In recognition of the fact that health research can bring numerous tangible benefits to the health status of people, IJMA shall be a catalyst for developing the next generation of top-notch researchers, scientists, academics, and public health leaders in the developing world by providing a platform for peer mentorship, intellectual exchange, and academic publishing.

  • <h7>It is morally wrong to make a mother choose between treatment for herself and treatment for her newborn.  It is morally wrong that people should be dying of AIDS when treatment is available.</h7><p><i>Michel Sidibe, UNAIDS Executive Director</i></p>
  •  <h7> To learn how to protect yourself. </h7>
  • <h7>It is morally wrong that babies are still being born with HIV when we know how to prevent it.  It is morally wrong that children are still growing up as AIDS orphans. </h7><p><i>Michel Sidibe, UNAIDS Executive Director</i></p>
  • <h7>To be a partner for women and girls against violence and injustice, you do not have to be experts on human rights or gender. You do have to be committed to always asking in your daily work: 'How can I better engage women and girls to understand what they need'</h7><p><i>Michel Sidibe, UNAIDS Executive Director</i></p>
  • <h7>When the history of our times is written, will we be remembered as the generation that turned our backs in a moment of global crisis or will it be recorded that we did the right thing?</h7><p><i>Nelson R. Mandela, The Nelson Mandela Foundation</i></p>
  • <h7>No disease group is as vast and complex in scope as the noncommunicable diseases (NCDs). Incorporating social determinants such as income and education, the NCDs call for an equally massive and comprehensive response</h7><p><i>Mirta Moses, Director, PAHO.</i></p>
  • <h7>There are 1.2 billion adolescents across the world, 9 out of 10 of these young people live in developing countries.  Millions are denied their basic rights to quality education, health care, protection and exposed to abuse and exploitation. </h7><p><i>UNICEF, 2011</i></p>
  • <h7>A society that cuts itself off from its youth severs its lifeline; it is condemned to bleed to death.</h7><p>Kofi Annan, former United Nations Secretary-General</p>
  • <h7>Of all the forms of inequality, injustice in health care is the most shocking and inhumane.</h7><p>Rev. Martin Luther King, Jr. </p>

About the Journal

The International Journal of MCH and AIDS (IJMA) is a United States-based multidisciplinary, peer-reviewed, global health, open access journal that publishes original research articles, review articles, clinical studies, evaluation studies, policy analyses, and commentaries/opinions in all areas of maternal, infant, child health, (MCH) and HIV/AIDS in low and middle-income countries, and in populations that are experiencing health disparities (i.e. inequalities) around the world. The journal focuses on the social determinants of health and disease as well as on the disparities in the burden of communicable, non-communicable, and neglected tropical diseases affecting infants, children, women, adults, and families across the life span in developing countries and around the world.

IJMA focuses on the intersection between MCH and HIV/AIDS around the world but more especially in the low and middle-income countries (LMICs), as classified by the World Bank. Diseases or healthcare policy issues impacting populations in LMICs, also known as developing countries or the global South, are currently under-documented and underreported in existing western-based, peer-reviewed journals. IJMA therefore places a huge emphasis on the documentation and dissemination of work and new findings especially when those papers are the products of collaboration between researchers in the global North and South.

Worldwide Geographic and Subject-matter Leadership
IJMA’s editorial team comprises of 52 multi-disciplinary, global health experts, representing 21 countries from all regions of the World Health Organization reflecting a wide spectrum of the developed and developing countries. This means that each manuscript submitted to IJMA receives rigorous and fairest opportunity from experts who possess both subject-matter and geographic expertise in the subject area of the submission. Each of our reviewers understand not only the subject but the area where the work was conducted thus bringing perspective to the rigorous review process and support to authors.

IJMA’s primary focus is on the broader life-span trajectory of MCH and HIV/AIDS issues in developing countries. The journal’s Editors also recognize that there are widening socioeconomic and health inequalities in populations in developed countries; therefore, IJMA welcomes high-quality papers, opinion articles, and commentaries from scientists, researchers, policy experts, and other professionals working with health disparity populations and issues in the developed countries of the world. This includes cross-national studies that compare health and social inequalities between and within racial or different social and economic groups, as well as within or between developing and developed countries.

Free Manuscript Submission
Manuscript submission to IJMA is free to all established and emerging scientists, researchers, and program officials from all parts of the world.

Scope and Areas of Coverage
The journal covers, but is not limited to, the following global health subject areas:

  • Life expectancy, cause-specific mortality, and human development,
  • Maternal, infant, child, and youth mortality and morbidity in developing countries,
  • Determinants and consequences of childhood and adolescent obesity and sedentary behaviors, including smoking, alcohol,
    substance use, violence and injury,
  • Quality of life and mental health disparities affecting MCH and HIV/AIDS populations,
  • Social, behavioral, and biological determinants of MCH and HIV/AIDS and well-being
  • Disparities in health and well-being based on gender, race, ethnicity, immigrant status, social class, education, income,
    disability status, etc.,
  • Region and/or country specific studies,
  • Family health, including changing dynamics of modern families,
  • Human sexuality and human development,
  • Neglected tropical diseases,
  • Use of science, technology and innovation to address national and global health issues
  • Technological innovations to address family health, MCH and HIV/AIDS,
  • Cross-national research on MCH and HIV/AIDS issues across the world,
  • Issues of resilience among populations impacted by HIV/AIDS,
  • Linkages between research results and national public policy formulation process,
  • Applications of surveillance, trend, and multilevel methods, and use of novel approaches in both quantitative and qualitative research studies.

EDITOR-IN-CHIEF: Romuladus E. Azuine, DrPH, MPH, RN

EDITOR: Gopal K. Singh, PhD, MS, MSc

NON-PROFIT PUBLISHER: Global Health and Education Projects, Inc., Washington, DC, USA.

FREQUENCY: Continuous –accepted papers are published on a rolling basis.

ISSN: 2161-864X (Online)

ISSN: 2161-8674 (Print)





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Original Article

International Journal of MCH and AIDS
Volume 3, Issue 1, Pages 44-52
Household Headship and Infant Mortality in India: Evaluating the Determinants and Differentials
Ashish Kumar Gupta, M Phil; Kakoli Borkotoky, M Phil; Amit Kumar, M Phil;

Systematic Review

International Journal of MCH and AIDS
Volume 3, Issue 1, Pages 31-43
Anti-retroviral Therapy and Pregnancy Outcomes in Developing Countries: A Systematic Review
Fekadu Mazengia Alemu, MPH; Alemayehu Worku Yalew, PhD; Mesganaw Fantahun, PhD; Eta Ebasi Ashu, Msc;

Review Article

International Journal of MCH and AIDS
Volume 3, Issue 1, Pages 22-30
Mental Health in Developing Countries: Challenges and Opportunities in Introducing Western Mental Health System in Uganda
Janice Katherine Kopinak, MHSc, MSc., RN;

Original Article

International Journal of MCH and AIDS
Volume 3, Issue 1, Pages 16-21
Social and Economic Barriers to Exclusive Breastfeeding in Rural Zimbabwe
Munyaradzi Muchacha, BSW; Edmos Mtetwa, MSc;

Original Article

International Journal of MCH and AIDS
Volume 3, Issue 1, Pages 7-15
Infant and Young Child Feeding Behavior among Working Mothers in India: Implications for Global Health Policy and Practice
Vinay Kumar, MD, MPH; Gunjan Arora; Ish Kumar Midha, MBBS, DCH; Yogender Pal Gupta, PhD;


International Journal of MCH and AIDS
Volume 3, Issue 1, Pages 1-6
Ebola Virus Disease Epidemic: What Can the World Learn and Not Learn from West Africa?
Romuladus E. Azuine, DrPH, RN; Sussan E. Ekejiuba, DVM, PhD; Gopal K. Singh, PhD; Magnus A. Azuine, PhD;

Original Article

International Journal of MCH and AIDS
Volume 2, Issue 2, Pages 244-249
Prevention-of-Mother-To-Child-Transmission of HIV Services in Sub-Saharan Africa: A Qualitative Analysis of Healthcare Providers and Clients Challenges in Ghana
Amos Kankponang Laar, PhD; Belynda Amankwa, MPH; Charlotte Asiedu, MPH;

Original Article

International Journal of MCH and AIDS
Volume 2, Issue 2, Pages 236 - 243
Evaluation and Utility of a Family Information Table to Identify and Test Children at Risk for HIV in Kenya
Michelle Meyer, BA; Molly Elmer-DeWitt, BA; Cinthia Blat, MPH; Starley B. Shade, PhD; Ijaa Kapule, MBChB; Elizabeth Bukusi, MBChB, PhD; Craig R. Cohen, MD; Lisa Abuogi, MD;

Original Article

International Journal of MCH and AIDS
Volume 2, Issue 2, Pages 229 - 235
Population and Public Health Implications of Child Health and Reproductive Outcomes Among Carrier Couples of Sickle Cell Disorders in Madhya Pradesh, Central India
Ranbir S. Balgir, PhD;

Original Article

International Journal of MCH and AIDS
Volume 2, Issue 2, Pages 220 - 228
Nutritional Deficiencies and Food Insecurity Among HIV-infected Children in Tanzania
Chelsea E. Modlin, BA; Helga Naburi, MD; Kristy M. Hendricks, ScD, RD; Goodluck Lyatuu, MD; Josphine Kimaro, RD; Lisa V. Adams, MD; Paul E. Palumbo, MD; C. Fordham von Reyn, MD;

Original Article

International Journal of MCH and AIDS
Volume 2, Issue 2, Pages 212 - 219
Socio-economic and Demographic Determinants of Antenatal Care Services Utilization in Central Nepal
Srijana Pandey, PhD; Supendra Karki, MPH, MA;


International Journal of MCH and AIDS
Volume 2, Issue 2, 2014, Pages 209 – 211
Forward to AIDS 2014: Now is the Time to Unite for the Global HIV/AIDS Epidemic
Gregory Pappas, MD, PhD
International Journal of MCH and AIDS
Volume 2, Issue 2, 2014, Pages 209 – 211
Forward to AIDS 2014: Now is the Time to Unite for the Global HIV/AIDS Epidemic

Gregory Pappas, MD, PhD1

1 International Global Health Consultant, Washington, DC, USA

imgCorresponding author e-mail:



As AIDS activists, advocates, researchers, practitioners, scientists, and policy makers from around the world prepare for the forthcoming 20th International AIDS Conference (AIDS 2014) which takes place from 20-25 July in Melbourne, Australia, Gregory Pappas, MD, PhD, former Executive Director of the Washington DC’s local Host Committee, International AIDS Society (IAS) organizing committee member, and Director, HIV/AIDS Program in the District of Columbia, Washington, DC, USA, reflects, for the first time, on his experiences hosting the world conference and bringing AIDS conference to United States after 22 years. He shares some of the key challenges and opportunities confronting program planners, policy makers and advocates in the efforts to address the global epidemic.

Copyright 2014 © Pappas. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

From 22-27 July 2012, the XIX International AIDS Conference (AIDS 2012) was held in Washington DC, USA—the nation’s capital. The meeting of International AIDS Society (IAS) had not been held in the United States in 22 years because of a ban on travel of HIV+ people into the United States which began after the 1990 meeting held in San Francisco. During the early days of the Obama administration the ban was lifted. Then, in recognition, the IAS planned its return to DC. The theme of the conference was “Turning the Tide” seizing the moment when so much science has made the end of AIDS a realistic goal.

AIDS 2012 was the premier gathering for scientists, policy makers, and advocates working on HIV/AIDS science, policy, and advocacy to end the epidemic. Much of the planning and content of the program was done by people living with the virus. The meetings presented recent scientific developments and lessons learned from around the globe, and gave a collective direction to the global fight against HIV/AIDS.

The meeting included abstract-driven presentations to symposia, bridging and plenary sessions. The Global Village was free and open to the public and provide, satellite viewing of the meetings, exhibitions and affiliated independent events. The Global Village was held inside the Washington Convention Center, in a space below where the scientific portion of the meeting was held. Because the space was public, it was a favorite for demonstrations and advocacy events, which have been a part of IAS meetings since their beginnings.

As the host city, the District of Columbia, United States capital, was in the global spot light—not for what was going on in the United States Congress or the White House—but instead for what was happening in neighborhoods and the local government’s fight against the virus. I had a unique opportunity to help plan and participate as the director of the city government’s HIV/AIDS program. The Mayor of DC launched a Host Committee to work with IAS to ensure the meeting went smooth and was well supported by city services, that the program and scientific work done in DC were used as show cases, and that financial benefit come to the city through hosting the meeting. I was the executive director of the Host Committee and a member of the IAS organizing committee. From this unique perspective I reflect on the HIV/AIDS epidemic in DC and the way that the global becomes local and local becomes global.

First, the meeting was an opportunity to reframe the fight against HIV in the nation’s capital which has been compared to African epidemics and claims were often repeated that DC had the highest rates of HIV in the nation. This narrative was familiar to many and promoted both by critics of the city and those who sought to dramatize the depths of the epidemic. In fact, DC has emerged as a model local response and leader in the implementation of the US National HIV/AIDS Strategy. According to a US Centers for Disease Control and Prevention (CDC) study, half of the people living with HIV in the US resided in twelve cities: although DC was not at the top of that list, it hovered between 3rd or 4th position depending on the measures.[1]

DC exemplified the theme of the meeting, Turning the Tide, by cutting new diagnoses of HIV in half over a five year period and decreasing disparities.[2] This happened during an era when the number of US national infections had stagnated at about 55,000 a year for a decade. DC made these strides by following the evidence base that guided the US National HIV/AIDS Strategy. The strategy emphasized aggressive and early testing; rapid connection to care; and suppression of viral load through adherence. The DC Mayor’s HIV/AIDS Commission had endorsed “Treatment on Demand” in the District and everyone in the city has access to antiretrovirals regardless of ability to pay or immigration status. Following this initiative, testing for HIV has increased dramatically over the past years with HIV testing available through the city, routine in most clinics, and available in non-clinical settings including the Department of Motor Vehicles where people waited for driver’s license and other related purposes. By 2012, over 80% of newly diagnosed were connected to care in three months, a dramatic increase from 2008. The standard expected by the city with the contracted community based organization was to have a newly diagnosed person into a doctor’s office within 48 hours. While sustained adherence remains a problem, rates of viral suppression increased over the same period. Movement towards greater coordination between providers and progress toward better care through Patient Centered Medical Homes has begun.

