Income inequality as a determinant of neonatal mortality in the Americas during 2000-2019: implications for the attainment of Sustainable Development Goal target 3.2.

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.

Neonatal mortality in countries of the Americas, 2000-2020: trends, inequalities, and target-setting.

Objective: To analyze temporal trends and inequalities in neonatal mortality between 2000 and 2020, and to set neonatal mortality targets for 2025 and 2030 in the Americas. Methods: A descriptive ecological study was conducted using 33 countries of the Americas as units of analysis. Both the percentage change and average annual percentage change in neonatal mortality rates were estimated. Measurements of absolute and relative inequality based on adjusted regression models were used to assess cross-country social inequalities in neonatal mortality. Targets to reduce neonatal mortality and cross-country inequalities were set for 2025 and 2030. Results: The estimated regional neonatal mortality rate was 12.0 per 1 000 live births in 2000-2004 and 7.4 per 1 000 live births in 2020, representing a percentage change of -38.3% and an average annual percentage change of -2.7%. National average annual percentage changes in neonatal mortality rates between 2000-2004 and 2020 ranged from -5.5 to 1.9 and were mostly negative. The estimated excess neonatal mortality in the 20% most socially disadvantaged countries, compared with the 20% least socially disadvantaged countries, was 17.1 and 9.8 deaths per 1 000 live births in 2000-2004 and 2020, respectively. Based on an extrapolation of recent trends, the regional neonatal mortality rate is projected to reach 7.0 and 6.6 neonatal deaths per 1 000 live births by 2025 and 2030, respectively. Conclusions: National and regional health authorities need to strengthen their efforts to reduce persistent social inequalities in neonatal mortality both within and between countries.

Scenarios of maternal mortality reduction by 2030 in the Americas: insights from its tempo.

BACKGROUND: The enduring threat of maternal mortality to health worldwide and in the Americas has been recognized in the global and regional agendas and their targets to 2030. To inform the direction and amount of effort needed to meet those targets, a set of equity-sensitive regional scenarios of maternal mortality ratio (MMR) reduction based on its tempo or speed of change from baseline year 2015 was developed. METHODS: Regional scenarios by 2030 were defined according to: i) the MMR average annual rate of reduction (AARR) needed to meet the global (70 per 100,000) or regional (30 per 100,000) targets and, ii) the horizontal (proportional) or vertical (progressive) equity criterion applied to the cross-country AARR distribution (i.e., same speed to all countries or faster for those with higher baseline MMR). MMR average and inequality gaps -absolute (AIG), and relative (RIG)- were scenario outcomes. RESULTS: At baseline, MMR was 59.2 per 100,000; AIG was 313.4 per 100,000 and RIG was 19.0 between countries with baseline MMR over twice the global target and those below the regional target. The AARR needed to meet the global and regional targets were -7.60% and -4.54%, respectively; baseline AARR was -1.55%. In the regional MMR target attainment scenario, applying horizontal equity would decrease AIG to 158.7 per 100,000 and RIG will remain invariant; applying vertical equity would decrease AIG to 130.9 per 100,000 and RIG would decrease to 13.5 by 2030. CONCLUSION: The dual challenge of reducing maternal mortality and abating its inequalities will demand hefty efforts from countries of the Americas. This remains true to their collective 2030 MMR target while leaving no one behind. These efforts should be mainly directed towards significantly speeding up the tempo of the MMR reduction and applying sensible progressivity, targeting on groups and territories with higher MMR and greater social vulnerabilities, especially in a post-pandemic regional context.

Recent trends in maternal and child health inequalities in Latin America and the Caribbean: analysis of repeated national surveys.

