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Background: The work of the WHO Commission on the Social Determinants of Health has been fundamental to provide a conceptual framework of the social determinants of health. Based on this framework, this study assesses the relationship of income inequality as a determinant of neonatal mortality in the Americas and relates it to the achievement of the Sustainable Development Goal target 3.2 (reduce neonatal mortality to at least as low as 12 deaths per 1,000 live births). The rationale is to evaluate if income inequality may be considered a social factor that influences neonatal mortality in the Americas. Methods: Yearly data from 35 countries in the Americas during 2000–2019 was collected. Data sources include the United Nations Inter-agency Group for Child Mortality Estimation for the neonatal mortality rate (measured as neonatal deaths per 1,000 live births) and the United Nations University World Institute for Development Economics Research for the Gini index (measured in a scale from 0 to 100). This is an ecological study that employs a linear regression model that relates the neonatal mortality rate (dependent variable) to the Gini index (independent variable), while controlling for other factors that influence neonatal mortality. Coefficient estimates and their robust standard errors were obtained using panel data techniques. Results: A positive relationship between income inequality and neonatal mortality is found in countries in the Americas during the period studied. In particular, the analysis suggests that a unit increase in a country's Gini index during 2000–2019 is associated with a 0.27 (95% CI [− 0.04, 0.57], P =.09) increase in the neonatal mortality rate. Conclusion: The analysis suggests that income inequality may be positively associated with the neonatal mortality rate in the Americas. Nonetheless, given the modest magnitude of the estimates and Gini values and trends during 2000–2019, the findings suggest a potential limited scope for redistributive policies to support reductions in neonatal mortality in the region. Thus, policies and interventions that address higher coverage and quality of services provided by national health systems and reductions in socio-economic inequalities in health are of utmost importance. [ABSTRACT FROM AUTHOR]

In May 2012, the 65th World Health Assembly (WHA) approved six global nutrition targets by 2025 aimed to reduce stunting in children under five by 40%, maintain childhood wasting below 5%, halt obesity, cut anemia in women by 50%, lower low birth weight prevalence by 30%, and increase exclusive breastfeeding (EBF) within the first 6 months to 50%. These targets were extended to 2030, with all of them remaining as originally planned, but the EBF one (increased to 70%), wasting and overweight (both objectives set to eliminate them to negligible concern). Mexico is projected to achieve only one of the six nutrition targets (wasting) by 2025, falling far short of the stunting, low birth weight, anemia, and exclusive breastfeeding for the updated goals by 2030. This letter to the editor describes the most recent prevalence of malnutrition among mothers and children in Mexico. It discusses the challenges pregnant women and children under five years of age face exercising their right to good food, nutrition, and development. The authors reflect on the urgent need to make structural changes to achieve the global nutrition targets by 2030, highlighting the paramount importance of addressing the profound structural obstacles in Mexico and how Mexico's government must prioritize poverty reduction, reduce the marked inequalities, enhance the quality of nutritional care and healthcare infrastructure, and implement climate-resilient agricultural practices to address this pressing issue. [ABSTRACT FROM AUTHOR]

Our goal was to synthesize qualitative studies on HIV-related stigma as experienced by women living with HIV (WLWH) in the U.S. Qualitative metasynthesis techniques as developed by Sandelowski et al. (Res Nurs Health 30(1):99–111, 2007) were used to integrate and update findings on stigma in WLWH in the U.S. in 43 reports of qualitative studies conducted between 2004 and 2023 with 1118 participants. Developed themes explored a collective narrative of women first surviving the intersectionality of multiple sources of stigma, discovering non-linear pathways to transcend their stigma, and finally experiencing resilience through their transcendence of stigma. While this metasynthesis revealed similarities to an earlier metasynthesis in the ubiquity and persistence of stigma, they differ primarily in women's abilities to find agency in managing and opposing their stigma. This cognitive reframing of their stigma helped women to redefine stigma as ignorance and move towards a more positive assessment of the self. In doing so, they separated themselves from their stigma and the damaging effects of it. Findings from this metasynthesis may serve as a useful tool for the development of stigma reduction interventions specific to the needs and experiences of WLWH in the U.S. [ABSTRACT FROM AUTHOR]

