Evolution in key indicators of maternal and child health across the wealth gradient in 41 sub-Saharan African countries, 1986-2019

BACKGROUND

Aggregate trends can be useful for summarizing large amounts of information, but this can obscure important distributional aspects. Some population subgroups can be worse off even as averages climb, for example. Distributional information can identify health inequalities, which is essential to understanding their drivers and possible remedies.

METHODS

Using publicly available Demographic and Health Survey (DHS) data from 41 sub-Saharan African countries from 1986 to 2019, we analyzed changes in coverage for eight key maternal and child health indicators: first dose of measles vaccine (MCV1); Diphtheria-Pertussis-Tetanus (DPT) first dose (DPT1); DPT third dose (DPT3); care-seeking for diarrhea, acute respiratory infections (ARI), or fever; skilled birth attendance (SBA); and having four antenatal care (ANC) visits. To evaluate whether coverage diverged or converged over time across the wealth gradient, we computed several dispersion metrics including the coefficient of variation across wealth quintiles. Slopes and 5-year moving averages were computed to identify overall long-term trends.

RESULTS

Average coverage increased for all quintiles and indicators, although the range and the speed at which they increased varied widely. There were small changes in the wealth-related gap for SBA, ANC, and fever. The wealth-related gap of vaccination-related indicators (DPT1, DPT3, MCV1) decreased over time. Compared to 2017, the wealth-gap between richest and poorest quintiles in 1995 was 7 percentage points larger for ANC and 17 percentage points larger for measles vaccination.

CONCLUSIONS

Maternal and child health indicators show progress, but the distributional effects show differential evolutions in inequalities. Several reasons may explain why countries had smaller wealth-related gap trends in vaccination-related indicators compared to others. In addition to service delivery differences, we hypothesize that the allocation of development assistance for health, the prioritization of vaccine-preventable diseases on the global agenda, and indirect effects of structural adjustment programs on health system-related indicators might have played a role.

Explaining the poor-rich gap in anthropometric failure among children in India: An econometric analysis of the NFHS, 2021 and 2016

Wealth inequality in anthropometric failure is a persistent concern for policymakers in India. This necessitates a comprehensive analysis and identification of various risk factors that can explain the poor-rich gap in anthropometric failure among children in India. We analyze the fifth and fourth rounds of the Indian National Family Health Survey collected from June 2019 to April 2021 and January 2015 to December 2016, respectively. Two samples of children aged 0-59 and 6-23 months old with singleton birth, alive at the time of the survey with non-pregnant mothers, and with valid data on stunting, severe stunting, underweight, severely underweight, wasting, and severe wasting are included in the analytical samples from both rounds. We estimate the wealth gradients and distribution of wealth among children with anthropometric failure. Wealth gap in anthropometric failure is identified using logistic regression analysis. The contribution of risk factors in explaining the poor-rich gap in AF is estimated by the multivariate decomposition analysis. We observe a negative wealth gradient for each measure of anthropometric failure. Wealth distributions indicate that at least 60% of the population burden of anthropometric failure is among the poor and poorest wealth groups. Even among children with similar modifiable risk factors, children from poor and poorest backgrounds have a higher prevalence of anthropometric failure compared to children from the richest backgrounds. Maternal BMI, exposure to mass media, and access to sanitary facility are the most significant risk factors that explain the poor-rich gap in anthropometric failure. This evidence suggests that the burden of anthropometric failure and its risk factors are unevenly distributed in India. The policy interventions focusing on maternal and child health, implemented with a targeted approach prioritizing the vulnerable groups, can only partially bridge the poor-rich gap in anthropometric failure. The role of anti-poverty programs and growth is essential to narrow this gap in anthropometric failure.

Climate shocks and wealth inequality in the UK: evidence from monthly data

This paper investigates both the linear and nonlinear effects of climate risk shocks on wealth inequality in the UK using the local projections (LPs) method, based on high-frequency, i.e., monthly data. The linear results show that climate risk shocks lead to an increase in wealth inequality in the longer term. The nonlinear results present some evidence of heterogeneous responses of wealth inequality to climate risk variable shocks between high- and low-climate risk regimes. The findings highlight the disproportionate increased burden of climate change on households that are already experiencing poverty, particularly households in high-climate risk areas. As such, measures to mitigate the adverse effects of climate change need to be tailored so as not to overburden the poor.

