results Health determinants’ indicators – access to improved drinking sources, accountability, and average years of schooling – were statistically significant in particular health outcome regressions. Statistically significant coefficients were more common for mortality rate regressions than for coverage rate regressions. Responsiveness was systematically associated with poorer health and health service coverage. With respect to levels of inequality in health, the indicator of responsiveness problems experienced by the unhealthy poor groups in the population was statistically significant for regressions on measles vaccination inequalities between rich and poor. For the broader determinants, the Gini mattered most for inequalities in child mortality; education mattered more for inequalities in births attended by skilled personnel. Conclusions This paper adds to the literature on comparative health systems research. National and international health monitoring frameworks need to incorporate indicators on trends in and impacts of other policy sectors on health. This will empower the health sector to carry out public health practices that promote health and health equity.

Implications of the Adelaide Statement on Health in All Policies

Data presented at the United Nations Summit in September in New York has revealed that many countries are unlikely to achieve all the health targets of the Millennium Development Goals by 2015.1 The simultaneous and interrelated challenges of poverty, health, food security, energy, the global economic crisis and climate change should be viewed by the global community as a unique opportunity to develop innovative approaches to achieve sustainable growth without compromising health equity.

Analysis of selected social determinants of health and their relationships with maternal health service coverage and child mortality in Vietnam.

Introduction Achieving a fair and equitable distribution of health in the population while progressing toward universal health coverage (UHC) is a key focus of health policy in Vietnam. This paper describes health barriers experienced by women (and children by inference) in Vietnam, and measures how UHC, with reference to maternal health services and child mortality rates, is affected by selected social determinants of health (SDH), termed ‘barriers’. Methods Our study uses a cross-sectional design with data from the 2011 Vietnam Multiple Indicator Cluster Survey. The study sample includes 11,663 women, aged 15–49 years. Weighted frequency statistics are cross-tabulated with socioeconomic characteristics of the population to describe the extent and distribution of health barriers experienced by disadvantaged women and children in Vietnam. A subset of women who had a live birth in the preceding two years (n=1,383) was studied to assess the impact of barriers to UHC and health. Six multiple logistic regressions were run using three dependent variables in the previous two years: 1) antenatal care, 2) skilled birth attendants, and 3) child death in the previous 15 years. Independent predictor variables were: 1) low education (incomplete secondary education), 2) lack of access to one of four basic amenities. In a second set of regressions, a constructed composite barrier index replaced these variables. Odds ratios (ORs) and 95% confidence intervals (95% CI) were used to report regression results. Results In Vietnam, about 54% of women aged 15–49 years in 2011, had low education or lacked access to one of four basic amenities. About 38% of poor rural women from ethnic minorities experienced both barriers, compared with less than 1% of rich urban women from the ethnic majority. Incomplete secondary education or lack of one of four basic amenities was a factor significantly associated with lower access to skilled birth attendants (OR=0.28, 95% CI: 0.14–0.55; OR=0.19, 95% CI: 0.05–0.80) and a higher risk of having had a child death in the previous two years (OR=1.71, 95% CI: 1.28–2.30; OR=1.59, 95% CI: 1.20–2.10). Conclusions Our study shows the need for accelerating education and infrastructure investments for ethnic minority communities living in rural areas so as to be able to contribute to equity-oriented progress toward UHC.Introduction Achieving a fair and equitable distribution of health in the population while progressing toward universal health coverage (UHC) is a key focus of health policy in Vietnam. This paper describes health barriers experienced by women (and children by inference) in Vietnam, and measures how UHC, with reference to maternal health services and child mortality rates, is affected by selected social determinants of health (SDH), termed ‘barriers’. Methods Our study uses a cross-sectional design with data from the 2011 Vietnam Multiple Indicator Cluster Survey. The study sample includes 11,663 women, aged 15–49 years. Weighted frequency statistics are cross-tabulated with socioeconomic characteristics of the population to describe the extent and distribution of health barriers experienced by disadvantaged women and children in Vietnam. A subset of women who had a live birth in the preceding two years (n=1,383) was studied to assess the impact of barriers to UHC and health. Six multiple logistic regressions were run using three dependent variables in the previous two years: 1) antenatal care, 2) skilled birth attendants, and 3) child death in the previous 15 years. Independent predictor variables were: 1) low education (incomplete secondary education), 2) lack of access to one of four basic amenities. In a second set of regressions, a constructed composite barrier index replaced these variables. Odds ratios (ORs) and 95% confidence intervals (95% CI) were used to report regression results. Results In Vietnam, about 54% of women aged 15–49 years in 2011, had low education or lacked access to one of four basic amenities. About 38% of poor rural women from ethnic minorities experienced both barriers, compared with less than 1% of rich urban women from the ethnic majority. Incomplete secondary education or lack of one of four basic amenities was a factor significantly associated with lower access to skilled birth attendants (OR=0.28, 95% CI: 0.14–0.55; OR=0.19, 95% CI: 0.05–0.80) and a higher risk of having had a child death in the previous two years (OR=1.71, 95% CI: 1.28–2.30; OR=1.59, 95% CI: 1.20–2.10). Conclusions Our study shows the need for accelerating education and infrastructure investments for ethnic minority communities living in rural areas so as to be able to contribute to equity-oriented progress toward UHC.