Activism and advocacy were also important at AIDS 2012. The meetings demonstrated again that the local has truly become global and that global is always local. A year in advance to the meeting, when consciousness of the meeting had just begun, international activists from many aspects of the fight against AIDS reached out to local counterparts in DC and local activists from around the world were in contact. The movement to promote safe infections (also known as needle exchange) provides a vivid example of the complexities and opportunities these dynamics provide. DC has a very successful needle exchange program which cut new diagnoses among intravenous drug users (IVDU) in half since the program started to scale up in 2007. City tax dollars are used to support community based programs to provide clean needles and other services to IVDU including a van that travels in neighborhoods late into the night, distributing educational materials, condoms and clean needles. This happens in the shadow of the federal government which forbids use of federal dollars for needle exchange. Because of the unique relationship between DC and the federal government, the city budget, including allocation of taxes collected by the city, must go through a federal committee for approval. Sensitive national social issues (abortion, needles exchange) are frequent flash points between the city and the federal government.

The success of DC’s needle exchange program is in large part due to the thoughtful way in which the program was designed and executed. Those who request needles must register with the community based organization that provides them with a card. This card can be shown to law enforcement officers who are educated about the program, in a city in which these needles are illegal outside of the medical prescription context.

The global activists were aware of the local program and some of them had helped create the original local policy. When the planning for AIDS 2012 began, they started planning for advocacy to draw in the thousands attending the conference and the hundreds of journalists from around the world. Initially the global activists had agreed with the local activists to distribute clean needle in and around the conference. Safe infection was an emotional issue for many local and global HIV/AIDS activists. The proposed demonstration would have clearly been in violation of city law and could possibly draw the notice of federal law makers opposed to the programs.

After considerable negotiations at many levels (including highest federal) it was agreed upon that the DC Van would be parked inside the Global Village but that needles would not be distributed or on display. Special sessions on safe infections and attention to the city’s successes were highlighted in the Global Village and in a number of media opportunities. Global became local and may have disrupted the city program and success. Local global collaboration ensured a successful conference for all parties.

The 20th International AIDS Conference (AIDS 2014) will be held from 20-25 July 2014 in Australia at the Melbourne Convention and Exhibition Centre. The meeting will spotlight diverse nature of the epidemic and the response to it in the Asia Pacific region. As the world turns its attention to AIDS 2014, lessons learned from our experience planning and hosting AIDS 2012 raise a number of programmatic, policy, and advocacy issues.

The global IAS meetings continue to be an exciting opportunity for scientists, program and service providers, the media, and activists to come together. The epidemic and medical response to the disease has changed so much advocacy and activism. While the desperation of activism in earlier IAS meetings has waned, activism still has a critical role to play in promoting science, policy, and funding. Activism continues to play the watch dog role on public and private actors, governments, and drug companies. The time may have come, however, for consolidation of efforts that are disparate and uncoordinated. In an era of waning funds available to activist organization many of these organizations have folded or have weakened. It is better that they merge and find common voice. In the US alone there are still dozens of different organizations working on HIV/AIDS. This may be the time for emergence of a unified voice for HIV/AIDS, analogous to the American Cancer Society, and for other disease areas. The epidemic in the US and in many parts of the globe continues to spread and people still die prematurely. AIDS 2012 was a time to reconsider advocacy and explore new ways to work together to fight the epidemic. AIDS 2014 should be the time for all to come together.

Conflict of Interest: None declared


1.Hall, HI, Espinoza L, Benbow N, Hu YW. Epidemiology of HIV infection in large urban areas in the United States. PloS One. 2010; 5(9): e12756.

2.District of Columbia Department of Health. 2012 Annual Epidemiology and Surveillance Report. Washington, DC; 2014. Accessed March 12, 2012.

Original Article

International Journal of MCH and AIDS
Volume 2, Issue 2, 2014, Pages 200 – 208
Do Infant Birth Outcomes Vary Among Mothers With and Without Health Insurance Coverage in Sub-Saharan Africa? Findings from the National Health Insurance and Cash and Carry Eras in Ghana, West Africa
Abdallah Ibrahim, DrPH; Anne Marie O’Keefe, PhD, JD
International Journal of MCH and AIDS
Volume 2, Issue 2, 2014, Pages 200 – 208
Do Infant Birth Outcomes Vary Among Mothers With and Without Health Insurance Coverage in Sub-Saharan Africa? Findings from the National Health Insurance and Cash and Carry Eras in Ghana, West Africa
Abdallah Ibrahim, DrPH;1 Anne Marie O’Keefe, PhD, JD2
1School of Public Health, College of Health Sciences, University of Ghana, Accra, Ghana.
2School of Community Health and Policy, Morgan State University, Baltimore, Maryland 21251, USA.
imgCorresponding author e-mail:



Background: Beginning in the late 1960’s, and accelerating after 1985, a system known as “Cash and Carry” required the people of Ghana to pay for health services out-of-pocket before receiving them. In 2003, Ghana enacted a National Health Insurance Scheme (NHIS) (fully implemented by 2005) that allowed pregnant women to access antenatal care and hospital delivery services for low annual premiums tied to income. The objective of this study was to compare trends in low birth weight (LBW) among infants born under the NHIS with infants born during the Cash and Carry system when patients paid out-of-pocket for maternal and child health services.

Methods: Sampled birth records abstracted from birth folders at the Tamale Teaching Hospital (TTH) were examined. Chi-squared tests were performed to determine differences in the prevalence of LBW. A p-value of ≤ 0.05 was considered statistically significant. Analyses were conducted for selected variables in each year from 2000 to 2003 (Cash and Carry) and 2008 to 2011(NHIS).

Results: Higher birth weights were not observed for deliveries under NHIS compared to those under Cash and Carry. More than one-third of infants in both eras were born to first-time mothers, and they had a significantly higher prevalence of LBW compared to infants born to multiparous mothers.

Conclusion and Global Health Implications: Understanding the factors that affect the prevalence of LBW is crucial to public health policy makers in Ghana. LBW is a powerful predictor of infant survival, and therefore, an important factor in determining the country’s progress toward meeting the United Nations Millennium Development Goal of reducing under-five child mortality rates (MDG4) by the end of 2015.

Keywords: Infant Birth Outcomes • Low Birth Weight • Sub-Saharan Africa • Ghana • National Health Insurance Scheme • Cash and Carry

Copyright © 2014 Ibrahim et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


Prior to the nation’s independence, the health care system in Ghana under colonial rule was organized primarily for the benefit of the elite few. The development of public health services in Ghana (formerly the Gold Coast) dates back to the 1880s, when the Gold Coast Medical Department was established to provide rudimentary services to European colonial government officials.[1] In the 20th century, a colonial health policy of prevention for the indigenous population was recognized through the establishment of the Sanitary Branch in 1909, and the Medical Research Institute in 1917, which trained paramedical personnel.[1] The colonial government provided free health services to civil servants, but those not in civil service and their families were left to secure their own health care at their own expense.

When Ghana attained independence under Kwame Nkrumah in 1957, a national health service (NHS) similar to that of Britain’s was established to extend free care to the entire population at government health facilities. The NHS system remained in place until shortly after 1966, when the Nkrumah government was overthrown in a military coup.[2,3] A system for health service fees was introduced through the Hospital Fees Decree in 1969, later amended by the Hospital Fees Act in 1971, but the fees were never fully implemented. Fees were eventually imposed under the Hospital Fees Regulation of 1985, when economic growth slowed and rising inflation crippled Ghana’s economy and forced the country to turn to the International Monetary Fund and the World Bank for financial assistance.[4,5]

As Ghana’s economy worsened, government expenditures on health care, which averaged 2.3 percent of the gross domestic product in 1998-2002, declined to around 1.9 percent in 2003-2004.[4,6] Declining government expenditures on health care shifted the burden of health costs onto the Ghanaian population through health user fees (a system also known as “Cash and Carry”) that required patients to pay money upfront to health facilities before services were provided. The Cash and Carry system created financial barriers to health services for the majority of the nation’s poor who could not afford to pay for even basic health care, including reproductive health services. While the Cash and Carry system was in effect, disparities in health care access and health status between Ghana’s rural and urban populations became more pronounced.[7] Even though some services, such as antenatal and postnatal care and immunizations, were to be exempted from health user fee payments, in practice they often were not, and the out-of-pocket costs had a negative impact on people’s overall health, especially on birth outcomes among the most vulnerable. Many studies found that in Ghana and elsewhere, the number of patients treated at government health facilities dropped immediately following the introduction of health user fees.[1,7,8]

The majority of poor people in Northern Ghana faced the biggest barrier to health care due to high out-of-pocket costs.[8,9] Eliminating the financial barriers to health care for the majority poor in Ghana, especially those in Northern Ghana, was the government’s primary public health goal when it introduced the national health insurance scheme (NHIS) after passage of the National Health Insurance Act (NHIA) by Ghana’s Parliament in 2003.[10]

Access to health services through programs such as the national health insurance scheme in Ghana allows pregnant women the opportunity to visit health facilities for antenatal and delivery services that they could not otherwise afford. The NHIS, which started in 2003 on a limited basis in four of Ghana’s ten regions, was fully implemented nationwide by 2005. The program requires all adults in Ghana aged18 and older to enroll in the NHIS and pay premiums that range from the equivalent of $2.50 up to $50.00 annually, depending on each enrollee’s financial and employment status.[11,12] The scheme provides coverage for children 17 years and younger without premium payments, provided the child’s parents are fully registered in the program. Pregnant women with low incomes are also provided free coverage under the NHIS to enable them to access antenatal services and skilled care at delivery.[13] Although membership in the NHIS had declined in some of Ghana’s districts, there was a 118 percent increase in membership among the indigent population in Northern Ghana between 2007 and 2008. Overall, NHIS participants in Northern Ghana increased from 143,460 to 863,099 users between 2005 and 2008, a 502 percent increase in just three years.[14] The increase in enrollment among the poor in Northern Ghana ensured that a majority of pregnant women would be able to access skilled care at the hospital rather than deliver at home.

The NHIS has been operational in Ghana for a decade now, supporting increased access to skilled care at health facilities for the majority of indigent pregnant women in Northern Ghana. However, research has not adequately tracked the program’s utilization, particularly service utilization and birth outcomes among the poor in Northern Ghana. Most studies of the NHIS have focused on enrollment and access; very few address birth outcomes. Particularly absent are studies that compare birth outcomes under the Cash and Carry system with those under national health insurance in sub-Saharan Africa, especially in Ghana.[15]


This study used sampled birth records abstracted from birth registry folders at the Tamale Teaching Hospital (TTH), the primary referral hospital for the entire northern sector of Ghana. Tamale, the regional capital of the Northern Region, is the fourth largest city in Ghana. It has a population of a little less than 380,000, of which 51 percent are female and 49 percent male. The annual population growth rate of Tamale is about 3 percent.[16]

Birth outcome data at TTH are recorded in the labor and maternity ward’s delivery folders at the time of birth. The validity of these records is ensured through cross-checking by a head nurse and the supervising obstetrician. For this research, the delivery folders for the years 2000-2003 (when Cash and Cary was in effect) and 2008-2011 (after full implementation of NHIS) were arranged chronologically, and selected in a systematic sampling method that examined and abstracted birth records of each day’s deliveries. Days with fewer or no birth records were accommodated by over-sampling records from the day before or after. Sampling ensured representation of Northern Ghana’s dry and wet climatic seasons. The sampled birth records were analyzed using STATA, Version 11.2 (Stata Corp, College Station, TX).

The primary aim of this study was to examine trends in LBW among infants delivered under the Cash and Carry system, compared to the NHIS. Chi-squared tests were used to determine changes in prevalence (and significance) of LBW. Analyses were performed for each of the selected variables in both periods 2000-2003 and 2008-2011. Analyses with a p-value ≤ 0.05 were considered statistically significant. The dependent variable – birth weight (in grams) of live births – which is a continuous variable, was coded as a dichotomous variable so that LBW (< 2,500g) and normal birth weights (≥ 2,500g) yielded the desired outcomes in repeated measurements. The independent variables — maternal age, parity (number of times a woman has given birth), maternal hemorrhage (blood loss), miscarriage (including induced abortion), type of birth (vaginal or Caesarian section), fetal heart rate, and gender — were selected because they have been documented in previous research to be associated with birth weight. Deliveries during the Cash and Carry period were used as a proxy for lack of access to insurance and professional antenatal care prior to childbirth, while deliveries under NHIS represented access to health insurance and at least four antenatal care visits prior to childbirth at TTH. It had already been established that in Ghana more than 98 percent of pregnant women receive antennal services under the NHIS; the majority of women (85% or more) receive at least the four antenatal visits recommended by the World Health Organization prior to delivery.[13,17,18]

The Administration at Tamale Teaching Hospital in Ghana granted permission for the abstraction of the birth records from the hospital’s labor and maternity ward. Morgan State University’s Institutional Review Board (IRB) also approved this research.


The total number of birth records examined for this study was 7,895. This included 3,686 Cash and Carry and 4,209 NHIS live birth records. The mean maternal age was 27 (SD=6), with a range of 14 to 50 years. The mean birth weight was 2,875grams (SD=576). Table 1 presents a descriptive outcome of total delivery records of live births analyzed in this study.