BACKGROUND: Although most Latin American and the Caribbean (LAC) countries made important progress in maternal and child health indicators from the 1990s up to 2010, little is known about such progress in the last decade. This study aims at documenting progress for each country as a whole, and to assess how within-country socioeconomic inequalities are evolving over time. METHODS: We identified LAC countries for which a national survey was available between 2011-2015 and a second comparable survey in 2018-2020. These included Argentina, Costa Rica, Cuba, the Dominican Republic, Guyana, Honduras, Peru, and Suriname. The 16 surveys included in the analysis collected nationally representative data on 221,989 women and 152,983 children using multistage sampling. Twelve health-related outcomes were studied, seven of which related to intervention coverage: the composite coverage index, demand for family planning satisfied with modern methods, antenatal care (four or more visits and eight or more visits), skilled attendant at birth, postnatal care for the mother and full immunization coverage. Five additional impact indicators were also investigated: stunting prevalence among under-five children, tobacco use by women, adolescent fertility rate, and under-five and neonatal mortality rates. For each of these indicators, average annual relative change rates were calculated between the baseline and endline national level estimates, and changes in socioeconomic inequalities over time were assessed using the slope index of inequality. RESULTS: Progress over time and the magnitude of inequalities varied according to country and indicator. For countries and indicators where baseline levels were high, as Argentina, Costa Rica and Cuba, progress was slow and inequalities small for most indicators. Countries that still have room for improvements, such as Guyana, Honduras, Peru and Suriname, showed faster progress for some but not all indicators, although also had wider inequalities. Among the countries studied, Peru was the top performer in terms of increasing coverage and reducing inequalities over time, followed by Honduras. Declines in family planning and immunization coverage were observed in some countries, and the widest inequalities were present for adolescent fertility and antenatal care coverage with eight or more visits. CONCLUSIONS: Although LAC countries are well placed in terms of current levels of health indicators compared to most low- and middle-income countries, important inequalities remain, and reversals are being observed in some areas. More targeted efforts and actions are needed in order to leave no one behind. Monitoring progress with an equity lens is essential, but this will require further investment in conducting surveys routinely.

The Every Woman Every Child initiative: supporting countries in Latin America and the Caribbean to reduce social inequalities in health.

The Every Woman Every Child Latin America and the Caribbean (EWEC-LAC) initiative was established in 2017 as a regional inter-agency mechanism. EWEC-LAC coordinates the regional implementation of the Global Strategy for Women's, Children's and Adolescents' Health in Latin America and the Caribbean (LAC), including adaptation to region specific needs, to end preventable deaths, ensure health and well-being and expand enabling environments for the health and well-being of women, children and adolescents. To advance the equitable achievement of these objectives, EWEC-LAC's three working groups collectively support LAC countries in measuring and monitoring social inequalities in health, advocating for their reduction, and designing and implementing equity-oriented strategies, policies and interventions. This support for data-driven advocacy, capacity building, and policy and program solutions toward closing current gaps ensures that no one is left behind. Members of EWEC-LAC include PAHO, UNAIDS, UNFPA, UNICEF, UN WOMEN, the World Bank, the Inter-American Development Bank, USAID, LAC Regional Neonatal Alliance, and the LAC Regional Task Force for the Reduction of Maternal Mortality. To date, EWEC-LAC has developed and collected innovative tools and resources and begun to engage with countries to utilize them to reduce equity gaps. These resources include a framework for the measurement of social inequalities in health, data use and advocacy tools including a data dashboard to visualize trends in social inequalities in health in LAC countries, a methodology for setting targets for the reduction of inequalities, and a compendium of tools, instruments and methods to identify and address social inequalities in health. EWEC-LAC has also engaged regionally to emphasize the importance of recognizing these inequalities at social and political levels, and advocated for the reduction of these gaps. Attention to closing health equity gaps is ever more critical in the face of the COVID-19 pandemic which has exploited existing vulnerabilities. More equitable health systems will be better prepared to confront future health shocks.

RESUMEN: La iniciativa Todas las mujeres, Todos los niños América Latina y el Caribe (EWEC-LAC, por su sigla en inglés) se estableció en 2017 como un mecanismo interinstitucional regional. Coordina la implementación regional de la Estrategia Mundial para la Salud de la Mujer, el Niño y el Adolescente en América Latina y el Caribe (ALC), incluyendo la adaptación a necesidades específicas de la región, para poner fin a muertes evitables, garantizar la salud y el bienestar y ampliar entornos propicios para la salud y el bienestar de mujeres, niños, niñas y adolescentes. Para promover el logro equitativo de estos objetivos, los tres grupos de trabajo de EWEC-LAC colectivamente apoyan a los países de ALC en la medición y monitoreo de las desigualdades sociales en salud, la abogacía por la disminución de estas y el diseño e implementación de estrategias, políticas e intervenciones orientadas a la equidad. Este apoyo para cerrar brechas actuales asegura que nadie se quede atrás. Miembros de EWEC-LAC incluyen FPNU, OPS, ONU Mujeres, ONUSIDA, UNICEF, el Banco Mundial, el Banco Interamericano de Desarrollo, USAID, la Alianza Regional Neonatal para ALC, y el Grupo de Trabajo Regional para la Reducción de la Mortalidad Materna. A la fecha, EWEC-LAC ha desarrollado y recopilado herramientas y recursos innovadores y ha comenzado a colaborar con los países para utilizarlos a fin de reducir brechas de equidad. Estos incluyen un marco de medición de desigualdades sociales en salud, herramientas de promoción de datos incluyendo un tablero de datos para visualizar tendencias en desigualdades sociales en salud, una metodología para establecer metas en la disminución de las desigualdades y un compendio de herramientas y métodos para identificar y abordar las desigualdades sociales en salud. EWEC-LAC ha trabajado en la región para enfatizar la importancia de reconocer estas desigualdades a niveles sociales y políticos, y ha abogado por la disminución de éstas. La atención para cerrar las brechas de equidad en salud es cada vez más crítica frente a la pandemia de COVID-19, que ha agudizado las vulnerabilidades existentes. Sistemas de salud más equitativos estarán mejor preparados para hacer frente a futuras crisis de salud.