Wealth inequalities in physical and cognitive impairments across Japan and Europe: the role of health expenditure and infrastructure

Although prior research has provided insights into the association between country-level factors and health inequalities, key research gaps remain. First, most previous studies examine subjective rather than objective health measures. Second, the wealth dimension in health inequalities is understudied. Third, a handful of studies explicitly focus on older adults. To bridge these research gaps, this study measures wealth-related inequalities in physical and cognitive impairments and examines the extent to which welfare states moderate wealth inequalities in physical and cognitive impairments among older people across Japan and Europe. We utilized harmonized data on non-institutionalized individuals aged 50-75 from the Japanese Study of Aging and Retirement (JSTAR) and the Survey of Health, Ageing and Retirement in Europe (SHARE) (N = 31,969 for physical impairments and 31,348 for cognitive impairments). Our multilevel linear regression analyses examined whether national public health spending and healthcare access resources explained cross-country differences in wealth inequalities in physical and cognitive impairments. We applied a concentration index to quantify the degree of wealth inequalities in impairments. The findings indicate that inequalities in both impairment outcomes favored wealthier individuals in all countries, but the magnitude of inequality varied by country. Furthermore, a higher share of public health spending, lower out-of-pocket expenditure, and higher investment in healthcare resources were associated with lower wealth inequalities, especially for physical impairments. Our findings suggest that different health interventions and policies may be needed to mitigate specific impairment inequalities.

Cross-national differences in wealth inequality in health services and caregiving used near the end of life

Background

Socioeconomic inequality in access to and use of health services and social care provided near the end of life, or end-of-life care (EOLC), is not well understood in many countries. We examined wealth inequality in EOLC-hospital, nursing home, and hospice use and receipt of formal and informal caregiving-in 22 countries in Europe, Asia (South Korea), and North America (United States, Mexico).

Methods

We used harmonized data from nationally representative studies of people aged 50 and older that collected information on healthcare utilisation and caregiving receipt in the time preceding death. We categorized countries according to their level of public long-term care (LTC) spending and examined EOLC prevalence across countries. We used logistic regression models to estimate wealth inequality in each type of EOLC.

Findings

In the USA the least wealthy had more hospital (OR 1.30, p = 0.008) and nursing home/care use (OR 1.88, p < 0.001). In South Korea the least wealthy had more nursing home/care use (OR 2.24, p = 0.003). The least wealthy in high LTC Europe had less hospice use (OR 0.56, p = 0.003). The least wealthy were also less likely to be hospitalized in European countries with low LTC spending (OR 0.81, p = 0.04), but more likely to receive informal caregiving (OR 1.25, p = 0.033). Formal care was more common among the least wealthy in high LTC Europe (OR 1.57, p = 0.002), the USA (OR 1.42, p < 0.001) and South Korea (OR 1.69, p = 0.028), but less common among the least wealthy in Mexico (OR 0.17, p < 0.001).

Interpretation

Wealth inequality in EOLC exists across countries and reflects differences in the organization, financing, and delivery of care in different countries. The findings highlight the need to consider equity in current and future plans to improve EOLC access.

Funding

United States National Institute on Aging Grant R01AG030153.

Effect of wealth inequality on child and infant mortality in Togo

At birth, individual has a health capital that depends on family, environmental and personal characteristics which depreciates over time requiring investment. It's in this sense that this article aims to analyze the effect of wealth inequality on infant and child mortality in Togo. This effect is accessed by a semi-parametric proportional hazard duration model of Cox. According to the model estimation which is based on data from the Multiple Indicator Cluster Survey (MICS) carried out in Togo in 2017, the results obtained show in one hand that coming from a less wealthy household increases the risk of death for children. On other hand, the results show that the possession of a source of drinking water, the possession of health insurance by the mother, and the mastery of the use of new information technologies and communication reduce the risk of infant and child mortality. In view of these results, policies to reduce wealth inequalities could help reduce the risk of infant and child mortality in proportions ranging from 0.075 to 0.264.

