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Edlira Zere,1,* Prabhat Kumar Chaudhari,2,* Jitendra Sharan,3 Kunaal Dhingra,4 Nitesh Tiwari5 1Department of Orthodontic and Craniofacial Anomalies, School of Graduate Dentistry, Rambam Health Care Campus, Technion Faculty of Medicine, Haifa, Israel; 2Division of Orthodontics and Dentofacial Deformities, Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi, India; 3Department of Dentistry, All India Institute of Medical Sciences, Bhubaneswar, India; 4Division of Periodontics, Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi, India; 5Division of Pedodontics and Preventive Dentistry, Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi, India *These authors contributed equally to this work Abstract: Class III malocclusion represents a growth-related dentofacial deformity with mandibular prognathism in relation to the maxilla and/or cranial base. Its prevalence varies greatly among and within different races, ethnic groups, and geographic regions studied. Class III malocclusion has a multifactorial etiology, which is the expression of a moderate distortion of normal development as a result of interaction between innate factors or genetic hereditary with environmental factors. Various skeletal topographies of underlying Class III malocclusion are due to discrepancy in the maxillary and mandibular growth along with vertical and/or transverse problems apart from sagittal malformations. The spectrum of complications for Class III malocclusion ranges in gravity from dentoalveolar problems with functional anterior shift of the mandible to true skeletal problems with serious maxillomandibular discrepancies, which makes its diagnosis highly challenging in growing children. Concern regarding early treatment and the need for interceptive care in the case of Class III malocclusion has always been a dilemma, knowing that not all problems will be solved in these cases until maxillomandibular growth is further completed, and the long-term outcome of various treatment approaches may depend on the growth tendency of an individual. Interceptive treatment of Class III malocclusions should be undertaken if it prevents damage to the oral tissues and/or significantly reduces the amount or severity of future orthodontic and surgical interventions. This paper presents an overview of developing Class III malocclusion, with the emphasis on challenges and their solutions based on the best current available evidence. Keywords: Class III malocclusion, facemask therapy, maxillary expansion, chin cup appliance, bone-anchored maxillary protraction, growth treatment response vector

Examines the technical efficiency and productivity of public sector hospitals in three South African provinces. Basic idea underlying the concept and measurement of technical efficiency; Factors that influence the efficiency of hospitals; Changes in the productivity of acute care hospitals.

The aim of this systematic review was to compare the treatment outcomes of digital nasoalveolar moulding (dNAM) technique with conventional nasoalveolar moulding (cNAM) or non-presurgical intervention protocol in infants with unilateral (UCLP) or bilateral (BCLP) cleft lip and palate. A bibliometric search by MEDLINE (via Ovid), Embase, Cochrane Library, grey literature and manual method was conducted without language restriction until November 2023. Literature screening and data extraction were undertaken in Covidence. The risk of bias was evaluated using the Newcastle-Ottawa Scale and RoB-2. Pooled effect sizes were determined through random-effects statistical model using R-Software, and the certainty of evidence was assessed using the GRADE approach. Among 775 retrieved articles, nine studies were included for qualitative synthesis (6-UCLP, 3-BCLP), with only three eligible UCLP studies for meta-analysis. In the UCLP group, very low certainty of evidence indicated no difference in alveolar cleft width (SMD, 0.13 mm; 95% CI, -0.31 to 0.57; I 2 , 0%), soft tissue (lip) cleft gap, nasal width, nasal height, and columellar deviation angle changes between dNAM and cNAM. In the BCLP group, qualitative synthesis suggested similar changes in alveolar, lip, and nasal dimensions with dNAM and cNAM. In both cleft groups (UCLP, BCLP), reduced alveolar cleft width was observed in the dNAM group compared to the non-presurgical intervention protocol, along with fewer clinical visits and reduced chairside time for dNAM compared to cNAM. It can be concluded that the treatment outcomes with dNAM were comparable to cNAM in reducing malformation severity and were advantageous in terms of chairside time and clinical visit frequency. However, the overall quality of evidence is very low and standardization is needed for the virtual workflow regarding the alveolar movements and growth factor algorithms. Registration: PROSPERO-database (CRD42020186452)., (© 2024 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Evidence regarding the possible influence of nutritional status on the facial morphology has thus far been insufficient. We examined whether or not the physical body compositions and dietary behaviors were correlated with any morphological characteristics of the face. One hundred and fifteen young Japanese women participated. Variables representing the dietary behaviors were extracted from self-reported survey data, and corresponding three-dimensional (3D) facial images and body compositions were examined. Multivariate analyses identified significant relationships between the nutritional status and facial topography (p < 0.05). The clustering method revealed the existence of three dietary condition patterns ("balanced diet", "high-calorie-diet" with obesity tendency, and "imbalanced low-calorie-diet" with sarcopenic obesity tendency). Among these three patterns, a round face (increased facial width; analysis of variance [ANOVA], p < 0.05) was observed in the high-calorie-diet pattern, while the imbalanced low-calorie-diet pattern showed a more masculine face (increased face height, decreased eye height, increased non-allometric sexual shape differences; ANOVA, p < 0.05), thus suggesting the possibility of sex-hormonal influences. In summary, the body composition and dietary behaviors were found to influence the facial morphology, and potential biological influences were discussed., (© 2022. The Author(s).)