[SDG3-related inequalities in women's, children's and adolescents' health: an SDG monitoring baseline for Latin America and the Caribbean using national cross-sectional surveysDesigualdades relacionadas ao ODS 3 na saúde da mulher, da criança e do adolescente: linha de base para o monitoramento do ODS na América Latina e no Caribe por meio de pesquisas transversais nacionais]. / Desigualdades relacionadas con el ODS 3 en la salud de las mujeres, los niños y los adolescentes: línea de base para el monitoreo de los ODS en América Latina y el Caribe por medio de encuestas transversales nacionales.

Objectives: Latin America and the Caribbean (LAC) countries have made important progress towards achieving the Sustainable Development Goal (SDG) targets related to health (SDG3) at the national level. However, vast within-country health inequalities remain. We present a baseline of health inequalities in the region, against which progress towards the SDGs can be monitored. Setting: We studied 21 countries in LAC using data from Demographic and Health Surveys and Multiple Indicator Cluster Survey carried out from 2011 to 2016. Participants: The surveys collect nationally representative data on women and children using multistage sampling. In total, 288 207 women and 195 092 children made part of the surveys in the 21 countries. Outcome measures: Five health intervention indicators were studied, related to reproductive and maternal health, along with adolescent fertility and neonatal and under-five mortality rates. Inequalities in these indicators were assessed through absolute and relative measures. Results: In most countries, subnational geographical health gradients were observed for nearly all women, child, and adolescent (WCA) indicators. Coverage of key interventions was higher in urban areas and among the richest, compared with rural areas and poorer quintiles. Analyses by woman's age showed that coverage was lower in adolescent girls than older women for family planning indicators. Pro-urban and pro-rich inequalities were also seen for mortality in most countries. Conclusions: Regional averages hide important health inequalities between countries, but national estimates hide still greater inequalities between subgroups of women, children and adolescents. To achieve the SDG3 targets and leave no one behind, it is essential to close health inequality gaps within as well as between countries.

Objetivos: Os países da América Latina e do Caribe obtiveram avanços significativos rumo à consecução do Objetivo de Desenvolvimento Sustentável relacionado à saúde (ODS 3) no nível nacional. No entanto, enormes desigualdades em saúde persistem nos países. Apresenta-se uma linha de base das desigualdades em saúde na região, com referência à qual é possível monitorar o progresso rumo aos ODS. Contexto: Foram estudados 21 países da América Latina e do Caribe usando dados de pesquisas de demografia e saúde e pesquisas de grupos de indicadores múltiplos feitas de 2011 a 2016. Participantes: As pesquisas coletam dados nacionalmente representativos sobre mulheres e crianças, por meio de amostragem multietápica. No total, 288.207 mulheres e 195.092 crianças participaram das pesquisas nos 21 países. Medição dos resultados: Foram estudados cinco indicadores de intervenções de saúde relacionadas à saúde reprodutiva e materna, à fertilidade das adolescentes e às taxas de mortalidade neonatal e de menores de cinco anos. As desigualdades nesses indicadores foram então avaliadas, empregando medidas absolutas e relativas. Resultados: Gradientes geográficos de saúde nos níveis subnacionais foram observados na maioria dos países para quase todos os indicadores referentes às mulheres e à população infantil e adolescente. A cobertura das principais intervenções foi maior nas áreas urbanas e nos quintis mais ricos do que nas áreas rurais e nos quintis mais pobres. As análises por idade das mulheres mostraram que a cobertura das adolescentes era inferior à cobertura das mulheres adultas no que se refere aos indicadores de planejamento familiar. Além disso, foram observadas desigualdades na mortalidade que favoreciam as áreas urbanas e os ricos, na maioria dos países. Conclusões: As médias regionais mascaram desigualdades significativas na saúde entre os países, mas as estimativas nacionais mascaram desigualdades ainda maiores entre os subgrupos de mulheres, crianças e adolescentes. Para alcançar as metas do ODS 3 e não deixar ninguém para trás, é essencial abordar não apenas as lacunas da desigualdade em saúde entre os países, mas também dentro deles.

