Equity in health - a fluid concept

As the German proverb goes ‘the only equity is in the cemetery’. But contrary to the state of many other developing countries Sri Lanka has maintained at least near equity in many sectors, best examples being education and health.

In fact, Sri Lanka has exceptionally good health indices for a developing nation. However, these are not reflected in all groups of Sri Lankan population, as explained by Dr. Narada Warnasuriya, President, Sri Lanka Medical Association (SLMA) at the pre-congress theme seminar of the 123rd Annual Scientific Sessions of the SLMA.

The academic sessions will be based on achieving ‘equity in health’ and the Sri Lankan experience. Dr. Warnasuriya said, while reflecting on the achievements it is also necessary to look for ways to not only sustain them but also enhance them.

However, access to health invariably still depends, to some extent, on factors such as wealth, power and social status pointed out Dr. Ravi Ruberu, Secretary, Ministry of Health. He said although ‘equity in health’ would be rather a difficult task to achieve, ‘We should do our very best’.

Dr. Ravi Rannan-Eliya, Executive Director, Institute of Health Policy (IHP) corroborated that access to health services does depend on income, according to statistics.

He pointed out that some services that are available to private health care are not available in the private sector due to under investment, plus environmental conditions act in favour of high income households. But the overall mortality rate does not depend on income level. In fact, it is ironical that high income generating segment of the society is more prone to NCDs (None Communicable Diseases) such as diabetes, as pointed out by Dr. Rannan-Eliya.

According to the 2005 Sri Lanka Diabetes Cardio Vascular Survey, higher the income higher the risk factors that contribute to cardiovascular diseases such as low activity, hypertension, obesity and diabetes. The only risk factor that decreases with increased income is smoking. But the case is not so in asthma. Although it is also a NCD, asthma mortality is lower in richer households. Which shows that asthma mortality depends heavily on medical intervention.

Apart from income level, the child mortality rate depends on other social dimensions such as area of residence, sex and education level. Child mortality rate decreases with higher levels of education. It is higher in estate areas than in urban or rural areas. However, the health sector has reduced this disparity by more than half of 1997 by 2007.

Considering this Dr. Rannan-Eliya said Sri Lanka is doing even better than most advanced nations such as the US and Australia.

Dr. Ravi Rannan-Eliya said Sri Lanka fares relatively well in equity in health outcomes. “Specially considering maternal and child health indicators Sri Lanka performs extremely well,” he said. Moreover, he pointed out that disparities between the richest and the poorest segments of society is relatively modest compared to other developing countries in the Asia region. In addition the percentage of healthcare used by poorest quintile - which is 23.6 % - presents the best prognosis among other developing nations.

Statistics indicate that while the use of public healthcare increases with increasing poverty, use of private healthcare increases with increased income levels. Dr. Rannan-Eliya pointed out that this trend is rather unusual and is observed only in developing countries such as Malaysia and Jamaica.

But according to the statistics presented by Dr. Rannan-Eliya Sri Lanka is not doing so well concerning maintaining equity in nutrition. Although compared to other developing nations Sri Lanka has low levels of stunting, disparities according to income levels are very high in Sri Lanka. The poorest segment of Sri Lankan society is suffering from malnutrition.

Dr. Rannan-Eliya said Sri Lanka performs much better than most other developing nations, but not so well compared to developed countries in terms of ensuring high and equal levels of use of medical services, protecting families against impoverishment due to healthcare expenditure. “Inequalities are modest but healthcare is still not adequate to meet the need.”

Dr. Rannan-Eliya explained that broad social determinants such as education, female empowerment, infrastructure and income redistribution as well as changes in healthcare system such as public financing through taxation, expansion of healthcare provision, emphasis on risk protections and access to healthcare has determined Sri Lanka’s performance in the healthcare sector.

In fact Dr. Rannan-Eliya said Sri Lanka’s emphasis on risk protection predates international policy recommendations. These health gains have been sustained through periods of economic stagnation as well as economic growth.

Dr. Rannan-Eliya identified three issues in the healthcare sector: the need for a shift in focus in the health system to management of NCDs, reintegration of eastern and northern regions politically and health-wise and inadequate public financing of a mixed healthcare system. Dr. Godfrey Goonathilake, Director Emeritus, Marga Institute said, “Health transition in Sri Lanka was exceptional in that it occurred with unusual rapidity and continuity for a low income country.” He explained that although there are disparities in income distribution, this does not prevent the reduction of health qualities as evident by survival and life expectancy. “They can however lower the quality of life” said, Dr. Goonathilake.

He pointed out that there exists a disparity in the availability of specialised care, accessibility to medical services and affordability of healthcare and quality assurance. Dr. Goonathilake said scarce human resources are thinly distributed over public and private health sectors. He saw ageing of population as another major problem Sri Lanka would have to face, resulting in healthcare disparities in the aged and the rest of the population. He emphasized the need to focus on the disparities within micro-economic levels rather than the disparity between the richest and the poorest. Prof. Sir Michael Marmot, Chairman, WHO Commission on Social Determinants of Health; President elect British Medical Association agreeing with Dr. Godfrey Goonathilake said by focusing on the poorest segment of society one tends to miss a good part of the problem.