Background: The persistence of racial/ethnic inequities in rates of engagement along the HIV care continuum signals the need for novel approaches. We developed six behavioral intervention components for use in an optimization trial, grounded in a model that integrates critical race theory, harm reduction, and self-determination theory, designed to address various barriers that African American/Black and Latino persons living with HIV (PLWH) experience to the HIV care continuum. The components were: health education, motivational interviewing sessions, pre-adherence skill building, peer mentorship, focused support groups, and navigation. The present qualitative exploratory study describes participants' perspectives on the components' acceptability, feasibility, and impact. Methods: Participants were African American/Black and Latino PLWH poorly engaged in HIV care and with non-suppressed HIV viral load in New York City. From a larger trial, we randomly selected 46 participants for in-depth semi-structured interviews. Interviews were audio-recorded and transcribed verbatim, and data were analyzed using directed content analysis. Quantitative data on sociodemographic and background characteristics and components' acceptability and feasibility were also collected. Results: On average, participants were 49 years old and had lived with HIV for 19 years. Most were cisgender-male and African American/Black. Participants reported a constellation of serious social and structural challenges to HIV management including chronic poverty, unstable housing, and stigma. Across components, a non-judgmental and pressure-free approach and attention to structural and cultural factors were seen as vital to high levels of engagement, but lacking in most medical/social service settings. Prominent aspects of individual components included establishing trust (health education); developing intrinsic motivation, goals, and self-reflection (motivational interviewing sessions); learning/practicing adherence strategies and habits (pre-adherence skill building); reducing social isolation via peer role models (peer mentorship); reflecting on salient goals and common challenges with peers without stigma (focused support groups); and circumventing structural barriers to HIV management with support (navigation). Components were found acceptable and feasible. Findings suggested ways components could be improved. Conclusions: The present study advances research on interventions for African American/Black and Latino PLWH, who experience complex barriers to engagement along the HIV care continuum. Future study of the components is warranted to address racial/ethnic health inequities in HIV. [ABSTRACT FROM AUTHOR]

Significant progress has been made to advance Maternal, Newborn and Child Health (MNCH) in Ethiopia. Further, the country has enshrined equity as a core value in their strategic and development frameworks and policies. Although national statistics show improved health outcomes, there exists persistent inequities in avoidable health risks and premature deaths. Additionally, the improving health statistics mask the disparities in health outcomes based on education, employment status, income level, gender and ethnicity dimensions. The EquiFrame framework was used to assess the extent to which equity was entrenched in MNCH health policies and plans. The framework, which describes core concepts against which health policies and plans can be assessed, also provides a scoring criterion for policy assessment. The framework was modified to include the concept of intersectionality, which is increasingly gaining significance in the health policy ecosystems. The policies and plans reviewed in this analysis exercise were selected based on (1) their relevance – only policies and plans in force as of the year 2020 were considered; (2) availability in the public domain as this study was limited to desk research; and (3) relevance to MNCH. A total of five policies and plans were analyzed and evaluated against the 15 core concepts presented in the modified EquiFrame framework. Following the outcomes of the assessment, documents were ranked as either being low, moderate, or high, in exhaustively addressing the core concepts. The Ethiopia Health Sector Transformation Plan (2016–2020) is the only policy or plan that earned a high ranking. The other four policies and plans were ranked as moderate. This shows that while majority of the Ethiopian health sector policies and plans exist and address the core health equity concepts, they fail to: (i) spell out plans to implement and monitor the proposed interventions; and (ii) demonstrate evidence that the interventions were implemented or monitored. With the global goal of leaving no one behind, future policy development in Ethiopia needs to prioritize equity considerations in order to enhance the ongoing health improvement. [ABSTRACT FROM AUTHOR]

