Poorest Population Groups Research Articles

THE EFFECT OF PARTICIPATION IN JKN ON UNMET NEEDS FOR HEALTHCARE SERVICES

Background: The National Health Insurance or Jaminan Kesehatan Nasional (JKN) program is one of the steps taken by the Indonesian government in developing Universal Health Coverage (UHC). However, increased participation in the National Health Insurance is not followed by an increase in met needs for healthcare services. Aims: This study aimed to examine the effect of participation in the National Health Insurance on unmet needs for healthcare services in poor and non-poor population groups. Methods: This study used data from the 2018 National Socio-Economic Survey/ Survei Sosial Ekonomi Nasional (SUSENAS) and Village Potential Survey/ Survei Potensi Desa (PODES). Data were processed using binary logistic model analysis to identify the effect of participation in the National Health Insurance on the unmet needs for healthcare services. Results: Participation in the National Health Insurance, including beneficiary program for poor groups could reduce the risks of unmet needs for healthcare services by 7.7%, while non-beneficiary program could reduce the risks of unmet needs for health services for non-poor groups by 10.4%. Conclusion: Both beneficiaries and non-beneficiaries affect the unmet needs for health services for both poor and non-poor groups. However, the non-beneficiary program is more elastic than beneficiary program to fulfill needs for both sample groups. Keywords: Healthcare services, national health insurance, logit, unmet need

Backyard poultry farming with improved germplasm: Sustainable food production and nutritional security in fragile ecosystem

Approximately 3 billion people were unable to afford a healthy diet in 2019 because of poverty and inequality. Most of these people live in Asia and Africa. Furthermore, 30% of the world population was affected by moderate to severe food insecurity in 2020, and most of this population lives in low- and middle-income countries. The world is at a critical juncture, and there is an urgent need for transformative food systems that ensure the empowerment of poor and vulnerable population groups, often smallholders with limited access to resources or those living in remote locations, as well as the empowerment of women, children, and youth (FAO,2018). The backyard poultry production system (BPPS), as practiced by 80% of the world's rural population, can be that transformative change in low- and middle-income countries. Although the BPPS has low productivity, it still plays an important role in the food and nutritional security of rural people living in fragile ecosystems. Backyard poultry has been recognized as a tool for poverty alleviation and women empowerment besides ensuring food and nutritional security for rural poor. Poultry meat and eggs are the cheapest and best source of good quality protein, minerals, and vitamins. The introduction of improved backyard poultry germplasm has improved the productivity of this system in resource-poor settings and thereby improved the income and nutritional security of poor households. With these birds, the availability, access, utilization, and stability of food security have improved at household and national levels. Diseases, predation, non-availability of improved germplasm, lack of access to markets, and lack of skills are the major constraints to the adoption of improved backyard poultry. These constraints can be addressed by involving a network of community animal service providers. The improved backyard poultry germplasm will dominate the backyard poultry production system in the future and will be a tool for ensuring food and nutritional security on a sustainable basis, more particularly in low- and middle-income countries.

Out-of-Pocket expenditure and patient experience of care under-Indonesia's national health insurance: A cross-sectional facility-based study in six provinces.

Low- and middle-income countries worldwide are striving to achieve universal health coverage (UHC), frequently through expansion of statutory health insurance schemes. However, oftentimes evidence is lacking on progress towards quality patient-centred care and out-of-pocket expenditure (OOPE), particularly for poor population groups. We contribute patient-centred evidence examining patient experience and OOPE under JKN, the Indonesian social health insurance. Using data from 2526 patient exit interviews conducted among JKN beneficiaries in 2015, we computed a summative patient experience measure from 14 experience items. We used descriptive statistics to assess patient experience and the probability, amount and components of OOPE. We applied a two-part model to examine the relationships between socio-demographics, facility types, and OOPE and an OLS regression on patient experience determinants. The mean patient experience measure was 11.7 out of 14 maximal points. Differences were observed between single items, with highest ratings on ease of understanding providers' language (97%) and lowest on waiting time (54%). OOPE were reported by 20% of patients with a mean equivalent to US$40, the most prevalent reason being medicines (61% of all OOPE). Considerable OOPE heterogeneity occurred by province and facility type. We found differentials in OOPE by gender (females paying more likely, but less) and subsidised JKN membership (same likelihood as non-subsidised, but paying less). Our findings suggest that during its early implementation, patients under JKN reported mostly positive patient experience yet a fifth incurred OOPE, mostly on medicines. Further patient-centred research is needed to ensure JKN's progress towards UHC.

