Main Theories Relating Health & Development

Proochista ArianaInternational Development &

HealthHilary Term 2009

Your Initial Thoughts

• Your background• What is ‘development’?/What is

‘health’• How does development relate to

health?• What you hope to get from this

course

Overall Aims• Provide basic understanding of how

development processes relate to health• Demonstrate the implicit and political

nature of policies and their relevance in mediating the relationship between development and health

• Illustrate, through historical and contemporary examples, the intended and unintended, positive and negative health consequences of development

Course Overview

• Main theories relating health & development• The complexities of development & the shift

from economic to human development• Policy process and health governance• Economic transitions and health• Inequality, environmental changes,

epidemiological shifts, nutritional transitions• Famine, conflicts and natural disasters

Course Logistics

• Lectures• Class Discussions

-Questions & clarifications on lecture & readings

-Extra readings-Current issues

• Group Case Studies

Relevance of Health for Development

• Intrinsic Value– Elemental dimension of human

development– Human right

• Instrumental– Economic ends– Other aspects of human development

Human Development

“The basic objective of development is to create an enabling environment

for people to enjoy long, healthy, and creative lives.”

(UNDP 1990 Human Development Report)

Human Development

• Alternative approach to development• Humans as centre of development

process (and not the means to economic ends)

• HDI developed by Mahbub ul Haq and colleagues for the UNDP and formed the basis for the Human Development Reports

• Three components: education, household income, and health

Health as Human Right

"the enjoyment of the highest attainable standard of health is one of the fundamental rights of every

human being..." (WHO Constitution)

General Comment on the Right to Health (2000)

• Availability: Functioning public health and health care facilities, goods and services, as well as programmes in sufficient quantity.

• Accessibility: Health facilities, goods and services accessible to everyone, within the jurisdiction of the State party. Accessibility has four overlapping dimensions: – non-discrimination – physical accessibility – economical accessibility (affordability) – information accessibility

• Acceptability: All health facilities, goods and services must be respectful of medical ethics and culturally appropriate as well as sensitive to gender and life-cycle requirements.

• Quality: Health facilities, goods and services must be scientifically and medically appropriate and of good quality.

(UN Committee on Economic, Social and Cultural Rights, Comment on the Right to Health, 2000)

‘Core Content’

• Essential primary health care • minimum essential and nutritious

food • sanitation • safe and potable water • essential drugs

Millennium Development Goals

• September 2000 UN General Assembly• United Nations Millennium Declaration

“We recognize that, in addition to our separate responsibilities to our individual societies, we have a collective responsibility to uphold the principles of human dignity, equality and equity at the global level. As leaders we have a duty therefore to all the world’s people, especially the most vulnerable and, in particular, the children of the world, to whom the future belongs.”

8 Goals

1. Eradicate extreme poverty and hunger2. Achieve universal primary education3. Promote gender equality and empower women4. Reduce child mortality5. Improve maternal health6. Combat HIV/AIDS, malaria and other diseases7. Ensure environmental sustainability8. Develop a Global Partnership for Development

(http://www.un.org/millenniumgoals/)

Health Related MDGs• End Poverty & Hunger

– Halve, between 1990 and 2015, the proportion of people who suffer from hunger

• Improve Child Health– Reduce by two thirds the <5 mortality rate

• Improve Maternal Health– Reduce by three quarters the maternal mortality ratio– Achieve universal access to reproductive health

• Combat HIV/AIDS, Malaria, and other major diseases– Have halted by 2015 and begun to reverse the spread

of HIV/AIDS– Achieve, by 2010, universal access to treatment for

HIV/AIDS for all those who need it– Have halted by 2015 and begun to reverse the

incidence of malaria and other major diseases (TB)

Relevance of Health

• Intrinsically valuable• Elemental to human development• A fundamental human right• Half the MDGs are refer to an aspect

of health

Main Theories Relating Health & Development

Points for Reflection• What is the relevance of health?• Is EG necessary to achieve health?• How can health facilitate EG?• Health is instrumental to what other

components of human development?• What are the problems with the

measures we rely on and the methods we use to relate health and EG?

