Transcript Theories Relating Health & Development

Main Theories Relating
Health & Development
Proochista Ariana
International Development & Health
Hilary Term 2009
Your Initial Thoughts
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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:
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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’
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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
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Eradicate extreme poverty and hunger
Achieve universal primary education
Promote gender equality and empower women
Reduce child mortality
Improve maternal health
Combat HIV/AIDS, malaria and other diseases
Ensure environmental sustainability
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
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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?
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Outline
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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
GDP per Capita United Kingdom
35000
30000
GDP per capita PPP
25000
20000
15000
10000
5000
0
Year
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 2005
Human Development Report 2003
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
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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
Positive
Negative
Unintended
context
Evaluation
Programme
implementation
Identification/
Information
Policy
formulation
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
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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
Life Expectancy & GDP per Capita
United Kingdom
35000
90
GDP per capita
Life Expectancy
80
30000
70
60
20000
50
15000
40
30
10000
20
5000
10
0
0
1841
1847
1853
1859
1865
1871
1877
1883
1889
1895
1901
1907
1913
1919
1925
1931
1937
1943
1949
1955
1961
1967
1973
1979
1985
1991
1997
2003
GDP per capita PPP
25000
Population Increases
Population Growth
70000000
60000000
Total Population
50000000
40000000
30000000
20000000
10000000
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Year
Population & GDP
Total Population
Population & GDP per Capita
United Kingdom
70000000
35000
60000000
30000
50000000
25000
40000000
20000
30000000
15000
20000000
10000
10000000
5000
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Year
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