W4R Ess.Ch.3 - —I—-——__._ Lrannms flatrtrrvrs By...

Info iconThis preview shows pages 1–13. Sign up to view the full content.

View Full Document Right Arrow Icon
Background image of page 1

Info iconThis preview has intentionally blurred sections. Sign up to view the full version.

View Full DocumentRight Arrow Icon
Background image of page 2
Background image of page 3

Info iconThis preview has intentionally blurred sections. Sign up to view the full version.

View Full DocumentRight Arrow Icon
Background image of page 4
Background image of page 5

Info iconThis preview has intentionally blurred sections. Sign up to view the full version.

View Full DocumentRight Arrow Icon
Background image of page 6
Background image of page 7

Info iconThis preview has intentionally blurred sections. Sign up to view the full version.

View Full DocumentRight Arrow Icon
Background image of page 8
Background image of page 9

Info iconThis preview has intentionally blurred sections. Sign up to view the full version.

View Full DocumentRight Arrow Icon
Background image of page 10
Background image of page 11

Info iconThis preview has intentionally blurred sections. Sign up to view the full version.

View Full DocumentRight Arrow Icon
Background image of page 12
Background image of page 13
This is the end of the preview. Sign up to access the rest of the document.

Unformatted text preview: —I—-——__._ Lrannms flatrtrrvrs By the end of this chapter the reader mil. be able to: - Describe the linlts beta-aen health and education 0 Discuss the connections between health. prodeet-ivity. anti earnings 4 Describe hey relationships between health, the costs of “lungs, and the impact at health expenditure on poverty I Discuss some connections between health and equiv.- * Describe sutne relationships henveen expenditure on health and health outcomes I Differentiate between public anti: private expenditures on health ' Understand the use of cost-Effectiveness analysis as one tool For making investment choices in health - Distuss the two-way relationship between health and develop- ment 'ti'IEN E'ITES "invithit lived in a poor village in north lnclia. When sitt- first hecarnc sick, she visited an unlicensed "doctor." She did not recover and then went to a practitioner oilndian Systems of' Medicine. After another tern weeks or" illness. she went to the outpatient clinic of the main hospital. By the time Savithtt had begun to recover. she had spent $20 equivalent on health services and on the transport tn get to them. She had also linseed two weeks ni'worl-C. during which she lost another 'SEU of income. The total cost of this illness was about their of Savitha’s annual earnings. Mohantmct‘l was in first grade in a small town in north— errt Nigeria. Mohammed's family was poor. Mohammad was 'I-"L'l'}" small for his age. WEE- vcry thinI and got sick more often than rttost children. Because of his poor health. Mohammad CHAPTER was unable to attend school regularly and was forced to quit school aiiter only i year. Unfortunately. he could not read or write, had little knowledge of how to work with figures, and was most liltciy destined for a life oiiimited ioli prospects at very low pay. [iirtc was horn in Dentttari-t to a middle class family. She was exclusively hreastfed until she was six months old. when appropriate complementary foods were introduced. Her tarnin took her regularly [or "well hahy“ check—tips and she received all of her scheduled childhood immunizations. ller hearing and her eyesight were checked before she enrolled in school. Birtc attended school regularly. she was attentive in class. and she performed well there. She lwas aisle to complete high school and medical school and today is a physician. ABC company was looking,r for investments in forest products and examined in detai] the possibility of invest- ing in Africa. Mler careFLIIly considering the potential costs Mid returns to such an invcstlttcnt. the company decided. however. not to invest in Africa but to invest instead in Asia. in the end. the company believed that they were Unlikely to make an acceptable profit on any husiness in Africa because so many oi their workers would be infected with. HW and malaria. INTRDDUETIDN Health and economic matters are intimately linked in a number of ways. First, health is an important contributor to people's ability to be productive and to accumulate the knowledge and sltilis they need to be productive, known as "human capital.” Second. health status is aiso a major determinant of one’s enrollment in and success in school. .fll'E‘tJZ. .' which itself is an important contributor to future earnings. Third. the costs of healdi care are also extremely important to individuals. especially to poor people, because large out- of~pocket expenditures can have a major impact on their financial status and can push them into poverty. Fourth. the costs of health care are also very important to countries. because health is a major item of national expendltme in all countries. Finally. the approach that different countries take to the financing and carrying out of health services raises important issues of equity.l The objective of this chapter is to help you gain an intro- ductory understanding of the ovoaway relationship between health and development. The chapter examines tlte connec- tion between health and education. it then reviews the link between health and poverty and health and equity. Lastly. the chapter explores the link between health and income at the level of individuals and the connections between health and development more broadly. its it reviews these themes, the chapter will introduce you to some of the basic concepts ofhoth global health and of healtlt economics. HEALTH. EDUCATI'DN. PRUDUCTIUIW, AND PDUERT'I" Health and Education Essentially. there are tltree ways that health and education are connected. First. there are intergenerational