DEPARTMENT OF PUBLIC HEALTH DEPARTMENT OF INTERNATIONAL DEVELOPMENT I NTRODUCTION TO T HEORIES R ELATING H EALTH & D EVELOPMENT P ROOCHISTA A RIANA I NTERNATIONAL.

DEPARTMENT OF PUBLIC HEALTH

DEPARTMENT OF INTERNATIONAL DEVELOPMENT

INTRODUCTION TO THEORIES RELATING HEALTH & DEVELOPMENT

PROOCHISTA ARIANA

INTERNATIONAL HEALTH AND DEVELOPMENTHILARY TERM 2010

INTRODUCTION

Course Aims Class Structure Readings Case Project Assessment

International Health & DevelopmentHilary Term 2010

LEARNING OBJECTIVES

Understand the main paradigms relating health to development

the instrumentality of health for development

the role of development in generating health

Understand the mechanisms through which economic growth impacts health

Discern the shortcomings of conventional linkages between wealth and health

POINTS FOR REFLECTION

What is the relevance of health? Is EG necessary to achieve health? How can health facilitate EG? What are the intervening factors that relate economic growth to health?

What are the problems with the measures we rely on and the methods we use to relate health and EG?

What are the policy implications of how we understand the relationship?

OUTLINE

A bit of history Preston Curves Causality of relationship Instrumentality of health for EG Instrumentality of health for other dimensions of human development

Mechanisms Methodological considerations

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.)

NOT NECESSARILY 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)

IS POPULATION A PROBLEM?

DISSOCIATION BETWEEN HEALTH AND ECONOMIC GROWTH

Widespread diffusion of scientific knowledge medical and health technologies public health practices Infrastructure (water and sanitation) housing conditions

PRESTON CURVES

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

TWO IMPORTANT FEATURES

Upward shift: Each subsequent decade requires less income to achieve the same level health (on aggregate) than the previous decades. Could be explained by public goods:

Germ theory of disease International transmission of knowledge Public health programmes (vector control, vaccinations, water and sanitation, housing conditions)

Healthcare services and medicines

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

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

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

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

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)

‘WEALTHIER IS HEALTHIER’

• “wealthier nations are healthier nations” as demonstrated by the strong and consistent (aggregate) 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)

HIGH VARIABILITY

Great deal of inequality in health both between an within countries

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

“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)

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

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)

• 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”

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

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)

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

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

INTRINSIC, INSTRUMENTAL & BIDIRECTIONAL

Health is intrinsically valuable

Instrumental to economic development

Instrumental to human development Nutrition and cognitive development Health shocks and poverty Health and economic opportunities (income generating potential)

Development processes, in turn, affect health through various mechanisms and at various stages

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

WHY IS HEALTH IMPROVING

Advancements in scientific and public health knowledge (e.g. Germ theory of disease)

International transmission of knowledge

Public health programmes (vector control, vaccinations, water and sanitation, housing conditions)

Healthcare services and medicines

Education

Governance (water, sanitation, housing, etc)

MEDICAL TECHNOLOGY

Scientific discoveries on aetiology of disease and development of modes of prevention and cures

Development of vaccines

Discovery of antibiotics

Diagnostic equipment

Pharmaceuticals

MCKEOWN’S EVIDENCE

contribution of public health knowledge and technology to health is not limited to medical technologies in prevention and cure (i.e. vaccines and antibiotics)

much of the decline in mortality at the turn of the century in England and Wales preceded the introduction of such technologies

TUBERCULOSIS

MEASLES

WHOOPING COUGH

POLIOMYELITIS

MCKEOWN’S CONCLUSION

McKeown suggested that (at least for England and Wales at the turn of the century) important factors for health related to improvements in nutrition and household conditions

Factors which he attributed to the general economic growth of the time

SZRETER’S RETORT

comprehensive historical review of economic growth and health in Britain between 1750-1870

not economic growth but rather social and political action that motivated the improvements in housing and nutrition which benefited the health of the population

4 D’S OF ECONOMIC GROWTH

economic growth, “… if given free rein, may lead directly to the four Ds [disruption, deprivation, disease, and death]” (Szreter, 1997).

Exemplified by urban centres where income and real wages were growing rapidly but life expectancy was either declining or remaining stagnant.

