Oscar J Mujica

Métodos de medición de las desigualdades de salud

RESUMEN La medicion de las desigualdades en el campo de la salud es una condicion indispensable para avanzar en la mejoria de la situacion de salud de la Region, donde el analisis de los valores medios ha dejado de ser suficiente. Este tipo de analisis es una herramienta fundamental para la accion en busca de una mayor equidad en salud. Existen diferentes metodos de medicion y niveles de complejidad cuya eleccion depende del objetivo del estudio. Este articulo tiene como objetivo familiarizar a los profesionales de la salud y a las instancias decisorias con los aspectos metodologicos de la medicion y el analisis simple de las desigualdades en el campo de la salud, utilizando datos basicos registrados con regularidad y agregados por unidades geopoliticas. Se presenta la forma de calcular los siguientes indicadores y se comentan sus ventajas y desventajas: la razon y la diferencia de tasas, el indice de efecto, el riesgo atribuible poblacional, el indice de disimilitud, el indice de desigualdad de la pendiente y el indice relativo de desigualdad, el coeficiente de Gini y el indice de concentracion. Los metodos presentados son aplicables a la medicion de las desigualdades de diferentes tipos y a distintos niveles de analisis.Measuring health inequalities is indispensable for progress in improving the health situation in the Region of the Americas, where the analysis of average values is no longer sufficient. Analyzing health inequalities is a fundamental tool for action that seeks greater equity in health. There are various measurement methods, with differing levels of complexity, and choosing one rather than another depends on the objective of the study. The purpose of this article is to familiarize health professionals and decision-making institutions with methodological aspects of the measurement and simple analysis of health inequalities, utilizing basic data that are regularly reported by geopolitical unit. The calculation method and the advantages and disadvantages of the following indicators are presented: the rate ratio and the rate difference, the effect index, the population attributable risk, the index of dissimilarity, the slope index of inequality and the relative index of inequality, the Gini coefficient, and the concentration index. The methods presented are applicable to measuring various types of inequalities and at different levels of analysis.

Salud, equidad y los objetivos de desarrollo del milenio

In September 2000 representatives of 189 countries met for the Millennium Summit, which the United Nations convened in New York City, and adopted the declaration that provided the basis for formulating the Millennium Development Goals (MDGs). The eight goals are part of a long series of initiatives that governments, the United Nations system, and international financial institutions have undertaken to reduce world poverty. Three of the eight goals deal with health, so the health sector will be responsible for implementing, monitoring, and evaluating measures proposed to meet targets that have been formulated: to reduce by two-thirds the mortality rate in children under 5 years of age between 1990 and 2015; to reduce by three-quarters the maternal mortality rate between 1990 and 2015; and to halt and begin to reverse the spread of HIV/AIDS by the year 2015, as well as to halt and begin to reverse the incidence of malaria, tuberculosis, and other major diseases. The health sector must also work with other parties to achieve targets connected with two other of the goals: to improve access to affordable essential drugs, and to reduce the proportion of persons who do not have safe drinking water. Adopting a strategy focused on the most vulnerable groups-ones concentrated in locations and populations with the greatest social exclusion-would make possible the largest total reduction in deaths among children, thus reaching the proposed target as well as producing greater equity. In the Region of the Americas the principal challenges in meeting the MDGs are: improving and harmonizing health information systems; designing health programs related to the MDGs that bring together the set of services and interventions that have the greatest impact, according to the special characteristics of the populations who are intended to be the beneficiaries; strengthening the political will to support the MDGs; and guaranteeing funding for the measures undertaken to attain the MDGs.

