Measurement of Inequity in Health Care with Heterogeneous Response of Use to Need

We propose a method of measuring and decomposing inequity in health care utilisation that allows for heterogeneity in the use-need relationship. This makes explicit inequity that derives from unequal treatment response to variation in need, as well as that due to differential effects of non-need determinants. Under plausible conditions concerning heterogeneity in the use-need relationship and the distribution of need, existing methods that impose homogeneity will underestimate pro-rich inequity. This prediction is confirmed for four low-middle income Asian countries

What explains the Rural-Urban Gap in Infant Mortality — Household or Community Characteristics?

The rural-urban gap in infant mortality rates is explained using a new decomposition method that permits identification of the ontribution of unobserved heterogeneity at the household and the community level. Using Demographic and Health Survey data for six Francophone countries in Western Sub-Saharan Africa, we find that differences in the distributions of factors that determine mortality – not differences in their effects – explain almost the entire gap. Higher infant mortality rates in rural areas mainly derive from the rural disadvantage in household level characteristics; both observed and unobserved, which explain three-quarters of the gap. Among the observed characteristics, household environmental factors—potable water, electricity and quality of housing materials—are the most important contributors explaining 38% of the gap. Unobserved household level determinants explain 10% of the gap. Community level determinants explain 13% of the gap, including 3% that is due to unobservable community level heterogeneity

The Health Penalty of China's Rapid Urbanization

Rapid urbanization could have positive and negative health effects, such that the net impact on population health is not obvious. It is, however, highly pertinent to the human welfare consequences of development. This paper uses community and individual level longitudinal data from the China Health and Nutrition Survey to estimate the net health impact of China’s unprecedented urbanization. We construct an index of urbanicity from a broad set of community characteristics and define urbanization in terms of movements across the distribution of this index. We use difference-in-differences estimators to identify the treatment effect of urbanization on the self-assessed health of individuals. The results reveal important, and robust, negative causal effects of urbanization on health. Urbanization increases the probability of reporting fair or poor health by 5 to 15 percentage points, with a greater degree of urbanization having larger health effects. While people in more urbanized areas are, on average, in better health than their rural counterparts, the process of urbanization is damaging to health. Our measure of self-assessed health is highly correlated with subsequent mortality and the causal harmful effect of urbanization on health is confirmed using more objective (but also more specific) health indicators, such as physical impairments, disease symptoms and hypertension

Betwist bestuur in Rotterdam: een bestuurskundige heranalyse

Het proefschrift is feitelijk een bestuurskundig vervolg op het bestuurshistorische boek ‘Betwist bestuur – Wijkraden en deelgemeenten in Rotterdam’ (2017) van dezelfde auteur. In het proefschrift is een uitvoerige samenvatting van dit boek opgenomen.In beide geschriften wordt vooral het bestuurlijk besluitvormingsproces inzake binnengemeentelijke territoriale decentralisatie van bestuur in Rotterdam beschreven, zoals vormgegeven door de Rotterdamse gemeenteraad en het college van burgemeester en wethouders. Meer concreet gaat het om de politiek-bestuurlijke besluitvorming op ‘de Coolsingel’ betreffende de instelling van wijkraden en deelgemeenten in Rotterdam tussen 1947 en 2014. In dat laatste jaar werden de deelgemeenten in Rotterdam en Amsterdam door een wijziging van de Gemeentewet opgeheven.In het proefschrift wordt de empirie, zoals beschreven in het boek ‘Betwist bestuur’ uit 2017, aan een bestuurskundige heranalyse onderworpen. Dit geschiedt aan de hand van drie bestuurskundige modellen om complexe besluitvormingsprocessen te reconstrueren: het fasenmodel, het stromenmodel en het rondenmodel. Door de bestuurskundige heranalyse komt met name de proceskant van het bestuurlijke besluitvormingsproces over decentraal bestuur in Rotterdam scherper in beeld. Succes- en faalfactoren om het primaire beleidsdoel – het beter betrekken van de Rotterdammers bij het bestuur van de gemeente en van delen daarvan – te bereiken, kunnen beter worden herkend.Security and Global Affair

Are Urban Children really healthier?