Legitimate Wealth? How Wealthy Business Owners are Portrayed in the Press

Germany has one of the highest levels of wealth concentration of any Western capitalist country. Research on the legitimization of economic inequality highlights that wealth elites tend to stress meritocratic arguments for legitimizing elite positions and wealth accumulation. However, whether this is also the case for wealthy business owners and how the media tends to portray those remains largely unknown. Drawing on a unique sample of 899 press articles from eight different media outlets between 2014 and 2018, we find a rather generous media debate. Based on descriptive evidence and a latent class analysis, we identify six latent frames illustrating how wealthy business owners are portrayed in the press. We show that the sources of wealth (inheritance, investment, entrepreneurship) are often used to highlight these owners' deep economic relevance to the German economy, while the use of wealth is predominantly framed as a mean for profit-seeking. For wealthy business owners, moral evaluation of personal conduct is less present in the media and, when it is present, is rarely negative. Our study is the first analysis of press coverage of the wealthiest German business owners indicating a legitimizing media debate of high wealth concentration in an advanced capitalist society.

The gender wealth gap in the United States: Trends and explanations

It is difficult to study the gender wealth gap because wealth is usually measured at the household level, and men and women often live in the same household. I use person-level measures of wealth, attributing to each person the assets and debts owned in their name, to study the gender wealth gap in the United States among working age people. Using the Survey of Income and Program Participation, I find that the existence of the gender wealth gap is primarily explained by the gender income gap. However, although the gender income gap has narrowed, the gender wealth gap has widened from the mid-1990s to the mid-2010s. This widening occurred across the wealth distribution and among almost every subgroup by marital status, education, race, and age. This widening of the gender wealth gap cannot be explained by changes in socioeconomic characteristics but is consistent with the trend of increasing wealth inequality.

The multiple mediators of early differences in academic abilities by parental financial resources in Germany

This paper examines the mediators of differences in academic abilities by parental income and wealth among pre-schoolers in Germany. Families' investment, parental stress and parenting, neighbourhood effects, and parents' educational norms and aspirations are considered as mediators. Unlike most existing studies, we explicitly consider the interdependence of these mediators and, therefore, apply sequential joint mediation analysis. We find that children in income-poor households score up to 0.34 standard deviations lower and children in households with a negative net worth up to 0.24 standard deviations lower in tests of academic ability, even when controlling for a comprehensive set of other familial characteristics. All mediators together explain on average 47% of the differences by income, but only 17% of the wealth differences. Parental investment is the most important mediator, followed by neighbourhood effects. Parental Stress, mother-child interaction quality, and educational norms and aspirations seem to be less relevant as mediators.

Rural Kids and Wealth

Wealth ownership is a critical component of economic well-being, and wealth in early adulthood provides important clues about the trajectories along which individuals move throughout their lives. Using data from the National Longitudinal Study of Adolescent Health (Add Health), we find an association between growing up rural and adult wealth that varies across the components of wealth. We also find that growing up rural has unique implications for young adult wealth ownership that differ from growing up in other geographic regions, particularly in urban areas. Our results highlight an important outcome that is conditioned by growing up rural and underscores the importance of context for understanding how families save and accumulate wealth.

Factors contributing to household wealth inequality in under-five deaths in low- and middle-income countries: decomposition analysis

BACKGROUND

The burden of under-5 deaths is disproportionately high among poor households relative to economically viable ones in developing countries. Despite this, the factors driving this inequality has not been well explored. This study decomposed the contributions of the factors associated with wealth inequalities in under-5 deaths in low- and middle-income countries (LMICs).

METHODS

We analysed data of 856,987 children from 66,495 neighbourhoods across 59 LMICs spanning recent Demographic and Health Surveys (2010-2018). Under-5 mortality was described as deaths among live births within 0 to 59 months of birth and it was treated as a dichotomous variable (dead or alive). The prevalence of under-five deaths was stratified using household wealth status. A Fairlie decomposition analysis was utilized to investigate the relative contribution of the factors associated with household wealth inequality in under-5 deaths at p<0.05. The WHO health equity assessment toolkit Plus was used to assess the differences (D) ratios (R), population attributable risk (PAR), and population attributable fraction (PAF) in household wealth inequalities across the countries.