Objective: This review will compare the efficacy of nasoalveolar molding plates fabricated using a digital workflow to conventional fabrication methods or no intervention in infants with cleft lip or palate., Introduction: Nasoalveolar molding reduces the severity of orofacial defects in infants with cleft lip or palate using a series of adaptable plates for the maxillary arch. The conventional method needs multiple patient visits at short intervals for treatment. A digital workflow can be used to fabricate multiple plates in one appointment, which eliminates human error, reduces the number of appointments, and allocates more time for patient care for the orthodontic team than appliance fabrication., Inclusion Criteria: This review will consider clinical studies that report the results of digital nasoalveolar molding in infants with cleft lip or palate and compare it to the conventional method or to no treatment. Outcomes of interest will be objective measures of craniofacial form, nasolabial measurements, or palatal form., Methods: This review will be conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Databases including PubMed, Embase, Cochrane Oral Health Group Trial Register, and ClinicalTrials.gov will be searched using appropriate keywords. Publications in English will be considered. Screening based on titles and abstracts will be done after de-duplication, followed by full-text reading for selection based on the inclusion criteria. Data extracted from the studies will be tabulated and assessed for risk of bias. If applicable, a meta-analysis of the pooled data will be conducted., Systematic Review Registration Number: PROSPERO CRD42020186452., Competing Interests: The authors declare no conflict of interest., (Copyright © 2022 JBI.)

Examining the extent to which sex differences in three-dimensional (3D) facial soft tissue configurations are similar across diverse populations could suggest the source of the indirect evolutionary benefits of facial sexual dimorphism traits. To explore this idea, we selected two geographically distinct populations. Three-dimensional model faces were derived from 272 Turkish and Japanese men and women; their facial morphologies were evaluated using landmark and surface-based analyses. We found four common facial features related to sexual dimorphism. Both Turkish and Japanese females had a shorter lower face height, a flatter forehead, greater sagittal cheek protrusion in the infraorbital region but less prominence of the cheek in the parotid-masseteric region, and an antero-posteriorly smaller nose when compared with their male counterparts. The results indicated the possible phylogenetic contribution of the masticatory organ function and morphogenesis on sexual dimorphism of the human face in addition to previously reported biological and psychological characteristics, including sexual maturity, reproductive potential, mating success, general health, immune response, age, and personality., (© 2021. The Author(s).)

Preorthodontic socket preservation after tooth extraction is intended to enhance favorable dentoalveolar ridge morphology and architecture, and facilitate orthodontic tooth movement (OTM) and extraction space closure. This 13-year-old skeletal Class II case presents a unique opportunity to evaluate and compare the OTM extraction space closure by means of a split-mouth analysis in a single patient. The comprehensive orthodontic-periodontal treatment included nonsimultaneous extraction of the bilateral periodontally compromised mandibular first molars and the eruption of bilateral impacted mandibular canines. While the right post-extraction space underwent a natural healing process, the left one was grafted using 4BONE BCH (hydroxyapatite β-tricalcium phosphate [HA-β-TCP], HA 60%, and β-TCP 40%). The 3-year multidisciplinary treatment approach resulted in Class I relationships on the right side and Class II on the left side, improved facial appearance, and dento-skeletal jaw relationships. However, a 3-mm residual alveolar space remained unclosed on the grafted left-site, along with an unerupted left third molar. This split-mouth comparative analysis of the orthodontic space closure demonstrated a significant clinical difference in the outcome. Preorthodontic placement of HA-β-TCP grafting material on the left segment, proved to be an obstacle for OTM extraction space closure, hindering the establishment of good occlusion.