[The Every Woman Every Child initiative: supporting countries in Latin America and the Caribbean to reduce social inequalities in healthA iniciativa "Todas as mulheres, todas as crianças" oferece apoio aos países da América Latina e Caribe para reduzir as desigualdades sociais de saúde]. / La iniciativa Todas las Mujeres Todos los Niños brinda apoyo a los países de América Latina y el Caribe para reducir las desigualdades sociales en la salud.

Every Woman Every Child Latin America and the Caribbean (EWEC-LAC) was established in 2017 as a regional inter-agency mechanism. EWEC-LAC coordinates the regional implementation of the Global Strategy for Women's, Children's and Adolescents' Health in Latin America and the Caribbean (LAC), including adaptation to region specific needs, to end preventable deaths, ensure health and well-being and expand enabling environments for the health and well-being of women, children and adolescents. To advance the equitable achievement of these objectives, EWEC-LAC's three working groups collectively support LAC countries in measuring and monitoring social inequalities in health, advocating for their reduction, and designing and implementing equity-oriented strategies, policies and interventions. This support for data-driven advocacy, capacity building, and policy and program solutions toward closing current gaps ensures that no one is left behind. Members of EWEC-LAC include PAHO, UNAIDS, UNFPA, UNICEF, UN WOMEN, the World Bank, the Inter-American Development Bank, USAID, LAC Regional Neonatal Alliance, and the LAC Regional Task Force for the Reduction of Maternal Mortality. To date, EWEC-LAC has developed and collected innovative tools and resources and begun to engage with countries to utilize them to reduce equity gaps. These resources include a framework for the measurement of social inequalities in health, data use and advocacy tools including a data dashboard to visualize trends in social inequalities in health in LAC countries, a methodology for setting targets for the reduction of inequalities, and a compendium of tools, instruments and methods to identify and address social inequalities in health. EWEC-LAC has also engaged regionally to emphasize the importance of recognizing these inequalities at social and political levels, and advocated for the reduction of these gaps. Attention to closing health equity gaps is ever more critical in the face of the COVID-19 pandemic which has exploited existing vulnerabilities. More equitable health systems will be better prepared to confront future health shocks.

A iniciativa "Todas as mulheres, todas as crianças da América Latina e Caribe" (EWEC-LAC, na sigla em inglês) foi criada em 2017 como um mecanismo interinstitucional regional. Coordena a implementação regional da Estratégia Mundial para a Saúde da Mulher, da Criança e do Adolescente 2016-2030 na América Latina e Caribe (ALC), incluindo sua adaptação a necessidades específicas da região, para acabar com as mortes evitáveis, garantir a saúde e o bem-estar e expandir ambientes propícios para a saúde e o bem-estar de mulheres, crianças e adolescentes. Para promover o alcance equitativo desses objetivos, os três grupos de trabalho da EWEC-LAC apoiam coletivamente os países da ALC com a medição e o monitoramento das desigualdades sociais de saúde, a promoção de sua redução, e o delineamento e a implementação de estratégias, políticas e intervenções voltadas para a equidade. Esse apoio para fechar as lacunas atuais assegura que ninguém seja deixado para trás. Os membros da iniciativa EWEC-LAC incluem UNFPA, OPAS, ONU Mulheres, UNAIDS, UNICEF, Banco Mundial, Banco Interamericano de Desenvolvimento, USAID, Aliança Neonatal Regional para ALC e Grupo de Trabalho Regional para a Redução da Mortalidade Materna. Até o momento, a EWEC-LAC desenvolveu e compilou ferramentas e recursos inovadores e começou a colaborar com os países para utilizá-los a fim de reduzir as lacunas de equidade. Isso inclui uma estrutura de medição das desigualdades sociais de saúde, ferramentas de promoção de dados (como um painel de dados para visualizar tendências nas desigualdades sociais de saúde), uma metodologia para estabelecer metas para reduzir as desigualdades e um compêndio de ferramentas e métodos para identificar e abordar as desigualdades sociais de saúde. A EWEC-LAC trabalhou na região para enfatizar a importância de reconhecer essas desigualdades nos níveis social e político, e defendeu sua redução. A atenção para o fechamento das lacunas de equidade na saúde é cada vez mais crítica frente à pandemia de COVID-19, que exacerbou as vulnerabilidades existentes. Sistemas de saúde mais equitativos estarão mais bem preparados para lidar com futuras crises de saúde.

Leaving no one behind: a methodology for setting health inequality reduction targets for Sustainable Development Goal 3.