Outline

• A bit of history• Preston Curves• Causality of relationship• Instrumentality of health for EG• Instrumentality of health for other

dimensions of human development

A bit of History

• Dramatic decreases in mortality in the 20th century

• Observation that such decreases were correlated with economic growth

• Wealth-health paradigm: economic growth is responsible, directly or indirectly, for improved health

• Economic growth is seen as a powerful proxy which effectively and reliably encompasses all the intervening factors (e.g. Food, shelter, housing, etc.)

Mortality Declines/Increased LE

Economic Growth

Not Necessarily a Good

• Decreases in mortality led to increases in population size which was believed to cause increased poverty and compromised economic growth (Malthusian view)

• Economic growth continued but poverty increased as did inequality (due in part to unequal pace of economy to provide jobs & state to provide public goods for increasing population)

Population Growth

Is Population a Problem?

Inequality

Unequal Economic Growth

Unequal Health Improvements

Inequalities Growing

Growth and Poverty

Preston Curves

• Preston demonstrated that the actual links between LE and GNP per capita (globally) were getting stronger

• But the contribution of income per se was small (10-25%)

“factors exogenous to a country’s current level of income probably account for 75-90 per cent of the growth in life expectancy for the world as a whole between the 1930s and the 1960s”

Source: Preston, 1975

Two Important Features

• Upward shift: Each subsequent decade requires less income to achieve the same level health (on aggregate) than the previous decades

• Diminishing returns: The marginal returns to each unit of income lessens as income increases

Diminishing Returns

Once basic needs are met (most important of which are nutrition, housing conditions, and education), the added benefits of income for life-expectancy become less important

Public Goods may Explain the Upward Shift

• Germ theory of disease • International transmission of

knowledge • Public health programmes (vector

control, vaccinations, water and sanitation, housing conditions)

• Healthcare services and medicines

Bi-directionality of Relationship

Does economic growth improve health or does a healthy population foster economic growth?– Human capital approach (healthier is

wealthier) so if we are concerned with economic growth, we should focus on health

– Effect of income on health is causal (wealthier is healthier) so if we want to improve health, we should focus on economic growth

‘Wealthier is Healthier’

• “wealthier nations are healthier nations” as demonstrated by the strong and consistent association between per capita income and child mortality (Pritchett & Summers 1996)

• The effect of income on health is causal (not accounted for by reverse causation or a third variable)

• For every unit change in per capita income, there is a 0.2-0.4 drop in child mortality rate

• So if we focus on economy we will save children’s lives

Angus Deaton (2006)

• No evidence that economic growth will automatically improve health

• Examples where health achievements have been made without high incomes (i.e. Sri Lanka, Cuba, Costa Rica, Kerala)

• Many contributions to health that do not depend on EG or income

• Likely a third factor that relates both to EG and Health (i.e. education or governance)

Negative Outliers

• New and resurgent infections (HIV, SARS, MDRTB) which do not respect national boundaries

• Breakdown of public health infrastructure

• Decreased accessibility of medicines (due to patents)

• Multiple-drug resistant diseases

High Variability

• Great deal of inequality in health both between an within countries

• “the need for commodities to achieve any specified living conditions can, in fact, vary greatly with various physiological, social, cultural, and other contingent features” (Anand and Ravallion, 1993)

Inequalities in Health

Inequality in Health within Countries

Necessary but not Sufficient

“… a higher income implies and facilitates, though it does not necessarily entail, larger real consumption of items affecting health, such as food, housing, medical and public health services, education, leisure, health-related research and, on the negative side, automobiles, cigarettes, animal fats and physical inertia”

(Preston, 1975)

Allocation of Resources

Some countries have been able to achieve high health standards incommensurate with their level of national income (i.e. the positive outliers on the Preston Curves) due to concerted political and/or social efforts (i.e. by allocating a larger portion of national resources to healthcare, disease prevention, and education)

Health Expenditures

Economic Growth & Human Development

• Cross-country regressions of 35 to 76 developing countries from 1960-1992

• Economic growth is necessary but not sufficient for achieving human development

• Economic growth itself will not be sustained unless preceded or accompanied by improvements in human development

(source: Ranis, Stewart & Ramirez, 2000)

Human Development Report 2003Human Development Report 2005

Economic Growth & Health

• Economic growth (or income) functions through factors that may be variably associated with both income and health