Table 1.     Characteristics of all live births under Cash and Carry and NHIS systems at Tamale Teaching Hospital in Northern Ghana


Trends in the prevalence of LBW among all infants born in 2000-2003 and 2008-2011 are presented in Table 2. A higher prevalence of LBW was observed among young mothers (aged 18-24) compared to mothers aged 25 and older. The prevalence of LBW among younger mothers ranged from 17.5 percent to 36.8 percent [p<0.001] under Cash and Carry, compared to 16 percent and 22 percent [p>0.05] under NHIS.

Table 2.     Prevalence of LBW in live birth infants during the Cash and Carry and NHIS systems of care, and by selected maternal and other variables in Northern Ghana


First-time mothers (parity = none) under Cash and Carry were also significantly more likely to deliver low birth weight infants, with prevalence ranging from 17% to 35.8% [p<0.001], compared to the LBW prevalence among first-time mothers under NHIS of 17% to 21.9%, [p>0.05]. There were no significant changes observed in trends for LBW among mothers with prior childbirth experience (parity = one or more) under either Cash and Carry or NHIS.

In 2000-2003 (Cash and Carry), Caesarean deliveries comprised 11to 17 percent of total deliveries, compared to 2008-2011 (NHIS) when they accounted for 18 to 22 percent. The prevalence of LBW among Caesarean deliveries under Cash and Carry went from 14 percent in 2000 to 19 percent in 2003, compared to 15 percent in 2008 and 27 percent in 2011 under NHIS. However, vaginal deliveries showed mixed results for the prevalence of LBW in both periods. In 2000, the LBW prevalence for vaginal births was 26 percent; it decreased significantly to 15 percent [p<0.001] by 2003. In 2008, the LBW rate was 14 percent; this increased to 19 percent by 2011, but the change was not statistically significant.

Trends in LBW among infants with normal fetal heart rates of 130-140 beats per minute prior to birth significantly decreased from 25 percent [p<0.001] in 2000 to 15.6 percent [p<0.01] in 2003; LBW in this category increased from 15 percent [p>0.05] in 2008 to 20.8 percent [p<0.05] in 2011, which was not statistically significant.


This study examined trends in LBW among infants born during the Cash and Carry period compared to infants born under the NHIS. Associations between LBW and factors such as maternal age, parity, Caesarean delivery, and infant’s gender have all been well documented in other research.[19,20] The majority of infants in this study – approximately 85 percent – were delivered by mothers 18 to 34 years old. Mothers aged 18 to 24 in both the Cash and Carry and NHIS systems were more prone to deliver LBW infants compared to older mothers. This suggests that regardless of the mother’s insurance status at delivery, her age was a factor in her infant’s birth weight. This finding is consistent with similar findings from Tanzania.[21]

The current study showed that more than one-third of infants were born to first-time mothers, who experienced significantly higher prevalence of LBW in both the Cash and Carry and NHIS periods. However, there were no substantial differences in the prevalence of LBW among infants born to mothers with prior birth experience (parity = one or more) in 2001-2003 (Cash & Carry) compared to infants born in 2009-2011 (NHIS) by mothers with similar parity. This suggests that delivery under NHIS, which guaranteed access to antenatal care, did not translate into a reduction in LBW births among multiparous mothers. This is also confirmed by research on multiparous women and LBW conducted in other African countries and the US.[22,23]

More than 90 percent of all infants from the Cash and Carry and the NHIS periods were born to mothers with no history of miscarriages or prior experience of induced abortion. Year-to-year trends showed that during the Cash and Carry period, mothers with no history of miscarriage gave birth to infants with a significantly higher prevalence of LBW in 2000, which decreased by as much as 38 percent by 2003. Under the NHIS, there was a lower prevalence of LBW in 2008, which increased by about 50 percent by 2011. This indicates that access to health services under NHIS had little impact on infants’ birth weight for mothers with no history of miscarriage. The improvement in birth weights among mothers with no history of fetal loss during Cash and Carry is consistent with similar findings observed among African-born Black women in the US.[23]

Fewer mothers had Caesarean deliveries during Cash and Carry compared to NHIS. Caesarean deliveries in the former period generally constituted less than 15 percent of total births (except 17% in 2003), which the WHO recommends should be the upper limit for Caesarean deliveries compared to all births.[24] Under NHIS, more deliveries occurred by Caesarean, which increased from 18 percent in 2008 to 22 percent by 2011. The increased use of Caesarean sections may have resulted from several factors including the availability of insurance coverage, which provided an incentive for compromised pregnancies to be surgically delivered. The observed increased use of Caesarean deliveries under the Ghanaian insurance program was similar to that seen in a large East African hospital.[25] These results highlight the possibility that when patients pay for care out-of-pocket, fewer opt for the more expensive Caesarean procedure. The significant increase in the prevalence of LBW among Caesarean-sectioned infants observed under NHIS could be explained by the availability of NHIS making it possible for more mothers with compromised pregnancies (and therefore prone to having LBW infants) taking advantage of Caesarean delivery to prevent adverse pregnancy outcomes.

Infants with normal fetal heart rates of 130-140 bpm were generally born at higher birth weights than infants who had abnormal fetal heart rates. The observed association between normal pre-delivery fetal heart rates and higher birth weights in this study is consistent with the results of other research.[26]

More than half of all infants born under Cash and Carry and NHIS were male. Access to the NHIS had no impact on the sex ratio of new babies.


Even though this study revealed mixed trends on birth weights related to selected variables under the Cash and Carry and NHIS periods, the large sample size and the comparability of the birth records increased the robustness of the study. However, there are some significant limitations in this research, including the fact that hospital-based data in sub-Saharan Africa generally exclude those women who choose to deliver at home. At-home delivery is still a common practice in Northern Ghana and elsewhere in Africa despite the availability of insurance and skilled care.[18,27]Data on mothers who opted for the services of traditional birth attendants (TBA) even after accessing antenatal care services at the hospital were not included in this research. Other important variables that have been shown to affect birth weight, such as gestational age and mother’s weight gain during pregnancy, were not available and therefore not included in this analysis.[28,29] The absence of socioeconomic information about the mothers was also a major limitation. Though the delivery folders generally capture a range of birth outcome data at the time of delivery, information such as mother’s income, educational level, employment status, marital status, and religion are not recorded in the delivery folders. These factors might have provided important additional information about trends in birth weights during the Cash and Carry and NHIS periods.

Despite its limitations, the hospital-based delivery data set showed that overall trends in birth weight outcomes were not significantly impacted by the introduction of NHIS compared to Cash and Carry. However, younger and first-time mothers delivered more LBW babies under Cash and Carry compared to NHIS, and more LBW babies were delivered by Caesarian under NHIS. Although Northern Ghana is an economically deprived part of the country, it is also possible that women with higher socioeconomic status self-selected to deliver at the hospital during Cash and Carry.

This research reveals important information about the birth weights of infants born at Northern Ghana’s major hospital. However, the limitations discussed earlier make a strong argument for further research on birth outcomes, especially birth weights. Future research should incorporate the key factors that limited this study, including: mothers’ socioeconomic status; gestational age; maternal weight gain during pregnancy; and the number of antenatal care visits for each mother prior to delivery. If available, data from at-home births should also be included to help clarify causation and increase the generalizability of the research.

Global Health Implications

There is a consensus in public health research that insurance coverage, which reduces the financial barriers to health care services, improves general health outcomes. Understanding the differences in the prevalence of low birth weight between the Cash and Carry and NHIS systems in Northern Ghana is important for public health policy makers there, especially as the country hopes to meet the United Nations Millennium Development Goals (MDG) by the end of 2015. Since birth weight is an important predictor of infants surviving their first year of life, the variables revealed by this research to be related to LBW under NHIS should help guide maternal and child health policies, particularly as they relate to health facilities, TBAs, antenatal services, and nutritional guidelines to improve birth outcomes. The mortality rate for children under five years remains high in Ghana, especially in the Northern Region. By understanding the factors that affect LBW, the country can focus its resources and efforts to ensure that infants are born at normal birth weights, which is a well documented indicator for their survival.[30]

Financial Disclosure: None; Funding Support: None; Conflicts of Interest: None;

Acknowledgements: The authors acknowledge the staff of the Tamale Teaching Hospital for their immense contribution during the data collection at the hospital including Dr. David Kolbila, Dr. Abass Adam, Nathanial Akorli, Hussein Abdul-Rahman, Abdul-Jalil Mohammed, Abdul-Shattar Abdulai, Awal Alhassan, and Nurudeen Haruna.


1.Mill A. Health policy reforms and their impact on the practice of tropical medicine. British Medical Bulletin. 1998; 54(2):503–513.

2.Johnson JA, Stoskopf CH. Comparative health systems: Global perspectives for the 21st century. Jones & Bartlett, Sudbury, MA. 2010.

3.Ibrahim A. The role of an American nongovernmental organization (NGO) in promoting democracy in Ghana: 1992-2000. Master’s Thesis, Morgan State University, Baltimore, MD. 2002.

4.Nketiah-Amposah E. Demand for health insurance among women in Ghana: Cross sectional evidence. International Research Journal of Finance and Economics. 2009;(33): 179–191.

5.Nyonator F, Kutzin J. Health for some? The effects of user fees in the Volta Region of Ghana. Health Policy and Planning. 1999; 14(4):329–341.

6.World Health Organization (2005). Health expenditure trends in selected countries. Accessed 10 October 2013.

7.Asenso-Okyere WK. Financing health care in Ghana. World Health Forum. 1995; (16): 86–94.

8.Horton R. Ghana: defining the African challenge. The Lancet. 2001; (358):2141–2149.

9.Biritwum RB. Promoting and monitoring safe motherhood in Ghana. Ghana Medical Journal. 2006; 40(3):78–79.

10.Gobah FK, Liang Z. The National Health Insurance Scheme in Ghana: prospects and challenges: A cross-sectional evidence. Global Journal of Health Sciences. 2011; 3(2).

11.Frempong G. An evaluation of the National Health Insurance Program in Ghana. Global Development Network (GDN) Dissemination Workshop, Pretoria, South Africa. 2009.

12.Sarpong N, Loag W, Fobil J, Meyer CG, Adu-Sarkodie A, May J, Schwarz NG. National Health Insurance coverage and socio-economic status in a rural district of Ghana. Tropical Medicine & International Health. 2010; 15(2):191–197.

13.Sulzbach S, Garshong B, Owusu-Banahene G. Evaluating the effects of the National Health Insurance Act in Ghana: Baseline report. Partners for Health Reformplus (No. TE 090), Bethesda, Maryland. 2005.

14.SEND–Ghana. Balancing access with quality health care: An assessment of the NHIS in Ghana (2004-2008). Program Report, Accra, Ghana. 2010.

15.Saaka M. Maternal dietary diversity and infant outcome of pregnant women in Northern Ghana. International Journal of Child Health and Nutrition. 2012; 1(2):148-156

16.Ghana Statistical Service. Ghana living standards survey: report of the fifth round (GL SS 5). Accra, Ghana. 2008.

17.Mills S, Williams JE, Adjuik M, Hodgson A. Use of health professionals for delivery following the availability of free obstetric care in Northern Ghana. Maternal and Child Health Journal. 2008; 12:509-518.

18.Hatt L, Chankova S, Sulzbach S. Maternal health in Ghana: investigating the impact of the National Health Insurance Scheme on maternal health indicators. USAID-Health Systems 20/20. 2009; Accessed 23 November 2013.

19.Yadav H, Lee N. Maternal factors in predicting low birth weight babies. Medical Journal of Malaysia. 2013; 68(1).

20.Assefa NB, Berhane Y, Worku A. Wealth status, mid upper arm circumference (MUAC) and antenatal care (ANC) are determinants for low birth weight in Kersa, Ethiopia. PLoS ONE 7(6): e39957. DOI:10.1371/journal.pone.0039957. 2012.

21.Muganyizi PS, Kidanto HL. Impact of change in maternal age composition on the incidence of Caesarean section and low birth weight: Analysis of delivery records at a tertiary hospital in Tanzania, 1999–2005. BMC Pregnancy and Childbirth. 2009; 9(30). Accessed 6 July 2013.

22.Andersson R, Bergstrom S. Maternal nutrition and socio-economic status as determinants of birthweight in chronically malnourished African women. Tropical Medicine and International Health. 1997; 2(11):1080-1087.

23.David RJ, Collins RW. Differing Birth weight among infants of U.S.-Born Blacks, African-Born Blacks, and U.S.-Born Whites. 1997. Accessed 9 July 2012.

24.Chaillet N, Dubé E, Dugas M, Francoeur D, Dubé J, Gagnon S, Poitras L, Dumont A. Identifying barriers and facilitators towards implementing guidelines to reduce Caesarean section rates in Quebec. Bulletin of the World Health Organization. 2007; 85(10):733-820.

25.Worjoloh A, Manongi R, Oneko O, Hoyo C, Daltveit AK, Westreich D. Trends in Cesarean section rates at a large East African referral hospital from 2005-2010. Open Journal of Obstetrics and Gynecology. 2012; (2):255-261. DOI:10.4236/ojog.2012.23053. Accessed from

26.Coutinho PR, Cecatti JG, Surita FG, Costa ML, Morais SS. Perinatal outcomes associated with low birth weight in a historical cohort. Reproductive Health. 2011; 8(18).

27.Shiferaw S, Spigt M, Godefrooij M, Melkamu Y, Tekie M. Why do women prefer home births in Ethiopia? BMC Pregnancy and Childbirth. 2013; 13(5). Doi:10.1186/1471-2393-13-5.

28.Ezeaka V, Eroha E, Egri-Okwaji WT. Maternal socio-biological factors associated with low birth weight in Lagos, Nigeria. Nigerian Quarterly Journal of Hospital Medicine. 2003;13:1-2.

29.Onyiriuka A. Low birthweight infants in twin gestation. Current Pediatric Research. 2011; 15(1): 37-41.