Background: The aim of this study is to monitor the concept of 'leaving no one behind' in the Sustainable Development Goals (SDGs) to track the implications of the mobilization of health care resources by the National Health Insurance Fund (NHIF) of Sudan. Methods: A cross-sectional study was used to monitor 'leaving no one behind' in NHIF by analyzing the secondary data of the information system for the year 2016. The study categorized the catchment areas of health care centers (HCCS) according to district administrative divisions, which are neighborhood, subdistrict, district, and zero. The District Division Administrative Disaggregation Data (DDADD) framework was developed and investigated with the use of descriptive statistics, maps of Sudan, the Mann-Whitney test, the Kruskal-Wallis test and health equity catchment indicators. SPSS ver. 18 and EndNote X8 were also used. Results: The findings show that the NHIF has mobilized HCCs according to coverage of the insured population. This mobilization protected the insured poor in high-coverage insured population districts and left those living in very low-coverage districts behind. The Mann-Whitney test presented a significant median difference in the utilization rate between catchment areas (P value < 0.001). The results showed that the utilization rate of the insured poor who accessed health care centers by neighborhood was higher than that of the insured poor who accessed by more than neighborhood in each state. The Kruskal-Wallis test of the cost of health care services per capita in each catchment area showed a difference (P value < 0.001) in the median between neighborhoods. The cost of health care services in low-coverage insured population districts was higher than that in high-coverage insured population districts. Conclusion: The DDADD framework identified the inequitable distribution of health care services in low-density population districts leaves insured poor behind. Policymakers should restructure the equation of health insurance schemes based on equity and probability of illness, to distribute health care services according to needs and equity, and to remobilize resources towards districts left behind. [ABSTRACT FROM AUTHOR]

Background: Decision-making on postings and transfers -- that is, the geographic deployment of the health workforce -- is a key element of health workforce governance. When poorly managed, postings and transfers result in maldistribution, absenteeism, and low morale. At stake is managing the balance between organisational (i.e., health system) and individual (i.e., staff preference) needs. The negotiation of this potential convergence or divergence of interests provides a window on practices of postings and transfers, and on the micro-practices of governance in health systems more generally. This article explores the policies and processes, and the interplay between formal and informal rules and norms which underpin postings and transfers practice in two rural districts in the Greater Accra Region of Ghana. Methods: Semi-structured interviews were conducted with eight district managers and 87 frontline staff from the district health administration, district hospital, polyclinic, health centres and community outreach compounds across two districts. Interviews sought to understand how the postings and transfers process works in practice, factors in frontline staff and district manager decision-making, personal experiences in being posted, and study leave as a common strategy for obtaining transfers. Results: Differential negotiation-spaces at regional and district level exist and inform postings and transfers in practice. This is in contrast to the formal cascaded rules set to govern decision-making authority for postings and transfers. Many frontline staff lack policy clarity of postings and transfers processes and thus 'test' the system through informal staff lobbying, compounding staff perception of the postings and transfers process as being unfair. District managers are also challenged with limited decision-space embedded in broader policy contexts of systemic hierarchy and resource dependence. This underscores the negotiation process as ongoing, rather than static. Conclusions: These findings point to tensions between individual and organisational goals. This article contributes to a burgeoning literature on postings and transfers as a distinct dynamic which bridges the interactions between health systems governance and health workforce development. Importantly, this article helps to expand the notion of health systems governance beyond 'good' governance towards understanding governance as a process of negotiation. [ABSTRACT FROM AUTHOR]

