The Link between Inequality and Population Health in Low and Middle Income Countries: Policy Myth or Social Reality?

An influential policy idea states that reducing inequality is beneficial for improving health in the low and middle income countries (LMICs). Our study provides an empirical test of this idea: we utilized data collected by the Demographic and Health Surveys between 2000 and 2011 in as much as 52 LMICs, and we examined the relationship between household wealth inequality and two health outcomes: anemia status (of the children and their mothers) and the women'' experience of child mortality. Based on multi-level analyses, we found that higher levels of household wealth inequality related to worse health, but this effect was strongly reduced when we took into account the level of individuals'' wealth. However, even after accounting for the differences between individuals in terms of household wealth and other characteristics, in those LMICs with higher household wealth inequality more women experienced child mortality and more children were tested with anemia. This effect was partially mediated by the country''s level and coverage of the health services and infrastructure. Furthermore, we found higher inequality to be related to a larger health gap between the poor and the rich in only one of the three examined samples. We conclude that an effective way to improve the health in the LMICs is to increase the wealth among the poor, which in turn also would lead to lower overall inequality and potential investments in public health infrastructure and services.     

Stunting,double orphanhood and unequal access to public services in democratic South Africa

Orphans who lack household or community support face significant socio-economic disadvantages. In particular, they are at greater risk of malnutrition and stunting in developing countries. Children who have no living parents, also called double orphans, are most likely to require support from extended families or public institutions. This paper explores how WASH infrastructure, and public health and social services relate to stunting. It is one of the first studies to analyse these factors with a specific focus on double orphans, who tend to live in under-serviced areas with high stunting rates and poor access to public resources. We collate a cross sectional spatial dataset with local child stunting rates from 2013, rates of double orphanhood, private household resources, and public services from 2011 for South Africa, a country where the HIV/AIDS pandemic has led to high rates of double orphanhood. We estimate spatial econometric models that account for unobserved regional shocks and measurement bias, but which do not address other biases. Our results show that high stunting rates, particularly in areas with high proportions of double orphans, overlap strongly with poor provision of WASH and the availability of household resources. By contrast, other softer services accessed outside the home, such as access to health, social welfare and early childhood development facilities are not correlated with stunting in the same way. WASH is more strongly related to reduced stunting when infrastructure covers larger geographic areas and with the combined use of services from adjacent areas. This occurs because of economies of scale in provision and preventing transmission of disease across regions. Policy makers can explore the option to reduce stunting by expanding geographic networks of WASH service delivery into under-serviced areas where double orphans tend to locate.     

Geography and culture matter for malnutrition in Bolivia

The prevalence of health problems and malnutrition in Bolivia is exceptionally high, even in comparison to other underdeveloped countries. This study analyzes the relationship between a two measures of child health--height-for-age and weight-for-age z-scores--and a set of physical and cultural determinants of child nutrition, including mother's characteristics, household assets and access to public services. The ultimate aim is to identify the most important determinants of child health and to measure the relative impact of each factor on the height and weight z-scores. A sequential strategy was adopted in order to estimate a two-equation linear model with correlated error terms. A major finding points to geographical and cultural variables as main causes of nutritional status and highlights the role of mother's anthropometrical characteristics. This study uses data on over 3000 children gathered from a Demographic and Health Survey (DHS).     

Infant mortality and child health in Brazil

Child health is a central issue in the public policy agenda of developing countries. Several policies aimed at improving child health have been implemented over the years, with varying degrees of success. In Brazil, such policies have triggered a significant decline in infant mortality rates over the last 30 years. Despite this improvement, however, mortality rates are still high compared to international standards. Moreover, there is considerable imbalance across Brazilian municipalities suggesting that various policies should be adopted. We investigate the determinants of infant mortality at the municipal level and provide an analysis of the factors affecting child health at the individual level. To analyze the mortality rate, we estimate static and dynamic panel data models using four censuses covering the period from 1970 to 2000. The demand for child health, on the other hand, is addressed through a household decision model, estimated using anthropometric data from the 1996 Standard of Living Survey. The results obtained indicate that a rise in sanitation, education and per capita income contributed to the decline of infant mortality in Brazil, with stronger impacts in the long run than in the short run. The fixed effects associated with county characteristics explain the observed dispersion in child mortality rates. The results from the decision model are confirmed by the findings of the mortality model: education, sanitation and poverty are the most important causes of poor child health in Brazil.     