30.United Nations Children’s Fund and World Health Organization. Low birthweight: Country, regional and global estimates. UNICEF, New York. 2004

Original Article

International Journal of MCH and AIDS
Volume 2, Issue 2, 2014, Pages 190 – 199
Global Health Donor Presence, Variations in HIV/AIDS Prevalence, and External Resources for Health
in Developing Countries in Africa and Asia

Romuladus Emeka Azuine, DrPH, RN; Gopal K. Singh, PhD; Sussan E. Ekejiuba, DVM, PhD; Eta Ashu,
MSc; Magnus A. Azuine, PhD
International Journal of MCH and AIDS
Volume 2, Issue 2, 2014, Pages 190 – 199
Global Health Donor Presence, Variations in HIV/AIDS Prevalence, and External Resources for Health in Developing Countries in Africa and Asia

Romuladus Emeka Azuine, DrPH., RN;1,2 Gopal K. Singh, PhD;1,2 Sussan E. Ekejiuba, DVM, PhD;1 Eta Ashu, MSc;1,4 Magnus A. Azuine, PhD3

1 Center for Global Health and Health Policy, Global Health and Education Projects, Inc., Riverdale, MD 20738, USA.
2 Maternal and Child Health Bureau, Health Resources and Services Administration, US Department of Health and Human Services, Rockville, MD 20857, USA.
3 TransWorld Development Initiatives, Inc., Brentwood, MD 20772, USA.
4 Francophone Community Health Center, Hamilton/Niagara, 460 Main Street E, Hamilton, Ontario, L8N 1K4, Canada.
imgCorresponding author email:



Objective: The presence of multiple global health aid organizations in donor recipient countries at any point in time has led to arguments for and against aid coordination and aid pluralism. Little data, however, exist to empirically demonstrate the relationship between donor presence and longitudinal disease outcomes in donor-recipient countries. We examined the association between global health donor presence and changes in HIV/AIDS prevalence in 14 developing countries: 12 in Africa (Ethiopia, Kenya, Tanzania, Malawi, Zimbabwe, Mozambique, Rwanda, South Africa, Uganda, Zambia, Burkina Faso and Mali) and compared them with two developing countries in Asia (India and Vietnam).

Methods: To conduct our analyses, we conceptualized a framework for examining global health donor presence and disease outcomes. Donor presence data were derived from Mapping the Donor Landscape in Global Health: HIV/AIDS, a report published by the Kaiser Family Foundation, Washington, DC, USA. HIV/AIDS prevalence data were obtained and analyzed from the World Health Statistics and the Demographic and Health Surveys. Percent changes in national HIV/AIDS prevalence between 2009 and 2011 in the 14 developing countries were computed and correlation coefficients between donor presence and prevalence changes were calculated.

Results: Between 2009 and 2011, HIV/AIDS prevalence decreased in all but one of the 14 developing countries with the presence of 21 or more global health donors. There was about 40% overall reduction in HIV/AIDS prevalence across the 14 countries in our analyses. South Africa recorded the most reduction in HIV/AIDS prevalence (-6.7%) followed by Zambia (-6.3, %), and Mozambique (-5.7%). Ethiopia was the only country without a reduction in HIV/AIDS prevalence (+0.1%). A correlation coefficient of 0.43 implied greater reductions in HIV/AIDS prevalence associated with increased donor presence.

Conclusions and Public Health Implications: Our study shows a correlation between donor presence and HIV/AIDS disease burden in 14 donor-recipient countries. Our findings indicate that increased donor presence yields quantifiable reduction in global health disease burden. Further research is needed to demonstrate whether these gains can be observed in other global health disease outcomes.

Key words: Global health • Donor presence • Donor coordination • Developing countries • Africa • Asia • HIV/AIDS • Global health conceptual framework

Copyright: © 2014 Azuine et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

IntroductionAt any point in time, there are numerous aid organizations providing development aid to address global health and other social and economic development issues in low and middle income countries (LMICs), also known as developing countries, a phenomenon referred to as “aid pluralism.” The pluralistic nature of aid organizations and the programmatic fragmentation that culminates from aid pluralism have led to increasing calls for donor coordination in aid assistance. According to proponents, donor coordination in global health and international development is important in maximizing population-level impact in global health.[1] There are ongoing worries about the fragmented nature of donor activities and presence manifested often in duplicative programs or programs that ought to complement each other. Advocates of donor coordination argue that aid coordination leads to efficiency and effectiveness; they further argue that efficiency and effectiveness ensure that increased funding subsequently culminates in the reduction in disease burden in nations receiving aid from a more coordinated donor community.[2]In making their case for improved aid coordination, McCoy and colleagues[2] lamented that:

“The fragmented, complicated, messy and inadequately tracked state of global health finance requires immediate attention. In particular it is necessary to track and monitor global health finance that is channeled by and through private sources, and to critically examine who benefits from the rise in global health spending.”

Implicit in the calls for donor coordination are two principal assumptions. First, proponents of donor coordination believe that the presence of multiple donor organizations both from the public (governments) and private (foundations) sector actors is a reality with inherent benefits. Second, calls for donor coordination are fuelled by the assumption of the potential benefits of pooled resources (or economies of scale) in addressing major global health challenges within the donor receiving countries as evidenced in aid alignment through sector-wide approaches.[3] More recently, proponents of donor coordination are energized by the emerging concept of “collective impact,” an organizing concept that opines the importance of leveraging broad sector coordination to achieve large-scale social change.[4] Collective impact opines that although large-scale social change requires broad cross-sector coordination, the social sector regrettably remains focused on the isolated intervention of individual organizations.[4] One apparent acknowledgment of the importance of donor coordination in global health was the founding, in 2002, of the Global Fund to Fight AIDS, Tuberculosis, and Malaria (the Global Fund), an international financing institution working as a partnership between government, civil society, the private sector and communities living with TB, Malaria and AIDS.[5] Although it has enjoyed mixed reviews, Global Fund was a practical manifestation of the calls for donor coordination.

In opposition to aid coordination are proponents of aid pluralism who argue that having a range of active donors is in tandem with, and at the heart of, competitive economics that ought to be nurtured and not jettisoned within the development sector.[6,7] Proponents of aid pluralism argue that too much aid coordination is akin to low competition among donor organizations and that this could lead to unintended negative consequences—creating new aid monopolies—a milieu that is fraught with little aid effectiveness.[8] According to this view point, donors enjoying monopoly in a sector are more likely to impose their biases on recipient countries, their staff, and potentially tie aid to conditions, demonstrate the political nature of and consequently alienate recipients detracting from the overall goals of these development aids.[9] Aid pluralism proponents identify benefits of aid pluralism to include engendering of more ideas, competition, innovation, and consistent flow of funding.[6,7]

Calls for donor coordination and efforts or global health frameworks to engender donor coordination are not new, although they have been more prominent in the literature and in the advocacy world. In the last decade or so, there have been at least seven prominent global health efforts aimed at increasing donor coordination. These include the Organization for Economic Cooperation and Development’s (OECD’s) Development Assistance Committee (DAC) of 1960; the United Nations Development Program of 1965; the Rome High Level Forum on Donor Harmonization of 2003; the Paris Declaration on Aid Effectiveness of 2005; the Accra Agenda for Action of 2008; and the Busan Partnership for Effective Development Cooperation of 2011.[10] The 2005 Paris Declaration, endorsed by ministers of developed and developing countries and heads of multilateral and bilateral development institutions, committed to taking far-reaching and monitorable actions to reform the ways donor countries and agencies deliver and manage their aids. Five years later in 2010, leaders of eight leading global health agencies called for improved monitoring and evaluation of their own progress and performance and to be able to respond to increasing emphasis on results and accountability.[11] The Paris declaration earlier and the recent unified statement by the leading global health leaders underscore one poignant fact: while aid volume and development assistance resources need to increase to achieve desired goals—which include addressing the outcomes for which the funds were disbursed—there is an urgency for results and/or outcomes. Underscoring this is the increased calls for increase in aid effectiveness at the nucleus of which is coordination of aid assistance for collective impact.[11,12] It is not surprising therefore that the need to demonstrate the effectiveness of health development aid and assistance has culminated in calls for increased accountability in the reporting of global health data.[2] Donor agencies are under increased scrutiny by their boards or governance arms to demonstrate the effectiveness of their programs as a necessary prerequisite to retaining donor loyalty. Donor countries are facing increased demands for accountability from national legislatures and citizens. Writhing under tough global economic down turn, many donor nations are under duress to discontinue providing global health development aid when their own citizens are experiencing widespread economic adversity. For example, United States slowed its development assistance for health, the Global Fund to Fight AIDS, Tuberculosis, and Malaria did not make any new grants for two years, and global health funding by UN agencies stagnated and even plummeted.[1] According to reports, at the peak of the global economic turmoil, between 2011 and 2012, development aid from the world’s developed countries—who are the main aid donors—fell by 4%.[13]

A number of existing studies have evaluated the effects of global health initiatives on country health systems.[14,15] However, little data exist in the literature to empirically demonstrate the relationship between donor presence and specific disease outcomes in donor-recipient countries. To address this gap in the literature, we examine the relationship between donor presence and change in HIV/AIDS prevalence in 14 low-and-middle-income countries (developing countries). This paper provides one of the first glimpses of who actually benefits from the rise in global health spending evidenced by the magnitude of donor presence.


We hypothesized an inverse relationship between donor presence and HIV/AIDS prevalence in developing countries. Specifically, we expected that an increase in the number of donors in a particular country will result in a reduction in the prevalence of HIV/AIDS in the adult population between the periods for which data are available. Our goal was to empirically demonstrate the basic assumption of global health donor philosophy, i.e. using donor funding to reduce disease burden. To do so, we calculated the percent changes in national HIV/AIDS prevalence between 2009 and 2011 in the 14 developing countries using the following mathematical formula: ((y2 – y1) / y1)*100. In addition, we examined the overall relationship by computing the correlation coefficients between donor presence and prevalence changes. We analyzed external sources of funding for national health expenditure in the 14 developing countries to explore whether, as we hypothesize, these resources increased in a pattern that mirrors the magnitude of donor presence in the developing countries analyzed.

Data on Donor Presence. We obtained data on donor presence from Mapping the Donor Landscape in Global Health: HIV/AIDS, a report published by the Kaiser Family Foundation (KFF), a non-profit organization that analyzes major health care issues facing the U.S., as well as the U.S. role in global health policy.[16] The report measures the landscape of donor presence based on analyses of data from the OECD Creditor Reporting System (CRS) database. Briefly, the CRS database is the main source for comparable data across all major donors of international assistance and represents development assistance disbursements as reported by the 22 member countries of the OECD’s Development Assistance Committee, the European Commission and other international organizations.[10] Details of the CRS database are provided elsewhere.[10] The report calculates a cumulative number of global health donors and identified 14 out of 141 Developing countries with 20 or more bilateral or multilateral donors who provided development assistance for HIV for a three-year consecutive period covering the years 2009, 2010, and 2011. Substantive and detailed description of the KFF’s donor landscape reporting methodology can be found elsewhere.[16]

Data on HIV Prevalence. We extracted HIV/AIDS prevalence data among males and females aged 15-49 for the three-year period (2009-2011) for the 14 developing countries with the highest presence of donors for HIV covered in the donor landscape report using 2009 as our baseline and 2011 as the comparison period. HIV/AIDS prevalence data for the years 2009 and 2011 were obtained from the World Health Statistics 2011[17] and the World Health Statistics 2013[18] respectively. We augmented the prevalence data for two countries—Ethiopia and India—with data from the 2005 and 2011[19,20] Ethiopia Demographic and Health Surveys, and the 2005 India Demographic Health Surveys respectively.[21] The World Health Statistics and the Demographic Health Surveys are major sources of global epidemiological and demographic data with well-described methodologies. Percentage, positive or negative changes, in national HIV/AIDS prevalence between 2009 and 2011 in the 14 countries were computed and correlation coefficients between donor presence and changes in prevalence were calculated using Microsoft Excel.[22]

Data on External Resources for Health. We obtained data on the external resources for health from the World Health Organization’s National Health Account database published by the World Bank. The external resources for health captures the totality of funds or in-kind services that a nation receives from external entities.[22] We computed the comparison data for the two most recent years of available data within the periods 2009 and 2011.

Global Health Conceptual Framework: Existing global health conceptual frameworks have not examined the relationship between donor presence and change in health outcomes.[232425] To address this gap and to guide our analyses, we conceptualized a global health donor-presence and disease outcome conceptual framework (Figure 1) for understanding the proximal and distal relationships between donor presence and disease outcomes in developing countries. In our conceptual framework, we theorize that, at any given time, there is a collection of different global health donor organizations in a given developing country. These include unilateral, multilateral, and non-governmental donor organizations. We acknowledge in our framework that the intensity of donor presence in any developing country at any given time is dictated by the politico-economic situation at the donor agency’s home country but more so at the donor-recipient nation lending credence to some countries being described as “donor havens.”[26]

Figure 1.  Global Health Donor Presence and Disease Outcome Conceptual Framework


According to our conceptual framework, direct donor funding are disbursed at the recipient level via the highest national levels through government agencies namely, national governments, state governments, local governments, and national-level non-governmental or civil society organizations. Using these funds, national governments and/or non-government actors can address disease outcomes. Although donors disburse funds directly to national governments, the impact on disease outcomes is indirect. Some experts argue that disbursing funds through national governments provides the best potential for large-scale roll-out and national/population level impact therefore affecting outcome.[27,28]

Our global health framework shows that some global health donors disburse funds in developing countries through direct disbursement to specific diseases, programs, or system improvement projects at the national level. Through this mechanism, donors directly fund their priorities without going through government agencies. These types of direct disbursements have shorter latency and impact on disease outcomes because the recipients can affect outcomes more directly than they would if they had gone through government agencies. However, this type of indirect global health donor disbursements that do not go through government agencies have been frowned upon as a veiled method for averting national bureaucracy.[27] This type of funding mechanism is very fluid and are less utilized. Finally, our framework posits that, regardless of the donor disbursement pathway, the association between donor intensity can be empirically tested by evaluating the degree to which donor presence affects morbidity (incidence and prevalence) or reduces mortality (at individual, group, or population-level) in any given LMIC.