Background: The target date for achieving the Millennium Development Goals (MDGs) is now closer than ever. There is lack of sufficient progress in achieving the MDG targets in many low- and middle-income countries. Furthermore, there has also been concerns about wide spread inequity among those that are on track to achieve the health-related MDGs. Bangladesh has made a notable progress towards achieving the MDG 5 targets. It is, however, important to assess if this is an inclusive and equitable progress, as inequitable progress may not lead to sustainable health outcomes. The objective of this study is to assess the magnitude of inequities in reproductive and maternal health services in Bangladesh and propose relevant recommendations for decision making., Methods: The 2007 Bangladesh demographic and health survey data is analyzed for inequities in selected maternal and reproductive health interventions using the slope and relative indices of inequality., Results: The analysis indicates that there are significant wealth-related inequalities favouring the wealthiest of society in many of the indicators considered. Antenatal care (at least 4 visits), antenatal care by trained providers such as doctors and nurses, content of antenatal care, skilled birth attendance, delivery in health facility and delivery by caesarean section all manifest inequities against the least wealthy. There are no wealth-related inequalities in the use of modern contraception. In contrast, less desired interventions such as delivery by untrained providers and home delivery show wealth-related inequalities in favour of the poor., Conclusions: For an inclusive and sustainable improvement in maternal and reproductive health outcomes and achievement of MDG 5 targets, it essential to address inequities in maternal and reproductive health interventions. Under the government's stewardship, all stakeholders should accord priority to tackling wealth-related inequalities in maternal and reproductive health services by implementing equity-promoting measures both within and outside the health sector.

Background: The 58th World Health Assembly and 56th WHO Regional Committee for Africa adopted resolutions urging Member States to ensure that health financing systems included a method for prepayment to foster financial risk sharing among the population and avoid catastrophic health-care expenditure. The Regional Committee asked countries to strengthen or develop comprehensive health financing policies. This paper presents the findings of a survey conducted among senior staff of selected Eritrean ministries and agencies to elicit views on some of the elements likely to be part of a national health financing policy., Methods: This is a descriptive study. A questionnaire was prepared and sent to 19 senior staff (Directors) in the Ministry of Health, Labour Department, Civil Service Administration, Eritrean Confederation of Workers, National Insurance Corporation of Eritrea and Ministry of Local Government. The respondents were selected by the Ministry of Health as key informants., Results: The key findings were as follows: the response rate was 84.2% (16/19); 37.5% (6/16) and 18.8% said that the vision of Eritrean National Health Financing Policy (NHFP) should include the phrases 'equitable and accessible quality health services' and 'improve efficiency or reduce waste' respectively; over 68% indicated that NHFP should include securing adequate funding, ensuring efficiency, ensuring equitable financial access, protection from financial catastrophe, and ensuring provider payment mechanisms create positive incentives to service providers; over 80% mentioned community participation, efficiency, transparency, country ownership, equity in access, and evidence-based decision making as core values of NHFP; over 62.5% confirmed that NHFP components should consist of stewardship (oversight), revenue collection, revenue pooling and risk management, resource allocation and purchasing of health services, health economics research, and development of human resources for health; over 68.8% indicated cost-sharing, taxation and social health insurance as preferred revenue collection mechanisms; and 68.75% indicated their preferred provider payment mechanism to be a global (lump sum) budget., Conclusion: This study succeeded in gathering the preliminary views of senior staff of selected Eritrean ministries and agencies regarding the likely elements of the NHFP, i.e. the vision, objectives, components, provider payment mechanisms, and health financing agency and its governance. In addition to stakeholder surveys, it would be helpful to inform the development of the NHFP with other pieces of evidence, including cost-effectiveness analysis of health services and interventions, financial feasibility analysis of financing options, a survey of the political and professional acceptability of financing options, national health accounts, and equity analyses.

