Rebuilding India’s Public Health

Assuming impervious boundaries of public health service systems when searching for answers to its problems can be misleading as historically, economic and welfare planning to improve the quality of life of all was considered critical. Despite years of planning, the health sector in India has acquired a tumultuous trajectory with chaos prevailing at different levels – conceptualization, policy, financing, organization and community participation. Using the concept of order in Chaos, this paper attempts to trace four basic underlying elementary patterns in the developmental process rooted in the larger socio-political structures that led to this chaos. Its second section explores the roots from where these patterns explaining the links between health, poverty and inequality in health emanate - the zone of conflict of interests among those who hold power and those whom they represent. It explores how they altered the public health service system and settled in favour of a small but powerful elite (the corporates, the upper-middle class and the professionals) seeking international standards irrespective of the local context. Structural Adjustment and the Health Sector Reforms benefited them by shifting subsidies to the private/corporate sector, transforming services into a costly commodity, fragmented and marginalized primary health care and public hospitals while ushering in hi-tech medicine.

Financial Scarcity Undermines Health Across the Globe and the Life Course

The gradient between income and health is well established: the lower the income, the poorer the health. However, low income (having few economic resources) may not be enough to characterize economic vulnerability, and financial scarcity (perceiving having insufficient economic resources) may further reduce health. First, analysis of cross-national data (275,000+ participants from 200+ country-years) revealed that financial scarcity was associated with twice the odds of suffering from reduced self-rated health and feelings of unhappiness; this association was observed in ≈90% of the country-years and explained variance over and above income. Second, analysis of national longitudinal data (20,000+ participants over 20 years of assessment) revealed that facing financial scarcity in the course of one’s life decreased self-rated and objective health and increased feelings of depression; again, these effects explained variance over and above income. Two subsidiary findings were obtained: (i) three adverse life events (illness, separation, family conflicts) predicted financial scarcity over the life course, and (ii) self-mastery (a component of sense of control) accounted for the detrimental longitudinal effects of financial scarcity on health. This research suggests that to understand socioeconomic inequality in health, one should consider not only an individual’s quantity of monetary resources but also the perceived sufficiency of these resources.

Inequalities in COVID-19 Research from Sub-Saharan Africa: Differences in the Prestige of Journal Articles with Internal and External Lead Authors, Collaborations and Publishers

Inequality in health research in Sub-Saharan Africa existed before the onset of the COVID-19 pandemic because of the dearth of research resources. The onset of COVID-19 has exacerbated inequality because of the changes in workplace settings. This study presents an insight into the extent of inequalities during the first year of COVID-19 using citation data of Sub-Saharan African countries' COVID-19 research. Citation data of all the 46 Sub-Saharan Africa countries was collected from Scopus, Web of Science and PubMed. After data cleaning and removal of duplicate records, collaboration type and publishers' country information was coded. Author processing charges of the Open Access articles were obtained from publishers' websites. CiteScore data was collected using Publish or Perish software and Scopus CiteScore report. Only 13.4% of the publishers are in Sub-Saharan African countries, and 21.14% of the articles were published in Sub-Saharan African journals. USA (20.92%) and the UK (13.73%), and India (6.21%) house the highest number of publishers. Publishers from the Netherlands (30.72%), the UK (24.23%) and the USA (14.81%) published the highest number of journals. The CiteScore of journals and mega journals published outside Sub-Saharan Africa was five and twenty-five times more prestigious than those published in the region, respectively. More equitable research practices that will recognize local authors from Sub-Saharan Africa as lead authors in studies about or in Sub-Saharan Africa and journals that are published in the region as a choice for important research may reduce the imbalances as observed in this study.

Predictors of health insurance enrolment and wealth-related inequality in Nepal: evidence from Multiple Indicator Cluster Survey (MICS) 2019

ObjectivesWe analysed predictors of health insurance enrolment in Nepal, measured wealth-related inequality and decomposed inequality into its contributing factors.DesignCross-sectional study.SettingWe used nationally representative data based on Nepal Multiple Indicator Cluster Survey 2019. Out of 10 958 households included in this study, 6.95% households were enroled in at least one health insurance scheme.Primary outcomemeasures health insurance (of any type) enrolment.ResultsHouseholds were more likely to have health insurance membership when household head have higher secondary education or above compared with households without formal education (adjusted OR 1.87; 95% CI: 1.32 to 2.64)). Households with mass media exposure were nearly three times more likely to get enroled into the schemes compared with their counterparts (adjusted OR 2.96; 95% CI 2.03 to 4.31). Hindus had greater odds of being enroled (adjusted OR 1.82; 95% CI 1.20 to 2.77) compared with non-Hindus. Dalits were less likely to get enroled compared with Brahmin, Chhetri and Madhesi (adjusted OR 0.66; 95% CI 0.47 to 0.94). Households from province 2, Bagmati and Sudurpaschim were less likely to have membership compared with households from province 1. Households from Richer and Richest wealth quintiles were more than two times more likely to have health insurance membership compared with households from the poorest wealth quintile. A positive concentration index 0.25 (95% CI 0.21 to 0.30; p<0.001) indicated disproportionately higher health insurance enrolment among wealthy households.ConclusionsEducation of household head, exposure to mass media, religious and ethnic background, geographical location (province) and wealth status were key predictors of health insurance enrolment in Nepal. There was a significant wealth-related inequality in health insurance affiliation. The study recommends regular monitoring of inequality in health insurance enrolment across demographic and socioeconomic groups to ensure progress towards Universal Health Coverage.