Outbreak of acute renal failure in Panama in 2006: a case-control study

OBJECTIVE In September 2006, a Panamanian physician reported an unusual number of patients with unexplained acute renal failure frequently accompanied by severe neurological dysfunction. Twelve (57%) of 21 patients had died of the illness. This paper describes the investigation into the cause of the illness and the source of the outbreak. METHODS Case-control and laboratory investigations were implemented. Case patients (with acute renal failure of unknown etiology and serum creatinine > 2 mg/dl) were individually matched to hospitalized controls for age (+/- 5 years), sex and admission date (< 2 days before the case patient). Questionnaire and biological data were collected. The main outcome measure was the odds of ingesting prescription cough syrup in cases and controls. FINDINGS Forty-two case patients and 140 control patients participated. The median age of cases was 68 years (range: 25-91 years); 64% were male. After controlling for pre-existing hypertension and renal disease and the use of angiotensin-converting enzyme inhibitors, a significant association was found between ingestion of prescription cough syrup and illness onset (adjusted odds ratio: 31.0, 95% confidence interval: 6.93-138). Laboratory analyses confirmed the presence of diethylene glycol (DEG) in biological samples from case patients, 8% DEG contamination in cough syrup samples and 22% contamination in the glycerin used to prepare the cough syrup. CONCLUSION The source of the outbreak was DEG-contaminated cough syrup. This investigation led to the recall of approximately 60 000 bottles of contaminated cough syrup, widespread screening of potentially exposed consumers and treatment of over 100 affected patients.

Los sistemas de información geográfica como herramienta para monitorear las desigualdades de salud

OBJETIVOS: Mostrar la aplicacion de los sistemas de informacion geografica (SIG) como instrumento tecnologico para apoyar las actividades en las areas de politica sanitaria y salud publica. METODOS: Se evaluo la relacion entre la mortalidad infantil y diversos factores determinantes de caracter socioeconomico y geografico. Al ilustrar la aplicacion, se hace hincapie en la capacidad integradora de los SIG, que permite simplificar, agilizar y automatizar la evaluacion epidemiologica, tomando en cuenta el analisis multiple simultaneo de variables determinantes con diferentes niveles de agregacion. La aplicacion de los SIG abarco, en este estudio, el analisis de la mortalidad infantil en tres niveles de agregacion en paises de las Americas entre 1995 y 2000. RESULTADOS: La mortalidad infantil estimada para la Region tuvo un promedio de 24,4 defunciones por 1 000 nacidos vivos, pero las desigualdades observadas indican que la probabilidad de una muerte infantil es casi 20 veces mayor en los paises de menos recursos que en los mas prosperos. El mapeo de la mortalidad infantil a escala regional permitio identificar los paises que requieren mayor atencion en sus politicas y programas de salud, pero no distinguir donde se requerian acciones mas prioritarias. Un analisis de las unidades geopoliticas mas pequenas (estados y municipios) revelo importantes diferencias dentro de los paises y permitio reproducir el patron de desigualdad regional, que no se ve reflejado por el valor promedio de los indicadores a escala nacional. Al analizarse la relacion entre el analfabetismo femenino y la desnutricion como factores determinantes de la mortalidad infantil en Brasil y Ecuador, se identificaron estratos sociales y epidemiologicos con distribuciones diferenciales de factores de riesgo que requieren intervenciones sanitarias adecuadas para sus respectivos perfiles socioepidemiologicos. CONCLUSIONES: Gracias a este tipo de analisis epidemiologico a escala local de los servicios de salud mediante el uso de los SIG, es facil reconocer como se comportan un fenomeno de salud y sus factores de riesgo determinantes en un periodo definido. Asimismo, es posible identificar patrones en la distribucion espacial de los factores de riesgo y sus posibles efectos sobre la salud. La utilizacion adecuada de los SIG permitira lograr mayor eficacia y equidad en la prestacion de los servicios de salud publica.

Socioeconomic inequalities and mortality trends in BRICS, 1990?2010

OBJECTIVE To explore the presence and magnitude of--and change in--socioeconomic and health inequalities between and within Brazil, the Russian Federation, India, China and South Africa--the countries known as BRICS--between 1990 and 2010. METHODS Comparable data on socioeconomic and health indicators, at both country and primary subnational levels, were obtained from publicly available sources. Health inequalities between and within countries were identified and summarized by using standard gap and gradient metrics. FINDINGS Four of the BRICS countries showed increases in both income level and income inequality between 1990 and 2010. The exception was Brazil, where income inequality decreased over the same period. Between-country inequalities in level of education and access to sanitation remained mostly unchanged but the largest between-country difference in mean life expectancy increased, from 9 years in 1990 to 20 years in 2010. Throughout the study period, there was disproportionality in the burden of disease between BRICS. However, the national infant mortality rate fell substantially over the study period in all five countries. In Brazil and China, the magnitude of subnational income-related inequalities in infant mortality, both absolute and relative, also decreased substantially. CONCLUSION Despite the economic prosperity and general improvements in health seen since 1990, profound inequalities in health persist both within and between BRICS. However, the substantial reductions observed--within Brazil and China--in the inequalities in income-related levels of infant mortality are encouraging.

