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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
International Health & DevelopmentHilary Term 2010
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?
International Health & DevelopmentHilary Term 2010
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
International Health & DevelopmentHilary Term 2010
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.)
International Health & DevelopmentHilary Term 2010
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)
International Health & DevelopmentHilary Term 2010
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
International Health & DevelopmentHilary Term 2010
PRESTON CURVES
Preston demonstrated that the actual links between LE and GNP per capita (globally) were getting stronger
International Health & DevelopmentHilary Term 2010
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
International Health & DevelopmentHilary Term 2010
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
International Health & DevelopmentHilary Term 2010
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
International Health & DevelopmentHilary Term 2010
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)
International Health & DevelopmentHilary Term 2010
‘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
International Health & DevelopmentHilary Term 2010
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)
International Health & DevelopmentHilary Term 2010
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
International Health & DevelopmentHilary Term 2010
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”
International Health & DevelopmentHilary Term 2010
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)
International Health & DevelopmentHilary Term 2010
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)
International Health & DevelopmentHilary Term 2010
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
International Health & DevelopmentHilary Term 2010
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
International Health & DevelopmentHilary Term 2010
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
International Health & DevelopmentHilary Term 2010
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
International Health & DevelopmentHilary Term 2010
YOUR THOUGHTS
International Health & DevelopmentHilary Term 2010
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)
International Health & DevelopmentHilary Term 2010
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
International Health & DevelopmentHilary Term 2010
THANK YOU
International Health & DevelopmentHilary Term 2010