SZRETER’S EVIDENCE

SOCIAL MOBILISATION & POLITICAL WILL

economic growth often brings with it political and social disruption which can readily lead to deprivation, disease and death if not actively countered by political and social systems

Counter efforts may take the form of redistribution of wealth, provision of public health resources, or mechanisms that give political voice to the poor

ALLOCATION OF RESOURCES

Szreter’s argument corresponds to the claim that countries that were able to achieve high health standards incommensurate with their level of national income (i.e. the positive outliers on the Preston Curves) did so with concerted political and/or social efforts (i.e. by allocating a larger portion of national resources to healthcare, disease prevention, and education)

URBAN LIVING TODAY

Urban population has grown from 220 million to 2.8 billion over the 20th century

As of 2008, 3.3 billion people live in urban areas

Of the urban dwellers, about 1 billion live in slums

(Source: Social Determinants of Health Final Report)

Source: Social Determinants of Health 2008

SLUM LIVING

Lack of running water No drainage or sanitation Poor or inadequate housing Overcrowding No electricity Rubbish accumulation, rats and other pests Violence/insecurity

SLUM HEALTH

In Nairobi, where 60% of the city’s population live in slums, child mortality in the slums is 2.5 times greater than that in other areas of the city

In Manila’s slums, up to 39% of children aged between 5 and 9 are already infected with TB – twice the national average

(Source: Social Determinants of Health Final Report)

SLUM HEALTH

Source: McMichael et al 2004

‘DEFECTIVE’ MODERNIZATION

Increases in trauma-related deaths, chronic diseases, and persistent infectious diseases resulting from defective technology

Inability to sustain the high costs associated with maintaining the modern technology

Adjustments of traditional lifestyles to accommodate the technology

MEXICO

“We bought a refrigerator and filled it full of meat and milk, where once we would have dried our beef. We bought a cooler and put it into the kitchen window, where once there came a breeze in summer. We filled in the outhouse and put a flush toilet next to the kitchen. Now there is no electricity. The meat rots in the refrigerator; the cooler blocks the window; and the toilet won’t flush because the pump fails without power… Everything is modern, but nothing works. It’s Mexican style. We are better off without it.” (Simonelli, 1987 p.23)

(IN)APPROPRIATE TECHNOLOGY

inter-relationship between technologies, their availability and accessibility, and changing lifestyles

Sustainability & adaptability

Unintended negative consequences Air conditions (Legionnaires) Hospitals (MRSA) Vehicles (traffic accidents)

TECHNOLOGY AND POLITICAL WILL

Technological advancements in medicine and public health may be regarded as tools which may improve population health given appropriate policies which lead to adequate access

This access requires increased public awareness (i.e. via education), allocation of resources toward provision of public health measures (i.e. requiring political commitment), and sufficient individual or household means (i.e. resources)

DYNAMIC PROCESS

It is not only a one-time provision of technologies which is needed, however, but an active (re)assessment of which technologies are most beneficial for the particular time and place

A lack of attention to maintenance of infrastructure and monitoring of services may thwart the gains in health and may even contribute to its deterioration

ECONOMIC GROWTH FACILITATES

Enhanced employment opportunities

Infrastructural development (roads, water, sanitation, electricity, telecommunication)

Provision of social services

Investments in education

Improvements in healthcare

BUT ALSO IMPACTS

Environment

Migration/urbanisation

Lifestyles and behaviours

New risks and vulnerabilities

Diet and activities

Disease patterns

Kinds of employment opportunities

COMING UP

Evolution of Development Theory and Practice Multidimensional Poverty and the Capability Approach

The Political Nature of Policy and Policy Processes

Challenges in Global Health Governance Aid and Collective Action

Understanding Health

Economic, Epidemiological & Nutritional Transitions

Development, Inequality, and Health Development, Environment, and Health The Politics of Famine Conflict and Disasters

THANK YOU

DEPARTMENT OF PUBLIC HEALTH DEPARTMENT OF INTERNATIONAL DEVELOPMENT I NTRODUCTION TO T HEORIES R ELATING H EALTH & D EVELOPMENT P ROOCHISTA A RIANA I NTERNATIONAL.

eginstrumentality of

relevance of health

level health

improved healtheconomic

public goods

unit of income

added benefits of income

increased poverty

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