HIV/AIDS Prevalence. All but two of the 14 developing countries with the highest donor presence were from sub-Saharan Africa. The two exceptions were Vietnam and India from South East Asia. Altogether, 332 donors provided development assistance for HIV/AIDS in the 14 countries included in this analysis. Ethiopia has the highest number of donor presence of 27, followed by Kenya with 26 donors. Each of Tanzania, Malawi, Zimbabwe and Mozambique had 25 donors. Our analyses showed that within the two-year period, HIV/AIDS prevalence decreased in all but one of the 14 developing countries with the presence of 20 or more global health donors (see Table 1). In 2009, there was a combined HIV/AIDS prevalence (unweighted average) burden of 6.7% in the 14 countries. In 2011, this burden dropped to 4.0%. Overall, there was about 40% reduction in HIV/AIDS prevalence across the 14 developing countries in our analysis. South Africa recorded the most reduction in HIV/AIDS prevalence (-6.7%) followed by Zambia (-6.3%), and Mozambique (-5.7%). The HIV/AIDS prevalence in Malawi dropped from 11% in 2009 to 6% in 2011, a 5.1% reduction in HIV prevalence. With the highest number of donor presence among the 14 countries, Ethiopia was the only country that did not achieve a reduction in HIV/AIDS prevalence (+0.1%) between the two periods. The correlation coefficient between donor presence and changes in HIV/AIDS prevalence for 12 countries (excluding Ethiopia and India) was estimated to be 0.43, implying that the higher the number of donors present, the greater the reduction in HIV/AIDS prevalence.

External Sources of Funding. External resources for health account for part of a nation’s health expenditure and for developing countries, these are from multiple mechanisms including foreign governments, bilateral organizations, or foreign nonprofit organizations.[22] Conceptually, external resources for health should mirror the magnitude of donor presence in developing countries and should increase with increasing donor presence. We found that between 2009 and 2010, external resources for health accounted for greater than 20% of the total health expenditures in 10 of the 14 developing countries in this analysis (see Table 2). In Mozambique, Malawi, Rwanda, and Zambia, external resources for health accounted for 62%, 58%, 48% and 44% of the total national expenditure on health. External resources for health increased in all but five of the 14 countries between 2009 and 2010 demonstrating that donor contributions provide substantial cushion to donor-recipient countries.

Table 1.     Donor Presence and Changes in HIV/AIDS Prevalence in Developing Countries, 2009-2011


Figure 2.  Percent Decrease in HIV/AIDS Prevalence from 2009-2011 in Developing Countries


Table 2.     Donor Presence and Changes in External Resources for Health in Developing Countries, 2009-2010


Figure 3.  Percent Decrease in External Resources for Health from 2009-2010 in Developing Countries



Calls for more donor coordination have gained increasing traction due to the global economic downturn of the last few years.[13] More funding organizations and countries are demanding for empirical evidence that their aids donations change lives and making the desired impact in the lives of average people in the developing world. Almost four years ago, before the global economic downturn, McCoy and colleagues lamented that the fragmented, complicated, messy and inadequate tracking of the state of global health finance require immediate attention.[2] They opined that it was particularly necessary to track and monitor global health finance that is channeled by and through private sources, and to critically examine who benefitted from the rise in global health spending. Our study begins to address this need and provides one of the few empirical data on the impact of global health aids in developing world. We must emphasize that the data we present in this analysis represent associations, albeit correlations. We are cognizant of the many nationally driven programs and expenditure for HIV/AIDS that are taking place in these countries and do not intend to minimize these efforts. Further studies might be needed to explore the national expenditure/spending on overall health and HIV/AIDS specifically in each of these countries and find to what extent can the benefits of the fight against HIV/AIDS could have been substantially driven by international aid. More studies are needed to empirically support the relationships presented in our debutant conceptual frame work presented given the paucity of conceptual frameworks exploring donor presence and global health disease burden.[29,30]

Conclusion and Global Health Implications

HIV/AIDS prevalence remains unacceptably high in developing countries. However, results from this study show that the global health investments are yielding fruit in addressing the epidemic in these poor countries of the world. Given the increasing scrutiny and often criticisms facing global health donor organizations, findings from this study could provide some evidence to demonstrate that populations in developing countries obtain improved health outcomes from donor organizations. Making the connection between aid and improved health outcome is at the center of global health and international development. Many donor organizations conduct impact evaluations of their programs to make this point. However, results of these evaluations are not widely disseminated firstly because some of the results were not what the sponsors intended or secondly because these reports did not garner enough support by both sponsors and evaluators that dissemination becomes challenging. Our study provides important information for global health officials in the countries included in this country to examine benefits from donor organizations. For managers of global health organizations, our study provides solace that aids work especially in countries where they are directed at need and to the affected populations.

Financial Disclosure: None to report. Funding/Support: None. Conflicts of Interest: None.

Ethical approval: No IRB approval was required for this study, which is based on the secondary analysis of publicly available databases.

Acknowledgements: The views expressed are those of the authors’ and not necessarily those of their respective organizations.


1.Leach-Kemon K, Chou D, Matthew T, Schneider M, Tardif A, Dieleman J, et al. The Global Financial Crisis Has Led To A Slowdown In Growth Of Funding To Improve Health In Many Developing Countries. Health Affairs. 2011; 31(1): p. 228-235.

2.McCoy D, Chand S, and Sridhar D. Global health funding: how much, where it comes from and where it goes. Health Policy and Planning. Health Policy and Planning. 2009; 24(6): p. 407-417.

3.Stierman E, Ssengooba F, Bennett S. Aid Alignment: A Longer Term Lens on Trends in Development Assistance for Health in Uganda. Global Health. 2013 February; 9(7).

4.Kania J, Kramer M. Collective Impact. Stanford Social Innovation Review. 2011 Winter; 63.

5.The Global Fund for The Global Fund to Fight AIDS, Tuberculosis and Malaria. The Global Fund for The Global Fund to Fight AIDS, Tuberculosis and Malaria. [Online].; 2002 [cited 2014 January 25. Available from:

6.Frot E, Santiso J. Crushed Aid: Fragmentation in Sectoral Aid. Working Paper No. 284. OECD, OECD Development Centre; 2010.

7.Organization for Economic Cooperation and Development. The Paris Declaration on Aid Effectiveness and the Accra Agenda for Action. [Online].; 2008 [cited 2013 July 21. Available from:

8.McKinsey & Company. Global Health Partnerships: Assessing Country Consequences. Seattle, WA: McKinsey & Company; 2005.

9.Buse K. Keeping a tight grip on the reins: donor control over aid coordination and management in Bangladesh. Health Policy and Planning. 1999 September; 14(3).

10.Lawson M. Foreign Aid: International Donor Coordination of Development Assistance. CRS Report No. R41185. Washington, DC: USA : Congressional Research Service; 2013.

11.Chan M, Kazatchkine M, Lob-Levyt J, Obaid T, Schweizer J, Sidibe M, et al. Meeting the Demand for Results and Accountability: A Call for Action on Health Data from Eight Global Health Agencies.. PLoS Medicine. 2010; 7(1).

12.Organisation for Economic Co-operation and Development (OECD). The Paris Declaration on Aid Effectiveness and the Accra Agenda for Action. Washington, DC: Organisation for Economic Co-operation and Development (OECD); 2005.

13.Organisation for Economic Co-operation and Development (OECD). Aid to Poor Countries Slips Further as Governments Tighten Budgets. [Online].; 2013 [cited 2013 July 21. Available from:

14.Biesma R, Brugha R, Harmer A, Walsh A, Spicer N, and Walt G. The Effects of Global Health Initiatives on Country Health Systems: a Review of the Evidence from HIV/AIDS Control. Health Policy and Planning. 2009; 24(4): p. 239-252.

15.Spicer N, Aleshkima J, Biesma R, Brugha R. National and subnational HIV/AIDS coordination are global health initiatives closing the gap between intent and practice. Globalization and Health. 2010; 16(3).

16.Kates J, Michaud J, Wexler A, Valentine A. Mapping the Donor Landscape in Global Health: HIV/AIDS. Washington, DC: Kaiser Family Foundation; 2013.

17.World Health Organization. World Health Statistics 2011. Geneva, Switzerland:; 2011.

18.World Health Organization. World Health Statistics 2013. Geneva, Switzerland: World Health Organization; 2013.

19.Measure DHS. Ethiopia Demographic and Health Surveys. [Online].; 2005 [cited 2013 July 21. Available from:

20.Measure DHS. Ethiopia Demographic and Health Surveys. [Online].; 2011 [cited 2013 July 21. Available from:

21.Measure DHS. India Demographic and Health Surveys. [Online].; 2005 [cited 2013 July 21. Available from:

22.The World Bank. Open Data – Indicators. [Online].; 2014 [cited 2014 January 25. Available from:

23.Woodward D, Drager N, Beaglehole R, Lipson D. Globalization and Health: a Framework for Analysis and Action. Bulletin of World Health Organization. 2001 October; 79(9): p. 875-881.

24.Kayvan B, Victoria A, Saint PT. The “Global Health” Education framework: a Conceptual Model for Monitoring, Evaluation and Practice. Globalization and Health. 2011 April; 7(8).

25.McManus S, Thai K. Comparative Health Systems: a Conceptual Framework. Journal of Health amd Human Services Administration. 1998 Spring; 20(4): p. 520-36.

26.Armah SE. Does Political Stability Improve the Aid-growth Relationship? Apnel Evidence on Selected Sub-saharan African Countries. African Review of Economics and Finance. 2010 December; 2(1).

27.Dietrich S. Bypass or Engage? Explaining Donor Delivery Tactics. Princeton, Rhode Island: Princeton University, Niehaus Center for Globalization and Governance; 2011.

28.Dietrich S. Foreign Aid Delivery, Donor Selectivity and Poverty: a Political Economy of Aid Effectiveness. Rhode Island: Princeotn University, Niehaus Center for Globalization and Governance; 2011.

29.Huynen M, Martens P, Hilderink H. The Health Impacts of Globalization: a Conceptual Framework. Global Health. 2005 August; 3(1): p. 14.

30.Picard M, Sabiston C, McNamara J. The Need for a Trans-Disciplinary, Global Health Framework. Journal of Alternative Complementary Medicine. 2011 February; 17(2): p. 179-84.

Original Article

International Journal of MCH and AIDS
Volume 2, Issue 2, 2014, Pages 182 – 189
Overview of Maternal, Neonatal and Child Deaths in South Africa: Challenges, Opportunities,
Progress and Future Prospects

Musawenkosi H L Mabaso, PhD; Thoko Ndaba, MSc; Zilungile L Mkhize-Kwitshana, PhD
International Journal of MCH and AIDS
Volume 2, Issue 2, 2014, Pages 182 – 189
Overview of Maternal, Neonatal and Child Deaths in South Africa: Challenges, Opportunities, Progress and Future Prospects

Musawenkosi H L Mabaso, PhD;1 Thoko Ndaba, MSc;2 Zilungile L Mkhize-Kwitshana, PhD3

1 HIV/AIDS, STI, and TB, Epidemiology and Strategic Information Unit, Human Sciences Research Council, Durban, South Africa.
2 Save the Children South Africa, 2nd Floor SAQA House, 1067 Arcadia Street, Hatfield, Pretoria, South Africa.
3 School of Laboratory Medicine and Medical Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa.img
Corresponding author e-mail address:



Background: The fact that most sub-Saharan Africa countries including South Africa (SA) are not on track to meet the 2015 target of improving maternal, neonate and child health (MNCH) is a major public health concern. The aim of this paper to give an overview of the current state of MNC deaths in SA, their relative causes, highlight challenges, existing opportunities, progress made and future prospects.

Methods: The overview involved a synthesis and review of recent data and information from key national representative peer reviewed articles and grey literature from the National Department of Health and related stakeholder reports.

Results: Since 1990 the situation in SA aroused a lot of research interest in tracing the historical context of the problem, evaluating progress made and actions for improving MNCH. In 2009 the SA government established three national committees for confidential enquiry on MNC deaths. Multifactorial systems’ related challenges were identified. Subsequently, the new National Strategic Plan for MNC and Women’s Health and Nutrition has, in addition to provision of comprehensive interventions, been linked and aligned with efforts to strengthen the health systems particularly through the re-engineering of the Primary Health Care (PHC) services and district health systems.

Conclusion and Global Health Implications: The overview gives an insight of the process that has influenced MNCH policy and programs in the country. The SA experience and current MNCH situation may be different compared to other African countries, however, the political commitment and government stewardship coupled with critical and yet complimentary research is exemplary, especially, given several global and regional plans and commitments to improve MNCH in the continent.

Keywords: South Africa • Maternal, neonatal, child deaths • Health • Interventions • Millennium Development Goals

Copyright 2014 © Mabaso et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

BackgroundIn sub-Saharan Africa (SSA) it is estimated that 4.7 million mothers, newborns and children (under 5 years) die annually[1]. Globally, high-level support for actions to improve maternal, newborn and child health (MNCH) has gained momentum with the pledge of US$ 40 billion to address women’s and children’s health through the attainment of the United Nations (UN) Millennium Development Goals (MDG) over the five years 2010-2015[2,3]. MDGs for maternal health (MDG-5) and child health (MDG-4) call for a reduction in maternal mortality by three-quarters and child mortality by two thirds by the year 2015. However, many developing regions including Africa are not on track to meet this target[4].In SSA where maternal mortality is highest, the annual decline has been 1.7%[2]. Children continue to die of causes that can be both prevented and treated using proven, low-cost interventions. Progress has been slower for reducing newborn deaths than for deaths among post-neonatal age children[2]. It is estimated that between 66% and 85% of Africa’s maternal, newborn, and child mortality could be prevented through implementation of available interventions[5]. In South Africa the dire MNCH situation elicited a lot of responses from the government and scientific community in an effort to understand where and why these deaths occur. Has increased attention translated into programmatic action for MNCH in the country?The aim of this paper is to give an overview of the current state of maternal, neonatal and child deaths in South Africa, their relative causes and to highlight existing challenges, opportunities, progress made and future prospects. Such an insight will help inform future priorities for accelerating progress for reduction of MNC deaths towards MDG 4 and 5 targets in the country.Methods

The purpose of this overview was by no means an attempt to do a comprehensive systematic literature review but focuses on the collation and synthesis of information on current status and country’s experience in dealing with MNC deaths. The assessment was carried out through synthesis and review of recent data and information from key national representative peer reviewed articles and grey literature from the national Department of Health and related stakeholder reports, all which are referenced accordingly. This was done with the view of assessing the current status of MNCH in the country with the focus on mortality and related causes, and to identify existing challenges, opportunities for reducing MNC deaths, progress made and future prospects.