The effect of the health care supply environment on children's nutritional status in rural Nepal

This article examines the effect of access to health infrastructure, personnel and services on children's nutritional status in rural Nepal. Data for the study come from the 1996 Nepal Living Standards Survey, which includes individual- and household-level information on children's nutritional status and its environmental and socioeconomic determinants, and community-level information on the availability of health care infrastructure, personnel and services. The study uses a structural modelling approach to assess the relative contributions of the health care supply environment on children's anthropometric status via the pathway of maternal and child health (MCH) service use. The findings suggest that improvements in the availability of outreach clinics and the structural quality of the closest public facility would be expected to have statistically significant and large effects on the use of MCH services, and that increases in MCH service use would have a statistically significant impact on weight-for-age, but not weight-for-height or height-for-age. The overall impact of the heath care supply environment on nutritional status is assessed through a series of policy simulations.     

Health care utilization, socioeconomic factors and child health in India

This paper models the proximate determinants of height, weight and haemoglobin concentration of over 25,000 Indian children using data from the National Family Health Survey-3. The effects of public and private health care service utilization, food consumption patterns and maternal health status on child health were investigated in a multidisciplinary framework. Methodological issues such as potential endogeneity of explanatory variables and the appropriateness of combining height and weight as the body mass index were tackled. The results from models for children's heights and weight showed beneficial effects of child vaccinations against DPT, polio and measles, and negative effects of not utilizing government health facilities. The models for children's haemoglobin concentration indicated beneficial effects of food consumption patterns and treatment against intestinal parasites. The results provide several insights for improving child health in India.     

Valuing mother and child health: The intrauterine environment

The paper estimates the value a mother assigns to own health relative to child health. Estimation of relative health valuation requires the decomposition of a child health improvement into its direct effect on the child's health and its indirect effect, through improvements in maternal health. Failure to distinguish the impact of the direct and indirect effects can lead to biased estimates. We consider the intrauterine environment of a pregnant mother and her unborn child, where maternal health inputs are choice variables and her health affects child health. The empirical estimates suggest that mothers value child health up to six times higher than own health, and that the relative value depends on maternal consumption patterns and household characteristics.     

Private and public determinants of child nutrition in Nicaragua and Western Honduras

We present a multivariate regression model of nutritional indicators, including interactions between education levels and overall community development, as well as estimates of community fixed effects, for two data sets: the first one is from a 2001 nationwide household survey in Nicaragua while the second set was collected in the Western regions of Honduras in 2002, as part of an evaluation process for a family entitlement program. Maternal stature, age difference with an older sibling, household size and income are seen as the main determinants of anthropometric development. Within the more homogeneous communities of Western Honduras, woman's education is also related to the child's nutritional status. The importance of individual community variables is much lower and the inclusion of community fixed effects does not alter the other parameters. However, in the Honduran sample, overall community development (assessed through the community fixed effects) has a small but significant and synergistic effect on the impact of child and household variables. The characteristics of this study and the complex design of entitlement programs prevent an adequate evaluation of those interventions within the poverty reduction strategies. The improvement of intra-community targeting seems to be a key orientation for redesign. An improved socio-economic situation, sound population and family policies, and an appropriate preventive public health care still are safe investments towards improvement of child health and nutrition.     

Association between Maternal and Child Dietary Diversity: An Analysis of the Ghana Demographic and Health Survey

Objective (s)

This study examined the association between maternal and child dietary diversity in a population-based national sample in Ghana.

Methods

The data for this analysis are from the 2008 Ghana Demographic and Health Survey. We used data obtained from 1187 dyads comprised of mothers’ ages 15–49 and their youngest child (ages 6–36 months). Maternal and child dietary diversity scores (DDS) were created based on the mother’s recall of her own and her child’s consumption of 15 food groups, during the 24 hours prior to the in-home survey. The same food groups were used to compose both maternal and child DDS. Linear regression was used to assess the relationship between the predicted outcome – child DDS -- and maternal DDS, taking into account child age and sex, maternal factors (age, education, occupation, literacy, empowerment, number of antenatal visits as an indicator of health care use), household Wealth Index, and urban/rural place of residence.