Income-related inequalities in health care utilization among old adults in six LMICs: China, Ghana, India, Mexico, Russian and South Africa

Common and long-running concern across the world relates to the impact of increasing population aging on health care utilization and more evidence about the inequality in health care utilization by older adults in low- and middle-income countries (LMICs) is necessary for assessing the capacity of health care systems in LMICs to align with the universal health coverage agenda. In this paper, using data from WHO Study on Global Ageing and adult health (SAGE) in China, Ghana, India, Mexico, Russian Federation and South Africa, the multi-national magnitude in inequality of health care use is measured by concentration index in each country. The results show that a pro-rich inequality in health care utilization existed: China Mexico and Ghana show up with a high degree of inequality in outpatient service utilization; most of the countries show up with a low level of inequality for inpatient service (except China). Then especially India, but also Ghana, South Africa, and China, show up with a high degree of inequality and inequity in chronic diseases service utilization. However, there doesn’t appear to be one system characteristic of inequality in health care utilization since these six countries all have very diverse characteristics with different stages of the demographic and epidemiological transitions. The decomposition shows that income itself is the most important but not the only driving factor. And the distribution of education, health insurance, and urban/rural residents are the prime other contributors to health inequality. Also, this paper shows that inequalities for non-communicative diseases service utilization in LMICs produce big challenges, which underlines the role of prevention and health promotion throughout the life course to help reduce the burden due to non-communicable diseases. This paper provides a number of new insights on population aging’s impact on health care utilization in low- and middle-income countries.

A detailed explanation and graphical representation of the Blinder-Oaxaca decomposition method with its application in health inequalities

This paper introduces the Blinder-Oaxaca decomposition method to be applied in explaining inequality in health outcome across any two groups. In order to understand every aspect of the inequality, multiple regression model can be used in a way to decompose the inequality into contributing factors. The method can therefore be indicated to what extent of the difference in mean predicted outcome between two groups is due to differences in the levels of observable characteristics (acceptable and fair). Assuming the identical characteristics in the two groups, the remaining inequality can be due to differential effects of the characteristics, maybe discrimination, and unobserved factors that not included in the model. Thus, using the decomposition methods can identify the contribution of each particular factor in moderating the current inequality. Accordingly, more detailed information can be provided for policy-makers, especially concerning modifiable factors. The method is theoretically described in detail and schematically presented. In the following, some criticisms of the model are reviewed, and several statistical commands are represented for performing the method, as well. Furthermore, the application of it in the health inequality with an applied example is presented.

Evaluation of Health and Social Inequalities in the Occurrence of Different Types of Chronic Stress and Their Effect on Immunoregulation

Inequality in health and its multiple dimensions is an essential aspect of social injustice. Several studies have shown that mental and physical health in adulthood is not a phenomenon independent of one’s childhood. Those from lower socioeconomic status have higher mortality and shorter life expectancy. Individualism and utilitarianism in social relationships have led to a wide range of social instability, poverty, deprivation, and inequality in societies. In addition to widespread social effects, they have made harmful consequences on the basic vital systems and organs through interference with multiple biological processes. In modern societies, people live in highly stressful situations, and several studies have pointed a strong relationship between the higher prevalence of diseases and social and physiological stresses. Studies of normal and experimental situations also showed their significant effects on the immune response. Accordingly, increased incidence of invasive behaviors has been associated with increased cytokines and immune-cellular activity in animal studies. According to the stimulus type and contact duration, chronic stress influences both innate and acquired immune factors. Stress affects the immune system via activation of the hypothalamus-pituitary-adrenal axis and affects the innate immune agents such as monocytes, macrophages, and proinflammatory cytokines, causing the increase of stress hormones (glucocorticoid-catecholamines). Chronic stress influences the acquired immune components by changing the immune cell population and altering the balance between immune cells and their secreted cytokine levels.

Determinants for use of direct-to-consumer telemedicine consultations in primary healthcare—a registry based total population study from Stockholm, Sweden

Background In recent years, telemedicine consultations have evolved as a new form of providing primary healthcare. Telemedicine options can provide benefits to patients in terms of access, reduced travel time and no risk of disease spreading. However, concerns have been raised that access is not equally distributed in the population, which could lead to increased inequality in health. The aim of this paper is to explore the determinants for use of direct-to-consumer (DTC) telemedicine consultations in a setting where telemedicine is included in the publicly funded healthcare system. Methods To investigate factors associated with the use of DTC telemedicine, a database was constructed by linking national and regional registries covering the entire population of Stockholm, Sweden (N = 2.3 million). Logistic regressions were applied to explore the determinants for utilization in 2018. As comparators, face-to-face physician consultations in primary healthcare were included in the study, as well as digi-physical physician consultations, i.e., telemedicine consultations offered by traditional primary healthcare providers also offering face-to-face visits, and telephone consultations by nurses. Results The determinants for use of DTC telemedicine differed substantially from face-to-face visits but also to some extent from the other telemedicine options. For the DTC telemedicine consultations, the factors associated with higher probability of utilization were younger age, higher educational attainment, higher income and being born in Sweden. In contrast, the main determinants for use of face-to-face visits were higher age, lower educational background and being born outside of Sweden. Conclusion The use of DTC telemedicine is determined by factors that are generally not associated with greater healthcare need and the distribution raises some concerns about the equity implications. Policy makers aiming to increase the level of telemedicine consultations in healthcare should consider measures to promote access for elderly and individuals born outside of Sweden to ensure that all groups have access to healthcare services according to their needs.