Good governance, public health expenditures, urbanization and child undernutrition Nexus in Ethiopia: an ecological analysis

A realist synthesis to develop an explanatory model of how policy instruments impact child and maternal health outcomes

BACKGROUND

Child and maternal health, a key marker of overall health system performance, is a policy priority area by the World Health Organization and the United Nations, including the Sustainable Development Goals. Previous realist work has linked child and maternal health outcomes to globalization, political tradition, and the welfare state. It is important to explore the role of other key policy-related factors. This paper presents a realist synthesis, categorising policy instruments according to the established NATO model, to develop an explanatory model of how policy instruments impact child and maternal health outcomes.

METHODS

A systematic literature search was conducted to identify studies assessing the relationships between policy instruments and child and maternal health outcomes. Data were analysed using a realist framework. The first stage of the realist analysis process was to generate micro-theoretical initial programme theories for use in the theory adjudication process. Proposed theories were then adjudicated iteratively to produce a set of final programme theories.

FINDINGS

From a total of 43,415 unique records, 632 records proceeded to full-text screening and 138 papers were included in the review. Evidence from 132 studies was available to address this research question. Studies were published from 1995 to 2021; 76% assessed a single country, and 81% analysed data at the ecological level. Eighty-eight initial candidate programme theories were generated. Following theory adjudication, five final programme theories were supported. According to the NATO model, these were related to treasure, organisation, authority-treasure, and treasure-organisation instrument types.

CONCLUSIONS

This paper presents a realist synthesis to develop an explanatory model of how policy instruments impact child and maternal health outcomes from a large, systematically identified international body of evidence. Five final programme theories were supported, showing how policy instruments play an important yet context-dependent role in influencing child and maternal health outcomes.

Unraveling the South Asian enigma: concurrent manifestations of child anthropometric failures and their determinants in selected South Asian countries

Malnutrition among children is pervasive in South Asia and there are also reports of overnutrition. To better understand this phenomenon, we need a composite measure. However, the existing measures such as CIAF (Composite Index of Anthropometric Failure) and its revised version have ignored the overnutrition aspect of the phenomenon. This study proposes an extended version of CIAF which also considers overnutrition. This new measure was compared with the existing measures by using data from 1990 to 2018 for three selected South Asian countries including Pakistan, India and Bangladesh. We also examined the effects of socioeconomic and environmental variables on the outcome variable. The results reveal that the new measure (ECIAF) is better at measuring the phenomena. The burden of overall malnutrition has been decreased in the region. However, an increase in the concomitant prevalence of wasting and underweight is observed in both Pakistan and India and stunting and overweight is observed only in India. Besides, political stability, prevalence of undernourishment, anemia in children, mother's education, household size, dependency ratio, air pollution and unimproved sanitation are significantly correlated with childhood malnutrition. The findings also testified to long-run cointegrating relationship among the variables.

Air pollution, governance quality, and health outcomes: evidence from developing countries

While studies have demonstrated that air pollution can be catastrophic to the population's health, few empirical studies are found in the economic literature because a considerable proportion of the evidence comes from epidemiological studies. Because of the crucial role of governance in the health community, good governance has been a contentious issue in public sector management in recent years. Therefore, the aim of this study is to examine the effects of air pollution and the role of governance on health outcomes. This study employed the generalized method of moment (GMM) estimation techniques to analyse panel data for 72 developing countries from 2010 to 2017. The empirical results confirm that higher PM_2.5 and CO₂ levels have a detrimental influence on life expectancy and healthy life expectancy, whereas the role of governance has a positive impact on life expectancy and healthy life expectancy. Furthermore, the findings show governance quality plays a role in moderating the negative effect of PM_2.5 on health outcomes. The ongoing rise in air pollution has had a significant impact on the health of developing countries. It appears that governance quality has improved health outcomes. The findings have important policy implications, such that strengthening governance can reduce air pollution emissions in developing countries. However, to reduce the health effects of air pollution, developing countries must implement effective environmental development policies and track the implementation and enforcement of such policies.