Engaging policy makers in action on socially determined health inequities: developing evidence-informed cameos

This article describes an innovative knowledge translation project involving researchers and key stakeholders commissioned by the World Health Organization (WHO) for the Commission on Social Determinants of Health (CSDH). The project aimed to develop ‘cameo’ reports of evidence-based policies and interventions addressing social determinants of health, intended for use by leaders and advocates, as well as policy and programme decision makers, to advance global action. The iterative process of developing the framework and content of the cameos, in the context of a limited evidence base, is described, and a number of issues related to the integration of multiple sources of evidence for knowledge translation action are identified.

A life-course approach to health: synergy with sustainable development goals.

Abstract A life-course approach to health encompasses strategies across individuals’ lives that optimize their functional ability (taking into account the interdependence of individual, social, environmental, temporal and intergenerational factors), thereby enabling well-being and the realization of rights. The approach is a perfect fit with efforts to achieve universal health coverage and meet the sustainable development goals (SDGs). Properly applied, a life-course approach can increase the effectiveness of the former and help realize the vision of the latter, especially in ensuring health and well-being for all at all ages. Its implementation requires a shared understanding by individuals and societies of how health is shaped by multiple factors throughout life and across generations. Most studies have focused on noncommunicable disease and ageing populations in high-income countries and on epidemiological, theoretical and clinical issues. The aim of this article is to show how the life-course approach to health can be extended to all age groups, health topics and countries by building on a synthesis of existing scientific evidence, experience in different countries and advances in health strategies and programmes. A conceptual framework for the approach is presented along with implications for implementation in the areas of: (i) policy and investment; (ii) health services and systems; (iii) local, multisectoral and multistakeholder action; and (iv) measurement, monitoring and research. The SDGs provide a unique context for applying a holistic, multisectoral approach to achieving transformative outcomes for people, prosperity and the environment. A life-course approach can reinforce these efforts, particularly given its emphasis on rights and equity.