links; the health and education of parents affects the ltealth and education of their children. Second. malnutrition and disease affect the cognitive development and school performance of children. Lastly. education contributes to the prevention of illness. The MUS epidemic worldwide shows how the poor health of one generation can affect the schooling prospects and future earnings of the next generation. When mothers die of HIV. for example. children are more likely to be poorly fed, malnourished, and in ill health. its a result. they are also more lilter to attend school less frequently and to perform poorly in school when they are there. During the period that a mother is aisle with AIDS, it is also lilter that one or more of her children “dill stay out ofscl'tool to attend to the mother’s health and the chores that the mother is no longer able to do. Malnutrition or illness can limit schooling and school per— formance in a number of ways. First, families sometimes delay the enrollment of a sick or malnourished child in school. in addition. malnutrition and illness can also reduce attendance at school and. thereby, reduce an in dividual's performance in school. Malnutrition and illness can also decrease mental ability. fill of these factors ultimately constrain what children will learn in school. decrease the number of years of schooling they comple’EE. and. thereby. reduce future earnings. Education. Poverty. and the Economy However. there is also a lHJWCI‘l—Lll connection between health and education in the other direction—rdae impact of education on health. We already know that education and knowledge of appropriate heald-t behaviors are important determinants of health and. indeed. that the education of a child's mother is an important predictor ofthe health of a child. Studies like one done in Guatemala have consistentlyshown. in fact. that the higher the level ofeducation ofa mother, the more likely she is to lInmLiJ'll'LC her child. as noted in. Figure 3—1.’ Another study done in the Philippines illustrated how better educaied mothers are able to keep their children heald'ty. even in locations without a safe water supply.“ in a study of a large number of dev ‘lopin g countries. it was shown that every 10% increase in the level of education of mothers led to a reduction in the infant mortality rate by 4.1 tleatllis for every than live hirths.-" in addition, there is evidence from many countries that education affects the extent to which people make use of health services and better education dis- courages people front engaging in unhealthy behaviors. This Will be referred to in a number ofplaces in this hook. Health. Productivity, and Earnings Health has an important impact on labor productivity and earnings. separate from its link with education. Pirst, grind health increases longevity and the longer that one lives, the lorl get one can earn. and the higher one's lifetime earnings. Second, a number olstudies have shown that healthy work- ers are more productive than unhealthy workers. Among the most cited of such studies was one dutte on men who tapped rubber trees in lndonesia, many of whom were anemic due to hookworm infection. When the workers were treated for their infections, they became less anemic and their produc- tivity incrEased by about 20%.4 Third. many people when ill can not go to work. and when they are absent from work, they often do not earn. Health. the Costs of Illness. and Poverty The costs of illness to individuals and their Families can be high. can force them to lose or dispose of assets. and can cause them to fall into poverty. When people become ill in poor countries. as noted in the vignette about Savitha at the start ofthis chapter. they usually do seeit health care and they often seek care of different types. They frequently have to pay for treatment and for drugs. the costs of which can he a very substantial share of their income. in addition. illness often leads to a decline in earnings. because people miss work. There are also other indirect costs that people hear when they are illI such as the costs oftrartsportation to and from a health service provider. S is ts a it But‘itirt: Fast: s No tutu-caries Beyond the costs of either a short—term or a chronic illness. we must also remember tlte cost to individuals of living with the disability that comes from different health conditions. Measles or meningitis. For example. could lead to severe disability. Polio can lead to paralysis. and leprosy can lead to deformity. .5. number of mental health conditions are associated with long-term disability. as discussed further in Chapter [2. There is an increasing number of people with diabetes in rich and peer counLries alilcc. and diabetes is often associated with at ya riety of disabilities. Long lasting dis— abilities generally require considerable expenditure on health services. They usually also lead to a significant decline in the earnings of die disabled person. cent pa red to what they could earn if they were not disabled. The costs of illness can be devastating for poor fami— lies. a study done in Hangladesh. for example, showed that a Bangladeshi lest the equivalent of four months of income from getting TB} Surveys done in india showed dtat hos- pitalisation was a major contributor to people and families falling into poverty. Of the patients who were hospitalixed at some time during a I year period that was surveyed. almost 25% of the people hospitalized were pushed below the offi— cial Indian poyerty line because of the costs of their hospi— talization. related expenditures. and lost wages. Moreover. [DUNTR'I' I Illgher Education more than titles of these hospitalized borrowed money or sold assets to pay for their health care.lr Indeed. in a study of the poor tltat was carried out as a background to the preparation of the Eillltll World Development Report of the World Bank. the poor