Background

Malawi, Maeve O'Neill, 2009

I have been struck again and again by how important measurement is to improving the human condition. – Bill Gates

There is unprecedented availability of comparative data on health and social policy. Combining such data with dramatic improvements in the quality of comparative health data and the evolution of multidisciplinary methods for estimating policy effects, it is now possible to examine how social policies influence distributions of morbidity and mortality cross-nationally.

As highlighted by the Millennium Development Goals, it is critical to reduce mortality for children under the age of 5 and women under the age of 50, as well as halt the spread of HIV/AIDS, tuberculosis and other major diseases, in order to eliminate poverty and inequality.  Understanding the effects of different social policy approaches on population health and health inequalities is imperative to ensuring that programs and initiatives designed to target these key issues have an equitable impact for women and children.


Background


Millennium Development Goals

Established at the 2000 Millennium Summit, the Millennium Development Goals (MDGs) represent a global commitment to achieve defined progress in three health areas between 1990 and 2015. MDG 4 focuses on reducing infant and under-five mortality by two thirds, MDG 5 aims to reduce the maternal mortality ratio by three-quarters, and MDG 6 targets the stopping and reversal of the spread of major diseases, including HIV/AIDS.

Despite substantial reductions in global child and maternal mortality, many countries remain far from reaching these goals and progress has been highly uneven across regions and countries.  Low-and-middle-income countries (LMICs) are falling particularly short, having achieved reductions of 33% for infant mortality and 34% for under-five mortality; according to the World Health Organization only 23 of the 74 Countdown countries (those accounting for >95% of global maternal and child deaths) are on track to achieve MDG 4 for reducing child mortality. Maternal mortality remains a serious challenge in LMICs; according to the World Bank maternal mortality is almost twenty times higher in LMICs than in high-income countries. Only 9 of 74 Countdown countries are on track to achieve MDG 5 for reducing maternal mortality. Despite evidence that incidence of HIV and tuberculosis (TB) is declining there are several worrying trends, including the greater burden HIV/AIDS among women in Sub-Saharan Africa and rising rates of multi-drug resistant TB. Given the intensive policy focus on improving maternal and child health over the past decade, and in light of unmet goals, it is imperative to understand what policies and programs effectively reduce child mortality, improve maternal health, and combat HIV/AIDS, TB and other diseases.

Child Morbidity and Mortality

Most deaths among infants and young children are preventable, and many causes of infant and child mortality can be profoundly affected by social policy. According to the World Health Organization, malnutrition is linked to approximately one third of all child deaths, and 43% of child deaths under the age of five take place during the neonatal period, resulting primarily from infections, premature birth and related complications, and birth injuries related to complications during delivery. Other primary causes of death in children under five are acute respiratory diseases, diarrheal disease, malaria, measles, and HIV/AIDS. Many of the efforts to address infant and child mortality have focused on selected medical and public health interventions. While there is evidence that scaling up important child survival interventions can prevent many child deaths, resources are limited, and coverage gaps remain wide. Given these restraints, it is critical to understand how broad scale social policies can reduce poverty and gender inequality and address the conditions that drive multiple causes of death and illness in children.

Maternal Morbidity and Mortality

Maternal morbidity and mortality continues to represent a substantial challenge confronting the international community. As many as half a million women die each year from complications in childbirth. The World Health Organization estimates that pregnancy-related complications are among the leading causes of death and disability for women aged 15-49 in low-and middle-income countries. Compelling evidence shows a strong association between poverty and high rates of maternal mortality with more than a hundred-fold difference between the poorest and wealthiest areas. Family income, access to and affordability of transportation, ability to take time off from work to access care, and women’s ability to make decisions within the household influence whether they receive care during pregnancy and delivery. Despite a known gradient by income and gender equity, little research has systematically examined how social policies targeting poverty and gender inequalities would impact maternal morbidity and mortality. MACHEquity seeks to provide knowledge on what works to improve women’s lives in this crucial area.

HIV/AIDS and Tuberculosis

While tuberculosis (TB) and HIV incidence are declining globally after many years of international action and tens of billions of dollars, these diseases remain among the most common causes of death and disability worldwide, especially in low-income countries. According to the World Health Organization and UNAIDS, in 2009 there were an estimated 9.4 million new TB cases and 2.6 million new HIV infections. TB and HIV/AIDS caused 1.7 million and 1.8 million deaths respectively– the equivalent of 9,600 people dying from TB or HIV every day. Women and girls account for the majority of all HIV-infections worldwide, and girls aged 15-24 are 8 times more likely to be HIV-infected than boys of the same age. Globally, TB is one of the top 3 causes of death in women aged 15-44. These epidemics continue to disproportionately affect the poor. In 2008, the TB mortality rate in low-income countries was 48 times the mortality rate in high-income countries, and the HIV/AIDS mortality rates 22 times greater. In high- and low-income countries, inequality has been associated with HIV risk behaviors. Analyzing which programs and policies effectively mitigate the spread of infectious disease in an equitable fashion is critical.

Poverty, Gender Equity and Health Outcomes

There is a great deal of evidence demonstrating a social gradient in health: adults and children of higher socioeconomic status experience less illness and have lower mortality rates. The effect of poverty may vary depending on the age of the child and the outcomes examined, and there is growing evidence that the adverse health effects of poverty accumulate over the life-course. Studies have shown that chronic poverty is especially harmful for young children. Evidence is similarly strong that gender equity is associated with better health outcomes for women. MACHEquity investigates which social policies can reduce socioeconomic inequalities and improve health outcomes.

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