RESULTS

The proportion of children from poor households was 45%. The prevalence of under-5 deaths in all samples was 51 per 1000 children, with 60 per 1000 and 44 per 1000 among children from poor and non-poor households (p<0.001). The prevalence of under-5 deaths was higher among children from poor households than those from non-poor households in all countries except in Ethiopia, Tanzania, Zambia, Lesotho, Gambia and Sierra Leone, and in the Maldives. Thirty-four of the 59 countries showed significantly higher under-5 deaths in poor households than in non-poor households (pro-non-poor inequality) and no significant pro-poor inequality. Rural-urban contexts, maternal education, neighborhood socioeconomic status, sex of the child, toilet kinds, birth weight and preceding birth intervals, and sources of drinking water are the most significant drivers of pro-poor inequities in under-5 deaths in these countries.

CONCLUSIONS

Individual-level and neighbourhood-level factors were associated with a high prevalence of under-5 deaths among poor households in LMICs. Interventions in countries should focus on reducing the gap between the poor and the rich as well as improve the education and livelihood of disadvantaged people.

"Caught in the Middle! Wealth Inequality and Conflict over Redistribution"

A vast literature documents that wealth inequality has risen throughout advanced democracies, especially the accumulation of wealth among the rich. Yet, instead of increasing wealth redistribution, governments have done the seemingly opposite. Key to understanding why democratic governments do not increase wealth redistribution in times of rising inequalities is to shed light on the public's preferences. In this paper, we map the public's redistributive preferences in fourteen countries based on new survey data. We show that traditional socioeconomic cleavages in preferences for wealth redistribution are undermined by diverging mobility expectations. People who expect to climb up the wealth distribution, mostly lower wealth groups, are less supportive of redistribution than people with high stakes of major wealth losses, mainly upper wealth groups. We show that future expectations among the rich and the poor have a highly moderating role for the class conflict over wealth redistribution. Moreover, the middle class, the decisive group in democracies, is highly unresponsive to future prospects. The findings suggest that the middle class does not have much to lose or to win, and therefore, wealth redistribution is of low salience among this group.

The impact of past pandemics on economic and gender inequalities

This paper estimates how previous major pandemic events affected economic and gender inequalities in the short- to medium run. We consider the impact of six major pandemic episodes - H3N2 Flu (1968), SARS (2003), H1N1 Swine Flu (2009), MERS (2012), Ebola (2014), and Zika (2016) - on cross-country inequalities in samples of 46-167 countries observed over 1950-2019. Results show that the past pandemics have moderately increased income inequality in the affected countries in the period of four to five years after the pandemic's start. On the other hand, we do not find any robust negative impacts on wealth inequality. The results concerning gender inequality are less consistent, but we find some evidence of declining gender equality among the hardest hit countries. Moreover, the gender gap in unemployment grew within the four years after the onset of the pandemic.

Impact of the 2008 Recession on Wealth-Adjusted Income and Inequality for US Cohorts

OBJECTIVE

To examine distributional effects of the 2008 recession and subsequent recovery across generational cohorts.

METHODS

Using data from the Survey of Consumer Finances (2007-2016), we constructed a measure of economic well-being accounting for income, household size and annuitized value of assets. We examine trajectories of adjusted income and inequality, using Gini coefficients and income shares by decile, for the overall population and by cohort during the recession and recovery.

RESULTS

Inequality declined temporarily during the recession, but reached new highs during the recovery. During recovery, population-level increases in economic resources were not reflected among below-median households, as the more concentrated financial assets rose while broader-based home equity and employment fell or remained stagnant. Inequality measures increased for cohorts in their primary working years (Generation-X and Baby Boomers), but not among the younger Millennials, who were at early stages of education, workforce entry and household formation.

DISCUSSION

The study illustrates an integrative approach to analyzing cumulative dis/advantage by considering interactions between historically consistent macro-level events, such as economic shocks or policy choices affecting all cohorts, and the persistent life-course processes that tend to increase heterogeneity and inequality as cohorts age over time. Although recovery policies led to rapid recovery of financial asset values, they did not proportionately reach those below the median or their economic resource-types. Results suggest that in a high-inequality environment, recovery policies from economic shocks may need tailoring to all levels of resources in order to achieve more equitable recovery outcomes and prevent exacerbating cohort inequality trajectories.

Wealth-related inequalities in demand for family planning satisfied among married and unmarried adolescent girls and young women in sub-Saharan Africa

Background

The use of modern contraception has increased in much of sub-Saharan Africa (SSA). However, the extent to which changes have occurred across the wealth spectrum among adolescents is not well known. We examine poor-rich gaps in demand for family planning satisfied by modern methods (DFPSm) among sexually active adolescent girls and young women (AGYW) using data from national household surveys.