OBJECTIVES: To present a methodology for the simultaneous setting of quantitative targets that reflect both an improvement in the national average of an indicator for Sustainable Development Goal 3 (SDG3), as well as a reduction in its geographic inequality. METHODS: A five-step algorithm was developed: (a) calculate the national average annual percent change (AAPC) for an SDG3 indicator; (b) normatively define geographic strata from the subnational distribution of the indicator in a baseline year; (c) apply a proportional progressivity criterion to the AAPC to project the stratum-specific indicator value for the target year; (d) set the national target as the weighted average of the indicator in the subnational territorial units for the target year; and (e) set the inequality reduction targets by calculating the absolute and relative gaps between the bottom and top strata for the target year. RESULTS: The algorithm was applied to SDG indicator 3.1.1 (maternal mortality ratio, MMR), disaggregated by Guatemala's 22 departments at the baseline year 2014 (MMR = 113 per 100,000 live births). By sustaining the AAPC rate attained from 2009 to 2014 (-4.3%) and focalizing its actions with territorial progressivity, by 2030 the country could reduce its MMR to 53 per 100,000 and its absolute and relative inequality gaps by 72% and 48%, respectively. CONCLUSIONS: The proposed methodology allows for simultaneously setting targets for overall progress and inequality reduction in health, making explicit the primacy of the equity principle contained in the SDG commitment to leave no one behind, whose urgency takes on renewed relevance in the current pandemic scenario.

New Health Sciences Descriptors to classify and retrieve information on equity.

The Health Sciences Descriptors (DeCS) vocabulary establishes a unique and common language that allows the organization and facilitates the search and retrieval of technical and scientific literature on health available in the information sources of the Virtual Health Library. The DeCS, created by the Latin American and Caribbean Center on Health Sciences Information (BIREME), a specialized center of the Pan American Health Organization/World Health Organization (PAHO/WHO), is the translation and extension of the Medical Subject Headings (MeSH) vocabulary, maintained by the United States National Library of Medicine. BIREME, in coordination with experts from Latin America and the Caribbean, has included in the DeCS the topics of equity, gender, ethnicity and human rights-cross-cutting themes in the programmatic framework of PAHO/WHO technical cooperation-to ensure better retrieval and use of scientific information and evidence related to these topics. The objective of this article is to describe the methodology used during the terminology review of the DeCS and to report the results obtained and the impacts of the terminology expansion in the field of equity, which included the inclusion of 35 new descriptors.

El vocabulario Descriptores en Ciencias de la Salud (DeCS) establece un lenguaje único y común que permite la organización y facilita la búsqueda y recuperación de la literatura técnica y científica en salud disponible en las fuentes de información de la Biblioteca Virtual en Salud. El DeCS, creado por el Centro Latinoamericano y del Caribe de Información en Ciencias de la Salud (BIREME), un centro especializado de la Organización Panamericana de la Salud/Organización Mundial de la Salud (OPS/OMS), es la traducción y la extensión del vocabulario Medical Subject Headings (MeSH), mantenido por la National Library of Medicine de los Estados Unidos. BIREME, en coordinación con expertos de América Latina y el Caribe, ha incluido en el DeCS los temas de equidad, género, etnicidad y derechos humanos ­temas transversales en el marco programático de la cooperación técnica de la OPS/OMS­ para garantizar una mejor recuperación y uso de la información y evidencia científica relacionadas a estos temas. El objetivo de este artículo es describir el método de revisión terminológica del DeCS e informar los resultados obtenidos y los impactos de la ampliación terminológica en el área de equidad, que comprendió la inclusión de 35 nuevos descriptores.

[Social inequality in the use of screening tests in Mexico: an analysis of the national health surveys 2006 and 2012]. / Desigualdad social en México enel uso de servicios de tamizaje en adultos: un análisis de las encuestas nacionales de salud 2006 y 2012.

OBJECTIVE: To measure health inequality in the use of screen-ing services in adults from 20 to 59 years of age from the 2006 and 2012 national health and nutrition surveys. MATERIALS AND METHODS: dults (detection of diabetes, hypertension, breast cancer, cervical cancer and prostate cancer), the Kuznets index, the slope inequality index and the health concentration index were estimated. Considering as social indicators schooling, ethnicity, unemployment, socioeconomic level and type of health protection. RESULTS: The coverage of the five tests increased, but the inequality observed only decreased in the interventions in women; and in the case of the detection of prostate cancer it was increased. CONCLUSIONS: While it is important to monitor the performance of curative services, the challenge remains to ensure effective and equitable access to early diagnosis services.