Background: With the date for achieving the targets of the Millennium Development Goals (MDGs) approaching fast, there is a heightened concern about equity, as inequities hamper progress towards the MDGs. Equity-focused approaches have the potential to accelerate the progress towards achieving the health-related MDGs faster than the current pace in a more cost-effective and sustainable manner. Ghana's rate of progress towards MDGs 4 and 5 related to reducing child and maternal mortality respectively is less than what is required to achieve the targets. The objective of this paper is to examine the equity dimension of child and maternal health outcomes and interventions using Ghana as a case study., Methods: Data from Ghana Demographic and Health Survey 2008 report is analyzed for inequities in selected maternal and child health outcomes and interventions using population-weighted, regression-based measures: slope index of inequality and relative index of inequality., Results: No statistically significant inequities are observed in infant and under-five mortality, perinatal mortality, wasting and acute respiratory infection in children. However, stunting, underweight in under-five children, anaemia in children and women, childhood diarrhoea and underweight in women (BMI < 18.5) show inequities that are to the disadvantage of the poorest. The rates significantly decrease among the wealthiest quintile as compared to the poorest. In contrast, overweight (BMI 25-29.9) and obesity (BMI ≥ 30) among women reveals a different trend - there are inequities in favour of the poorest. In other words, in Ghana overweight and obesity increase significantly among women in the wealthiest quintile compared to the poorest. With respect to interventions: treatment of diarrhoea in children, receiving all basic vaccines among children and sleeping under ITN (children and pregnant women) have no wealth-related gradient. Skilled care at birth, deliveries in a health facility (both public and private), caesarean section, use of modern contraceptives and intermittent preventive treatment for malaria during pregnancy all indicate gradients that are in favour of the wealthiest. The poorest use less of these interventions. Not unexpectedly, there is more use of home delivery among women of the poorest quintile., Conclusion: Significant Inequities are observed in many of the selected child and maternal health outcomes and interventions. Failure to address these inequities vigorously is likely to lead to non-achievement of the MDG targets related to improving child and maternal health (MDGs 4 and 5). The government should therefore give due attention to tackling inequities in health outcomes and use of interventions by implementing equity-enhancing measure both within and outside the health sector in line with the principles of Primary Health Care and the recommendations of the WHO Commission on Social Determinants of Health.

Background: Implementing initiatives to achieve the targets of MDG 5 requires sufficient financial resources that are mobilized and utilized in an equitable, efficient and sustainable manner. Informed decision making to this end requires the availability of reliable health financing information. This is accomplished by means of Reproductive Health (RH) sub-account, which captures and organizes expenditure on RH services in two-dimensional tables from financing sources to end users. The specific objectives of this study are: (i) to quantify total expenditure on reproductive health services; and (ii) to examine the flow of RH funds from sources to end users., Methods: The RH sub-account was part of the general National Health Accounts exercise covering the Financial Years 2007/08 and 2008/09. Primary data were collected from employers, medical aid schemes, donors and government ministries using questionnaire. Secondary data were obtained from various documents of the Namibian Government and the health financing database of the World Health Organization. Data were analyzed using a data screen designed in Microsoft Excel., Results: RH expenditure per woman of reproductive age was US$ 148 and US$ 126 in the 2007/08 and 2008/09 financial years respectively. This is by far higher than what is observed in most African countries. RH expenditure constituted more than 10-12% of the total expenditure on health. Out-of-pocket payment for RH was minimal (less than 4% of the RH spending in both years). Government is the key source of RH spending. Moreover, the public sector is the main financing agent with programmatic control of RH funds and also the main provider of services. Most of the RH expenditure is spent on services of curative care (both in- and out-patient). The proportion allocated for preventive and public health services was not more than 5% in the two financial years., Conclusion: Namibia's expenditure on reproductive health is remarkable by the standards of Africa and other middle-income countries. However, an increasing maternal mortality ratio does not bode well with the level of reproductive health expenditure. It is therefore important to critically examine the state of efficiency in the allocation and use of reproductive health expenditures in order to improve health outcomes.