Inequity and benefit incidence analysis in healthcare use among Syrian refugees in Egypt

BackgroundThe Syrian conflict has created the worst humanitarian refugee crisis of our time, with the largest number of people displaced. Many have sought refuge in Egypt, where they are provided with the same access to healthcare services as Egyptian citizens. Nevertheless, in addition to the existing shortcomings of the Egyptian health system, many obstacles specifically limit refugees’ access to healthcare. This study looks to assess equity across levels of care after observing services utilization among the Syrian refugees, and look at the humanitarian dilemma when facing resource allocation and the protection of the most vulnerable.MethodsA cross‐sectional survey was used and collected information related to access and utilization of outpatient and inpatient health services by Syrian refugees living in Egypt. We used concentration index (CI), horizontal inequity (HI) and benefit incidence analysis (BIA) to measure the inequity in the use of healthcare services and distribution of funding. We decomposed inequalities in utilization, using a linear approximation of a probit model to measure the contribution of need, non-need and consumption influential factors.ResultsWe found pro-rich inequality and horizontal inequity in the probability of refugees’ outpatient and inpatient health services utilization. Overall, poorer population groups have greater healthcare needs, while richer groups use the services more extensively. Decomposition analysis showed that the main contributor to inequality is socioeconomic status, with other elements such as large families, the presence of chronic disease and duration of asylum in Egypt further contributing to inequality. Benefit incidence analysis showed that the net benefit distribution of subsidies of UNHCR for outpatient and inpatient care is also pro-rich, after accounting for out-of-pocket expenditures.ConclusionOur results show that without equitable subsidies, poor refugees cannot afford healthcare services. To tackle health inequities, UNHCR and organisations will need to adapt programmes to address the social determinants of health, through interventions within many sectors. Our findings contribute to assessments of different levels of accessibility to healthcare services and uncover related sources of inequities that require further attention and advocacy by policymakers.

Scaling weather and climate services for agriculture in Senegal: Evaluating systemic but overlooked effects

In the West African Sahel, climate variability and climate change pose huge challenges to food security and health, particularly for poor and marginalised population groups. Co-production of actionable climate information between scientists and users has been advocated to increase its use in climate change adaptation. Consequently, Weather and Climate Services (WCS) co-production models have been expanding, but there have been few evaluations of their effects. Those that exist mostly focus on the end user. The empirical contribution of this paper is an evidence-based evaluation of the scaling of WCS based on co-production models in Senegal. The methodological contribution is a systemic and iterative evaluation method involving multiple analytical tools. The scaling of WCS in Senegal involved at least 161 actors and resulted in five axes of transformation: 1) continuous improvement of WCS, 2) emergence and consolidation of WCS facilitators, 3) inclusion of WCS in action planning, 4) active mobilisation to sustain WCS scaling, and 5) empowerment of actors. New users and uses emerged beyond agriculture, involving the fisheries, water and energy sectors, producing changes in institutional communication strategies, operational planning, and in coordination between actors. Enabling factors for scaling included capacity strengthening, knowledge-sharing and action platforms, interaction opportunities, and financial and political support. However, reduced precision of forecasts over time is perceived. New challenges are emerging including improving delivery and finer grain information, getting the private sector involved, and building capacity and trust at a large scale, to keep pace with the increase in uses and users

Poverty and survival from COVID-19 in Mexico.