consis- tently noted the importance to them of maintaining good health. in addition. that report noted that ill health is an important contributor to poverty and to the economic yol- nerahilr'ty that also is at the foundation ofpoyerty problems.F indeed. we know that a certain segment of the population in many countries that do not have adequate health insurance are at fish that catastrophic costs of health care will drive them to poverty or bankruptcy. In Chapter 5. you will read about how different health systems try to protect the poor from the costs of health care. HEALTH END ElilUI'l'lIIr There are a number of equity issues that arise when consid— ering global health matters. especially when examining the health. social. and economic status of poor people. disad— vantaged ethnic groups. and women. The most important of these are access to health services. the manner in which health systems are respottsiye to the needs of people. and the extent to which the [banning of health systems is fair. when taking the income of the health system users into account."5 One important theme that runs throughout this hook is the fact that poor people, disadvantaged groups such as poor ethnic minorities. people who dwell in distant locations from health services, and women often have less access to health services than do better off groups. Sometimes, especially for the pocir and For minority groups. this reflects the fact that there are fewer health Services available in the areas in. which they live because those pieces may be distant from larger towns and cities. We would expect, for example. in most countries. that rural areas will have {river health services than urban ones. If we look at the Andean region, for cat-ampleI we will see that indigenous groups often live in highland areas that are relatively lacking in health services compared to more urban areas. The same would he true in the moun- tainoua areas ufdsia, such as in Nepal. in which the western part of the country has an extraordinarily limited supply of health-services. and people may have to walk for days to access health services. a. related issue, however, is that the poor, women. and other groups that lack social and political power or "voice" 11 3 'E :I E E 3- 3:- LI. 5 3 fi Io-. :I E E '5 et. INCOME IIULN'I'ILE r'Eii'lrt. Povertygand the Economy generally sash and are accorded less access to health services than those who are better oft", more powerful politically,-and have more voice in the allocation of resources.: Figure 3-2, for example, shows the coverage of basic childhood immuniv nation, by income group, in a set of selected countries. As you can clearly see. the higher the income of the child’s family. the greater is the likelihood that the cltild will he immunized. This pattern will be common in almost all low— and middle—income countries. All better off countries. except the United States. have some type of mandatory and universal health insurance sys— tem mat is meant to ensure that access to health services is not dependent on income. Many middleuincome countries also have sttch insurance systems. However, most low- income countries do not have formalized health insurance systems. outside of the Free or low cost provision of some health services by the public sector or nongovernme ntai sec- tors. Thus. many low—income countries fail to protect their poor from potentially catastrophic health costs that higher income individuals could afford. In addition, the relative cost of those health services is much greater for the poor than For better offpeople. which also raises important equity issues. -—¢-r LJ‘L'II'I America and the Lanilibun --l -- Middle East and North Africa “8” South Asia “NH Southeast Mlfl -—It-- Sub-Saharan nines Another set of im portant equity conoertts that is related to the financing ofhealth deals with the question of the extent to which different income groups bettth from public subsidies for health services. This can be a complicated issue to assess.“ Nonetheless. it is clear that there are many countries in which public subsidies for health are disproportionately received by better off people, as shown it: Figure 3—3, for India. it is easy to imagine. for example, a country in which poor people use basic health services that are financed by the public sector which are relatively inexpensive. while better .oFf people in the urban areas disproportionately use publicly sttpported hospital services that are relatively expensive. Under these circumstances. better off people, who will have higher rates of non-communicable disease, will get tnost of the expensive surgeries. Those surgeries will cost hundreds of times what basic health care costs1 and the country would be providing a disproportionate share of public subsidies to the better off, rather titan to the poor. There is no justification on clinical. economic, or equity grounds for this being the ease. HEALTH EXPENDITURE AND HEALTH DUTEEIMES One of the reasons why health is so important to countries is that they spend a lot of money on it. In addition, as noted earlier. they are also trying. in principle. to get the most for e 2 E E .h' as =. I. E a a i .. a M [urll‘lin Hllltlt [an-l. I‘l'fl-‘l'flfi HEaIflt-Eflpend'iiutb-aft'diflfl _ the ntoney they spend, consistent with national values. Figure 3-4 shows tlte relationship between gross domestic product {GDP} per capita and health expenditure as a share ofGDP. The main themes that emerge from this figure are clean - The higher a country‘s income per person, the more money it is likely to spend per person on health. - Most high—income countries cluster around an expen— diture of 9—: 2% of their national income on health. I Most countries that are lot--r income cluster-around an expenditure of 34% of their national income on health. This can be seen in the figure in Bangladesh, Ghana. and Nigeria. Ir Despite the clustering. there