The Need to Monitor Actions on the Social Determinants of Health

Intersectoral actions, defined as the alignment of strategies and resources between actors from two or more policy sectors to achieve complementary objectives,1 are central to the health-related sustainable development goals (SDGs).2 The World Health Organization’s (WHO) Commission on Social Determinants of Health recommended a subset of intersectoral actions to improve health equity in 2008.3 Intersectoral actions address the social, commercial, cultural, economic, environmental and political determinants of health. Without intersectoral actions, the health sector will probably not achieve SDG 3, that is, ensuring healthy lives and promoting well-being for all at all ages.4 National governments have committed to and implemented several of these intersectoral actions through multisectoral development and health policy frameworks, including the 2030 agenda for sustainable development,4 the Rio Political Declaration on Social Determinants of Health,5 the New Urban Agenda6 and the Marrakech Ministerial Declaration on Health, Environment and Climate Change.7 We argue for monitoring intersectoral actions because such assessment draws attention to those government interventions that improve living conditions, but are outside the immediate control of the health sector. These interventions often have established co-benefits across multiple policy sectors (for instance, emission-free public transport systems improve air quality, transport and health). Action monitoring can also strengthen coherence and efficiency across sectors. The SDGs’ extensive multisectoral indicator framework8 offers health policy-makers the opportunity to link action monitoring to the SDGs, as national governments begin their SDG implementation.4 In particular, actions taken in the context of policy frameworks that address the social determinants of health, such as those in the five action areas of the Rio Political Declaration,5 need to be monitored. Therefore, we define and categorize indicators for intersectoral actions on social determinants of health that improve health equity. If these indicators are drawn from the SDG indicator system,8 they will enable policy-makers to link intersectoral actions to sustainable development.9 For social determinants of health, we use WHO commission’s definitions,3 which refer to the wider set of social, commercial, cultural, economic, environmental and political determinants that drive patterns of health inequalities. These determinants are the daily conditions in which people grow, live, work and age; they are the forces and systems shaping living conditions. Determinants include population exposure to the physical environment; occupational hazards, housing, chemicals, air and water quality, sanitation and hygiene, and climate change. The determinants converge and accumulate over time to shape the health of population groups according to their social status. This is defined by, for example, education, ethnicity including indigeneity and migrant status, gender, gender identity, income, occupation and sexual orientation. Hence, changes in health equity that result from specific interventions or policy frameworks aimed to improve social determinants of health may take time to show. Using the commission’s evidencebased recommendations for intersectoral action,3 we offer a classification of three groups of intersectoral interventions that focus on the determinants and are relevant to the SDGs’ equity and sustainable development foci.4 The first group includes governance interventions, defined as political and decisionmaking structures and processes that improve health equity, such as wholeof-government or multisectoral committees, funds or plans, or human rights legislation. The second group consists of socioeconomic interventions, defined as those policies and programmes that allocate social and or financial resources to improve health equity. Such interventions could improve early child development, education, living wage, pay equity and social protection. The third group includes environmental interventions, defined as policies or programmes for the built or natural environment that improve health equity. Examples of such interventions are slum upgrading, air and drinking water quality improvement, sanitation and hygiene improvement and climate change mitigations and adaptations. Of the commission’s 39 intersectoral action recommendations,3 17 are for governance interventions, 16 for socioeconomic interventions and 6 for environmental interventions (Box 1). Effective action monitoring requires valid, sensitive and reliable indicators drawn from a solid evidence base on intervention effectiveness. Theoretical evidence suggests that interventions focussed on social determinants of health could be used as action indicators, since they are theorized to improve these determinants, health service use, health The need to monitor actions on the social determinants of health Frank Pega, Nicole B Valentine, Kumanan Rasanathan, Ahmad Reza Hosseinpoor, Tone P Torgersen, Veerabhadran Ramanathan, Tipicha Posayanonda, Nathalie Röbbel, Yassine Kalboussi, David H Rehkopf, Carlos Dora, Eugenio R Villar Montesinos & Maria P Neira

Quality of perinatal care services from the user's perspective: a Dutch study applies the World Health Organization's responsiveness concept

BackgroundThe concept of responsiveness was introduced by the World Health Organization (WHO) to address non-clinical aspects of service quality in an internationally comparable way. Responsiveness is defined as aspects of the way individuals are treated and the environment in which they are treated during health system interactions.The aim of this study is to assess responsiveness outcomes, their importance and factors influencing responsiveness outcomes during the antenatal and delivery phases of perinatal care.MethodThe Responsiveness in Perinatal and Obstetric Health Care Questionnaire was developed in 2009/10 based on the eight-domain WHO concept and the World Health Survey questionnaire. After ethical approval, a total of 171 women, who were 2 weeks postpartum, were recruited from three primary care midwifery practices in Rotterdam, the Netherlands, using face-to-face interviews. We dichotomized the original five ordinal response categories for responsiveness attainment as ‘poor’ and good responsiveness and analyzed the ranking of the domain performance and importance according to frequency scores. We used a series of independent variables related to health services and users’ personal background characteristics in multiple logistic regression analyses to explain responsiveness.ResultsPoor responsiveness outcomes ranged from 5.9% to 31.7% for the antenatal phase and from 9.7% to 27.1% for the delivery phase. Overall for both phases, ‘respect for persons’ (Autonomy, Dignity, Communication and Confidentiality) domains performed better and were judged to be more important than ‘client orientation’ domains (Choice and Continuity, Prompt Attention, Quality of Basic Amenities, Social Consideration). On the whole, responsiveness was explained more by health-care and health related issues than personal characteristics.ConclusionTo improve responsiveness outcomes caregivers should focus on domains in the category ‘client orientation’.

Monitoring health determinants with an equity focus: a key role in addressing social determinants, universal health coverage, and advancing the 2030 sustainable development agenda

No abstract available. (Published: 16 December 2016) Citation: Glob Health Action 2016, 9 : 34247 - http://dx.doi.org/10.3402/gha.v9.34247 This paper is part of the Special Issue: Monitoring health determinants with an equity focus . More papers from this issue can be found at http://www.globalhealthaction.net and http://www.co-action.net/2015/09/si_who/