In South Africa, it is generally accepted that the maternal, neonatal and child (MNC) deaths are unacceptably high, however, the estimates vary depending on the source[6]. The mortality profile presented in this overview outlines the latest estimates extracted from the 2011 National Department of Health report[7].

Maternal Neonatal and Child Mortality in South Africa

In 2009 the National Department of Health gave a maternal mortality ratio estimate of 310 deaths per 100 000 live births, neonatal mortality rate of 14 deaths per 1000 live births and child (under 5 years) mortality rate (CMR) of 56 deaths per 100 000 live births[7]. The deaths were high in the Free State, Limpopo, KwaZulu-Natal, Eastern Cape, and lower in Mpumalanga North West, Northern Cape, Gauteng and Western Cape Provinces (Figure 1).

Causes of Maternal Neonatal and Child Mortality in South Africa

Five key causes of maternal deaths (Figure 2) that have remained consistent over the past five years include (i) non-pregnancy related infections (mainly HIV/AIDS, tuberculosis (TB), and pneumonia); (ii) complications of hypertension; (iii) obstetric hemorrhage (antepartum and postpartum hemorrhage); (iv) pregnancy related sepsis and (v) pre-existing maternal diseases[6,7]. These are attributed to (1) administrative weakness such as poor transport facilities; (2) lack of health care facilities and appropriately trained staff; (3) patient oriented problems such as no antenatal care (ANC) or infrequent ANC attendance and delay in seeking medical help; (4) health worker oriented problems such as health care provider failure to follow protocol (delay in referring patients) and poor initial assessment and recognition/diagnosis; and (5) communication problems[6,7-9].

Figure 1.  South African national estimates of maternal mortality ratio (per 100 000 live births), neonatal and child mortality rates (per 1 000 live births) by province in 2009[7]


Figure 2.  South African maternal, neonatal and childhood causes of death[6]


The major causes of childhood deaths identified are diarrheal disease, meningitis, lower respiratory tract infections such as pneumonia, perinatal conditions associated with HIV and AIDS and malnutrition as well as poor quality of care and coverage of reproductive health services[6,8,9]. Among neonates these also include perinatal and postnatal complications such as birth asphyxia, preterm birth, and congenital abnormalities (Figure 2). These are also attributed to poor communication, inadequate clinical care as well as lack of adherence to nutrition and immunization programs[6,8,9].

Overall the main causes of maternal and child mortality in South Africa are HIV and AIDS, pregnancy and childbirth complications, neonatal illness, childhood illness, and malnutrition, which are all related to poverty and great inequity. These are the countries’ big five challenges that need to be addressed in order to accomplish the health related MDGs[6,7-9]. The leading causes of death for both mothers and children less than five years of age are compounded by rising multi-drug resistant TB and HIV-TB co-infection[10].


An estimated 32-54% of all maternal, neonatal and child deaths are due to preventable causes that could have been avoided within the health care system[6,7]. Approximately 25-44% of these deaths had modifiable factors related to family/community action (inadequate ANC, delayed action in seeking help during labour, caregiver and family members not recognizing the severity of the illness)[6,7]. In 2009 a series of papers on health in South Africa presented the unique features of South Africa’s history that have contributed to the systemic problems existing today, and assessed the challenges that affect among others MNCH[8-12].

Multifactorial systems related challenges identified included poor health status and care of women, illiteracy plus lack of information with regard to available health services, poor antenatal and obstetric care both within the community and health facilities, absence of well-trained cadre of health extension workers, inadequate referral system and absence of or poor linkages of health centers with the communities[8]. Furthermore, there are substantial inequalities in maternal and child health service coverage and health outcomes with differences between socio-economic groups and geographical areas within the country[6]. Mothers, babies, and children in poor families are at increased risk of illness and face many challenges in accessing timely, high-quality care. This can also be attributed to poor use of health care facilities by patients, lack of transport and sub-optimal quality of care by some health providers[12]. Expanding coverage to ensure that the poorest, least educated and most-difficult-to reach mothers, their neonates and children under five years get accessible, timely, quality health care, remains a major challenge for the South African government.

In addition, great disparities exist between South Africa’s public and private health care systems with about 40% of the total health care expenditure allocated to the public health care system that caters for about 86% of the population[6]. The distribution and access to essential services is also unequal with the most deprived provinces and districts receiving the least primary care expenditure. Therefore addressing inequities is a pre-requisite to achieving MDGs in South Africa[69]. The challenge is to ensure not only high coverage for all but also higher-quality coverage, for example, a recent assessment showed that while more than 90% of women completed at least one antenatal visit, only about 11% received the full set of interventions required[8].

In addition to systemic challenges one study noted that South Africa, with a supportive policy and funding environment, is facing a “paradox of apparent progress yet worsening health outcomes”[8]. Another study observed that “the Ministry of Health’s role in providing overall guidance on activities that contribute to improving levels of health in South Africa has generally been characterized by good policies, but without equivalent emphasis on the implementation, monitoring, and assessment of these policies throughout the system”[11].

Opportunities for Improving MNCH in South Africa

South Africa is committed to addressing issues of inequality through providing universal coverage for maternal, neonatal and child interventions and by identifying and targeting poorest and under-served areas[7]. Given the magnitude of the problem, a multidisciplinary anonymous investigation sanctioned by the ministerial committee on health was carried out by (i) the National Committee on Confidential Enquiries into Maternal Deaths (NCCEMD), (ii) the National Perinatal Morbidity and Mortality Committee (NaPeMMCo) and (iii) the Committee on Morbidity and Mortality in Children under 5 Years (CoMMiC) at local, regional and national levels[613-16]. The committees were established to advise the National Department of Health on gaps in service delivery and how these can be addressed.

For maternal deaths NCCEMD initially identified four focal points that need to be prioritized and these included improving knowledge development, quality of care and coverage of reproductive health services, establishing norms and standards, and facilitating community involvement[13]. The recent report spells out five key points namely 5’H’s which include: HIV (promoting know you status and plan you pregnancy); hemorrhage (promote preventive interventions, severe obstetric hemorrhage must be tagged as “major alert” requiring a multidisciplinary approach to expedite resuscitation and stepwise approach to arresting hemorrhage); hypertension (all maternity facilities to provide calcium supplementation to all women throughout the antenatal care and ensure early detection, referral and timely delivery of women with hypertension in pregnancy, severe hypertension with imminent eclampsia is a major alert requiring urgent attention); health worker training in maternal care including HIV counseling, testing and initiation of HAART); Health systems strengthening (24 hour access to functioning emergency obstetrics care with basic and comprehensive care, provision of appropriate contraceptives that are accessible to all women and integrated into all levels health care)[14].

For neonates NPMMC recommended clinical skills improvement especially strengthening skills of interns, midwives and nurses; improving staffing, equipment and facilities; proper implementation of national maternal and neonatal guidelines; training and education of health care workers/communities; improving transport and referral routes; improving postnatal care; appointment of regional clinicians to establish, run, monitor and evaluate all outreach programs (at regional, district, hospital and clinic level) for maternal and neonatal health including data collection and review[13-16]. In addition Government should ensure that (i) constant health messages are conveyed to all and understood by all, (ii) management should adhere to national maternal and neonatal guidelines in all health care facilities, (iii) normalization of HIV infection as any chronic disease[14,16].

For children under 5 years CoMMiC recommended the strengthening of the existing child survival programs adopted by the NDOH which included the Community Health Worker (CHW) program, Integrated Nutrition Program and 10 steps for the management of severe malnutrition, Expanded Program on Immunization (EPI), Integrated Management of Childhood Illnesses (IMCI) and Prevention of Mother to Child Transmission (PMTCT) of HIV during ANC[13-16]. Additionally, strengthening of essential data systems, identifying key drivers to give and sustain actions required to improve the health of children across the country and developing a national child health strategy. The CoMMiC also recommended that primary health care be strengthened by adopting and implementing the Household and Community component of IMCI[16]. In addition, an unprecedented period of change in South Africa’s health sector and renewed political commitment has created new opportunities to tackle the unacceptably high maternal, newborn and child mortality in South Africa[17].


The revitalization and building of more Primary Health Care (PHC) facilities has significantly increased access to MNCH services at PHC level with over 120 million visits reported countrywide in 2010[17]. Significant shifts in policies towards HIV and AIDS treatment to prevent mother to child transmission is also having a significant impact on HIV related maternal and child mortality. In 2011 a 13% reduction in maternal mortality ratio was reported mainly as a result of decline in deaths from non-pregnancy-related infections such as HIV-infected pregnant women complicated by TB and pneumonia[14]. The 2012 WHO/UNICEF countdown to 2015 report showed that in South Africa PMTCT coverage has increased from 71% in 2009 to 96% in 2010[18]. A nationwide assessment of PMTCT impact showed that out of 10178 infants at 6weeks in 572 health facilities, vertical transmission rate was down to 2·7% in 2010 compared with 20–30% in the preceding decade[19]. This is among the country’s major achievements in terms of child mortality reduction. However, the PMTC triple therapy regime has been shown to be more effective in reducing mortality for children less than 5 years of age than in neonates[12].

In a recent appraisal of the South African health changes and challenges since 2009, the establishment of three national committees on maternal, perinatal and child mortality described in the current overview was seen as a step forward since this increased the profile and coordinated action for MNCH, linking national mortality audit data to action and transferring lessons learned from one province to another[12]. The assessment also noted that “re-engineering of primary health care and plans for the national health insurance (NIH) were important national themes”. Progress with the NHI funding scheme will help address challenges of inequalities caused by the skewed health care financing system which particularly disadvantaged the poor, women and children at all levels of care.

Future Outlook

The new 2012-2016 National Strategic Plan for Maternal, Newborn, Child and Women’s Health (MNCWH) and Nutrition, has in addition to provision of comprehensive interventions, been linked and aligned with efforts to strengthen the health system particularly through the re-engineering of the Primary Health Care services (PHCs) and district health systems[17]. This entails (1) establishment of local or ward (community level structure) based PHC outreach teams for delivering community-based MNCHW services at community and household levels and facilitating access to services at PHC and hospital levels, (2) strengthening of School Health services to improve health and learning outcomes for children and youth and (3) establishment of district clinical specialist teams to ensure provision of quality MNCWH services through supervision and support at all levels. The teams are made up of an obstetrician, a pediatrician, a family physician, an anesthetist and advanced midwife, pediatric and obstetrician nurse and a PHC nurse. The main goal of South Africa’s new strategic healthcare and nutrition plan for women and children is to reduce by 10% by 2016: the maternal mortality ratio (MMR); the neonatal mortality rate (NMR); the infant mortality rate (IMR); and the child mortality rate[17]. The implementation of NHI as a financing mechanism to promote universal coverage might also have positive spin offs for MNCH.

The latest assessment of the health system in the country as it affects among others the MNCH program, suggest that “change in leadership of the Ministry of Health has been key, but new momentum is inhibited by stasis within the health management bureaucracy and that the solution is effective human-resources system based on equity and merit”[12]. Training, mentoring and supportive supervisory systems will need to be strengthened to address these human resource issues. The recently renewed focus on quality assurance and improvement, and the proposed establishment the Office of Health Standards Compliance will fast-track the attainment of quality standards across the country[20]. In addition, performance management reform initiative which includes the organizational review of the National Department of Health was initiated to strengthen human resources and performance management systems through the development of key performance areas and competencies for critical positions to strengthen the provision of quality health care[21]. Therefore, given the availability of political will and the supportive policies and guidelines for MNCH in South Africa, increased government attention is needed to focus on implementation and monitoring of these policies and programs in order to improve women and children’s health[8,11].

Conclusion and Global Health Implications

Improving maternal, newborn and child survival across the continent depends on each country’s ability to reach women, newborns and children with effective interventions; the provision and use of timely data on quality of care; monitoring and evaluation of health outcomes. Pivotal to the successful implementation of intervention packages for maternal, neonatal and child mortality is the establishment and maintenance of stakeholder partnership strategies to ensure sustainability in the continuum of care[8,22]. An effective continuum of care addresses the needs of the mother, newborn, and child throughout the life cycle wherever care is provided. This involves strengthening the continuum of care linking home, community, primary health care, regional and district hospitals by ensuring the availability of right care in the right place at the right time at each level[22]. Continued funding and commitment by all stakeholders including government, NGOs and communities is vital for the successful and sustained reduction of MNC deaths in South Africa.

The South African experience and current MNCH situation may be unique and / or different compared to other countries in Africa given the historical context. However, the political commitment and government stewardship in response to worsening MNCH outcomes is exemplary in the continent. This is more relevant given several global and regional plans and commitments to improve MNCH in the continent, whose essential prerequisites for meaningful and sustained improvement in health are effective leadership and governance[23]. “Governance and leadership are needed throughout the process not only to create policies and implement them but also to ensure quality and efficiency of care, to finance health services sufficiently and in an equitable way, and to appropriately manage the health workforce”[24]. Finally, the use of critical and yet complimentary research for evidence based priority setting in SA, highlights the need for science to inform policy and practice which is often missing in many settings in Africa[25]. Given accumulating body of evidence on strategies for reducing MNC deaths in many countries which are part of the Countdown to 2015 initiative, translating such evidence into effective and sustainable program implementation for MNCH must be prioritized for MDG 4 and 5 targets to be realized.