How urbanization affects residents' health risks: evidence from China

Continued urbanization requires a deep understanding of how urbanization affects residents' health risks. This study used regression analysis of Chinese provincial-level panel data from 2004 to 2019 and empirically analyzed the nonlinear effects of urbanization on health risks and regional differences using STIRPAT model. Health risks were assessed by the average number of residents' visits to medical facilities and population mortality. We also examined the moderating effect of income and environmental factors. The results show that (1) urbanization increases the average number of residents' visits and reduces population mortality. The positive effect of urbanization in increasing the average number of visits is reinforced by an increase in income level and environmental pollution, whereas the negative effect of urbanization in reducing population mortality is weakened by environmental pollution. (2) Regarding long-term trends, urbanization has an N-shaped relationship with the average number of residents' visits, and a U-shaped relationship with population mortality; (3) Urbanization has an N-shaped relationship with the average number of residents' visits in the eastern, central, and western regions and an inverted N-shaped relationship with population mortality in the eastern region. Urbanization has significant effects on residents' health risks in areas with high levels of infrastructure. According to the results, suggestions are proposed, such as developing new-type urbanization, improving infrastructure, focusing on green urbanization, and promoting national fitness programs.

Bioethical Implications of Vulnerability and Politics for Healthcare in Ethiopia and The Ways Forward

Vulnerability and politics are among the relevant and key topics of discussion in the Ethiopian healthcare context. Attempts by the formal bioethics structure in Ethiopia to deliberate on ethical issues relating to vulnerability and politics in healthcare have been limited, even though the informal analysis of bioethical issues has been present in traditional Ethiopian communities. This is reflected in religion, social values, and local moral underpinnings. Thus, the aim of this paper is to discuss the bioethical implications of vulnerability and politics for healthcare in Ethiopia and to suggest possible ways forward. First, we will briefly introduce what has been done to develop bioethics as a field in Ethiopia and what gaps remain concerning its implementation in healthcare practice. This will give a context for our second and main task - analyzing the healthcare challenges in relation to vulnerability and politics and discussing their bioethical implications. In doing so, and since these two concepts are intrinsically broad, we demarcate their scope by focusing on specific issues such as poverty, gender, health governance, and armed conflicts. Lastly, we provide suggestions for the ways forward.

The Effect of Urbanization on Health Care Expenditure: Evidence From China

This paper investigates the impact and non-linear effects of urbanization on health care expenditure in China. The results indicate that urbanization in both Eastern and Central regions can significantly increase health care expenditure. But the impact of urbanization is not significant, which is related to the backward economic development level and low urbanization rate in the Western region. Taking population aging into consideration, the results of the panel threshold regression model imply that the positive relationship between urbanization and health care expenditure becomes greater when the level of population aging exceeds 10.72% in the Eastern region and 7.00% in the Western region. Therefore, in the urbanization process, the government should pay attention to the positive effect of urbanization on health care expenditure, provide more financial support for the construction of medical facilities, and expand the coverage of medical services and security for residents, especially for elderly people.

Trends in child growth failure among children under five years of age in Ethiopia: Evidence from the 2000 to 2016 Demographic and Health Surveys

INTRODUCTION

In a majority of low- and middle-income countries (LMICs), levels of child growth failure (CGF) have steadily declined since 2000. However, some countries show a different trend. Despite continued investment from the government of Ethiopia as well as donors, CGF levels are still high in Ethiopia. This study aimed to assess trends in CGF and associated sociodemographic, economic and water, sanitation, and hygiene (WASH) factors from 2000 to 2016 in Ethiopia.

METHODS

Data were taken from four rounds of the Ethiopia Demographic and Health Survey (EDHS). Children aged between 0 to 59 months were included. CGF indicators were categorised based on height-for-age z-score (HAZ) < -2 Standard deviation (SD), weight-for-age z-score (WAZ) < -2 SD and weight-for-height z-score (WHZ) < -2 SD. CGF trends were estimated for predicted probabilities and odds ratios (ORs) between 2000 and 2016.