On average, child health outcomes are better in urban than in rural areas of developing countries. Understanding the nature and the causes of this rural-urban disparity is essential in contemplating the health consequences of the rapid urbanization taking place throughout the developing world and in targeting resources appropriately to raise population health. We use micro data on child health taken from the most recent Demographic and Health Surveys for 47 developing countries. First, we document the magnitude of rural-urban disparities in child nutritional status and under-five mortality across all 47 developing countries. Second, we adjust these disparities for differences in population characteristics across urban and rural settings. Third, we examine rural-urban differences in the degree of socioeconomic inequality in these health outcomes. We find considerable rural-urban differences in mean child health outcomes. The rural-urban gap in stunting does not entirely mirror the gap in under-five mortality. The most striking difference between the two is in the Latin American and Caribbean region, where the gap in stunting is more than 1.5 times higher than that in mortality. On average, the rural-urban risk ratios of stunting and under-five mortality fall by respectively 53% and 59% after controlling for household wealth. Controlling thereafter for socio-demographic factors reduces the risk ratios by another 22% and 25%. In a considerable number of countries, the urban poor actually have higher rates of stunting and mortality than their rural counterparts. The findings imply that there is a need for programs that target the urban poor, and that this is becoming more necessary as the size of the urban population grows

Urbanization, Health and Inequality in the Developing World

Verstedelijking in ontwikkelingslanden leidt niet automatisch tot een betere volksgezondheid. Beleidsmakers in ontwikkelingslanden moeten zich bewust worden van het belang en noodzaak van stedelijke planning om de negatieve gezondheidseffecten van de immense verstedelijking om te buigen. Dat stelt Ellen Van de Poel in haar proefschrift ‘Urbanization, Health and Inequality in the Developing World’. Van de Poel promoveerde op donderdag 24 september 2009. Het aantal inwoners in steden neemt vooral in ontwikkelingslanden zeer snel toe en het is voorlopig nog onduidelijk welke gevolgen dit heeft voor de volksgezondheid. Van de Poel analyseerde databestanden van de Demographic and Health Surveys van 47 ontwikkelingslanden om de verbanden te bestuderen tussen verstedelijking, sterfte en ondervoeding bij kinderen. Daarnaast gebruikte ze data van de China Health and Nutrition Survey om de verbanden tussen verstedelijking en welvaartsziekten in China te onderzoeken. Ook wilde zij het algemene gezondheidseffect van de immense verstedelijking in China meten. Stadsbewoners zijn gemiddeld in een betere gezondheid dan mensen op het platteland, maar deze gemiddeldes verbergen grote ongelijkheden. Kinderen in arme gezinnen in steden, meestal geconcentreerd in sloppenwijken, hebben evenveel en soms zelfs meer kans op ondervoeding en sterfte dan kinderen in arme gezinnen op het platteland. Maar ook buiten de sloppenwijken kan verstedelijking de gezondheid schaden, bijvoorbeeld door milieuvervuiling en een veranderend eet- en leefpatroon. In China neemt met de gigantische urbanisatie, ook de prevalentie van welvaartsziektes zoals diabetes en hypertensie zeer snel toe, en verspreiden deze ziektes zich ook naar minder verstedelijkte gebieden. Beleidsmakers in ontwikkelingslanden moeten zich daarom realiseren dat tenzij verstedelijking gepaard gaat met een goed gepland ruimtelijk en sociaal beleid, dit proces de volksgezondheid niet ten goede zal komen. Ook moeten ze voorzichtig omspringen met het uitzetten van een gezondheidsbeleid op basis van vergelijkingen van gemiddelde gezondheid tussen verstedelijkte en landelijke gebieden. Het is belangrijk dat beleidsprogramma’s de steeds groter wordende arme stedelijke populaties niet langer over het hoofd zien

Trait mindfulness facets as a protective factor for the development of postpartum depressive symptoms