Conflict of interest: None


1.Kinney MV, Kerber KJ, Black RE, Cohen B, Nkrumah F, Coovadia H, Nampala PM, Lawn JE. Sub-Saharan Africa’s Mothers, Newborns, and Children: Where and Why Do They Die? PLoS Medicine. 2010;7:e294.

2.UN. Global Strategy for Women’s & Children’s Health. New York:United Nations, 2010.

3.The Global Campaign. Putting the Global Strategy for Women’s and Children’s Health into action. New York: The Global Campaign for the Health Millennium Development Goals, 2010.

4.Bhutta ZA, Chopra M, Axelson H, et al. Countdown to 2015 decade report (2000–10): taking stock of maternal, newborn, and child survival. Lancet.2010;375:2032–44.

5.Kinney MV, Lawn JE, Kerber KJ. Science in Action: Saving the lives of Africa’s mothers, newborns, and children. Cape Town, South Africa, African Science Academy Development Initiative; 2009.

6.South Africa Every Death Counts Writing Group. Every death counts: use of mortality audit data for decision-making to save the lives of mothers, babies, and children in South Africa. Lancet 2008; 371:1294–304.

7.National Department of Health. Health Data Advisory and Coordination Committee Report. Pretoria: Department of Health; 2011.

8.Chopra M, Daviaud E, Pattinson R, Fonn S, Lawn JE. Saving the lives of South Africa’s mothers, babies, and children: can the health system deliver? Lancet. 2009; 374:835-846.

9.Chopra, M, Lawn, JE, Sanders, D, Barron P, Abdool Karim SS, Bradshaw D, Jewkes R, Abdool Karim Q, Flisher AJ, Mayosi BM, Tollman SM, Churchyard GJ, Coovadia H. Achieving the health Millennium Development Goals for South Africa: Challenges and Priorities. The Lancet. 2009;374:1023-31.

10.Abdool Karim SS, Churchyard GJ, Abdool Karim Q, Lawn SD. HIV infection and tuberculosis in South Africa: an urgent need to escalate the public health response. Lancet. 2009;374: 921–933.

11.Coovadia H, Jewkes R, Barron P, Sanders D, McIntyre D. The health and health system of South Africa: historical roots of current public health challenges. Lancet. 2009;374: 817–834.

12.Mayosi BM, Lawn JE, van Niekerk A, Bradshaw D, Abdool Karim SS, Coovadia HM. Health in South Africa: changes and challenges since 2009. Lancet. 2012;380(9858):2029-43.

13.NCCEMD. National Committee on Confidential Enquiries into Maternal Deaths. Saving Mothers fourth report 2005–2007. Pretoria: Department of Health; 2009.

14.NCCEMD. National Committee on Confidential Enquiries into Maternal Deaths. Saving Mothers fourth report (2008–2010). Pretoria: Department of Health; 2011.

15.National Perinatal Mortality and Morbidity Committee Triennial Report (2008-2010). Pretoria: Department of Health; 2011.

16.CoMMiC. First Report of the Committee in Morbidity and Mortality in Children Under 5 years (2008-2010). Pretoria: Department of Health; 2011.

17.NDoH. Strategic plan for maternal, newborn, child and women’s health (MNCWH) and nutrition in South Africa, 2012-2016; 2012. Available from Accessed January 24, 2013.

18.WHO, UNICEF. Countdown to 2015: Maternal, Newborn and Child Survival – building a future for women and children, the 2012 Report. Geneva; 2012. Accessed Nov 9, 2012.

19.Goga AE, Dinh TH, Jackson DJ for the SAPMTCTE study group. Evaluation of the Effectiveness of the National Prevention of Mother-to-Child Transmission (PMTCT) Programme Measured at Six Weeks Postpartum in South Africa, 2010. South African Medical Research Council, National Department of Health of South Africa and PEPFAR/US Centers for Disease Control and Prevention; 2012.

20.Department of Health, Republic of South Africa. National Core Standards for Health Establishment in South Africa. Tshwane: South Africa; 2011.

21.Department of Health, Republic of South Africa. Annual Performance Plan 2011/2012. Tshwane: South Africa; 2011.

22.Kerber KJ, de Graft-Johnson JE, Bhutta ZA, Okong P, Starrs A, Lawn JE. Continuum of care for maternal, newborn, and child health: from slogan to service delivery. Lancet. 2007;3 70:1358–1369.

23.Sewankambo NK, Katamba A. Health systems in Africa: learning from South Africa. Lancet. 2009;374:957-959.

24.Countdown Working Group on Health Policy and Health Systems. Assessment of the health system and policy environment as a critical complement to tracking intervention coverage for maternal, newborn, and child health. Lancet 2008; 371:1284–93.

25.Bennett S, Ssengooba F (2010) Closing the Gaps: From Science to Action in Maternal, Newborn, and Child Health in Africa. PLoS Med 7(6): e1000298.

Original Article

International Journal of MCH and AIDS
Volume 2, Issue 2, 2014, Pages 174 – 181
Social Determinants of Depression: Social Cohesion, Negative Life Events, and Depression Among People Living with HIV/Aids in Nigeria, West Africa
Rasaki O. Shittu, MBBS, MPH, FWACP; Baba A. Issa, MBBS, MPH, FWACP; Ganiyu T. Olanrewaju, MBBS, FWACP; Abdulraheem O. Mahmoud, MBBS, FMCOph, FWACS, FICS; Louis O. Odeigah, MBBS, FWACP; Abdullateef G. Sule, MBBS, FWACP
International Journal of MCH and AIDS
Volume 2, Issue 2, 2014, Pages 174 – 181
Social Determinants of Depression: Social Cohesion, Negative Life Events, and Depression Among
People Living with HIV/Aids in Nigeria, West Africa
Rasaki O. Shittu,MB, BS, MPH, FWACP;1 Baba A. Issa,MB, BS, MPH, FWACP;2 Ganiyu T. Olanrewaju, MB, BS, FWACP;3 Abdulraheem O. Mahmoud, MB, BS, FMCOph, FWACS, FICS;4 Louis O. Odeigah, MB, BS, FWACP;5 Abdullateef G. Sule, MB, BS, FWACP6
1 Department of Family Medicine, Kwara State Specialist Hospital, Sobi, Ilorin, Nigeria.
2 Department of Behavioral Sciences, University of Ilorin Teaching Hospital, Kwara State, Nigeria.
3 Department of Behavioral Sciences, University of Ilorin Teaching Hospital, Kwara State,Nigeria.
4 Department of Ophthalmology, University of Ilorin Teaching Hospital, Ilorin, Nigeria.
5 Department of Family Medicine, University of Ilorin Teaching Hospital, Ilorin, Nigeria.
6 Department of Family Medicine, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria.

imgCorresponding author email:


Background: People Living with HIV/AIDS (PLWHA) continue to face persistent and deep rooted social barriers. Incidentally, studies in social determinants of depression are very limited, necessitating this study, which examined social determinants of depression and the impact of these determinants on depression.

Methods: This was a hospital based, cross sectional descriptive study of three hundred adult HIV/AIDS patients, attending the HIV clinic of Kwara State Specialist Hospital, Sobi, Ilorin, Nigeria. Depressive symptoms were measured by the PHQ-9 rating scale. Three variables of social determinants of depression: socio-economic status (years of school and self-reported economic status of family), social cohesion, and negative life events were examined.

Results: The self-reported economic status of the family varied from good 35(11.7%), average 162(54%), and poor among 103(34.3%) of the respondents. Social cohesion was low in 199(66.3%), fair in 65(21.7%) and high among 36(12%) of the respondents. There was significant association between social cohesion, negative life events, and depression.

Conclusion and Global Health Implications: Income was the most significant socio-economic determinant. Majority had very low social cohesion and more negative life events, while those with below average years of schooling were more depressed. These are statistically significant. Social determinants of depression should be given a lot of emphasis, when addressing the issue of depression, if we are to meaningfully tackle this increasing scourge in our society.

Key Words: Depression • Social determinants • PLWHA • Social cohesion • Negative life events • Nigeria • People living with HIV/AIDS

Copyright © 2014 Shittu et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background and Introduction

Depression is the most frequently observed psychiatric disorder among HIV/AIDS patients, with prevalence of two to three times higher than in the general population.[1]

The Diagnostic and Statistical Manual of Mental Disorders (DSM IVTR) describes major depressive disorder as being accompanied by clinically significant distress or impairment in social, occupational or other important areas of functioning.[2]

More recent work on the social influences on depression, found a significant correlation between social factors and depression.[3] During the past few decades, the depth and breadth of our understanding of health issues has greatly increased because of the bio-psycho-social medical model. Important to this understanding is the concept of Social Determinants of Health (SDH). SDH focuses on the “causes of the causes”-the fundamental structures of social hierarchy and the socially determined conditions. SDH are primarily responsible for health inequities-the unfair and avoidable differences in health status. The concept of social determinants seeks to theoretically and empirically explain how social organization affects health.

Economic status or variables related to income or financial status is reported to be significant determinant of depression.[4] The socio demographic factors of age, gender, marital status, education and income are important factors, in explaining the variability in depression prevalence rates. Key North American Studies, particularly the Epidemiologic Catchment Area study,[5]and the Ontario Health Survey[6] found prevalence rates of 2.8% and 3% based on age and gender respectively.

Pattern and Colleagues found significant interaction among age, sex, marital status and depression. Consistently, women have nearly double or triple prevalence rates than men. Several recent studies confirmed a strong inverse relationship between SES and mental disorder.[7] People in the lowest socio-economic class are more likely to suffer from psychiatric disorder, than those in the highest class.[8]

The social determinants of depression are social, economic and health condition people are born into and live. Poor social and economic circumstances affect health throughout life.[9] Social Support and Social Cohesion have been identified as playing major roles in the transmission and progression of HIV/AIDS and also depression.[9] While Social support enables people to negotiate life’s crisis, social cohesion helps to stabilize health threatening situations by including and accepting people, and by enabling them to participate freely within the families, the committees and the society.

Though literature abounds in other parts of the world on social determinants of depression, there is paucity of data in Africa in general, and Nigeria in particular, among People Living with HIV/AIDS (PLWHA).This study explores social determinants of health and depression among HIV/AIDS patients, in North Central Nigeria.


This study was conducted at HIV/AIDS treatment center in the Sobi Specialist Hospital, Ilorin, Kwara State, located in the North Central Nigeria. The HIV/AIDS treatment center started in the hospital in May, 2009. About 800 patients have been enrolled and over 600 are on Highly Active Antiretroviral Therapy (HAART). The center is currently being founded by an international Non-Governmental Organization (NGO), Friends for Global Health.

This is a descriptive, cross-sectional study carried out from March 1st to July 30th, 2013. The inclusion criteria were all concerted depressed HIV positive patients, who presented at the Clinic. The exclusion criteria were the critically-ill patients. The Patients Health Questionnaire – PHQ-9 was administered to screen for depression, until the estimated sample size of 300 was obtained. Respondents who scored one and more were assessed clinically for depression. The severity of the depression was further classified as minimal, mild-to-moderate and severe. The three keys of social determinants of depression (SDS) were assessed and the association with depression sought.

The sample size was estimated using the Fisher formula[10], using 21.3% from a previous study[11], as the best estimate of depressive disorders among People Living with HIV/AIDS (PLWHA). A minimum size of 218 was calculated using Fisher’s formula but 300 was used to increase the power and reliability of the study. Pretesting was carried out at the Kwara State Civil Service Hospital, using 30 respondents (10% of the sample size).

Ethical approval was obtained from the Ethical Review Committee of the Kwara State Ministry of Health before commencement of the study. An interviewer administered questionnaire was used.

Based on existing research[12], we used three key SDH: socioeconomic status, social cohesion and negative life events. Socioeconomic status included two indicators: years of schooling and self-reported economic status of the family, in general, in the previous year. Categories for years of schooling were as follows: above average (7 years and above), average (1-6 years) and below average (0 year). Economic status of the family was self-reported as good, average or poor. Social cohesion was assessed from responses to two questions: (1) In the previous year, how often did you ask someone for help when you had problems? (Never = 1; Seldom = 2; Sometimes = 3; Often = 4), and when you had problems? (spouse or lover; parents, brothers, sisters or children; other relatives; people outside the family; organization or schools with whom you are affiliated; government, party or trade unions; religious or non-governmental organizations; other organizations) (no = 0; yes = 1). Negative life events were assessed using a 12-item scale (serious illness in oneself, serious illness in the family, financial difficulties, conflict with spouse, conflict with other family members, conflict with people in the village, conflict between family members, infertility issues, problems at work or school, problems in an intimate relationship, abuse, and other events).[13] For each life event that occurred in the last year, or that occurred earlier but continued to have a psychological effect during the past 12 months, the respondent indicated when the life event occurred, its effect (positive or negative) and the length of time over the last year that the psychological effect lasted. We used the sum of the number of life events with a negative effect as a measure of negative life events.

Age, gender, marital status, education level, self-rated financial status, social support and social cohesion, employment status and estimated monthly income were the socio-demographic variables and potential confounders. Marital status, educational level, and occupation were assessed. Monthly income was assessed using the minimum wage stipulated by the Federal Government of Nigeria, which is Twenty Thousand Naira (N20,000), which is about $133.

Completed questionnaire and measurements were entered into a computer data base. The data were analyzed using the epidemiological information (Epi-info) 2005 software package developed by the US Centers for Disease Control and Prevention (CDC).The 2 by 2 contingency tables were used to carry out Chi-square test and to find out the level of significance; p-values that are less than 0.05 were regarded as statistically significant.