OBJETIVO: Medir la desigualdad en el uso de servicios de tamizaje en adultos de 20 a 59 años, a partir de las encuestas nacionales de salud y nutrición 2006 y 2012. MATERIAL Y MÉTODOS: A partir de la selección de cinco indicadores de tamizaje en adultos (detección de diabetes, hipertensión y cánceres de mama, cérvicouterino y de próstata) se estimaron el índice de Kuznets, el índice de desigualdad de la pendiente y el índice de concentración de salud, considerando como indicadores sociales la escolaridad, etnicidad, desempleo, nivel socioeconómico y tipo de protección en salud. RESULTADOS: Las coberturas de las cinco pruebas se incrementaron, sin embargo, la desigualdad observada disminuyó únicamente en las intervenciones en mujeres; en el caso de la detección de cáncer de próstata se incrementó. CONCLUSIONES: Si bien es importante monitorear el desempeño de los servicios curativos, persiste el reto de asegurar el acceso efectivo y equitativo a servicios de diagnóstico temprano.

[Leaving no one behind: Methodology to set health inequality reduction targets for Sustainable Development Goal 3Não deixar ninguém para trás: uma metodologia para estabelecer metas de redução das desigualdades em saúde sob o Objetivo de Desenvolvimento Sustentável 3]. / Sin dejar a nadie atrás: una metodología para establecer metas de reducción de desigualdad en salud del Objetivo de Desarrollo Sostenible 3.

OBJECTIVES: Present methodology for the concurrent development of quantitative targets that reflect improvement in the national average of an indicator for Sustainable Development Goal 3 (SDG3), as well as a reduction in geographic inequality. METHODS: A five-step algorithm was developed: a) calculate the national average annual percentage change (AAPC) for an SDG3 indicator; b) standardize the definition of geographic strata based on subnational distribution of the indicator in a base year; c) apply a criterion for proportional progress in the AAPC in order to project the stratum-specific indicator to the target year; d) set the national target as the weighted average of the indicator in the subnational territorial units for the target year; and e) develop inequality reduction targets by calculating absolute and relative gaps between the top and bottom strata for the target year. RESULTS: The algorithm was applied to SDG indicator 3.1.1 (maternal mortality ratio, MMR), disaggregated by Guatemala's 22 departments for base year 2014 (MMR = 113/100,000 live births). By sustaining the average AAPC rate attained from 2009 to 2014 (-4.3%) and targeting its actions to territorial progress, the country would reduce its MMR to 53/100,000 by 2030 and its absolute and relative gaps by 72% and 48%, respectively. CONCLUSIONS: The proposed methodology makes it possible to concurrently develop targets for the reduction of geographic inequalities in health and improvements in the national average, with explicit reference to the primacy of the principle of equity expressed in the SDGs' commitment to leaving no one behind, whose urgency is newly important in the current post-pandemic scenario.

OBJETIVOS: Apresentar uma metodologia para a formulação simultânea de metas quantitativas que reflitam tanto a melhoria da média nacional de um indicador do terceiro Objetivo de Desenvolvimento Sustentável (ODS3) quanto a redução das desigualdades geográfica nesse indicador. MÉTODOS: Estabelecemos um algoritmo em cinco etapas: (a) cálculo da variação percentual anual média (VPAM) em um país para um indicador do ODS3, (b) definição normativa de estratos geográficos a partir da distribuição subnacional do indicador em um ano base, (c) aplicação de um critério de progressividade proporcional da VPAM para projetar o indicador específico do estrato para o ano base, (d) estabelecimento da meta nacional como a média ponderada do indicador nas unidades territoriais subnacionais para o ano alvo e (e) estabelecimento de metas para a redução das desigualdades calculando a disparidade absoluta e relativa entre os estratos extremos para o ano alvo. RESULTADOS: Aplicamos o algoritmo ao indicador ODS 3.1.1 (razão de mortalidade materna, RMM), desagregado pelos 22 departamentos da Guatemala para o ano base de 2014 (RMM = 113 por 100.000 nascidos vivos). Se mantiver a intensidade média da VPAM observada entre 2009 e 2014 (-4,3%) e concentrar as suas ações com progressividade territorial, o país reduzirá, até 2030, a sua RMM para 53 por 100.000 e sua disparidade absoluta e relativa em 72% e 48%, respectivamente. CONCLUSÕES: A metodologia proposta permite formular simultaneamente metas para a redução das desigualdades geográficas em saúde e explicitar a primazia do princípio da equidade expresso no compromisso de não deixar ninguém para trás consagrado nos ODS, cuja urgência assume uma relevância renovada no atual cenário pós-pandêmico.