Background Postpartum depression has a prevalence rate of up to 17%. As there are many negative consequences of postpartum depressive symptoms, it is important to examine possible protective factors, such as trait mindfulness. Since postpartum depressive symptoms are variable over time between and within individuals, this study focused on the possible association between facets of trait mindfulness and trajectories of postpartum depressive symptoms throughout the first postpartum year. Methods A subsample of 713 women that participated in the HAPPY study completed the Three Facet Mindfulness Questionnaire-Short Form at 22 weeks of pregnancy and the Edinburgh Postnatal Depression Scale (EPDS) at six weeks, four months, eight months, and twelve months postpartum. Possible different EPDS trajectories were obtained by means of growth mixture modeling. Results Two EPDS trajectories (classes) were found: a low stable symptom class (N = 647, 90.7%) and an increasing-decreasing symptom class (N = 66, 9.3%). Women in the low stable class showed higher ‘acting with awareness’ and ‘non-judging’ scores. A higher score on the ‘non-judging’ facet of trait mindfulness was associated with a higher likelihood of belonging to the low stable class (OR = 0.79, 95% CI [0.72, 0.87], p < 0.001), adjusted for confounders and the other mindfulness facets. Conclusions The non-judging facet of trait mindfulness was associated with low stable levels of depressive symptoms during the first postpartum year. Mindfulness-based programs, focusing on enhancing non-judging may be of benefit for pregnant women to possibly decrease the risk of developing postpartum depressive symptoms after childbirt

Does health care utilization match needs in Africa? Challenging conventional needs measurement

Abstract. An equitable distribution of health care use, distributed according to people’s needs instead of ability to pay, is an important goal featuring on many health policy agendas worldwide. However, relatively little is known about the extent to which this principle is violated across socio-economic groups in Sub Saharan Africa (SSA). We examine cross-country comparative micro-data from eighteen SSA countries and find that (a) considerable inequalities in health care use exist and vary across countries, but that (b) identifying the extent to which these inequalities are unfair, i.e. do not correspond to inequalities in need, is not straightforward to ascertain with the conventional tools. These tools include rank-based measures such as the concentration index and the index of inequity. The two main concerns when using conventional tools to measure equity are (i) the reporting heterogeneity in self-reported health variables across socio-economic groups and (ii) the weak relationship between need and use. We show that the use of subjective self-reports of health leads to much lower measured degrees of socio-economic inequalities than those obtained using more objective indicators. This leads to an underestimation of the degree of inequity when using self-reported health measures. The observed weak relationship between indicators of ill-health and use of health care does not appear to provide an estimate of the adequate response to needs, which further puts a downward bias on equity measures. In all countries, apart from the more developed Mauritius, health care use is distributed according to wealth rather than to need. A better match of needs and use is realized in those countries with better governance and more physicians but, perhaps surprisingly, not those with greater urbanization. Given the importance of equity in many health policies worldwide, it is vital to develop more robust equity measures relevant to low income settings

How far does a big push really push?

BRAC implemented the Challenging the Frontiers of Poverty Reduction: Specially Targeted Ultra-Poor (CFPR) program in 2002 to mitigate ultra-poverty in the poorest districts of Bangladesh, providing multifaceted support in the form of asset-transfer, food-stipends, education, healthcare and social support for two years. Utilizing a four-round panel data spanning 9 years and combining regression and propensity score weighting, we evaluate CFPR’s short and long term impact on income, employment, social status, food security and asset ownership. While remarkable effects of CFPR are evident in short and medium-term (up to 6 years since baseline), longer-term effects (up to 9 years) are smaller. The latter happens due to a variety of factors including faster catch-up by the control group, due partly to various new interventions by state and non-state sectors. We see a shift from begging, working as maids and day-laboring to entrepreneurial activities in the short and medium term, but many CFPR households revert back to their baseline employment by 2011. Analyses of the heterogeneity of effects across baseline employment and gender of the household-head reveal greater long-term impact on per-capita income for entrepreneurs and greater short-term impact for female-headed households. Overall, despite the deceleration of the effects in the long run, the program was able to successfully bring its participants out of ultra-poverty and had important demonstration effects