are countries dtat are outliers and that sit significantly away From the general relationship between incotne per capita and percentage of national income spent on health. The United States spends more than any other country on heaitb as a share of GDP. Cambodia and Citbaspend relatively more than one would expect for cotmrries With their income. Having seen what countries spend on health. it is now important to ask what they get itt return for that expendi— ture. Do countries that spend higher shares of their national income on health have better ltealth outcomes? Figure 3—5 " '957'_Ehperty,. and the Economy 3! EL 3 ‘6 I. 1: a 1:! E n. E a E ll: a a E L? 4 htgenti na 3 Bangladesh 1, Brat-i! x Cambodia l. Elihu 1- Costa Rica - [Lilia - lie-mart 0 Ghana 3. Hadagascar molly-aria 0 Sn' Lanira ¢Thailand =Hhtml States of America HIT-IL MHUITLFRE 9H RENE“ #5 A PERCENTAGE DF GEMS MHE‘IIE PREDU'H plots health expenditure as a share ot'GDP against life expec— tancy for selected countries. We can see from this figure that: I Many low-income Countries spend a relatively lot-t share of their GDP on health and also have low life expectancy. "This is seen in lGhana, Kenya, and Mali- - Most high—income countries spend a relatively high share of their GDP on health and have high life expec- tancy. This can be seen from Germany and Iceland. I Home low—income Countries spend relatively little on health but still have relatively higher life expectancy than many countries that spend 'a lower share of GDP on health. This can be seen in Cuba. costa Rica. China, and Sri Lani-ta, I Some high-income countries spend relatively high shares of GDP on health but still have loner life expectancy than countries that spend a lower share of GDP on health than they do. This is best shown by the United States. which is an outlier on dais figure as well as on the figure that portrays public expendintte on health as a share of GDP. Why is it that some countries are outliers when consid— ering their health outcomes related to health expendihare? First, we know that health status depends on a number of genetic, social, and economic factors and those factors vary across countries. Second. however. health outcomes depend not only on how much expenditure countries make per capita on health. but tltey also depend on the particular investments they make with that money. In colloquial terms we could say, n'lt is not just how much money per capita they spend on health. but it is. also how they spend it that is important." This theme will also be explored throughout this book. PUBLIC AND PRIVATE EXPENDITURE DH HEALTH Another important concept is the distinction between pubv iii: and private expendittttes on health. Public expenditure refers to expenditure by the any level of government or of a govermuent agency. Expenditure by a city government, a state government, or a national government would be public is g. 3 I1 2‘. . s t s s E 4 Argentina I Bangladesh 1. Brazil 3: Banana fate x Cambodia a thin: + (Data Rica is tut-a — [finmartt e inlet a Banning,- I: 55m fiHait-i alleles-Id uIndnfin'ia filoan — Helen-i until 1' “brim I Nopa'l a Nigeria EPaIdstirL #Philippim 5' I an: tantra EII'ENIJIT‘HE 0H HEMTH 145 l. SMILE! [If EDP expenditure. Expenditure on health bv government agencies such asa social security system, as in man}r countries in Latin America. the national insurance agency. as in most countries in Western Europe. or of a specialized agency, such as a National Commission on HI'WMDS, would also be consid— ered public expenditure. Private expenditure is. that expenditure that comes from sources other than govemments. One such source is the money that individuals spend on health. When this mone}.r is' not covered or reimbursed bv an insurance programT it isaiso called out-of—pocltet expenditures on health. Other sources ofprivatc expenditure on health include.e:cpendirure by non— governmental organizations. such as by the Bangladesh Rural Advancement anunittee or the Self Employed Women’s Association in India In addition. private expenditure on health includes espenditure by the private For—profit sector. Private sector firms. for exampler might contribute to the oost of healdr insurance or health services for their emplov- .ees. They-r might also make contributions to the health work of other organizations. There is some debate about what are legitimate fomses of public expenditure on health.” However, there is wide- spread agreement that pabiic expenditure on health is war- ranted when the investment benefits societyr as a whole. such as an immunization program. when health investments pro— mote equitv. and when such expenditure provides Fmancial protection to the poor from expenditures on health that the}r can not afiorcl." THE [DST-EFFECTIVENESS DF HEALTH INTERVENTIDNS Most governments have a limited amount of moucv for health1 and that money is rarely enough to finance all of the health interventions that a country.r 1would like to carry out. Thus. governments have to decide what share of their total budget will go to health and how much of the health budget will be allocated to different health interventions. All governments have to set priorities For expenditure on health1 just as the}? have to set priorities For expenditure in other sectors One important tool for setting priorities for public expenditure on health is cost—effectiveness analysis. This is a method for comparing the .cost of an investment with the amount of health that can be purchased with that investment. The cost of the investment can be thought of as the price of the hivestmant. The amount of health that can be purchased could be measured in life years saved or DhL‘t's. The costnefl'ectiveness of an investment in health will depend, among other things, on the incidence and prevalence of the health condition being considered, the cost of the intervention, the extent to which it can reduce