Social inequalities and prevalence of depressive symptoms: a cross-sectional study of women in a Mexican border city, 2014.

OBJECTIVE: To assess the association between intersectional disadvantage and clinically significant depressive symptoms (CSDS), describing the magnitude of social inequalities in the prevalence of symptoms among adult women in Tijuana, Mexico. METHODS: This was a cross-sectional study. CSDS were assessed using the Centers for Epidemiological Studies Depression Scale among a probability sample of 2 345 women from 18 - 65 years of age in 2014. CSDS prevalence was calculated according to categories of three social stratifiers: socioeconomic status (SES), educational attainment, and fertility (number of children). Social inequality was measured with the slope index of inequality (SII) and the concentration index (CIx). Intersectionality among stratifiers was explored descriptively and with multivariable regression analysis. RESULTS: CSDS prevalence was 17.7% (95%CI: 15.1% - 21.0%). The SII and CIx showed inequity in all social stratifiers. The absolute difference in CSDS prevalence between the lowest and highest ends of the SES gradient was 21.9% (95%CI: 21.5% - 22.4%). Among the most disadvantaged women, i.e., those at the intersection of lowest SES, lowest educational attainment, and highest fertility, the CSDS prevalence was 39.5% (95% CI: 26.0% - 52.9%). CONCLUSIONS: Disadvantage along multiple axes was associated with CSDS. Efforts to improve the mental health of women should include equity-oriented policies that address its social determinants.

[New Health Science Descriptors to classify and retrieve information on equity]. / Nuevos Descriptores en Ciencias de la Salud para clasificar y recuperar información sobre equidad.

The Health Sciences Descriptors (DeCS) vocabulary establishes a unique and common language that allows the organization and facilitates the search and retrieval of technical and scientific literature on health available in the information sources of the Virtual Health Library. The DeCS, created by the Latin American and Caribbean Center on Health Sciences Information (BIREME), a specialized center of the Pan American Health Organization/World Health Organization (PAHO/WHO), is the translation and extension of the Medical Subject Headings (MeSH) vocabulary, maintained by the United States National Library of Medicine. BIREME, in coordination with experts from Latin America and the Caribbean, has included in the DeCS the topics of equity, gender, ethnicity and human rights-cross-cutting themes in the programmatic framework of PAHO/WHO technical cooperation-to ensure better retrieval and use of scientific information and evidence related to these topics. The objective of this article is to describe the methodology used during the terminology review of the DeCS and to report the results obtained and the impacts of the terminology expansion in the field of equity, which included the inclusion of 35 new descriptors.

[From words to action: measuring health inequalities to "leave no one behind"Da retórica à ação: mensurar as desigualdades em saúde para não deixar ninguém atrás]. / De la retórica a la acción: medir desigualdades en salud para "no dejar a nadie atrás".

Health equity is a guiding principle for public health action. Its noble purpose is to build healthier, sustainable societies that are also more just and inclusive. This is reflected in the global commitment to "leave no one behind", expressed in the 2030 Agenda for Sustainable Development, although none of the Agenda's 169 targets focuses on reducing health inequalities, either conceptually or quantitatively. Recognizing the urgency to go beyond words and move forward decidedly in the design and implementation of pro-equity social and health policies at both the local and global levels, this special report reviews the conceptual and methodological framework for tackling health equity. Concepts and methodology are explicitly linked in a practical proposal that promotes the analytical use of subnationally disaggregated administrative data to inform decision-making in that area. This report concludes by proposing the need to institutionalize the measurement, analysis, and monitoring of social disparities in health to create effective national capacity to act on the social and environmental determinants of health and ensure accountability in the commitment to "leave no one behind" on the road to sustainable development, universal health, and social justice.

A equidade em saúde é um princípio norteador da ação em saúde pública cujo propósito nobre é edificar sociedades mais saudáveis e sustentáveis e, ao mesmo tempo, mais justas e inclusivas. Isso está refletido no compromisso mundial de "não deixar ninguém atrás" que guia a Agenda 2030 para o Desenvolvimento Sustentável, apesar de nenhuma das 169 metas estabelecer de forma conceitual ou quantitativa a redução das desigualdades em saúde. Reconhecendo a urgência de transcender a retórica e avançar na formulação e implementação de políticas sociais e de saúde pró-equitativas do nível local ao global, são revistas as bases conceituais e metodológicas para a abordagem da equidade em saúde, vinculadas explicitamente em uma proposta instrumental e prática que promove o uso analítico dos dados administrativos disponíveis desagregados ao nível subnacional para subsidiar a tomada de decisão. Em conclusão, faz-se necessário institucionalizar a mensuração, análise e monitoramento das desigualdades sociais em saúde para efetivamente estabelecer capacidades nacionais para atuar nos determinantes sociais e ambientais da saúde e prestar contas quanto ao compromisso de não deixar ninguém atrás no rumo ao desenvolvimento sustentável, saúde universal e justiça social.