Background: The fifth Millennium Development Goal (MDG5) aims at improving maternal health. Globally, the maternal mortality ratio (MMR) declined from 400 to 260 per 100000 live births between 1990 and 2008. During the same period, MMR in sub-Saharan Africa decreased from 870 to 640. The decreased in MMR has been attributed to increase in the proportion of deliveries attended by skilled health personnel. Global improvements maternal health and health service provision indicators mask inequalities both between and within countries. In Namibia, there are significant inequities in births attended by skilled providers that favour those that are economically better off. The objective of this study was to identify the drivers of wealth-related inequalities in child delivery by skilled health providers., Methods: Namibia Demographic and Health Survey data of 2006-07 are analysed for the causes of inequities in skilled birth attendance using a decomposable health concentration index and the framework of the Commission on Social Determinants of Health., Results: About 80.3% of the deliveries were attended by skilled health providers. Skilled birth attendance in the richest quintile is about 70% more than that of the poorest quintile. The rate of skilled attendance among educated women is almost twice that of women with no education. Furthermore, women in urban areas access the services of trained birth attendant 30% more than those in rural areas. Use of skilled birth attendants is over 90% in Erongo, Hardap, Karas and Khomas Regions, while the lowest (about 60-70%) is seen in Kavango, Kunene and Ohangwena. The concentration curve and concentration index show statistically significant wealth-related inequalities in delivery by skilled providers that are to the advantage of women from economically better off households (C = 0.0979; P < 0.001).Delivery by skilled health provider by various maternal and household characteristics was 21 percentage points higher in urban than rural areas; 39 percentage points higher among those in richest wealth quintile than the poorest; 47 percentage points higher among mothers with higher level of education than those with no education; 5 percentage points higher among female headed households than those headed by men; 20 percentage points higher among people with health insurance cover than those without; and 31 percentage points higher in Karas region than Kavango region., Conclusion: Inequalities in wealth and education of the mother are seen to be the main drivers of inequities in the percentage of births attended by skilled health personnel. This clearly implies that addressing inequalities in access to child delivery services should not be confined to the health system and that a concerted multi-sectoral action is needed in line with the principles of the Primary health Care.

Background: National health accounts provide useful information to understand the functioning of a health financing system. This article attempts to present a profile of the health system financing in Malawi using data from NHA. It specifically attempts to document the health financing situation in the country and proposes recommendations relevant for developing a comprehensive health financing policy and strategic plan., Methods: Data from three rounds of national health accounts covering the Financial Years 1998/1999 to 2005/2006 was used to describe the flow of funds and their uses in the health system. Analysis was performed in line with the various NHA entities and health system financing functions., Results: The total health expenditure per capita increased from US$ 12 in 1998/1999 to US$25 in 2005/2006. In 2005/2006 public, external and private contributions to the total health expenditure were 21.6%, 60.7% and 18.2% respectively. The country had not met the Abuja of allocating at least 15% of national budget on health. The percentage of total health expenditure from households' direct out-of-pocket payments decreased from 26% in 1998/99 to 12.1% in 2005/2006., Conclusion: There is a need to increase government contribution to the total health expenditure to at least the levels of the Abuja Declaration of 15% of the national budget. In addition, the country urgently needs to develop and implement a prepaid health financing system within a comprehensive health financing policy and strategy with a view to assuring universal access to essential health services for all citizens.

