Socioeconomic inequalities in health: chronic disease prevalence, health care utilization, health expenditure and life course perspective in Botswana

Abstract

The debate on socioeconomic inequalities in health is currently dominating the research and policy agenda in many countries. In Botswana, empirical evidence on the socioeconomic inequalities linked to prevalence of NCDs, health care utilization, health expenditure and life course factors is extremely deficient and largely unknown. The main objective of this study was to explore and stir debate on socioeconomic inequalities in health in the face of the emerging burden of NCDs. Data used in this study was derived from the large sample survey on Chronic Non-Communicable Diseases in Botswana: A study on Prevalence, Health Care Utilization, Health Expenditure and Life Course (NCDs study, 2016). The NCDs study adopted a representative cross-sectional descriptive study design. Using a multi-stage probability sampling design, the survey was carried in selected urban and rural areas of Botswana, among males and females aged 15 years and over. The total sample was 1178. Evidence in this thesis indicates an increase in the prevalence of NCDs and associated risk factors. The most prevalent NCD in the study population was hypertension. Socioeconomic inequalities in health were measured by using the odd ratios and concentration index (CI). Overall, the study showed mixed findings on the association between socioeconomic status (SES) and health. The study noted that poor people were more likely to be exposed to NCD risk factors than the non-poor. For instance, they were found to have significantly higher odds of smoking, poor physical activity, and poor fruit and vegetable consumption. The poor were also found to be more likely to report multiple NCD risk factors than the non-poor. Meanwhile alcohol consumption was found to be high among the non-poor. Overweight/obesity did not show any variation by wealth status suggesting that both the poor and non-poor were overweight/obese. Though NCD risk factors are greater among the poor, the likelihood of reported morbidity for diabetes and hypertension was high among the non-poor. Educational and wealth status inequalities have been observed to exist for health care utilization outcomes. People with low education and wealth status were found to be less likely to have needed health care in the last one year, less likely to have gotten health care when they needed it, and to have sought health care for NCDs than for other disease conditions. As for the type of health facility utilized, less educated and poor people were found more likely to have visited public health facilities when they felt sick or needed to consult anyone about their health. The study established that wealth status was significantly associated with out-of-pocket health expenditure. This was evidenced by the non-poor more likely to report out-of-pocket expenditure for health care and medical insurance coverage than the poor. The findings of this study confirmed the notion that childhood SES influence adult health. It was noted that people who had poor childhood SES status were more likely to report smoking, alcohol consumption and poor fruit and vegetable consumption but were less likely to be overweight/obese. People with poor childhood SES were also found to be more likely to report hypertension, diabetes, single and multiple NCD conditions. Decomposition of inequalities analysis was done for hypertension and NCD risk factors. Overall, CI estimates were positive for poor physical activity, alcohol consumption and overweight/obesity indicating that these three NCD risk factors were more concentrated among the non-poor. Meanwhile negative CI estimates were observed for daily smoking and poor fruit and vegetable consumption. This suggests that the two risk factors were more concentrated among the poor. Decomposition of the concentration index revealed that wealth status itself was the leading contributor to socioeconomic inequality for four risk factors; daily smoking, poor FV consumption, overweight/obesity and poor physical activity. Education on the other hand, was the leading contributor to socioeconomic inequality for alcohol consumption. CI estimates for hypertension in the study population and population 50+ years were positive. Thus, the dominant factors to this inequality were education and wealth status, respectively. Mixed findings on the relationship between SES and various health outcomes shown in this study indicate the need for further research into understanding and explaining of such inequalities. This is because eliminating socioeconomic differences in health requires new knowledge about the determinants of disease. These inequalities might be reduced by improving educational opportunities, wealth distribution, health-related behavior, or access to health care.