Results

There was a statistically significant positive association between child and maternal DDS, after adjusting for all other variables. A difference of one food group in mother’s consumption was associated with a difference of 0.72 food groups in the child’s food consumption (95% CI: 0.63, 0.82). Also, statistically significant positive associations were observed such that higher child DDS was associated with older child age, and with greater women’s empowerment.

Conclusions

The results show a significant positive association between child and maternal DD, after accounting for the influence of child, maternal and household level factors. Since the likely path of influence is that maternal DDS impacts child DDS, public health efforts to improve child health may be strengthened by promoting maternal DDS due to its potential for a widened effect on the entire family.     

Millennium Development Goal Four and Child Health Inequities in Indonesia: A Systematic Review of the Literature

Introduction

Millennium Development Goal (MDG) 4 calls for reducing mortality of children under-five years by two-thirds by 2015. Indonesia is on track to officially meet the MDG 4 targets by 2015 but progress has been far from universal. It has been argued that national level statistics, on which MDG 4 relies, obscure persistent health inequities within the country. Particularly inequities in child health are a major global public health challenge both for achieving MDG 4 in 2015 and beyond. This review aims to map out the situation of MDG 4 with respect to disadvantaged populations in Indonesia applying the Social Determinants of Health (SDH) framework. The specific objectives are to answer: Who are the disadvantaged populations? Where do they live? And why and how is the inequitable distribution of health explained in terms of the SDH framework?

Methods and Findings

We retrieved studies through a systematic review of peer-reviewed and gray literature published in 1995-2014. The PRISMA-Equity 2012 statement was adapted to guide the methods of this review. The dependent variables were MDG 4-related indicators; the independent variable “disadvantaged populations” was defined by different categories of social differentiation using PROGRESS. Included texts were analyzed following the guidelines for deductive content analysis operationalized on the basis of the SDH framework. We identified 83 studies establishing evidence on more than 40 different determinants hindering an equitable distribution of child health in Indonesia. The most prominent determinants arise from the shortcomings within the rural health care system, the repercussions of food poverty coupled with low health literacy among parents, the impact of low household decision-making power of mothers, and the consequences of high persistent use of traditional birth attendants among ethnic minorities.

Conclusion

This review calls for enhanced understanding of the determinants and pathways that create, detain, and overcome inequities in child health in resource constraint settings like Indonesia and the promotion of actionable health policy recommendations and tailored investments.     

Determinants of malnutrition in Senegal: Individual, household, community variables, and their interaction

The relationship between poverty and nutrition is a two-sided one: on the one hand, economic growth (which is generally associated with an eradication of poverty) leads to reduced malnutrition. On the other hand, nutrition is one of the key ingredients for human capital formation, which in turn represents one of the fundamental factors of growth. There are numerous studies that show the correlates of malnutrition using both household- and community-level variables. However, few of these studies allow for the potential endogeneity of community infrastructure or indicate their interplay with characteristics of the mother. The current study considers the socio-economic determinants of child malnutrition and investigates how programs compensate for the increased risks facing young mothers and their children or substitute for a low social status of the mother in the household. The empirical results show that children of mothers giving birth at a young age are disadvantaged in terms of their anthropometric status. Interaction effects of the presence of a non-governmental organization (NGO) or a health post in the village with characteristics of the mother stress the important role played by these institutions in helping disadvantaged mothers overcome their difficulties. These findings have implications for efficient program design and represent a further step towards gaining an improved understanding of the complex determinants of child (mal)nutrition.     

Infant and child mortality in rural Egypt.

This research examines determinants of infant and child mortality in rural Egypt, primarily the effects of household economic status and the availability of health services. Certain features of the health service environment affect survival in the neonatal period. In early childhood, survival chances improve markedly as income increases and if the household depends almost exclusively on employment income. In infancy and in early childhood, mortality is strongly associated with region of residence and maternal demographic characteristics, and is weakly associated with parental schooling.     