Background: Inequities in the utilization of maternal health services impede progress towards the MDG 5 target of reducing the maternal mortality ratio by three quarters, between 1990 and 2015. In Namibia, despite increasing investments in the health sector, the maternal mortality ratio has increased from 271 per 100,000 live births in the period 1991-2000 to 449 per 100,000 live births in 1998-2007. Monitoring equity in the use of maternal health services is important to target scarce resources to those with more need and expedite the progress towards the MDG 5 target. The objective of this study is to measure socio-economic inequalities in access to maternal health services and propose recommendations relevant for policy and planning., Methods: Data from the Namibia Demographic and Health Survey 2006-07 are analyzed for inequities in the utilization of maternal health. In measuring the inequities, rate-ratios, concentration curves and concentration indices are used., Results: Regions with relatively high human development index have the highest rates of delivery by skilled health service providers. The rate of caesarean section in women with post secondary education is about seven times that of women with no education. Women in urban areas are delivered by skilled providers 30% more than their rural counterparts. The rich use the public health facilities 30% more than the poor for child delivery., Conclusion: Most of the indicators such as delivery by trained health providers, delivery by caesarean section and postnatal care show inequities favoring the most educated, urban areas, regions with high human development indices and the wealthy. In the presence of inequities, it is difficult to achieve a significant reduction in the maternal mortality ratio needed to realize the MDG 5 targets so long as a large segment of society has inadequate access to essential maternal health services and other basic social services. Addressing inequities in access to maternal health services should not only be seen as a health systems issue. The social determinants of health have to be tackled through multi-sectoral approaches in line with the principles of Primary Health Care and the recommendations of the Commission on Social Determinants of Health.

Background: Data Envelopment Analysis (DEA) has been used to analyze the efficiency of the health sector in the developed world for sometime now. However, in developing economies and particularly in Africa only a few studies have applied DEA in measuring the efficiency of their health care systems., Methods: This study uses the DEA method, to calculate the technical efficiency of 89 randomly sampled health centers in Ghana. The aim was to determine the degree of efficiency of health centers and recommend performance targets for the inefficient facilities., Results: The findings showed that 65% of health centers were technically inefficient and so were using resources that they did not actually need., Conclusion: The results broadly point to grave inefficiency in the health care delivery system of public health centers and that significant amounts of resources could be saved if measures were put in place to curb the waste.

Background: Growing scientific evidence points to the pervasiveness of inequities in health and health care and the persistence of the inverse care law, that is the availability of good quality healthcare seems to be inversely related to the need for it in developing countries. Achievement of the Millennium Development Goals is likely to be compromised if inequities in health/healthcare are not properly addressed., Objective: This study attempts to assess trends in inequities in selected indicators of health status and health service utilization in Malawi using data from the Demographic and Health Surveys of 1992, 2000 and 2004., Methods: Data from Demographic and Health Surveys of 1992, 2000 and 2004 are analysed for inequities in health/healthcare using quintile ratios and concentration curves/indices., Results: Overall, the findings indicate that in most of the selected indicators there are pro-rich inequities and that they have been widening during the period under consideration. Furthermore, vertical inequities are observed in the use of interventions (treatment of diarrhoea, ARI among under-five children), in that the non-poor who experience less burden from these diseases receive more of the treatment/interventions, whereas the poor who have a greater proportion of the disease burden use less of the interventions. It is also observed that the publicly provided services for some of the selected interventions (e.g. child delivery) benefit the non-poor more than the poor., Conclusion: The widening trend in inequities, in particular healthcare utilization for proven cost-effective interventions is likely to jeopardize the achievement of the Millennium Development Goals and other national and regional targets. To counteract the inequities it is recommended that coverage in poor communities be increased through appropriate targeting mechanisms and effective service delivery strategies. There is also a need for studies to identify which service delivery mechanisms are effective in the Malawian context.

Background: The pace of redressing inequities in the distribution of scarce health care resources in Namibia has been slow. This is due primarily to adherence to the historical incrementalist type of budgeting that has been used to allocate resources. Those regions with high levels of deprivation and relatively greater need for health care resources have been getting less than their fair share. To rectify this situation, which was inherited from the apartheid system, there is a need to develop a needs-based resource allocation mechanism., Methods: Principal components analysis was employed to compute asset indices from asset based and health-related variables, using data from the Namibia demographic and health survey of 2000. The asset indices then formed the basis of proposals for regional weights for establishing a needs-based resource allocation formula., Results: Comparing the current allocations of public sector health car resources with estimates using a needs based formula showed that regions with higher levels of need currently receive fewer resources than do regions with lower need., Conclusion: To address the prevailing inequities in resource allocation, the Ministry of Health and Social Services should abandon the historical incrementalist method of budgeting/resource allocation and adopt a more appropriate allocation mechanism that incorporates measures of need for health care.