RESULTS

A total sample size of 31978 for HAZ, 32045 for WAZ and 32246 for WHZ were included in the current study. Stunting decreased from an adjusted odds ratio (AOR) = 0.77 (95% CI: 0.67 to 0.88) in 2005 to an AOR = 0.45 (95% CI: 0.39 to 0.53) in 2016 compared with the year 2000. Compared with data in 2000, underweight decreased from an AOR of 0.70 (95% CI: 0.61 to 0.80) in 2005 to an AOR of 0.43 (95% CI: 0.36 to 0.50) in 2016. Wasting declined from an AOR of 0.91 (95% CI: 0.75 to 1.10) in 2005 to an AOR of 0.76 (95% CI: 0.61 to 0.94) in 2016, compared with data in 2000.

CONCLUSIONS

Between 2000 to 2016, there was a decline in CGF levels albeit the levels are still relatively high compared with the World Health Organization (WHO) cut-off levels for public health concern. Observed rates of change varied across sociodemographic, economic and WASH factors which suggest that interventions tailored towards addressing the imbalances across those factors are required.

The Effect of Urbanization on Population Health: Evidence From China

This paper explores the relationship between urbanization rate and death incidence by applying panel threshold regression model to the inland provinces of China. The empirical results highlight that there is a nonlinear single threshold effect between urbanization and population health indicators. In China's inland provinces, the negative impact of urbanization on death rate is reduced when per capita GDP exceeds the threshold, that is, the positive impact of urbanization on population health is significantly weakened. Similarly, this result can also be applied to the north provinces, while there is a no threshold effect in south. These asymmetric effects are strongly related to geographical location, historical background, economic development conditions, and health policies. Therefore, in the urbanization process, while promoting the steady development of population urbanization, the government should also increase health investment to improve the system and mechanism, formulate policies to raise health awareness, protect residents' health and reduce the waste of health resources.

Prevalence of rheumatic heart disease in a major referral cardiology clinic in Ethiopia: A retrospective cross-sectional study

Background

Rheumatic Heart Disease (RHD) remains one of the major causes of death and disability in developing countries. This preventable, treatable but not curable form of cardiovascular disease is needlessly killing scores of children and youth mainly due to the misunderstanding of the burden of the disease in these countries. We sought to describe the prevalence of RHD at one of the major referral cardiology clinics in Ethiopia.

Methods

This was a retrospective cross-sectional chart review of all patients referred for a cardiopathy at the Tikur Anbessa Referral Cardiac Clinic from June 2015 to August 2018. We excluded records of patients with a non-cardiac diagnosis and those without a clear diagnosis. A predesigned and tested EXCEL form was used to collect the data. The data was encoded directly from the patient record files. MATLAB’s statistics toolbox (MATLAB2019b) was used for statistical analysis.

Results

Among the total 7576 records analyzed 59.5% of the patients were women. 83.1% of the data belonged to adult patients with the largest concentration reported in the 18 to 27 age group. 69.7% of the patients were from urban areas. The median age of the study population was 30 (interquartile range = 21–50). 4151 cases were caused by RHD which showed that RHD constituted 54.8% of the cases. The median age for RHD patients was 25 (interquartile range = 19–34). The second most prevalent disease was hypertensive heart disease which constituted 13.6% that was followed by congenital heart disease with 9% prevalence rate.

Conclusion

The results of this study indicated the extent of the RHD prevalence in Ethiopia’s cardiac hospital was 54.8%. What was more critical was that almost 70% of the RHD patients were mainly the working-age group(19 to 34 years).

Air pollution effects on adult mortality rate in developing countries

Although industrialisation is a crucial aspect of economic growth across developing nations, through the release of air contaminants, industrial activities may also create adverse environmental health consequences. Noting that continuous production and other economic activities are crucial for continued survival, this study explores this issue by including the role of governance that is deemed essential but the literature is relatively sparse particularly in the context of developing countries. This research empirically analyses the relationship between air pollution and adult mortality rates from 72 developing countries from the period of 2010 until 2017. Particulate matter (PM_2.5) and carbon dioxide (CO₂) are used as indicators of air pollution. From the generalized method of moments (GMM) estimations, the results reveal that air pollution negatively affects adult mortality rate. The result reveals that a 10% increase in the PM_2.5 level induces the adult mortality rates to increase between 0.04% and 0.06%. In addition, the government significantly moderates the negative effect of air pollution on adult mortality, whereby a one-unit enhancement in governance quality index reduces mortality among the adults in the developing countries by 0.01%. On the other hand, CO₂ emission also appears to be positive, but not statistically significant. The results suggest that governance and public health interplay in the sense of a transition towards economic development for improved living and health states can be achievable with improved governance quality.