Background: The topic of this paper is related to equity in health within a country. In public health care sectors of many countries decisions on priority setting with respect to treatment of different types of diseases or patient groups are implicitly or explicitly made. Priorities are realized by allocation decisions for medical resources where moral judgments play an important role with respect to goals and measures that should be applied. The aim of this study is to explore the moral intuitions held in the German society related to priorities in medical treatment. Methods: We use an experimental questionnaire method established in the Empirical Social Choice literature. Participants are asked to make decisions in a sequence of distributive problems where a limited amount of treatment time has to be allocated to hypothetically described patients. The decision problems serve as an intuition pump. Situations are systematically varied with respect to patients' initial health levels, their ability to benefit from treatment time, and the amount of treatment time available. Subjects are also asked to describe their deliberations. We focus on the acceptance of different allocation principles including equity concepts and utilitarian properties. We investigate rule characteristics like order preservation or monotonicity with respect to resources, severity, or effectiveness. We check the consistency of individual choices with stated reasoning. Results: The goals and allocation principles revealed show that the moral intuitions held by our experimental subjects are much more complex than the principles commonly applied in health economic theory. Especially, cost-utility principles are rarely applied, whereas the goal of equality of health gain is observed more often. The principle not to leave any patient untreated is very dominant. We also observe the degrees to which extent certain monotonicity principles, known from welfare economics, are followed. Subjects were able to describe their moral judgments in written statements. We also find evidence that they followed their respective intuitions very consistently in their decisions. Conclusions: Findings of the kind presented in this paper may serve as an important input for the public and political discussion when decisions on priorities in the public health care sector are formed. [ABSTRACT FROM AUTHOR]

Introduction: Under the Millennium Development Goals (MDGs), United Nations (UN) Member States reported progress on the targets toward their general citizenry. This focus repeatedly excluded marginalized ethnic and linguistic minorities, including people of refugee backgrounds and other vulnerable non-nationals that resided within a States' borders. The Sustainable Development Goals (SDGs) aim to be truly transformative by being made operational in all countries, and applied to all, nationals and non-nationals alike. Global migration and its diffuse impact has intensified due to escalating conflicts and the growing violence in war-torn Syria, as well as in many countries in Africa and in Central America. This massive migration and the thousands of refugees crossing borders in search for safety led to the creation of two-tiered, ad hoc, refugee health care systems that have added to the sidelining of non-nationals in MDG-reporting frameworks. Conclusion: We have identified four ways to promote the protection of vulnerable non-nationals' health and well being in States' application of the post-2015 SDG framework: In setting their own post-2015 indicators the UN Member States should explicitly identify vulnerable migrants, refugees, displaced persons and other marginalized groups in the content of such indicators. Our second recommendation is that statisticians from different agencies, including the World Health Organization's Gender, Equity and Human Rights programme should be actively involved in the formulation of SDG indicators at both the global and country level. In addition, communities, civil society and health justice advocates should also vigorously engage in country's formulation of post-2015 indicators. Finally, we advocate that the inclusion of non-nationals be anchored in the international human right to health, which in turn requires appropriate financing allocations as well as robust monitoring and evaluation processes that can hold technocratic decision-makers accountable for progress. [ABSTRACT FROM AUTHOR]

In September 2012 the United Nations (UN) initiated a process that would extend and enhance the unfinished agenda of the Millennium Development Goals (MDGs), integrating a new vision for sustainable development beyond the year 2015. The initial consultation phase has been completed, with the UN and partner organizations undertaking eleven thematic consultations, including one on health. It is in this context that the European Commission (EC) has tasked the research consortium Goals and Governance for Global Health (Go4Health) with providing recommendations for the post-2015 health-related development goals and including voices that are routinely excluded from health-related decision-making processes. This has not been an easy task. It has led us to question how to define marginalization, how to access marginalized communities, as well as how community members could provide informed consent. The context of the communities we worked with was far removed from the reality of the post-2015 debates, where the MDGs and the new goals, are remote and abstract, and where the promise of immediate benefit from participation could not be assured. Given the social, historical, cultural, ethnic and geographical diversity of our chosen community partners, and the diversity of their lived experiences, could their unique situations be generalized in ways that could influence the global debate? In this special issue, we have tried to explore the uniqueness and the commonalities of the issues and barriers that marginalized communities face all over the globe, and present them in individual papers that, together, provide a nuanced and complex picture of the challenges that face the post-2015 health-related agenda setting-process. [ABSTRACT FROM AUTHOR]