Methods for measuring inequalities in health

RESUMEN La medicion de las desigualdades en el campo de la salud es una condicion indispensable para avanzar en la mejoria de la situacion de salud de la Region, donde el analisis de los valores medios ha dejado de ser suficiente. Este tipo de analisis es una herramienta fundamental para la accion en busca de una mayor equidad en salud. Existen diferentes metodos de medicion y niveles de complejidad cuya eleccion depende del objetivo del estudio. Este articulo tiene como objetivo familiarizar a los profesionales de la salud y a las instancias decisorias con los aspectos metodologicos de la medicion y el analisis simple de las desigualdades en el campo de la salud, utilizando datos basicos registrados con regularidad y agregados por unidades geopoliticas. Se presenta la forma de calcular los siguientes indicadores y se comentan sus ventajas y desventajas: la razon y la diferencia de tasas, el indice de efecto, el riesgo atribuible poblacional, el indice de disimilitud, el indice de desigualdad de la pendiente y el indice relativo de desigualdad, el coeficiente de Gini y el indice de concentracion. Los metodos presentados son aplicables a la medicion de las desigualdades de diferentes tipos y a distintos niveles de analisis.Measuring health inequalities is indispensable for progress in improving the health situation in the Region of the Americas, where the analysis of average values is no longer sufficient. Analyzing health inequalities is a fundamental tool for action that seeks greater equity in health. There are various measurement methods, with differing levels of complexity, and choosing one rather than another depends on the objective of the study. The purpose of this article is to familiarize health professionals and decision-making institutions with methodological aspects of the measurement and simple analysis of health inequalities, utilizing basic data that are regularly reported by geopolitical unit. The calculation method and the advantages and disadvantages of the following indicators are presented: the rate ratio and the rate difference, the effect index, the population attributable risk, the index of dissimilarity, the slope index of inequality and the relative index of inequality, the Gini coefficient, and the concentration index. The methods presented are applicable to measuring various types of inequalities and at different levels of analysis.

Índices para medir las desigualdades de salud de carácter social basados en la noción de entropía

Los indices descritos en la literatura para medir las desigualdades de salud de caracter social tienen facetas positivas pero tambien algunas insuficiencias, segun las circunstancias de su aplicacion. El objetivo de este articulo es proponer y demostrar, en los planos teorico y practico, las ventajas de las mediciones de la desigualdad basadas en la nocion de entropia, conocida ampliamente en la fisica y la teoria de la informacion. Se definen y exponen las principales propiedades de los indices basados en las nociones de entropia y redundancia. Se ilustra su aplicacion en dos conjuntos de datos ficticios y en datos reales, derivados de los indicadores basicos de salud para las Americas, de la Organizacion Panamericana de la Salud. Los indices basados en la nocion de entropia poseen, entre otras, las siguientes propiedades: a) no varian con los cambios de escala; b) son simetricos; c) incorporan la dimension social, y d) son faciles de interpretar gracias a la condicion de equivalencia entre la entropia y un sistema con dos clases.