Table 1, shows the socio-demographic characteristics of the respondents. In all, 170 sero-positive respondents with depression were recruited into the study. The age range 36-40 years, had the highest number of respondents 50(29.4%). Females 139(81.8%) outnumbered males 31(18.2%) giving a male: female ratio of 1:4.5. Predominantly, 139(81.8%) were Muslims; Christians constituted 30(17.6%); with 1(0.6) Traditional believers. Fourteen (8.2%) were married while the same number were single. One hundred and sixteen (68.3%) were separated/divorce while 26(15.3) were widow/widower. The majority of the respondents 56(32.9%) had no formal education; 55(32.4%) had primary education; while 42(24.7%) had secondary education. Only 17(10.0%) attended tertiary institution. Majority, 91(53.5%) were traders, while 14(8.2%) were unemployed and six (3.5%) were students.

Table 2 displays the variations according to self-reported economic status of the family, years of schooling, social cohesion in the previous year and negative life events. Eighty-eight (51.8%) had poor, 62 (36.5%), had average, while 20 (11.7%) had good self-reported economic status. Those with below average year of schooling or about 80 (47.0%) respondents were more depressed than those with above average year of schooling 45 (26.5%). This is statistically significant (p-value = 0.03). Negative life events were associated with depression. Nine (29.1%) males and 45 (32.3%) female’s respondents had more than three negative life events. This was of statistical importance (p-value = .004).

Table 1.     Socio-Demographic Characteristics of Study Respondents

Variable N = 170 (%)
Age group (years)
< 26
26 – 30
31 – 35
36 – 40
41 – 45
46 – 50
51 – 55
56 – 60
Marital Status
Educational level
Civil servant
Self employed
Monthly Income (N)
No Income
≤ 20000

Figure 1, shows that 130 (43.3%) of the respondents were not depressed; 170 (56.7%) satisfied the criteria for a depressive disorder using the PHQ-9. Among the respondents, 109 (36.3%) had minimal depression, while 4 (13%) were severely depressed.


The prevalence of depressive disorders among HIV/AIDS patients attending the HAART, at the Kwara State Specialist Hospital Sobi, was 56.7%. Our finding was similar to the previous studies. It also falls within the prevalence rates seen internationally.[14] It also agrees with most local studies.

The socio demographic factors of age, gender, marital status, education, and income have consistently been identified as important factors in explaining the variability in the prevalence of depression. Key North American studies, particularly the Epidemiologic Catchment Area Study, the National Co-morbidity Survey, the Canadian Health Population Health Survey pointed out this fact. Similarly, economic status or variables related to income or financial status were reported to be significant in Hong Kong[15] and Beijing.[16] O’Sullivan[17] while studying the psychosocial determinants of depression found social factors as a risk factor for depression.

Table 2.     Association Between Economic Status, Year of Schooling, Social Cohesion, Negative Life Events and Depression


Figure 1.  Levels of Depression among Respondents, Using the Patients Health Questionnaires (PHQ-9) Scale


Similar to other findings, there was female preponderance in prevalence of depressive disorders.[18] Prevalence of depression had been found to vary considerably based on gender.[19]Women (68.7%) reported significant higher prevalence of depression than men (32.3%) in a study in Russia.[20] The above findings are in consonant to our study.[21] On the contrary, a South-African study[22] found that the prevalence rate of depressive symptomatology to be almost equal in both sexes. The result of our study negates one previous finding that, in Africa, there are higher rates of depression among men than women in psychiatric institution.[23] Marital status had been found to interact with gender in accounting for variance in the prevalence rate of depression. In Australia,[24] for example, those who were separated or divorced PLWAs had a higher rate of depression. Similarly, another South-African Stress and Health Study (SASH),[25]found that mood disorders were more frequent among separated, widowed and divorced individuals and among people with only an elementary school level of education. This is similar to our findings. Women are more likely to experience negative social determinants than men because they carry the double burden of raising children and household work. Gender inequity in the spousal relationship, was related to depressive mood, hence there is need to pay more attention to gender relations in future research on social determinants of depressive mood.

Fifty (29.4%) respondents were in the 36 – 40 age range. Previous research had found that age was one of the demographic characteristics that accounted for much of the variance in the prevalence of depression. In a study in Nigeria,[26] there was no significant association between depression and age. Similarly in Bongongo study,[27] no relationship was found between age and depressive features among patients receiving HAART. One study reported that depression could occur at any age, and that individuals, may experience depression at different times of their lives for different reasons.[28] There were no significant differences between age group and depression. This was similar to the finding of Bongongo and colleagues[27] in South-Africa, where age group was not significant.

Table 3.     Depression and Social Cohesion According to Gender


Among the depressed respondents, the educational level was less than secondary school level in 55 (32.4%), while the lowest depression prevalence rate was found among respondents with tertiary education 17 (10.0%). This contrasts with the findings in Canada, where respondents, whose educational level were less than secondary education, had the lowest rate of depression and the highest prevalence rate of depression (13.4%), was seen among those with tertiary education. Education is a critical social determinant of health because, people with higher levels of education are often healthier than people with lower levels of educational attainment. There are three main reasons why education is important as a social determinant. Firstly, education leads to better health outcome because one’s level of education is highly correlated with other social determinants such as level of income, employment, security, and working conditions. Education enhances one’s socio-economic condition by creating opportunities for advancement in the workforce. Secondly, education protects people from the instability of the current job market by increasing their ability to access new training opportunities and career. Thirdly, education increases one’s ability to monitor their unhealthy living and eating habits, and creates alternative lifestyles that are more beneficial to their health status in the long-run, it is important that governments ensure that the public education system, and particularly post-secondary institutions are relatively affordable and accessible to the entire population – not just the privileged class.

About 25 (8.3%) were unemployed. Unemployment leads to poor physical mental health in a number of ways. When patients become unemployed, it is a stressful event that affects their self-esteems. Since employment generates income, a positive identity and the ability to live healthy lifestyles, unemployment leads to impoverishment, psychological stress and participate in health-threatening coping behaviors such as tobacco consumption, alcohol abuse, promiscuity. This is similar to another study, where depressive features were more common among the unemployed. Depression resulting from unemployment has increased over the years.[28] Six (2.0%) were students. The implication of this age group is that, youth, the future of Nigeria, should be targeted for HIV interventions. Unemployment is also responsible for mental health problems such as depression.

The highest prevalence rate of depression 129 (75.9%) was seen in patients with an income level of less than twenty thousand Naira (N20,000), which is the minimum recommended income by the Federal Government of Nigeria. This is similar to the findings in the province of Ontario, in Canadian Health Survey, where the highest prevalence of depression (18.4%), was seen in household, with an income level of less than $10,000 per year.[11] Income is the most significant social determinants of health, because it determines one’s overall living conditions, affect one’s psychological condition, and help shape one’s diet and eating habits. Low-income people living in poverty, cannot afford healthy food, sufficient clothing and good housing all of which are necessary preconditions of good health.

Social cohesion occurs when specific marginalized groups are not able to participate in their identity and social location. Social cohesion is based on four differences viz: denial of participation in civil affairs, denial of social funds, exclusion for social production and economic exclusion. In this study, Social Cohesion was very low in both males and females, 21 (67.7%) and 112 (80.6%) respectively among the depressed HIV patients. Only 2 (6.5%) males had high social cohesion. This is statistically significant (p – value = 0.005). Deprivation causes social exclusion when people are unable to participate in cultural, educational and recreational activities due to their poor social-economic conditions. In the long term social exclusion, negatively impacts on one’s physical and mental health. Income inequality is a key public health issue that must be addressed by governments and policy makers by increasing minimum wage and social assistance levels.

Social support and good social relationship makes an important contribution to health and prevent the depression. Social support also helps to give people the emotional and practical resources they need. Belonging to a social network of communication and mutual obligatory makes people feel cared for, loved, esteemed and valued. This has a powerful protective effect on health. Therefore, good social relationship can reduce depression. On the other hand, low social support causes more stress and can accelerate or worsen the progression from HIV to AIDS.[29]


The relatively small sample may be a potential limitation. Self-reported measures to assess economic status and depressive symptoms were used. These were prone to participant response bias, such as low reported symptoms due to stigma. Moreover, like all cross-sectional studies, it is difficult to establish causal association between independent and dependent variables. Furthermore, a cultural measure was lacking in this study.

Conclusion and Global Health Implications

The social determinants of depression are social, economic and health condition people are born into and live. Poor social and economic circumstances affect health throughout life.[9] Some socio-economic conditions refer to the relationship between income level and educational attainment. Socio-economic variations among the studied patients are strongly and positively associated with depression. The recognition that the disempowerment of women is in part responsible for the increased rate of depression call for more focus in gendered social determinant of depression. Unemployment puts health at risk and the risk is higher in patients with depression. Poverty, relative deprivation and social exclusion have a major impact on depression. This study calls for improved public health education and awareness, to highlighting the health impact of depressive symptoms and the role of social determinants of depression on the sample of HIV/AIDS patient in Nigeria. It also provides initial evidence on the importance of SDH in depression. Social inequity should be given high priorities when addressing the issue of depression.

Conflict of Interest: None Declared


1.Starace F, Ammassari A, Trotta MP, Murri R, De Longis P, Izzo C, et al. Depression is a risk factor for suboptimal adherence to highly active antiretroviral therapy. Journal Acquired Immune Deficiency Syndrome. 2002; 31(3): 136-39.

2.American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR. Arlington, VA: American Psychiatric Publishing, 2000.

3.Vilhjalmsson R. Life stress, social support and clinical depression; a reanalysis of the literature. Social Science and Medicine. 1993; 37: 331 – 342.

4.Lai DWL, Tong HM Comparison of social status determinants of depressive symptoms among elderly Chinese in Guangzhou, Hong King, Asian Journal. Gerontology Geriatric 2009 4:58-65.

5.Robins LN, Reiger DA. Psychiatric disorders in America: The Epidemiologic Catchment Area Study New York: The Free Press; 1991.

6.Offord DR, Boyle MH,Campbell D, Goering P,LinE,WongM,Racine YA et al. One year prevalence of psychiatric disorder in Ontarians 15 to 64 years of age. Canadian Journal of Psychiatry 1996, 41:559-563.

7.Lorant V, Deliege D, Eaton W, Robert A, Phillippot P, Ansseau M. Socio economical inequalities in depression: A meta- analysis. American Journal of Epidemiology 2003, 157:98-112.

8.Goode E. Deviant Behavior Upper Saddle River: Prentice Hall; 1997.

9.Canada. Houses of Commons Standing Committee on health 5/32. Ottawa; 1996.

10.Araoye MO. Data collection in: Research Methodology with Statistics for Health and Social Sciences. Nathadex publishers, Ilorin 2003; 130 – 159.

11.Ndu AC, Arinze SU, Aguwa EN, Obio IE. Prevalence of depression and role of support group in its management: A study of Adult HIV/AIDS patients attending HIV/AIDS Clinic in a tertiary health facility in South-eastern Nigeria; Journal of Public Health and Epidemiology 2011; 3(4): 182-86.

12.Word Health Organization, WHO. Closing the gap in a generation: health equity through action of on the social determinants of health (2008) Available: Accessed 28 June,2011.

13.Phillips MR, Yang GH, Zhang YP, Wang LJ, Ji HY. Risk factors for suicide in China: a national case-control psychological autopsy study. Lancet 2002; 360: 1728-36.

14.Pence B, Reil S, Whetten K, Leserman J, Stangl D, Swartz M Minorities, the poor and survivors of abuse: HIV-infected patients in the US. Deep South. South Medical. Journal. 2007; 100 1114-1122.

15.Klerman GL, Weissman M. Increasing rate of depression. JAMA 189;261(15):2229-35.

16.Zhan AY, Yu LC, Yuan J, Tong Z, Yang C, Foreman SE. Family and cultural correlates of depression among Chinese elderly. International Journal of social Psychiatry 1999; 43:199-212.

17.O’Sullivan. The psychosocial determinants of depression: a lifespan perspective. Journal of Nervous and Mental Disorder. 2004; 192 (9): 585-94.

18.Marco P. Gender differences in depression. The British Journal of Psychiatry, 2000; 177: 486-492.

19.Wade TJ, Cairney J, Prevaln DJ. Emergence of gender differences in depression during adolescence: National panel results from three countries. Journal of America. Academy. Child Adolescence. Psychiatry 2002; 41: 190 – 198.

20.Averina M, Nilssen O, Bren T, Brox J, Arhipovsky VL, Kalinin AG. Social and lifestyle determinants of depression, anxiety, sleeping disorders and self-evaluated quality of life in Russia population based study in Arkhangelsk. Social Psychiatry and Psychiatric Epidemiology. 2005; 40(7): 511-8.

21.Ihezue UH, Kumaraswany N. Socio-demographic characteristics of depressive illness among Nigerians. Acta Psychiatry Scandinavian. 1986; 73 (2): 128 – 132.

22.Mossa MYH, Jennah FY. Treating depression in HIV/AIDS. South-African Journal of Psychiatry 2007; 13(3):86-88.

23.Culberstson FM. Depression and gender. An international review. American Psychologist 1997;52(1):25-31.

24.Australia Bureau of Statistics 2006 (http//:www.ass/

25.Herman AA, Stein DJ, Seedat S. the South-African Stress and Health (SASH) study: 12-month and lifetime prevalence of common mental disorders. South African Medical Journal 2009;99(5):339-44.

26.Agbir TM, Audu MD, Adebowale TO, Goar SG. Depression among medical outpatients with diabetes: A cross-sectional study at Jos University Teaching Hospital, Jos, Nigeria. Annnal Medical 2010;9(1): 5-10.

27.Bongongo T, Tumbo J, Govender I. Depressive features among adult patients receiving antiretroviral therapy for HIV in Rustenburg district, South-Africa.

28.President and Fellows of Harvard College. Depression, sex and age. Cambridge, MA: Harvard Health Publications, 2007, 1-5.

29.Lesserman J, Pence BW, Whetten K. Relationship of lifetime trauma and depressive symptoms to mortality in HIV. America Journal of Psychiatry 2007;164(11):1707-13.

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