Stunting in childhood: an overview of global burden, trends, determinants, and drivers of decline

BACKGROUND

Progress has been made worldwide in reducing chronic undernutrition and rates of linear growth stunting in children under 5 y of age, although rates still remain high in many regions. Policies, programs, and interventions supporting maternal and child health and nutrition have the potential to improve child growth and development.

OBJECTIVE

This article synthesizes the available global evidence on the drivers of national declines in stunting prevalence and compares the relative effect of major drivers of stunting decline between countries.

METHODS

We conducted a systematic review of published peer-reviewed and gray literature analyzing the relation between changes in key determinants of child linear growth and contemporaneous changes in linear growth outcomes over time.

RESULTS

Among the basic determinants of stunting assessed within regression-decomposition analyses, improvement in asset index score was a consistent and strong driver of improved linear growth outcomes. Increased parental education was also a strong predictor of improved child growth. Of the underlying determinants of stunting, reduced rates of open defecation, improved sanitation infrastructure, and improved access to key maternal health services, including optimal antenatal care and delivery in a health facility or with a skilled birth attendant, all accounted for substantially improved child growth, although the magnitude of variation explained by each differed substantially between countries. At the immediate level, changes in several maternal characteristics predicted modest stunting reductions, including parity, interpregnancy interval, and maternal height.

CONCLUSIONS

Unique sets of stunting determinants predicted stunting reduction within countries that have reduced stunting. Several common drivers emerge at the basic, underlying, and immediate levels, including improvements in maternal and paternal education, household socioeconomic status, sanitation conditions, maternal health services access, and family planning. Further data collection and in-depth mixed-methods research are required to strengthen recommendations for those countries where the stunting burden remains unacceptably high.

Drivers of stunting reduction in Ethiopia: a country case study

BACKGROUND

Chronic undernutrition in children continues to be a global public health concern. Ethiopia has documented a significant decline in the prevalence of childhood stunting, a measure of chronic undernutrition, over the last 20 y.

OBJECTIVES

The aim of this research was to conduct a systematic assessment of the determinants that have driven child stunting reduction in Ethiopia from 2000 to 2016, focused on the national, community, household, and individual level.

METHODS

This study employed both quantitative and qualitative methods. Specifically, a systematic literature review, retrospective quantitative data analysis using Demographic and Health Surveys from 2000-2016, qualitative data collection and analysis, and analyses of key nutrition-specific and -sensitive policies and programs were undertaken.

RESULTS

National stunting prevalence improved from 51% in 2000 to 32% in 2016. Regional variations exist, as do pro-rich, pro-urban, and pro-educated inequalities. Child height-for-age z score (HAZ) decomposition explained >100% of predicted change in mean HAZ between 2000 and 2016, with key factors including increases in total consumable crop yield (32% of change), increased number of health workers (28%), reduction in open defecation (13%), parental education (10%), maternal nutrition (5%), economic improvement (4%), and reduced diarrhea incidence (4%). Policies and programs that were key to stunting decline focused on promoting rural agriculture to improve food security; decentralization of the health system, incorporating health extension workers to improve rural access to health services and reduce open defecation; multisectoral poverty reduction strategies; and a commitment to improving girls' education. Interviews with national and regional stakeholders and mothers in communities presented improvements in health service access, women and girls' education, improved agricultural production, and improved sanitation and child care practices as drivers of stunting reduction.

CONCLUSIONS

Ethiopia's stunting decline was driven by both nutrition-specific and -sensitive sectors, with particular focus on the agriculture sector, health care access, sanitation, and education.

