Association between internal migration and epidemic dynamics: an analysis of cause-specific mortality in Kenya and South Africa using health and demographic surveillance data.

BACKGROUND: Many low- and middle-income countries are facing a double burden of disease with persisting high levels of infectious disease, and an increasing prevalence of non-communicable disease (NCD). Within these settings, complex processes and transitions concerning health and population are underway, altering population dynamics and patterns of disease. Understanding the mechanisms through which changing socioeconomic and environmental contexts may influence health is central to developing appropriate public health policy. Migration, which involves a change in environment and health exposure, is one such mechanism. METHODS: This study uses Competing Risk Models to examine the relationship between internal migration and premature mortality from AIDS/TB and NCDs. The analysis employs 9 to 14 years of longitudinal data from four Health and Demographic Surveillance Systems (HDSS) of the INDEPTH Network located in Kenya and South Africa (populations ranging from 71 to 223 thousand). The study tests whether the mortality of migrants converges to that of non-migrants over the period of observation, controlling for age, sex and education level. RESULTS: In all four HDSS, AIDS/TB has a strong influence on overall deaths. However, in all sites the probability of premature death (45q15) due to AIDS/TB is declining in recent periods, having exceeded 0.39 in the South African sites and 0.18 in the Kenyan sites in earlier years. In general, the migration effect presents similar patterns in relation to both AIDS/TB and NCD mortality, and shows a migrant mortality disadvantage with no convergence between migrants and non-migrants over the period of observation. Return migrants to the Agincourt HDSS (South Africa) are on average four times more likely to die of AIDS/TB or NCDs than are non-migrants. In the Africa Health Research Institute (South Africa) female return migrants have approximately twice the risk of dying from AIDS/TB from the year 2004 onwards, while there is a divergence to higher AIDS/TB mortality risk amongst female migrants to the Nairobi HDSS from 2010. CONCLUSION: Results suggest that structural socioeconomic issues, rather than epidemic dynamics are likely to be associated with differences in mortality risk by migrant status. Interventions aimed at improving recent migrant's access to treatment may mitigate risk.

Donor and Domestic Financing of Primary Health Care in Low Income Countries.

Abstract-This paper evaluates resource commitments to primary health care (PHC) by donors and selected governments between 1990-2011. Donor commitments to financing PHC are assessed by reclassifying OECD/CRS data on health assistance into spending on 'PHC Service Delivery' versus spending on 'Health System Strengthening'. Domestic spending on PHC is assessed using a case study approach and National Health Accounts for two major recipients of donor assistance, Ethiopia and Nigeria. Results are generally consistent with three simple hypotheses that guide the inquiry. First, though donor funding for health among LICs has mushroomed over the last decade, it remains a miniscule share of per capita spending targets prescribed by international forums to attain universal access to basic/essential PHC services. Relative to levels of domestic public spending in LICs, however, donor funding has considerably more significance as a potential lever to improve PHC efficiency. Second, as reflected in on-going debate in the literature, donor spending on broader 'health system strengthening' has not kept up with mushrooming financing of disease control programs. Third, at country level, where the 'rubber meets the road', allocative efficiency of donor and domestic spending on health is highly conditional on contextual factors, especially political will to improve financing and delivery of PHC services, and the process of managing and implementing public spending on PHC.