Methods

We used recent Demographic and Health Surveys and Multiple Indicator Cluster Surveys to describe levels of wealth-related inequalities in DFPSm among sexually active AGYW using an asset index as an indicator of wealth. Further, we used data from countries with more than one survey conducted from 2000 to assess DFPSm trends. We fitted linear models to estimate annual average rate of change (AARC) by country. We fitted random effects regression models to estimate regional AARC in DFPSm. All analysis were stratified by marital status.

Results

Overall, there was significant wealth-related disparities in DFPSm in West Africa only (17.8 percentage points (pp)) among married AGYW. The disparities were significant in 5 out of 10 countries in Eastern, 2 out of 6 in Central, and 7 out of 12 in West among married AGYW and in 2 out of 6 in Central and 2 out of 9 in West Africa among unmarried AGYW. Overall, DFPSm among married AGYW increased over time in both poorest (AARC = 1.6%, p < 0.001) and richest (AARC = 1.4%, p < 0.001) households and among unmarried AGYW from poorest households (AARC = 0.8%, p = 0.045). DPFSm increased over time among married and unmarried AGYW from poorest households in Eastern (AARC = 2.4%, p < 0.001) and Southern sub-regions (AARC = 2.1%, p = 0.030) respectively. Rwanda and Liberia had the largest increases in DPFSm among married AGYW from poorest (AARC = 5.2%, p < 0.001) and richest (AARC = 5.3%, p < 0.001) households respectively. There were decreasing DFPSm trends among both married (AARC = − 1.7%, p < 0.001) and unmarried (AARC = − 4.7%, p < 0.001) AGYW from poorest households in Mozambique.

Conclusion

Despite rapid improvements in DFPSm among married AGYW from the poorest households in many SSA countries there have been only modest reductions in wealth-related inequalities. Significant inequalities remain, especially among married AGYW. DFPSm stalled in most sub-regions among unmarried AGYW.

Augmented wealth in Switzerland: the influence of pension wealth on wealth inequality

Entitlements for social security and occupational pensions present a major wealth component and play a central role for financial security. However, most individual-level data lacks information on pension wealth. By linking various data sources, this contribution estimates the present value of future pension entitlements in Switzerland for statutory pensions, occupational pensions and third pillar accounts and analyses the distribution of augmented wealth, which combines pension wealth and net worth. The CH-SILC survey from 2015 is used to estimate real assets, financial assets and pension wealth of retired individuals. The pension entitlements of non-retired individuals are simulated on the basis of their earning history from administrative records following the accrual method and assuming a real discount rate of 2%. When pension wealth is added to net worth, average wealth doubles, and the Gini-coefficient declines by 26%. The equalising effect is particularly strong for social security pensions. The wealth distribution differs strongly between the three pillars of the pension system; there are also strong differences between gender and age groups. In Switzerland, wealth accumulation continues after retirement age.

Monitoring the decomposition of wealth-related inequality in the use of regular antenatal care in Egypt (1995-2014)

BACKGROUND

Between 1995 and 2014 Egypt successfully increased the use of regular antenatal care (URAC) among women from 30.4 to 82.9%. The same period saw a decrease in the wealth-based inequality in URAC. This paper investigates the changes in the main determinants contributing to the wealth-based inequality in URAC for the 2 years of 1995 and 2014, and the determinants that underlined the declines in this inequality.

METHODS

The secondary analysis was based on data from the 1995 and 2014 rounds of the Egypt Demographic and Health Survey. Logistic regression was implemented to model URAC for the 2 years and inequality was measured using the concentration index. Decomposition of the concentration index and Blinder -Oaxaca decomposition were implemented to assess the contribution of the URAC determinants to its inequality and the changes between 1995 and 2014.

RESULTS

Decomposition of inequalities in URAC in 1995 and 2014 showed that social determinants were the main contributors to these inequalities. More than 90% of the inequalities were explained by the living in rural Upper Egypt, women and their husbands secondary and higher education, the household standard of living, and birth order. These same determinants were responsible for more than 76% of the decline in the inequality in URAC between 1995 and 2014. Wide spread of poverty in rural Upper Egypt was found to contribute significantly to the inequality in URAC. Women and their husbands who have secondary or higher education maintained their high odds of URAC.