BackgroundRecent evidence points to the relevance of poverty and inequality as factors affecting the spread and mortality of the COVID-19 pandemic in Latin America. This study aimed to determine whether COVID-19 patients living in Mexican municipalities with high levels of poverty have a lower survival compared with those living in municipalities with low levels.MethodsRetrospective cohort study. Secondary data was used to define the exposure (multidimensional poverty level) and outcome (survival time) among patients diagnosed with COVID-19 between 27 February and 1 July 2020. Crude and adjusted hazard ratios (HR) from Cox regression were computed.ResultsNearly 250 000 COVID-19 patients were included. Mortality was 12.3% reaching 59.3% in patients with ≥1 comorbidities. Multivariate survival analyses revealed that individuals living in municipalities with extreme poverty had 9% higher risk of dying at any given time proportionally to those living in municipalities classified as not poor (HR 1.09; 95% CI 1.06–1.12). The survival gap widened with the follow-up time up to the third to fourth weeks after diagnosis.ConclusionEvidence suggests that the poorest population groups have a lower survival from COVID-19. Thus, combating extreme poverty should be a central preventive strategy.

Small cities, big needs: Urban transport planning in cities of developing countries

Cities in developing countries face acute pressures due to increased motorization, urbanization and growing population. Urban transport planning systems can fuel healthy cities, yet research examining the interface between policies and needs in Africa remains scarce. A mixed-methods approach was used to assess the alignment between urban transport policies and self-reported citizens’ needs in Port Louis city (Mauritius). Logistic regression models were run to detect associations between needs and demographic indicators (age, gender, income). Three policy measures were assessed: light metro rail system, bus modernization scheme and road decongestion program. Six citizen needs and six mode of transit preferences were extracted from 1523 surveys (N). Citizens reported the need for improving sidewalks (80%), public spaces (77%), green spaces (67%), pedestrianizing strategic areas (66%), centralizing street-vendors at bus stations (57%) and regulating private vehicles entry in town (40%). The policies addressed 3 out of 6 needs, of which all were more likely to be expressed by poorer population groups. The policies did not respond to citizen needs for active modes of travel. They did not address health and social co-benefits of transport. Rather they emphasized an economic agenda focused on transport infrastructure as opposed to policy reforms in line with public needs that much more strongly highlight the integration of urban transport planning in social life. Citizen-centred approaches provide a unique opportunity to reform urban transport planning policies towards more healthy and equitable cities in developing countries.

COVID-19 Containment and Food Security in the Global South

Population-level COVID-19 containment strategies have been particularly hard on the urban poor and vulnerable population groups such as female-headed households, children, youth, the homeless, informal sector employers and employees, casual workers, the unemployed, and migrants and refugees. As a direct result of the COVID-19 outbreak, a secondary pandemic of hunger and food insecurity is now impacting many of these groups. An effective and sustainable global response to the COVID-19 (and any further) viral pandemics must ensure that food security is an essential piece of the containment and mitigation puzzle.

Comparison of Head and Neck Cancer Distribution in Turkish and Syrian Populations

Although oral health improves in several countries, global problems are still present. Predictably, the disadvantaged and poor population groups in both developing and developed countries have high rate of malign disease. The aim of this study was to evaluate the prevalence of head and neck cancers (HNCs) and to compare them between Syrian and Turkish population. A total of 4570 patients confirmed to have HNC histopathologically from Hatay Mustafa Kemal University Hospital Pathology report archive were retrospectively evaluated. Among them, 452 were Syrian patients while 4118 were Turkish patients. Data were collected from 2010 to 2017. Gender and age information were taken from medical records. According to the pathological results, HNCs were classified. In 474 patients, HNCs were inscriptived, of which 317 were in males and 157 in females aged 23-80 years with histologically approved cancer of head and neck area. Overall, 100 were Syrian patients while 374 were Turkish patients. In both Syrian and Turkish patients, the most observed HNC was squamous cell carcinoma (SCC). Nowadays, the prevalence of cancer is higher because of the excessive consumption of alcohol, tobacco, chewing, and smoking. For the higher cancer incidence in Syrian refugees, we thought that the impact of war such as stress may have been effective as well as the known several etiologic factors of cancer. For the increased risk of cancer, the early diagnosis of this become more important.