Background: The tremendous increase in knowledge on inequities in health and their drivers in recent decades has not been matched by improvements in health inequities themselves, or by systematic evidence of what works to reduce health inequities. Within health equity research there is a skew towards diagnostic studies in comparison to intervention studies showing evidence of how interventions can reduce disparities. Main text: The lack of sufficient specific evidence on how to implement specific policies and interventions in specific contexts to reduce health inequities creates policy confusion and partly explains the lack of progress on health inequities. In the field of research on equity in health, the time has come to stop focusing so much energy on prevalence and pathways, and instead shift to proposing and testing solutions. Four promising approaches to do so are implementation research, natural experimental policy studies, research on buy-in by policy-makers to action on health inequities, and geospatial analysis. Conclusion: The case for action on social determinants and health inequities has well and truly been made. The community of researchers on health equity now need to turn their attention to supporting implementation efforts towards achievements of the Sustainable Development Goals and substantive reductions in health inequities. [ABSTRACT FROM AUTHOR]

Background: The target date for achieving the Millennium Development Goals (MDGs) is now closer than ever. There is lack of sufficient progress in achieving the MDG targets in many low- and middle-income countries. Furthermore, there has also been concerns about wide spread inequity among those that are on track to achieve the health-related MDGs. Bangladesh has made a notable progress towards achieving the MDG 5 targets. It is, however, important to assess if this is an inclusive and equitable progress, as inequitable progress may not lead to sustainable health outcomes. The objective of this study is to assess the magnitude of inequities in reproductive and maternal health services in Bangladesh and propose relevant recommendations for decision making. Methods: The 2007 Bangladesh demographic and health survey data is analyzed for inequities in selected maternal and reproductive health interventions using the slope and relative indices of inequality. Results: The analysis indicates that there are significant wealth-related inequalities favouring the wealthiest of society in many of the indicators considered. Antenatal care (at least 4 visits), antenatal care by trained providers such as doctors and nurses, content of antenatal care, skilled birth attendance, delivery in health facility and delivery by caesarean section all manifest inequities against the least wealthy. There are no wealth-related inequalities in the use of modern contraception. In contrast, less desired interventions such as delivery by untrained providers and home delivery show wealth-related inequalities in favour of the poor. Conclusions: For an inclusive and sustainable improvement in maternal and reproductive health outcomes and achievement of MDG 5 targets, it essential to address inequities in maternal and reproductive health interventions. Under the government's stewardship, all stakeholders should accord priority to tackling wealth-related inequalities in maternal and reproductive health services by implementing equity-promoting measures both within and outside the health sector. [ABSTRACT FROM AUTHOR]

Myanmar is a developing country with considerable humanitarian needs, rendering its pursuit of the Millennium Development Goals (MDGs) an especially high priority. Yet progress to date remains under-examined on key fronts. Particularly within the three health-related MDGs (MDGs 4, 5, and 6), the limited data reported point to patchy levels of achievement. This study was undertaken to provide an overview and assessment of Myanmar's progress toward the health-related MDGs, along with possible solutions for accelerating health-related development into 2015 and beyond. The review highlights off-track progress in the spheres of maternal and child health (MDGs 4 and 5). It also shows Myanmar's achievements toward MDG 6 targets--in the areas of HIV/AIDS, malaria, and tuberculosis. Such achievements are especially notable in that Myanmar has been receiving the lowest level of official development assistance among all of the least developed countries in Asia. However, to make similar progress in MDGs 4 and 5, Myanmar needs increased investment and commitment in health. Toward moving forward with the post-2015 development agenda, Myanmar's government also needs to take the lead in calling for attention from the World Health Organization and its global development partners to address the stagnation in health-related development progress within the country. In particular, Myanmar's government should invest greater efforts into health system strengthening to pave the road to universal health coverage. [ABSTRACT FROM AUTHOR]