morbidity. Mortality. and disability. and how effectively it can be implemented. One important example of the use of cost-effectiveness analysis is to set priorities among different ways of achieving the same health goal. important studies were conducted, for example, on the rust—edectiveness of alternative approaches to treating tuberculosis. These studies examined the cost- effectiveness of ti months of treatment with direct supervi- sion ofpeople taking their medicines, compared to treatment that was not supervised. the-supervin method led to a higher rate than the unsupervised approach of people taldng all Di thEir medicine and being cared. fits a result, it proved to be more cost-ePFective than the traditional approach that had been used. It strengthened Lhe case for these studies, the World Health lCll'gtltii.'tation recommending the supervised approach to therapy, which continues to be the global stan- dard ofTB treatment.“| It is easy to imagine how important this type of cost— effectiveness analysis can be when considering different ways of delivering the same health services. In fact, there are many important issues in delivering health services in low~income countries in which such questions remain critical. in Haiti, for example, there is a program operated by Partners in Health. Those carrying out the program had to assess whether or not the services would he delivered as effectively by volunteer workers as they would he by workers who were paid a small amount for their efforts. Although it cost more to deliver the program Twhen the workers were paid, the outcomes were superior to those when the worit- ers were not paid, and Partners in Health has continued to use the approach of paid workers." nnother issue of great importance today is the extent to which antiretroviral drugs for HIVULIDS can he delivered effectively by nurses and community health workers, instead of physicians, because physicians are in such short supply in many countries that have high rates or prevalence of HIV. This question is one of many concerning the delivery of services for HIV that is in need of careful cost-effectiveness analysis. The second manner in which cost-cliectiveness analysis is used is to wmpare the costs and the gains of different health interventions so that investment choices can be made among them. For every tilflti, for example, that a govem— ment has to spend on health, what allocation: of government expenditure on health will buy the most tantra averted? What is the cost per disability adjusted life year saved from different iriter‘rentionsiI in a relatively poor country, with a high burden of communicable diseases, such as TB and malaria, is it more cost-effective to invest in infectious disease control or in coronary bypass surgery? in a richer eou titty. Will it he cost-effective to invest in vaccination against TB? Even if we examine the first question above in a some- what exaggerated and simplistic manner, it will still help us to understand some of the value of cost—effectiveness analy- sis. let us say, for example, that the cost nfcoronary bypass surgery in a low—income country is about noon. Lat us also say that the costs of such surgery are covered completely by the public sector. This surgery would benefit one individual, who will live an additional 20 years in perfectly good health because of the surgery. in the same country, we can assume an entire course of treatment for TB costs about $100. in addi- tion. we can assume that people who get 'l'il- will all he 4t) years olage and that dreywill live an additional 2t] years in perfectly good health if they are treated for TB. What this means. in prhiciplE, is that if these were the only choices tor the invest- ment of 550m] in health that a country Faced and that if this were the only type of analysis that would be done to assess investment choices. then the choice would be between saving one life or saving Sill lives. In addition, the choices would be between sarong 20 additional years of healthy life of the coro— nary bypass patient or soon additional healthy years ethic of the TB patient. Figure 3—6 illustrates the cost-effectiveness of a selected number of health interventions. One can see in the figure that the cost of avoiding ill health caused by TB. malaria, and hoolcworms. for example, is low, while the cost ofsaving a life through cancer treatment is high. It is very cost—effective to get people to use seat hells in ca rs, but much less cost—effective to save the lives of people after they have had car accidents. As discussed further in Chapter s, it is cost—effective to enhance the nutritional and health status of young children through supplementation with Vitamin A. However, it is much less cost-effective in health centers and hospitals to deal with the additional mor- bidity and mortality that occur Front measles and pneumonia for children who are deficient in ‘v'iLamin A.” it is important to note that cost—effectiveness analysis is rarely the sole means for determining choices among investments and generally should not he used in that way.” However, it is one valuable tool in making such choices. It will always be itnportant, however, to consider such analyses in light of a number of other factors, including: Intervention Larooaty Bypass Emit 111an Mt! Psychosocial Treatment of Depression Ural Rehydrat'ion Therapy FM Diarrhea improved EmEth'rlcp flbstetric [are Til- Treatment Bath.- Utildhwd Irat-.t-ines 'lll'lil LIJEIIZI 1|IIIJ.t'||:||'.