Urban Health Investments in India and Bangladesh: Rationale and Cost of Essential Health Services

Background: By 2030, the urban populations of India and Bangladesh are expected to nearly double. We describe the anticipated health needs of these urban populations, with an emphasis on equity. We propose a South Asia Urban Package (SAUP) of essential health interventions based on the Disease Control Priorities, 3rd edition (DCP3), and estimate its expected costs and mortality reductions. Methods: We used population data from the countries' censuses and United Nations Population Division. For causes of mortality in India, we used the Indian Million Death Study; to examine equity, we used data from the Indian National Family Health Surveys. Costs and mortality reductions expected with SAUP were estimated using the DCP3 model. Findings: Non-communicable disease (NCDs) rates have been rising for two decades, and communicable disease rates are declining. NCD risk factors in urban India are higher among the poorest population groups, who also have the least access to healthcare. The SAUP would cost about US$105 per capita in India and $75 in Bangladesh. Of this, 60% would be invested in prevention and treatment of NCDs and about 80% in primary care and first level hospitals. Investing in SAUP would return about $7 and $6 in welfare benefits per dollar spent in India and Bangladesh, respectively. Interpretation: Rapid urban population growth, high levels of NCDs, and the unfinished agenda of infectious diseases support the need for major investments in urban health. The SAUP would cost an additional $75 and $50 per capita, in India and Bangladesh, respectively, and would help India and Bangladesh substantially achieve their 2030 United Nations SDG goals. Funding Statement: The study was funded by the Asian Development Bank. EB, BC, HW, SK, and SR from the Asian Development Bank helped to draft the key messages and reviewed the drafts of the manuscript. Declaration of Interests: The authors state: No conflicts of interest to declare. Ethics Approval Statement: Missing.

Barriers to accessing adequate maternal care in Georgia: a qualitative study

BackgroundThe maternal health outcomes in Georgia are linked to shortcomings in healthcare such as inequities in access to adequate maternal care. Due to the macro-level, quantitative approach applied in most previous studies, little is known about the underlying reasons that influence maternal care and care-seeking behaviour of pregnant women.MethodsThis qualitative study explores the stakeholders’ perspectives on access to adequate maternal care in Georgia. Focus-group discussions are conducted with mothers who gave birth within in the past four years and in-depth interviews are conducted with decision-makers and health professionals in the field. Five access-related aspects are studied: availability, appropriateness, affordability, approachability and acceptability of maternal care. The method of direct content analysis is applied.ResultsResults indicate problems with maternal care standards, inequalities across population groups and drawbacks in maternal care financing. This includes gaps in clinical quality and staff skills, as well as poor communication between women and health professionals. Geographical barriers to adequate maternal care exist in rural and mountainous areas due to the weak infrastructure (poor roads and weak transportation), in addition to financial hardships. Despite improvements in the coverage of maternal care, affordability remains an access barrier. Poorer population groups are financially unprotected from the high out-of-pocket payments for maternal care services.ConclusionThese findings imply that micro-level indicators, such as disrespectful behaviour of health professionals and affordability of care, should be taken into account when assessing maternal care provision in Georgia. It should complement the existing macro-level indicators for a comprehensive evaluation of maternal care.

Change and continuity of income divide in the American Southeast: A metropolitan scale analyses, 2000–2014

Changing racial/ethnic diversity along with economic growth have also drawn renewed public attention to growing income inequality and lack of economic well-being in the American society. This paper investigates one element of contemporary inequality – the income divide between the richest and the poorest population groups in the metropolises of the U.S. Southeast. This paper examines income divide across southern U.S. metropolises in 2000 and 2014, their change during 2000–2014, their variation across major races/ethnicities, and their relationships with important metropolitan characteristics such as diversity, intermixing, socio-economic status and built-environment attributes. Cartographic, ranking/matrix, and correlations analyses suggest that the largest, most diverse, most segregated, and those with a greater presence of better educated are the most income divided metropolises, whereas the small-to-mid-sized metropolises, with lesser educated population are less divided. The income divide has increased during 2000–2014 in a majority of these metropolises, and for all races/ethnicities, even though Whites and Asians are relatively better-off compared to overall population whereas Blacks and Hispanics lag behind.