CONCLUSION

Since poverty in rural Upper Egypt, and inequality in education and parity are crucial social determinants of URAC inequality and its change overtime, new policies and interventions need to focus not only on the health system but on social initiatives with an equity lens to tackle the structural causes underlying these factors and their inequalities.

National-Level Wealth Inequality and Socioeconomic Inequality in Adolescent Mental Well-Being: A Time Series Analysis of 17 Countries

PURPOSE

Although previous research has established a positive association between national income inequality and socioeconomic inequalities in adolescent health, very little is known about the extent to which national-level wealth inequalities (i.e., accumulated financial resources) are associated with these inequalities in health. Therefore, this study examined the association between national wealth inequality and income inequality and socioeconomic inequality in adolescents' mental well-being at the aggregated level.

METHODS

Data were from 17 countries participating in three consecutive waves (2010, 2014, and 2018) of the cross-sectional Health Behaviour in School-aged Children study. We aggregated data on adolescents' life satisfaction, psychological and somatic symptoms, and socioeconomic status (SES) to produce a country-level slope index of inequality and combined it with country-level data on income inequality and wealth inequality (n = 244,771). Time series analyses were performed on a pooled sample of 48 country-year groups.

RESULTS

Higher levels of national wealth inequality were associated with fewer average psychological and somatic symptoms, while higher levels of national income inequality were associated with more psychological and somatic symptoms. No associations between either national wealth inequality or income inequality and life satisfaction were found. Smaller differences in somatic symptoms between higher and lower SES groups were found in countries with higher levels of national wealth inequality. In contrast, larger differences in psychological symptoms and life satisfaction (but not somatic symptoms) between higher and lower SES groups were found in countries with higher levels of national income inequality.

CONCLUSIONS

Although both national wealth and income inequality are associated with socioeconomic inequalities in adolescent mental well-being at the aggregated level, associations are in opposite directions. Social policies aimed at a redistribution of income resources at the national level could decrease socioeconomic inequalities in adolescent mental well-being while further research is warranted to gain a better understanding of the role of national wealth inequality in socioeconomic inequalities in adolescent health.

Too poor or too far? Partitioning the variability of hospital-based childbirth by poverty and travel time in Kenya, Malawi, Nigeria and Tanzania

BACKGROUND

In sub-Saharan Africa, women are most likely to receive skilled and adequate childbirth care in hospital settings, yet the use of hospital for childbirth is low and inequitable. The poorest and those living furthest away from a hospital are most affected. But the relative contribution of poverty and travel time is convoluted, since hospitals are often located in wealthier urban places and are scarcer in poorer remote area. This study aims to partition the variability in hospital-based childbirth by poverty and travel time in four sub-Saharan African countries.

METHODS

We used data from the most recent Demographic and Health Survey in Kenya, Malawi, Nigeria and Tanzania. For each country, geographic coordinates of survey clusters, the master list of hospital locations and a high-resolution map of land surface friction were used to estimate travel time from each DHS cluster to the nearest hospital with a shortest-path algorithm. We quantified and compared the predicted probabilities of hospital-based childbirth resulting from one standard deviation (SD) change around the mean for different model predictors.

RESULTS

The mean travel time to the nearest hospital, in minutes, was 27 (Kenya), 31 (Malawi), 25 (Nigeria) and 62 (Tanzania). In Kenya, a change of 1SD in wealth led to a 33.2 percentage points change in the probability of hospital birth, whereas a 1SD change in travel time led to a change of 16.6 percentage points. The marginal effect of 1SD change in wealth was weaker than that of travel time in Malawi (13.1 vs. 34.0 percentage points) and Tanzania (20.4 vs. 33.7 percentage points). In Nigeria, the two were similar (22.3 vs. 24.8 percentage points) but their additive effect was twice stronger (44.6 percentage points) than the separate effects. Random effects from survey clusters also explained substantial variability in hospital-based childbirth in all countries, indicating other unobserved local factors at play.

CONCLUSIONS

Both poverty and long travel time are important determinants of hospital birth, although they vary in the extent to which they influence whether women give birth in a hospital within and across countries. This suggests that different strategies are needed to effectively enable poor women and women living in remote areas to gain access to skilled and adequate care for childbirth.