• The associations and dissociations between health and economic growth suggest the need to better appreciate the dynamic mechanisms through which income and national economy impact health

• Also important to recognize the limitations of our measures

Measurement Issues

• Largely relying on Mortality or LE to encompass ‘health’

• Often incomplete or inaccurate vital registries – particularly in poor countries

• Life-expectancy is calculated using infant mortality and model life tables

• Implicitly or explicitly we are giving more weight to infant and child mortality

Instrumental Nature of Health

• World Bank’s 1993 World Development Report: Investing in Health

• Commission on Macroeconomics and Health (2001): Investing in Health for Economic Development

• Human Capital and the ‘quality of labour’ (e.g. Bloom et. al. 2003)

Healthier is Wealthier

• We should care about health, not only because it is an intrinsic good, but also because it contributes to economic growth

• Health, through its contribution to the quality of human capital as well as increases in savings and investments which correspond to longer lives, has a strong and significant affect on economic growth

Height & Wages

Means to Other Ends

• Health is intrinsically valuable• Instrumental to economic

development• Instrumental to human development• Development processes, in turn,

affect health through various mechanisms and at various stages

Health & Human Development

• Nutrition and cognitive development• Health shocks and poverty• Health and economic opportunities

(income generating potential)

Development’s impact on health

• Direct/Intended– Health related MDGs– Improve Maternal Health

• Indirect/Unintended– Infrastructure– Employment opportunities

• Positive– Reductions in mortality– Improved nutrition, housing, healthcare

• Negative– Road traffic accidents

Your Thoughts

Intended Unintended

Positive

Negative

Coming Up Next Week

• The evolution of development theory and practice

• Human development & the capability approach

• The political nature of policy and health governance

• Broadening our understanding of health

____THANK YOU____

Measuring MDGs

• Prevalence of underweight children under-five years of age

• Proportion of population below minimum level of dietary energy consumption

• Under-five mortality rate, infant mortality rate, & proportion of 1 year-old children immunised against measles

• Maternal mortality ratio & proportion of births attended by skilled health personnel

Measuring MDG 6• HIV prevalence among population aged 15-24 years• Condom use at last high-risk sex• Proportion of population aged 15-24 years with comprehensive

correct knowledge of HIV/AIDS• Ratio of school attendance of orphans to school attendance of

non-orphans aged 10-14 years • Proportion of population with advanced HIV infection with access

to antiretroviral drugs • Incidence and death rates associated with malaria• Proportion of children under 5 sleeping under insecticide-treated

bednets• Proportion of children under 5 with fever who are treated with

appropriate anti-malarial drugs• Incidence, prevalence and death rates associated with

tuberculosis• Proportion of tuberculosis cases detected and cured under directly

observed treatment short course

Transitions• Demographic Transition: decreases in

fertility lag behind decreases in mortality so have an increase in population and a shift in the population pyramid towards older age groups

• Epidemiological transition: shift in the types of diseases affecting the population

• Nutrition transitions: shift in the types of malnutrition (over- or under-nutrition)

Saudi Arabia Uruguay Russia Costa Rica Vietnam Morocco GDP per capita (PPPUS$) 15,711 9,962 10,845 9,481 3,071 4,555 Adult literacy rate (%) 82.9 96.8 99.4 94.9 90.3 52.3 Female literacy rate (%) 76.3 97.3 99.2 95.1 86.9 39.6 Life expectancy (years) 72.2 75.9 65 78.5 73.7 70.4 Under 5 mortality (0/00) 26 15 18 12 19 40 Political Rights/Civil Libertiesa 7/6 1/1 6/5 1/1 7/5 5/4 Human Development Index 0.812 0.852 0.802 0.846 0.733 0.646 Source: Human Development Report 2007/2008, see www.undp.org

a Freedom House 2008 (with 1 being most free and 7 less free), see www.freedomhouse.org

Life Expectancy and GDP

Population Increases

Population & GDP

Source: World Bank , WDR 1993

Population Growth

Source: http://www.sustainablescale.org

Source: Ranis, Stewart & Ramirez 2000

Development & Health

• Development is a process that influences and is influenced by health

• Development is directed and political