| EfiLLMiS FER DIL‘I‘ AVEHTEfi It Equity considerations; ! The burden of disease The extent to which the investment serves society as a whole The extent to which the investment produces benefits that are additional to its usual ones The impact of the intervention on the provision of insurance In addition. those who set priorities for health invest— ments will also have to take account of: I The capacity to deliver the proposed services It The links between the proposed services and other important services I The ability to change budget priorities in favor of the proposed investment - Any transitional costs associated witlt melting the proposed changes in priorities” in this hook. most ofthe assessments of costeeffectivencss will relate to Dr‘tlh’s averted. This is because examining the cost of life years saved from death would fail to capture the morbidity and disability that are also important aims of health interventions. In addition. it is important to note that there is no unique cut-off. below which interventions are "cost—effective" and above which they are not. Rather. it is preferable to group the cost—effectiveness of different inter— ventions into ranges and to use cost-effectiveness analysis to explore the relative extent to which various interventions will lead to DhiXs averted. Ln other words. it is not so important to think of TB control as cost-efiective. per set as it is to under— stand that in a county with a high prevalence ofTE. control of TB using directly observed therapy will he one of the most cost—effective investments in health that can be made." HEALTH AND DEVELBPMHT tin important question at the core of thinking about global health concerns the links between health and development. at the individual. community. and society levels. Does indi— vidual health produce more individual wealth and higher levels ofeconomicdevelopntent at the community and soci- etal ievelsi Or, are. the effects in the opposite direction: Dries more economic development at the level of society produce better health for individuals, communities. and societies? What we find when we examine these questions is that the effects of health and development go in both directions. There is no question that good ltealrh promotes economic development at the level of societies. First. we know that when countries have to spend money to address health problems, they can not use that money for other purposes. Countries that have to spend substantial resources treating malaria. for example. have less money to spend not only on other areas of health. but also on schools. roads, and other investments out- side of the healtlt sector that could spur economic growth. In addition. investment in economic activities. by local and foreign investors. is an essential ingredient to the eco— nomic growth prospects of luw~incume countries. 1let. as seen in one of the vignettes that opened titis chapter. conti- tries that have high burdens of communicable diseases do not appear to be good investment choices. In fact. in a study of the impact of malaria on economic development that is frequently cited. it was found that “a high prevalence of malaria is associated with a reduction of economic growth of 1% per year or more.”'5 Tltere is also growing evidence of the importance of health to economic development from a number of other studies done by economists. Some have shown that higher life expectancy at birth is associated with faster economic .growth rates. These studies suggest that a country with a life cttpeflttrtt‘y at birth of F? years would be expected to grow economically 1.6% faster each year than a country with a life expectancy at birth of49 years.” Another study showed that poor health was an important contributor to the slow pace of economic growth in Africa. compared to other countries with better health." Another series of studies showed that improvements in nutritional status and related health status improvements were very important historically in boosting labor productivity and spurring economic growdi in the United Kingdom and Europe.“ “m It is also true that higher levels of economic develop ment do promote better health at the level of both individu- als and of society. In fact. studies that have been done on the impact of income on the health of different societies suggest that higher income is associated with better health and ion- ger life expectancy.“ However. more recent analyses of this question suggest that while income growth is associated with better health indicators for a country. the effect of income alone on health indicators is less than previously thougltL Rather. these analyses suggest that a considerable share of the improvements in health indicators stem From technical progress such as the development of new vaccines or new drugs. or simple life saving approaches such as the use of . and the Economy oral rehydration for young children with diarrhea. rather than stemming from income growth.12 In this light, we should ask; is income growth necessary or stiflicient for enhancing health status at the individual. community. or societal levels? lliver die long run. increases in income will improve health. However. they will not improve it fast enough in most settings to achieve the health status objectives that many countries have set for themselves or that are necessary to achieve the MDGs‘ in the titne that has been set for them. 1v'v'hat low- and middle—income countries must do. therefore. is adopt public policy choices that will allow them to speed the achievement of their health aims. even in the face of constrained income. as Kerala did. As indicated earlier. and as will be repeated throughout the book. this is the approach that has been till-ten by the small nuttrbcr of countries that have been particularly successful itt meeting their health aims. THE EDPEN HAGEN CDHSEHSUS The importance of good healdi to economic development has increasingly been recognized. it. panel of economic experts was converted in 213% to try to identify the most cost— effective investments that would advance global welfare. Their work was referred to as “The {Iopenhagen Consensus." and Table 3—] indicates the rank order of the investmean that they considered. (if the four investments that were ranlced as “very good." three were investments