Background: Millennium Development Goal 1 encourages local initiatives for the eradication of extreme poverty. However, monitoring is indispensable to insure that actions performed at higher policy levels attain success. Poverty in rural areas in low- and middle-income countries remains chronic. Nevertheless, a rural area (Cuatro Santos) in northern Nicaragua has made substantial progress toward poverty eradication by 2015. We examined the level of poverty there and described interventions aimed at reducing it. Methods: Household data collected from a Health and Demographic Surveillance System was used to analyze poverty and the transition out of it, as well as background information on family members. In the follow-up, information about specific interventions (i.e., installation of piped drinking water, latrines, access to microcredit, home gardening, and technical education) linked them to the demographic data. A propensity score was used to measure the association between the interventions and the resulting transition from poverty. Results: Between 2004 and 2009, poverty was reduced as a number of interventions increased. Although microcredit was inequitably distributed across the population, combined with home gardening and technical training, it resulted in significant poverty reduction in this rural area. Conclusions: Sustainable interventions reduced poverty in the rural areas studied by about one- third. [ABSTRACT FROM AUTHOR]

Introduction: Promoting health equity is a key goal of many public health systems. However, little is known about how equity is conceptualized in such systems, particularly as standards of public health practice are established. As part of a larger study examining the renewal of public health in two Canadian provinces, Ontario and British Columbia (BC), we undertook an analysis of relevant public health documents related to equity. The aim of this paper is to discuss how equity is considered within documents that outline standards for public health. Methods: A research team consisting of policymakers and academics identified key documents related to the public health renewal process in each province. The documents were analyzed using constant comparative analysis to identify key themes related to the conceptualization and integration of health equity as part of public health renewal in Ontario and BC. Documents were coded inductively with higher levels of abstraction achieved through multiple readings. Sets of questions were developed to guide the analysis throughout the process. Results: In both sets of provincial documents health inequities were defined in a similar fashion, as the consequence of unfair or unjust structural conditions. Reducing health inequities was an explicit goal of the public health renewal process. In Ontario, addressing "priority populations" was used as a proxy term for health equity and the focus was on existing programs. In BC, the incorporation of an equity lens enhanced the identification of health inequities, with a particular emphasis on the social determinants of health. In both, priority was given to reducing barriers to public health services and to forming partnerships with other sectors to reduce health inequities. Limits to the accountability of public health to reduce health inequities were identified in both provinces. Conclusion: This study contributes to understanding how health equity is conceptualized and incorporated into standards for local public health. As reflected in their policies, both provinces have embraced the importance of reducing health inequities. Both concepualized this process as rooted in structural injustices and the social determinants of health. Differences in the conceptualization of health equity likely reflect contextual influences on the public health renewal processes in each jurisdiction. [ABSTRACT FROM AUTHOR]

Background: Formal engagement with non-state providers (NSP) is an important strategy in many low-and-middle-income countries for extending coverage of publicly financed health services. The series of country studies reviewed in this paper - from Afghanistan, Bangladesh, Bosnia & Herzegovina, Ghana, South Africa, Tanzania and Uganda – provide a unique opportunity to understand the dynamics of NSP engagement in different contexts. Methods: A standard template was developed and used to summarize the main findings from the country studies. The summaries were then organized according to emergent themes and a narrative built around these themes. Results: Governments contracted NSPs for a variety of reasons – limited public sector capacity, inability of public sector services to reach certain populations or geographic areas, and the widespread presence of NSPs in the health sector. Underlying these reasons was a recognition that purchasing services from NSPs was necessary to increase coverage of health services. Yet, institutional NSPs faced many service delivery challenges. Like the public sector, institutional NSPs faced challenges in recruiting and retaining health workers, and ensuring service quality. Properly managing relationships between all actors involved was critical to contracting success and the role of NSPs as strategic partners in achieving national health goals. Further, the relationship between the central and lower administrative levels in contract management, as well as government stewardship capacity for monitoring contractual performance were vital for NSP performance. Conclusion: For countries with a sizeable NSP sector, making full use of the available human and other resources by contracting NSPs and appropriately managing them, offers an important way for expanding coverage of publicly financed health services and moving towards universal health coverage. [ABSTRACT FROM AUTHOR]