Shelter from the storm: Upgrading housing infrastructure in Latin American slums

This paper provides empirical evidence regarding the causal effects that upgrading slum dwellings has on the living conditions of the extremely poor. In particular, we study the impact of providing better houses in situ to slum dwellers in El Salvador, Mexico and Uruguay. We experimentally evaluate the impact of a housing project run by the NGO TECHO (“roof”), which provides basic pre-fabricated houses to members of extremely poor population groups in Latin America. The main objective of the program is to improve household well-being. Our findings show that better houses have a positive effect on overall housing conditions and general well-being: the members of treated households are happier with their quality of life. In two countries, we also document improvements in children’s health; in El Salvador, slum dwellers who have received the TECHO houses also feel that they are safer. We do not find this result, however, in the other two experimental samples. There are no other noticeable robust effects in relation to the possession of durable goods or labor outcomes. Our results are robust in terms of both their internal and external validity because they are derived from similar experiments in three different Latin American countries.

Household Coverage of Fortified Staple Food Commodities in Rajasthan, India.

A spatially representative statewide survey was conducted in Rajasthan, India to assess household coverage of atta wheat flour, edible oil, and salt. An even distribution of primary sampling units were selected based on their proximity to centroids on a hexagonal grid laid over the survey area. A sample of n = 18 households from each of m = 252 primary sampling units PSUs was taken. Demographic data on all members of these households were collected, and a broader dataset was collected about a single caregiver and a child in the first 2 years of life. Data were collected on demographic and socioeconomic status; education; housing conditions; recent infant and child mortality; water, sanitation, and hygiene practices; food security; child health; infant and young child feeding practices; maternal dietary diversity; coverage of fortified staples; and maternal and child anthropometry. Data were collected from 4,627 households and the same number of caregiver/child pairs. Atta wheat flour was widely consumed across the state (83%); however, only about 7% of the atta wheat flour was classified as fortifiable, and only about 6% was actually fortified (mostly inadequately). For oil, almost 90% of edible oil consumed by households in the survey was classified as fortifiable, but only about 24% was fortified. For salt, coverage was high, with almost 85% of households using fortified salt and 66% of households using adequately fortified salt. Iodized salt coverage was also high; however, rural and poor population groups were less likely to be reached by the intervention. Voluntary fortification of atta wheat flour and edible oil lacked sufficient industry consolidation to cover significant portions of the population. It is crucial that appropriate delivery channels are utilized to effectively deliver essential micronutrients to at-risk population groups. Government distribution systems are likely the best means to accomplish this goal.

Risk of tuberculous infection in adolescents and adults in a rural community in Ethiopia.

The incidence of tuberculosis (TB) in sub-Saharan Africa is one of the highest in the world. To evaluate the prevalence of TB, the annual risk of tuberculous infection (ARTI) and associated risk factors in rural Ethiopia. A tuberculin skin test was performed among 2743 individuals in a rural community of Ethiopia around Ginci town, west of Addis Ababa, to estimate the prevalence of tuberculin reactivity and to assess factors associated with tuberculous infection. Among 2743 volunteer participants, test results were available for 2640, 691 (26.2%) of whom had an identifiable bacille Calmette-Guérin (BCG) scar; 221 (8.3%) reported household contact with a known TB case. The overall prevalence of TST reactions of ⩾ 10 mm was 29.7%. The ARTI was estimated at 1.7%. Tuberculin reactivity varied with age, sex, income and history of household contact with a TB case. Presence of BCG scar was not related to tuberculin reactivity. Our findings indicate that despite an effective TB control programme, TB transmission rates are still high in rural Ethiopia. Provision of isoniazid prophylaxis in close contacts of active TB cases among the poorest population groups may reduce TB incidence.