in health: treatment for HIWAIDS, micronutrient supplementation. and control of malaria. Five investments were ranked as "good." and the first among them was to combat malnutri— tion by developing new agriculture technologies. Four invest~ ments were ranlced “fair.” The second and third of these were addressing malnutrition through improving infant and child nutrition and reducing the prevalence of low hirthweight. The fourth was the scaling up of basic health sendcos. The economists who forged the Copenhagen Consensus were clearly convinced of the important link of health to develop- ment. the relatively inexpensive ways of addressing a number of lrey health concerns, and the high returns that would come From doing so.” EASE STU D‘I" Having read about the high returns to some investments in health and the need to prioritize investments in health. it will be valuable to end this chapter with a case study of another public health success story. This one concerns Guinea worm. Those interested in more detail in the case should consult Case Studies in Global Health: Millions Saved. 'Gontrol offlI‘WnlDS- 2. Malnutrition:- Providingmieronutcients. 3. Subsidies dud Trade-liberalization ' 4t Loweri'n'gibarriers to migration forsltifled workers 1:. Mahlutrititttl: improving infant and child nutrition 12-. Malnutrition: Reducing-the pkeshlence oflnw birthweight 13. Diseases: Control-ofttialsria Sealed—up basic health services- Gnoti E' collects Badges-eds 5. MlflllIlfifiQfit nos-imitatan agricultural ti.- and sanitation; _ __ Email-scale Water ledmolhfl-for livelihoods :t. Withstand Sanitation; I ' Cemmetemenescd reef-o'eee-afis.aafiiwi an s. wateemdfiaoitatiene Research on water productivity in food. production 9. Governance and corruption: Lore-ins firssait'ef'stsftfius-s use heme ; sit. Migration: finest-worker programs fol-the unskilled 15. 'Eflhnate: oponat c'arbon'tax retells-tats: Kyoto Protocol 1?. Climate: yaloe-at—rislt carbon test some manner- sermons; suitable Iientrant-tn:pt:emeramnttaaamreeentsaanonassesses July s. toes. The Ehallenge of Guinea Worm in Asia and Sub- Saharan Africa Background Dracunculiasis, or IGuinea worm disease, is an ancient scourge that once afflicted much of tlte world. Today. it is lruly a disease of the poor. persisting in many of the world’s most remote and disadvantaged regions with limited access to potable water. despite being one of the roost preventable parasitic diseases. [n the Hells. an estimated 3.5 million people in 20' countries in Africa and Asia were infected with tiuineu worm diseaser and an estimated 120 million were at risk of becoming infected." The disease is contracted by thinking stagnant water from a well or pond that is contaminated with tiny fleas that carry Guinea worm larvae. Once inside the human. the larvae can grow up to three feet long, After a year, the grown female worm rises to the skin in search of a water source to release her larvae. d- Paiflfill blister forms, usttttlljtr in the person's lower limbs. To ease the burning pain, infected individuals frequently submerge the blister in water, causing the hlister's rupture and the release of more larvae into the water. This contaminated water, when it is drunk. perpetuates the cycle of reinfection. Worma, usually as wide as a match, can take up to 12 weeks to emerge from the blister. They are coaxed ottt by being slowly wound around a stick a few centimeters each day. Dehilitating pain from this process can linger for as long as 13 months. filthough rarely fatal, the disease takes a heavy tell by causing low productivity that makes it both a symptom and perpetrator of povertye—in Mali. it is called the “disease of the empty granary.” Because water in contaminated ponds is widely consumed during peak periods of cyclical harvesting and planting, an entire community can be lefi debilitated and unable to Work during the busiest agricultural seasons. The economic damage is severe: annual econontic loss in 1l1ree rice-growing states in Nigeria was calculated at $20 million.2n While the disease afflicts all age groups, it particularly harms children.“ School abSt-rtteeisrti rises when infected children are unable to walk to school and when children forogo school to take on the agricultural and household work ol'siclt adults. The likelihood of a child in Sudan being malnourished is more than three times higher when the adults in tlte child's home are infected with the disease. The Intervention in 193D. when the US. Centers for Disease Control and Prevention {CDC} first proposed an eradication catnv paign. the Three interventions that would be required to address the disease effectively did not seem feasible: con— struction of expensive water sources; controlling the vec- tor that spread the disease through the use of larvicides in water sources; and health education campaigns promoting the filtration of water with a cloth filter. self—reporting of infestations. and avoidance of recontamination of public water sottrces. The absence of a vaccine or cure made suc— cess seem even more improbable. The International Drinking Water Supply and Sanitation Decade was launched the following year. however. and the CDC’s Dr. Donald [-Ienderson seized the opportunity to include the eradication of Guinea worm disease as a snhgoal of the Water Decade program. Nonetheless. progress against Guinea worm disease remained slow until 1936. when three key events occurred: WHO declared eradication of Guinea worm disease a goal. public health ministers from It nfrican nations met to affirm their commitment to the eradication effort. and Ll.S. President Iimrny Carter became a power- l'lIl advocate. personally persuading many leaders to launch national eradication efforts. He also recruited the help in the eradication program of two former popular heads of state of ivlali and Nigeria. General Torah? and General lIII—owon. respectively. thereby consolidating political commitment in Africa. Meanwhile. technical and financial resources of the donor community were marshaled. and by 1995. eradica— tion programs had been established in as countries. Water sources were provided. mainly through the construction of wells.