Understanding the Rapid Reduction of Undernutrition in Nepal, 2001–2011

South Asia has long been synonymous with unusually high rates of undernutrition. In the past decade, however, Nepal has arguably achieved the fastest recorded decline in child stunting in the world and has done so in the midst of civil war and post-conflict political instability. Given recent interest in reducing undernutrition–particularly the role of nutrition-sensitive policies–this paper aims to quantitatively understand this surprising success story by analyzing the 2001, 2006, and 2011 rounds of Nepal’s Demographic Health Surveys. To do so, we construct models of the intermediate determinants of child and maternal nutritional change and then decompose predicted changes in nutrition outcomes over time. We identify four broad drivers of change: asset accumulation, health and nutrition interventions, maternal educational gains, and improvements in sanitation. Many of these changes were clearly influenced by policy decisions, including increased public investments in health and education and community-led health and sanitation campaigns. Other factors, such as rapid growth in migration-based remittances, are more a reflection of household responses to changing political and economic circumstances.     

Husband involvement in the treatment of child illness in Guatemala

The aim of this study is to test prevailing assumptions that Guatemalan men are authoritative or aloof husbands and, in turn, are either problematic or irrelevant to child health. Based on survey data collected in 1994-95 about 959 children, this research examines whether, how and why husbands were involved in recent episodes of young children's illness and sheds light on the potential effect of husband involvement on treatment. A relatively high percentage of women reported that they asked for advice or assistance from their husbands regarding child illness, and, contrary to popular notions, the multivariate analyses suggest that husbands' involvement was not driven by their household authority. Rather, key determinants of whether husbands gave advice or assistance included characteristics of the illness and child and the availability of sources of social support, while key determinants of what kind of support husbands gave (namely whether they gave/bought medicines, recommended a provider visit, or gave other advice or assistance) largely related to characteristics of the illness and child, as well as the availability of biomedical health care providers in the community and ethnicity.     

Pursuing More Sustainable Consumption by Analyzing Household Metabolism in European Countries and Cities

Bringing about more sustainable consumption patterns is an important challenge for society and science. In this article the concept of household metabolism is applied to analyzing consumption patterns and to identifying possibilities for the development of sustainable household consumption patterns. Household metabolism is determined in terms of total energy requirements, including both direct and indirect energy requirements, using a hybrid method. This method enables us to evaluate various determinants of the environmental load of consumption consistently at several levels—the national level, the local level, and the household level.
The average annual energy requirement of households varies considerably between the Netherlands, the United Kingdom, Norway, and Sweden, as well as within these countries. The average expenditure level per household explains a large part of the observed variations. Differences between these countries are also related to the efficiency of the production sectors and to the energy supply system. The consumption categories of food, transport, and recreation show the largest contributions to the environmental load. A comparison of consumer groups with different household characteristics shows remarkable differences in the division of spending over the consumption categories.
Thus, analyses of different types of households are important for providing a basis for options to induce decreases of the environmental load of household consumption. At the city level, options for change are provided by an analysis of the city infrastructure, which determines a large part of the direct energy use by households (for transport and heating). At the national level, energy efficiency in production and in electricity generation is an important trigger for decreasing household energy requirements.     

Poverty, health infrastructure and the nutrition of Peruvian children

This paper offers empirical evidence on the impact of the expansion in health infrastructure of the 1990s upon child nutrition in Peru, as measured by the height for age z-score. Using a pooled sample of three rounds of the Peruvian DHS, I have controlled for biases in the allocation of public investments by using a district fixed effects model. The econometric analysis shows a positive effect of the expansion of the last decade in urban areas, but not in rural areas. Furthermore, the effect for urban children is highly non-linear and has a pro-poor bias, in the sense that the estimated effect is larger for children of less educated mothers. These findings support the idea that reducing distance and waiting time barriers is necessary to improve child health and nutrition in developing countries, but that we need more explicitly inclusive policies to improve the health of the rural poor, especially indigenous groups, that are caught in this type of poverty trap.     

Health-Related Financial Catastrophe,Inequality and Chronic Illness in Bangladesh

Background

Bangladesh has a high proportion of households incurring catastrophic health expenditure, and very limited risk sharing mechanisms. Identifying determinants of out-of-pocket (OOP) payments and catastrophic health expenditure may reveal opportunities to reduce costs and protect households from financial risk.

Objective

This study investigates the determinants of high healthcare expenditure and healthcare- related financial catastrophe.

Methods

A cross-sectional household survey was conducted in Rajshahi city, Bangladesh, in 2011. Catastrophic health expenditure was estimated separately based on capacity to pay and proportion of non-food expenditure. Determinants of OOP payments and financial catastrophe were estimated using double hurdle and Poisson regression models respectively.