He warned that a rapid increase in alcohol consumption would prove to be a major setback for the health sector of Sri Lanka if it already has not become one.

“We still need attitudinal reforms,” said Dr. Ruberu. “Empathy plays a major role in striving to achieve equity in health than plain old statistics.”

-SP

Daily Diet:

The controversy over salt

by Susan Brady

Table salt, kosher salt, sea salt, sel de gris, fine grained, course ground, rock salt, herbed salt, garlic salt-the varieties are endless.

Someone could open a salt store as big as a Starbucks and be able to fill all the shelves. We love salt and while it is essential to our bodies, overdosing on this popular flavour enhancer can be detrimental to our health, and there’s the rub.

While you can find a salt shaker on every home and restaurant table, in almost every packaged product at the supermarket, and in 90 percent of recipes (desserts included), Americans tend to overconsume on the small white granules. Salt helps to maintain the water content in blood, balances blood’s acids and bases, and is essential for the movement of electrical charges in the nerves that move our muscles.

But too much of a good thing can lead to high blood pressure and heart disease. In addition, a diet high in salt content is often associated with weight gain.

The National Institutes of Health and the American Heart Association recommends a diet containing no more than 2.4 grams (approximately 1 teaspoon) of sodium per day. On the average, American men consume 10.4 grams of salt, while American women average a salt intake of 7.3 grams daily. These numbers continue to rise, with 75 to 80 percent of all salt consumed coming from processed food.

The First Lady has spoken out about the need to limit salt in her campaign against obesity, and some manufacturers have gotten on the bandwagon, announcing cuts in sodium levels in their processed foods.

Kraft pledged a 10 percent reduction, which translates into the elimination of over 10 million pounds of salt in over 1,000 processed food items.

Additionally, a panel from the Institute of Medicine recommended that the Food and Drug Administration (FDA) regulate the amount of sodium used in processed food, citing decades of recommendations that have not been heeded by the public. Given the amount of processed food purchased in this country, the belief is that the best way to reduce salt consumption is by regulating the companies preparing the food.

Now the salt industry is pushing back. Cargills, one of the nation’s largest producers of salt, has hired food luminary Alton Brown to stump for sodium. The most recent ad, called Salt 101, has Brown trying to convince us that we need to have “plenty of salt in your kitchen at all times.”

And while we do “need” it, we need it in lesser amounts than we are currently consuming and the food industry is loathe to lower or eliminate salt in its products, because of the flavour-enhancing capabilities.

The answer could just be in cooking your own fresh food rather than relying on packaged ingredients. Doing so would eliminate the overuse of sodium, and overall would be healthier for you.

-Healthnews

Midnight snacking damages the teeth, warn experts

by Michelle Roberts

Researchers have found midnight snacking ups the risk of tooth loss, regardless of the type of food that is eaten.

Midnight snacks may stick to the teeth for longer, experts suspect. Eating food in the middle of the night can seriously damage your teeth, experts warn.

Researchers have found midnight snacking ups the risk of tooth loss, regardless of the type of food that is eaten.

The Danish investigators blame changes in saliva flow - it tends to dry up at night.

Enough saliva is important to remove food debris from the mouth, they explain in the Eating Behaviours journal.

Night nibbles

Working with colleagues from the US, the team at Copenhagen University examined the medical records of 2,217 Danes already enrolled in a medical study.

Of these 173 or 8%, could be classed as nocturnal eaters - meaning they consumed a quarter or more of their daily calories after dinner or would wake up in the middle of the night at least twice a week for a little moonlight snack.

Eating at night, when the mouth is driest and any food remains in the mouth longer, accentuates the impact of consuming sugary and acidic food and drinks Professor Damien Walmsley

Scientific adviser to the British Dental Association When the researchers tracked what happened to all of the study participants over a period of six years, a significant finding emerged.

The nocturnal eaters ended up losing more teeth, even after accounting for other factors such as age, smoking and sugar/carbohydrate consumption.While dentists may not be able to stop their patients feasting in the middle of the night, Dr Jennifer Lundgren and colleagues say they should make them aware of the associated risks.

“Practitioners should be aware of the oral health implications of nocturnal eating, increase screening and oral health education efforts among nocturnal eaters and make treatment referrals when appropriate,” they say.

Professor Damien Walmsley, scientific adviser to the British Dental Association, said: “Eating at night, when the mouth is driest and any food remains in the mouth longer, accentuates the impact of consuming sugary and acidic food and drinks.

“To minimise damage, it is important to brush teeth twice a day with fluoride toothpaste, with one of those brushes coming immediately before bedtime.

“Where possible, consume only water for at least an hour before the final brush of the day.”

-BBC