Increasing Emphasis on Humanitarian Assistance

As 2015 comes to a close, we express our concern for the many resource limited, global challenges facing medical and health professionals worldwide. War, disasters, disease, terrorism, and other insecurities continue to threaten the well-being of many communities around the world. This year marks the 10th anniversary of Hurricane Katrina, one of the most devastating natural disasters of the twenty-first century. While estimates vary, over 1,800 people lost their lives and 400,000 were forced to leave their homes, some permanently. In the city of New Orleans, hurricane damage to the levees and resulting floods destroyed entire communities. With suffering, death, and damages of more than $100 billion, this catastrophe triggered a serious reconsideration of the U.S. government's and communities' ability to prepare for and handle environmental risks, anticipate threats, and respond to natural and human-made hazards. A decade later, recovery still continues. Massive infusion of resources has helped with recovery efforts, with major infrastructure and services rebuilt, in some cases to even better standards than pre-Katrina, yet many affected regions still struggle and remain undeveloped. Katrina demonstrated that social disparities contribute significantly in costs to health and life, and poor post-disaster resilience. This slow but steady recovery in a U.S. region during peacetime can be contrasted with other countries suffering from protracted violence. Iraq, still suffering from armed conflict, has over three million internally displaced people (IDP). The four years of violence and war in Syria have produced almost 11 million IDP and refugees, with some 259,000 living in Iraq. Disparities in humanitarian aid are evident. The “less than 10 percent of IDPs, and 40 percent of refugees who live in camps get much more attention and organized assistance than the vast majority who live outside of camps” (Ferris & Teff, 2015). Iraq, Middle Eastern countries, many African nations, and neighboring poor communities still suffer from lack of sustainable resources and rising local corruption. Continued, ever-expanding conflicts create more IDP and refugees, promoting further disparities and violence. World communities continue to experience regional conflicts, terrorism, environmental degradation, death, and economic losses. Whole communities are uprooted. Many suffer from extreme weather exposure, famine, infections, and loss of basic health needs. The majority of victims are poor and vulnerable population groups. Occasionally international aid has been denied to victims because of political differences, internal insurgency, or corruption. Worse, healthcare infrastructure, medical personnel, and humanitarian workers are becoming frequent targets of terrorism and violence. In May 2015, the United Nations Secretary General Ban Ki-moon, appointed a high-level panel to address the widening gap between resources and financing for the world's ever-pressing humanitarian efforts. Despite rapid humanitarian response and successes, economic, medical, and psychological consequences are often staggering. The editors of WMHP are encouraged that the European Union and the Americas are responding to the mounting problems of refugees and coordinating their activities with the UN to increase humanitarian assistance (Avramopoulos, 2015). We are encouraging all stakeholders, and especially the international medical and health-care communities, to continue to submit manuscripts on the progress of these efforts, to inform our readership. We are also pleased to introduce to you a recent compendium of articles selected from among our journal contributors, and published under the title Disaster Response: Medical and Health Policies (Nicogossian & Stabile, 2015). We are grateful to the Policy Studies Organization (PSO) for their help and support for this project. Finally the editors would like to thank the many authors, contributors, and peer reviewers who supported our journal over the last year and wish you a prosperous 2016.

Time trends in socio-economic inequalities in the lack of access to dental services among children in Spain 1987-2011.

IntroductionAdult oral health is predicted by oral health in childhood. Prevention improves oral health in childhood and, consequently in adulthood, so substantial cost savings can be derived from prevention. The burden of oral disease is particularly high for disadvantaged and poor population groups in both developing and developed countries. Therefore, an appropriate and egalitarian access to dental care becomes a desirable objective if children’s dental health is to be promoted irrespective of socioeconomic status. The aim of this research is to analyse inequalities in the lack of access to dental care services for children in the Spanish National Health System by socio-economic group over the period 1987–2011.MethodsPooled data from eight editions of the Spanish National Health Survey for the years 1987–2011, as well as contextual data on state dental programmes are used. Logistic regressions are used to examine the related factors to the probability of not having ever visited the dentist among children between 6 and 14 years old. Our lack of access variable pays particular attention to the socioeconomic level of children’s household.ResultsThe mean probability of having never been to the dentist falls considerably from 49.5% in 1987 to 8.4% in 2011. Analysis by socioeconomic level indicates that, in 1987, the probability of not having ever gone to the dentist is more than two times higher for children in the unskilled manual social class than for those in the upper non-manual social class (odds ratio 2.35). And this difference is not reduced significantly throughout the period analysed, rather it increases as in 1993 (odds of 2.39) and 2006 (odds of 3.03) to end in 2011 slightly below than in 1987 (odds ratio 1.80).ConclusionThere has been a reduction in children’s lack of access to dentists in Spain over the period 1987–2011. However, this reduction has not corrected the socioeconomic inequalities in children’s access to dentists in Spain.