The Pan American Health Organization-adapted Hanlon method for prioritization of health programs.

OBJECTIVES: To document the underlying science of how the Pan American Health Organization (PAHO) adapted the Hanlon method, which prioritizes disease control programs, to its wider range of program areas and used it to implement the PAHO Strategic Plan 2014 - 2019. METHODS: In 2014, PAHO established a Strategic Plan Advisory Group (SPAG) with representatives from 12 Member States to work closely with the PAHO Technical Team to adapt the Hanlon method to disease and non-disease control programs. Three meetings were held in 2015 - 2016 during which SPAG reviewed existing priority-setting methods, assessed the original Hanlon method and subsequent revisions, and developed the adapted method. This project was initiated by Member States, facilitated by PAHO, and conducted jointly in transparent and horizontal technical cooperation. RESULTS: From the original Hanlon equation, the PAHO-adapted method maintains components A (size of problem), B (seriousness of problem), and C (effectiveness of intervention), drops component D (PEARL - Propriety, Economics, Acceptability, Resources, and Legality), and adds component E (inequity) and F (institutional positioning). The PEARL score was dropped because it serves a purpose for pre-screening process, but not in the priority-setting process for PAHO. CONCLUSIONS: The PAHO-adapted Hanlon method provides a refined approach for prioritizing public health programs that include disease and non-disease control areas. The method may be useful for the World Health Organization and country governments with similar needs.

[Four axiological considerations in social epidemiology for the monitoring of health inequality]. / Cuatro cuestiones axiológicas de la epidemiología social para el monitoreo de la desigualdad en salud.

As the conceptual components of the most important contemporary public health agendas at the global and regional levels are brought into alignment and as it becomes more clearly understood that equity is a constitutive principle of these agendas, there is also a growing awareness of the strategic value of monitoring social inequalities in health. This is the health intelligence tool par excellence, not only for objectively assessing progress towards achieving health equity, but also for reporting action on the social determinants of health, progress towards the attainment of health for all, and the success of intersectoral efforts that take a "health in all policies" approach. These transformations are taking place in the context of an increasingly evident paradigm shift in public health. This essay presents four axiological considerations inherent to-and essential for -conceptualizing and implementing ways to measure and monitor health inequalities: ecoepidemiology as an emerging field in contemporary public health; the determinants of health as the causal model and core of the new paradigm; the relationship between the social hierarchy and health to understand the health gradient; and the practical need for a socioeconomic classification system that captures the social dimension in the determinants of health. The essay argues that these four axiological considerations lend epidemiologic coherence and rationality to the process of measuring and monitoring health inequalities and, by extension, to the development of pro-equity health policy proposals.

[Educational inequalities in mortality and survival of women and men in the Americas, 1990-2010]. / Desigualdades educacionales en mortalidad y supervivencia de mujeres y hombres de las Américas, 1990-2010.

OBJECTIVE: Analyze magnitude and trends in educational inequality in mortality and survival of women and men in countries of the Americas. METHODS: Gap and gradient metrics were used to calculate inequality between countries in adult mortality, average age of death, life expectancy, and healthy life expectancy, according to educational level in men and women for 1990 and 2010. RESULTS: Between 1990 and 2010, the average number of years of education increased from 8 to 10 with no difference between sexes. Adult mortality (15-59 years) did not change: 1.9 per 1 000 women and 3.7 per 1 000 men. The slope index of inequality (SII) increased from -1.0 to -2.0 per 1 000 women and from -1.2 to -4.4 per 1 000 men. Life expectancy increased from 75.6 to 78.7 years in women and from 68.9 to 72.4 in men; absolute inequality decreased from 7.8 to 7.2 years in women and increased from 7.2 to 9.2 years in men. Healthy life expectancy increased from 63.7 to 65.9 years in women and from 59.5 to 62.5 years in men; the SII declined from 6.9 to 5.8 years in women and increased from 6.9 to 7.8 years in men. CONCLUSIONS: In the countries of the Americas, men are at greater risk of dying, die earlier, and live fewer disease- and disability-free years than women; educational level is a determinant of mortality and survival in both sexes, and educational inequalities are more pronounced and increasing among men, and are disproportionately concentrated in the most socially disadvantaged populations.