- in southeast Nigeria alone. village volunteers hand- dug more than too wells.m Larvicide was added to water sources to kill the fleas. People were taught to filter drink- ing water ttsing a simple cloth filter. However. theSe filters were found to clog up and were used as decoration items insteat .15 a newly developed nylon cloth was then donated by the Carter (Lenten Precision Politics. and Hui-Font. Public education campaigns. including intensive efforts during so— called worm weeks, encouraged people to use the nylon fil- ters. avoid recontautinating ponds. and report infestations}? Most of the eradication staff were volunteers trained by the ministries of health. but they pioneered a monthly reporting system for tracking and monitoring that is now hailed as a model for disease surveillance}3 The Impact The campaign led to a 99% drop in Guinea worm disease prevalence. In BUGS. fewer than II.EIot} cases were reported. compared with an estimated 3.5 million infected people in 19345. By “338. the campaign had already prevented between 9 million and 13 million cases of Guinea worm disease.“ The Asian countries that were targeted. India. Pakistan. and 1t’emen. are now Free of the disease. Most remaining cases are in Sudan where civil conflict impeded progress against the disease over many years. Costs and Benefits The total cost of the program hethen 1986 and 19‘93 was $815 million. with an estimated cost per case averted of $5 to $3.39 The World Bank determined that the campaign has been highly cost-effective and cost-heneficial. In addition. the program had a very high economic rate of return. even when basing the calculau'on ofeconomic benefits only on. increases in agricultural productivity that accrued from people having avoided the disease.“ lessons learned Success of the program has been attributed to three factors. The first is the exemplary coordination between major part— ners and donors. The second is the power of data. gatltercd through the monthly reporting system. to monitor national programs and to help keep countries focused and motivated on the program goals. The third is the high-level advocacy and political leadership from current and former heads of state. especially President Jimmy Carter and General Gowon. who visited and revisited villages in Nigeria to check on progress. Tire program drew on a truly global partnership betwta-n the CDC. [.TNICEF. WHO. the Carter Center. governments. NGGs. the private sector. and volunteers that was able to motivate changes in individnal and community behaviors and successfully control a disease. MAIN MESSAGES The aim of this chapter was to introduce you to some of the basic concepts of economics as they relate to the global health arena. One important message of the chapter is that education and health are cloSely linked. Good health encourages the enrollment of students in school at the appropriate age. enhanced student attendance at school. better cognitive performance of students. and more com- pleted: years of schooling. Education and knowledge are tottsistentiy correlated v.ith people's engagement in more appropriate health behaviors and living healthier lives than those with less schooling. In addition. education promotes greater opportunities for income earning. which itself is an nuportant determinant of health. We also learned that health is strongly aSsociated with |1rtttlttcl.l1-"l‘l'y and ea ruin gs. Healthier people can work harder. work tnore hours. and work over a longer lifetime than can those who are less healthy. Related to This in many ways, we also saw that health has an important relationship with pov— erty. If people work fewer hours because of ill health. then there is a risk that their incotne status' will decline. perhaps llelnw the poverty line. In addition. there is evidence from many countries that the direct and indirect costs to people of getting health services can itself push people into poverty. Health is an huportant subject for all countries for many reasons. among the most important of which is the amount of tttuttey they spend on health. High—income countries spend ruore moneyon health than do low—income countries. However. health outcomes depend not just on how much money is spent. but also on how the money is'used. Clue way that countries set priorities for health expenditure is lay using costuefiectiventas analysis. a tool that is. used in the health sector to compare how much health one can buy for a given level ofespendituro. All countries. of course. face the question of how they can maxi- mize the health of their poptdation for the minimum cost. There are also many strong relationships between the health of a population and the economic development of the society in which they live. Better health does promote wealth in a variety of ways. including enhancing labor productivity, reducing the amount countries have to spend on health. and enabling a more attractive investment cli- mate. In addition. the negative impact of some diseases on economic development. such as TE. HIWMDS. and malaria, can he very significant. Economic development does improve health: however. many gains in health stem from technological progress. such as on vaccines. and low— ineorne countries in particular have to develth approaches to improving health that will promote hetter population health faster than economic development alone will do. ...
View Full Document

Page1 / 13

W4R Ess.Ch.3 - —I—-——__._ Lrannms flatrtrrvrs By...

This preview shows document pages 1 - 13. Sign up to view the full document.

View Full Document Right Arrow Icon
Ask a homework question - tutors are online