Metrics matter: the case of assessing the importance of non-communicable diseases for the poor

As the saying goes, ‘bad publicity is better than no publicity.’ So I was gratified to see in IJE such a prominent, even if highly critical, reference to a piece that two colleagues and I did nearly 15 years ago and that I’d thought long forgotten. In our piece my colleagues and I had questioned, on equity grounds, the then-incipient shift in emphasis from communicable to non-communicable diseases (NCDs) in global health policy. Using 1990 data from the 1996 World Health Organization (WHO) global burden of disease (GBD) study, we had estimated that communicable illnesses were still responsible for a majority of the disease burden in the poorest quintile of the world’s population. But in the richest quintile, the situation was the reverse: NCDs were overwhelmingly dominant. This finding had led us to advocate a continuing focus on communicable diseases because of their central importance to the health of the global poor, a group of especially high priority in the 2015 Millennium Development Goals that were then being formulated. To move toward NCDs, we argued, would result in increased attention for a set of conditions far more relevant to the world’s better-off. Not surprisingly, perhaps, NCD advocates did not find this argument very compelling. Nor did any of the four commentatorson a similar argument for India advanced by S.V. Subramanian and colleagues in the article featured in this current IJE collection of papers on equity and the pattern of disease. In that article, Subramanian et al. challenge the argument that the distribution of cardiovascular diseases and risk factors has shifted so that they have become more prevalent in lowthan in high-income groups. The many problems they find with this argument lead them to consider a shift away from communicable diseases toward cardiovascular issues to be premature, or ‘jumping the gun’ as they put it. Among the several arguments advanced by the commentators disagreeing with this conclusion, two stand out. The first is that Subramanian et al. have simply misread the available literature, and that the burden of disease from NCDs is in fact higher among the poor. The second is that, even if they did not misread, NCDs now constitute an adequately important (and growing) minority of the disease burden in even the poorest population groups to justify significant attention.

Shelter from the Storm: Upgrading Housing Infrastructure in Latin American Slums

This paper provides empirical evidence on the causal effects that upgrading slum dwellings has on the living conditions of the extremely poor. In particular, we study the impact of providing better houses in situ to slum dwellers in El Salvador, Mexico and Uruguay. We experimentally evaluate the impact of a housing project run by the NGO TECHO which provides basic pre-fabricated houses to members of extremely poor population groups in Latin America. The main objective of the program is to improve household well-being. Our findings show that better houses have a positive effect on overall housing conditions and general well-being: treated households are happier with their quality of life. In two countries, we also document improvements in children’s health; in El Salvador, slum dwellers also feel that they are safer. We do not find this result, however, in the other two experimental samples. There are no other noticeable robust effects on the possession of durable goods or in terms of labor outcomes. Our results are robust in terms of both internal and external validity because they are derived from similar experiments in three different Latin American countries.

Dual burden households and intra-household nutritional inequality in Indonesia

Overweight is an increasing problem in many developing countries, coexisting with underweight and contributing to a dual burden of malnutrition, sometimes in the same households. We analyze the phenomenon of dual burden households in Indonesia, using 15-year panel data. Currently, 16 percent of Indonesian households are classified as dual burden. In these households, children are often underweight, whereas adults are overweight. The nutrition transition seems to have differential impacts on the body mass index of different age cohorts. Dual burden households are a transitory phenomenon. This phenomenon started in the richer segments, but now the prevalence of dual burden households is highest in the poorest population groups. Most households that move out of the dual burden category end up as overweight. We also develop a continuous Theil index of intra-household nutritional inequality. While the overall prevalence of dual burden households has hardly changed over the last 10 years, the Theil index increased steadily. This underlines that the dual burden classification has limitations in terms of capturing nutritional dynamics. Socioeconomic determinants of dual burden and nutritional inequality are analyzed with regression models.