Results

On average households spent 11% of their total budgets on health, half the residents spent 7% of the monthly per capita consumption expenditure for one illness, and nearly 9% of households faced financial catastrophe. The poorest households spent less on health but had a four times higher risk of catastrophe than the richest households. The risk of financial catastrophe and the level of OOP payments were higher for users of inpatient, outpatient public and private facilities respectively compared to using self-medication or traditional healers. Other determinants of OOP payments and catastrophic expenses were economic status, presence of chronic illness in the household, and illness among children and adults.

Conclusion

Households that received inpatient or outpatient private care experienced the highest burden of health expenditure. The poorest members of the community also face large, often catastrophic expenses. Chronic illness management is crucial to reducing the total burden of disease in a household and its associated increased risk of level of OOP payments and catastrophic expenses. Households can only be protected from these situations by reducing the health system''s dependency on OOP payments and providing more financial risk protection.     

Dying under the bird's shadow: narrative representations of degedege and child survival among the Zaramo of Tanzania

In this article, I examine the cultural interpretations of degedege, an indigenous illness commonly recognized by the Zaramo people of coastal Tanzania as life threatening. Drawing on the narratives of three bereaved parents who lost a child to degedege, I analyze the contextual and circumstantial factors involved in these parents' negotiation of the identity of an illness and in their subsequent therapy seeking behavior. I show that even though cultural knowledge and etiological beliefs about degedege may be shared locally, there is significant variation in the therapeutic pathways that parents follow to deal with an actual episode of the illness. I emphasize the need for more contextualized data on health-seeking behaviors, and argue that it is necessary to pay attention to the micropolitics of health care decision making at the household level. Finally, I also call attention to the politics of provider-patient communication at public health facilities as a means to improve public health interventions to increase child survival.     

Regional Integration and Household Resilience: Infrastructure Connectivity and Livelihood Diversity in the Southwestern Amazon

The Inter-Oceanic Highway is among the first wave of large infrastructure projects under the auspices of the Initiative for the Integration of Regional Infrastructure in South America, which proposes regional integration as a means of economic development. Such projects have reignited debates over infrastructure impacts, which in many ways center on the ramifications for natural resource management. We pursue an analysis of the implications of highway paving for local livelihoods by focusing on the effects of market connectivity on livelihood diversity. Given that infrastructure brings shocks to affected regions, we argue that livelihood diversity is usefully interpreted in terms of household resilience to such shocks. We draw on rural household surveys from the tri-national frontier where Bolivia, Brazil and Peru meet in the southwestern Amazon, where the Inter-Oceanic Highway has recently been paved. The findings show that households more connected to markets in terms of travel time and road paving have less diverse livelihoods. This confirms concerns about regional integration and rural household vulnerability.     

青藏高原牧区家庭能源消费对生态环境和人体健康的影响研究现状与展望

探究家庭能源消费对生态环境和人体健康的研究是系统推进家庭能源绿色低碳转型和实现联合国2030可持续发展目标的关键。重点综述了目前家庭能源消费、影响因素及其对生态环境和居民健康影响的国际研究现状。目前研究不足主要聚焦在以下两个方面：一方面,影响家庭能源消费因素的贡献率和影响消费行为的驱动机制尚不清晰;另一方面,目前主要针对家庭能源消费或者生态系统或者环境或者居民健康其中的某一方面或者某两个方面开展研究,鲜有研究系统的考虑家庭能源消费对生态环境和人体健康影响的综合研究。基于上述研究现状,结合青藏高原的实际情况,提出未来需要在宏观层面和微观层面加强研究。宏观层面：(1)亟需厘清青藏高原家庭能源与生态环境和人体健康之间的内在联系与驱动机制,形成青藏高原牧区“家庭能源-生态效应-环境效应-健康效应”的理论分析框架;(2)构建模块化的牧区“能源-生态-环境-健康-经济”等多学科交叉的综合评估模型,形成完整的、系统的评估方法。微观层面：(1)迫切开展青藏高原家庭能源消费特征与变化规律的研究;(2)深入开展家庭能源消费特征和变化规律与生态系统的反馈机制与量化研究;(3)加强牧区室内空气污染物浓度测定,...