Spatial heterogeneity of the association between temperature and hand, foot, and mouth disease risk in metropolitan and other areas

Interest in assessing the effects of temperature on hand, foot, and mouth disease (HFMD) has increased. However, little evidence is available on spatial heterogeneity in relationship to temperature and HFMD in metropolitan (capital city and municipal districts) and other areas where economic levels are significantly different. In this study, the Bayesian space-time hierarchy model was applied to identify the spatiotemporal heterogeneity of HFMD. GeoDetector was then used to quantify the determinant power of temperature to the disease in regions where the economic level has significant spatial heterogeneity. There was significant spatial heterogeneity in the influence of temperature on the incidence of HFMD in metropolitan and other areas. In metropolitan areas, where the disease risk is higher (hot spots), the HFMD incidence was higher alongside an increase in average temperature. However, in non-metropolitan areas, where the disease risk is lower (cold spots), there was an approximately S-shaped relationship between the temperature and the HFMD risk. More specifically, when the temperature was >25 °C, the HFMD incidence no longer increased monotonically with the increasing temperature. There was significant spatial heterogeneity in the effects of temperature on the HFMD incidence in metropolitan and non-metropolitan areas. This finding may serve as a suggestion and basis for the surveillance and control of this disease and it is conducive to the rational allocation of medical resources in different areas.

Drought and child undernutrition in Ethiopia: A longitudinal path analysis

BACKGROUND

The increase in the frequency of extreme events due to climate change poses a serious challenge to achieving the Sustainable Development Goal 2 of ending hunger by 2030. While evidence exists on the impact of drought on under-five children, its effect during late childhood and early adolescence remains less investigated.

OBJECTIVE

This study estimates the impact of concurrent and long-term exposure to drought on linear growth during late childhood and early adolescence.

METHODS

Four rounds (2002-2013) of data from the young lives Cohort Study dataset (n = 2000) was used. The associations of concurrent and long-term exposure to drought and Height-for-age z-score was analysed using structural equation modelling techniques. The study also explored the mediating role of interim period growth in the association of early exposure to drought and undernutrition at later age and the role of the Productive Safety Net Program in buffering the impact of drought on child nutrition.

RESULTS

Results show that both concurrent and long-term exposure to drought was negatively associated with Height-for-age z-score (p < 0.001). Exposure to drought at age 5, 8, and 12 years is associated with lower Height-for-age z- score at age 5, 8, and 12 years respectively. Exposure to drought at age 5 years was also negatively associated with Height-for-age z-score at age 12 years (p < 0.001). This association was mainly indirect (89%) and mediated through reduced child growth in subsequent years. Participation in productive safety net program by drought-affected children reduces but does not completely offset the negative effects of drought on Height-for-age z-score (p < 0.1). Moreover, girls were more likely to suffer poor growth than boys.

CONCLUSION

Drought exposure after the 1,000 days window could have a lasting impact on child growth. Given the importance of this period for child physical and mental development, children beyond the 1,000 days window should also be a focus of disaster relief programs.

Does Quality of Government Matter in Public Health?: Comparing the Role of Quality and Quantity of Government at the National Level

This study aims to examine the degree of direct or indirect impact of quality and quantity of government on public health. It is a very important topic in that previous studies did not consider the role of government; they focused on the impact of national economic, social, and political factors on public health, therefore, disregarding the governmental factors. We measured the quantity of government by public expenditure on heath (i.e., rate of share of government budget to gross domestic product (GDP)) and the quality of government by five variables such as corruption control, government effectiveness, regulatory quality, voice and accountability, and rule of law. Based on national-level panel data (three waves) that covered 148–194 countries, we examined how quality and quantity of government has an impact on four kinds of public health, i.e., infant mortality, under-five mortality, maternal mortality, and life expectancy. Results show that both the quality and quantity of government had a significant impact on public health. In the quality of government, government effectiveness has a positive impact on life expectancy and a negative influence on infant deaths. Moreover, the quality of government has a greater impact on public health than the quantity of government. Lastly, the quality of government plays a role in moderating the relationships between quantity of government and the predicted variables.