Métodos de mensuração das desigualdades em saúde

RESUMEN La medicion de las desigualdades en el campo de la salud es una condicion indispensable para avanzar en la mejoria de la situacion de salud de la Region, donde el analisis de los valores medios ha dejado de ser suficiente. Este tipo de analisis es una herramienta fundamental para la accion en busca de una mayor equidad en salud. Existen diferentes metodos de medicion y niveles de complejidad cuya eleccion depende del objetivo del estudio. Este articulo tiene como objetivo familiarizar a los profesionales de la salud y a las instancias decisorias con los aspectos metodologicos de la medicion y el analisis simple de las desigualdades en el campo de la salud, utilizando datos basicos registrados con regularidad y agregados por unidades geopoliticas. Se presenta la forma de calcular los siguientes indicadores y se comentan sus ventajas y desventajas: la razon y la diferencia de tasas, el indice de efecto, el riesgo atribuible poblacional, el indice de disimilitud, el indice de desigualdad de la pendiente y el indice relativo de desigualdad, el coeficiente de Gini y el indice de concentracion. Los metodos presentados son aplicables a la medicion de las desigualdades de diferentes tipos y a distintos niveles de analisis.Measuring health inequalities is indispensable for progress in improving the health situation in the Region of the Americas, where the analysis of average values is no longer sufficient. Analyzing health inequalities is a fundamental tool for action that seeks greater equity in health. There are various measurement methods, with differing levels of complexity, and choosing one rather than another depends on the objective of the study. The purpose of this article is to familiarize health professionals and decision-making institutions with methodological aspects of the measurement and simple analysis of health inequalities, utilizing basic data that are regularly reported by geopolitical unit. The calculation method and the advantages and disadvantages of the following indicators are presented: the rate ratio and the rate difference, the effect index, the population attributable risk, the index of dissimilarity, the slope index of inequality and the relative index of inequality, the Gini coefficient, and the concentration index. The methods presented are applicable to measuring various types of inequalities and at different levels of analysis.

Planificación de la preparación para la influenza pandémica: esfuerzos regionales

: Failure to establish a contingency plan prior to a public health emergency can have catastrophic consequences. The threat of a new influenza pandemic has prompted countries to draft national strategic preparedness plans to prevent, mitigate, and recover from a potential influenza pandemic. This paper examines these preparations in Latin America and the Caribbean and describes potential scenarios of pandemic impact on the burden of mortality and on health services in the Region. In particular, the paper reports on the progress made by Member States in developing national influenza pandemic preparedness plans and implementation mechanisms at both the national and local levels. These achievements were facilitated through a series of planning workshops and self-assessment exercises conducted by PAHO for intersectoral country teams and guided by the WHO global influenza preparedness plan. Although significant progress has been made in plan completeness, intercountry preparedness planning and local level implementation remain key challenges. Multisectoral partnerships are clearly paramount to securing the commitment and resources needed to reach and sustain effective pandemic preparedness in the Americas.

Ethnic group inequalities in coverage with reproductive, maternal and child health interventions: cross-sectional analyses of national surveys in 16 Latin American and Caribbean countries

Summary Background Latin American and Caribbean populations include three main ethnic groups: indigenous people, people of African descent, and people of European descent. We investigated ethnic inequalities among these groups in population coverage with reproductive, maternal, newborn, and child health interventions. Methods We analysed 16 standardised, nationally representative surveys carried out from 2004 to 2015 in Latin America and the Caribbean that provided information on ethnicity or a proxy indicator (household language or skin colour) and on coverage of reproductive, maternal, newborn, and child health interventions. We selected four outcomes: coverage with modern contraception, antenatal care coverage (defined as four or more antenatal visits), and skilled attendants at birth for women aged 15–49 years; and coverage with three doses of diphtheria-pertussis-tetanus (DPT3) vaccine among children aged 12–23 months. We classified women and children as indigenous, of African descent, or other ancestry (reference group) on the basis of their self-reported ethnicity or language. Mediating variables included wealth quintiles (based on household asset indices), womans education, and urban-rural residence. We calculated crude and adjusted coverage ratios using Poisson regression. Findings Ethnic gaps in coverage varied substantially from country to country. In most countries, coverage with modern contraception (median coverage ratio 0·82, IQR 0·66–0·92), antenatal care (0·86, 0·75–0·94), and skilled birth attendants (0·75, 0·68–0·92) was lower among indigenous women than in the reference group. Only three countries (Nicaragua, Panama, and Paraguay) showed significant gaps in DPT3 coverage between the indigenous and the reference groups. The differences were attenuated but persisted after adjustment for wealth, education, and residence. Women and children of African descent showed similar coverage to the reference group in most countries. Interpretation The lower coverage levels for indigenous women are pervasive, and cannot be explained solely by differences in wealth, education, or residence. Interventions delivered at community level—such as vaccines—show less inequality than those requiring access to services, such as birth attendance. Regular monitoring of ethnic inequalities is essential to evaluate existing initiatives aimed at the inclusion of minorities and to plan effective multisectoral policies and programmes. Funding The Bill & Melinda Gates Foundation (through the Countdown to 2030 initiative) and the Wellcome Trust.