Background: In most countries of the sub-Saharan Africa, health care needs have been increasing due to emerging and re-emerging health problems. However, the supply of health care resources to address the problems has been continuously declining, thus jeopardizing the progress towards achieving the health-related Millennium Development Goals. Namibia is no exception to this. It is therefore necessary to quantify the level of technical inefficiency in the countries so as to alert policy makers of the potential resource gains to the health system if the hospitals that absorb a lion's share of the available resources are technically efficient., Method: All public sector hospitals (N = 30) were included in the study. Hospital capacity utilization ratios and the data envelopment analysis (DEA) technique were used to assess technical efficiency. The DEA model used three inputs and two outputs. Data for four financial years (1997/98 to 2000/2001) was used for the analysis. To test for the robustness of the DEA technical efficiency scores the Jackknife analysis was used., Results: The findings suggest the presence of substantial degree of pure technical and scale inefficiency. The average technical efficiency level during the given period was less than 75%. Less than half of the hospitals included in the study were located on the technically efficient frontier. Increasing returns to scale is observed to be the predominant form of scale inefficiency., Conclusion: It is concluded that the existing level of pure technical and scale inefficiency of the district hospitals is considerably high and may negatively affect the government's initiatives to improve access to quality health care and scaling up of interventions that are necessary to achieve the health-related Millennium Development Goals. It is recommended that the inefficient hospitals learn from their efficient peers identified by the DEA model so as to improve the overall performance of the health system.

OBJECTIVES: To assess and quantify the magnitude of inequalities in under-five child malnutrition, particularly those ascribable to socio-economic status and to consider the policy implications of these findings. METHODS: Data on 3765 under-five children were derived from the Living Standards and Development Survey. Household income, proxied by per capita household expenditure, was used as the main indicator of socio-economic status. Socio-economic inequality in malnutrition (stunting, underweight and wasting) was measured using the illness concentration index. The concentration index was calculated for the whole sample, as well as for different population groups, areas of residence (rural, urban and metropolitan) and for each province. RESULTS: Stunting was found to be the most prevalent form of malnutrition in South Africa. Consistent with expectation, the rate of stunting is observed to be the highest in the Eastern Cape and the Northern Province - provinces with the highest concentration of poverty. There are considerable pro-rich inequalities in the distribution of stunting and underweight. However, wasting does not manifest gradients related to socio-economic position. Among White children, no inequities are observed in all three forms of malnutrition. The highest pro-rich inequalities in stunting and underweight are found among Coloured children and metropolitan areas. There is a tendency for high pro-rich concentration indices in those provinces with relatively lower rates of stunting and underweight (Gauteng and the Western Cape). CONCLUSION: There are significant differences in under-five child malnutrition (stunting and underweight) that favour the richest of society. These are unnecessary, avoidable and unjust. It is demonstrated that addressing such socio-economic gradients in ill-health, which perpetuate inequalities in the future adult population requires a sound evidence base. Reliance on global averages alone can be misleading. Thus there is a need for evaluating policies not only in terms of improvements in averages, but also improvements in distribution. Furthermore, addressing problems of stunting and underweight, which are found to be responsive to improvements in household income status, requires initiatives that transcend the medical arena.

The study was carried out to assess the magnitude of, and change in, inequities in self-reported adult illness and use of healthcare and to consider the policy implications of the findings. Datasets from three household surveys carried out in 1993, 1995, and 1998 were used. Inequities were measured using illness and healthcare-use concentration indices. Self-reported adult illness was greater among the rich in 1993, but this was reversed to reflect higher levels of reported illness among the poor in 1995 and 1998. Inequities were observed in self-reported injury and disability/chronic illness that favour the rich. The poor also reported more days of sickness compared to the rich. Overall, there were higher levels of use of doctors and hospital services by the rich, relative to their levels of reported illness. In contrast, there was a greater use of public-sector facilities by the poor. The time taken to reach a health facility also had a bias in favour of the rich. Although there were some favourable changes in the levels of inequities between the three time periods, there still remained considerable inequities that favoured the rich in self-reported adult illness and use of health services that need to be addressed. The consequences of higher concentration of chronic illness/disability and injury among the poor have far-reaching negative consequences on the socioeconomic welfare of the individuals and households. Redressing these inequities needs a holistic strategy that transcends the health sector.