global health promotion
Health, Education, Poverty, and the Economy
Chapter Three
Chapter three: Health, Education, Poverty and the Economy
1
To understand the two way relationship between health and development.
To examine the connection between health and education.
To review the link between health and poverty and health and equity.
To explore the link between health and income and health and expenditure at the individual and national level.
Learning Objectives
Learning Objectives
To understand the two way relationship between health and development
To examine the connection between health and education
To review the link between health and poverty and health and equity
To explore the link between health and income and health and expenditure at the individual and national level.
2
Health and education of parents affects health and education of children.
Malnutrition and disease affect cognitive development.
Education contributes to disease prevention.
Health and Education
Health, Education, Productivity, and Poverty
The AIDS epidemic has shown us the impact of parents’ health on children’s health. When mothers die of HIV/AIDS or get diagnosed with the disease, the children are more likely to be malnourished, less likely to attend the school, and more likely to drop out from school. When children are malnourished it affects the their ability to perform in the school by interacting with their cognitive development. Education is such a strong determinants of health that mothers education influence child health to a greater extent. Numerous studies have shown that better educated mothers are more likely to keep their children healthy, more likely to play a role in child’s survival. It was shown that higher educational attainment of mother is positively associated with reduced infant, neonatal and under five child mortality rate.
3
Health Productivity and Earnings
Good health increases longevity, lifetime earnings.
Healthy workers are more productive than unhealthy workers.
Health is wealth. A person’s productivity depends on his or her health. A study done in Indonesia on rubber worker, it was shown that workers’ productivity was increased by 20% after they were treated for anemia that was caused by hookworm infection. As it could be imagined that as good health increases the productivity, lacking good health cost high to the individual, family, and in the long run on the health care system.
4
Costs of health care are high.
Illness often leads to a decrease in earnings.
Health, the Costs of Illness, and Poverty
When people become sick in poor countries, they lose their earnings and need to pay for the direct and indirect cost of healthcare which could be a very substantial amount. On one hand they do not have earnings as they miss work, on another hand their spending after health increase. It puts them further in poverty which could be devastating. A study done in Bangladesh showed that a Bangladeshi lost the equivalent of four month income from getting TB . As it can be seen from the graph above, the perception of poor or fair health status depends on household income. Only 4% of people who live in a household income of 50K think they have poor or fair health in contrast to 21% of people who live in household of less than 15K.
5
From: The Economic Burden of Illness for Households in Developing Countries: A Review of Studies Focusing on Malaria, Tuberculosis, and Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome
Health, the Costs of Illness, and Poverty E.g.
This table is taken from a study that assessed the economic burden of illness in developing countries where they showed in low income countries like Bangladesh and India spent a significant amount of their annual household income on direct and indirect cost of illness, in this case TB.
6
Health equity is achieved when every person has the opportunity to “attain his or her full health potential” and no one is “disadvantaged from achieving this potential because of social position or other socially determined circumstances.” (CDC)
Health equity is multidimensional. ( Amartya Sen)
Differences in health that are not only unnecessary and avoidable, but also unfair and unjust. ( Margaret Whitehead)
Equity
Equity is an important issue in public health and so many opinions exist in regarding definition of Equity. For example, economist Amarty sen thinks equity is multidimensional and social justice, social arrangements, and countries resource allocation should act as a background for assessing equity. British Public health scholar Margaret Whitehead considered equity as a must for health and according to her differences in health unnecessary, avoidable, unjust and unfair. Next we will be examining equity in the context of health.
7
Equity Across Countries
Enormous variance in basic indicators of health across countries.
Largely, but not completely varies by income.
Health and Equity
Data source: World Bank
There is significance variance on basic health indicators across countries. High income countries have higher life expectancy and lower infant, child, and maternal mortality whereas low income countries are low on life expectancy and high on mortality (child, infant, maternal). The difference largely reflects the status of economic variance. Though weak economic development attributes to the health , it is not the only reason for such inequity. There are other factors play role in health inequity.
8
Maternal mortality by various factors by region
“Achieving the SDG target of a global MMR below 70 will require reducing global MMR by an average of 7.5% each year between 2016 and 2030. This will require more than three times the 2.3% annual rate of reduction observed globally between 1990 and 2015. Accurate measurement of maternal mortality levels remains an immense challenge, but the overall message is clear: hundreds of thousands of women are still dying due to complications of pregnancy and/or childbirth each year. Many of these deaths go uncounted. Working towards SDG 3.1 and ultimately towards ending preventable maternal mortality requires amplifying the efforts and progress catalysed by MDG 5. Among countries where maternal deaths remain high, efforts to save lives must be accelerated and must also be paired with country-driven efforts to accurately register births and deaths, including cause of death certification. Strengthening civil registration and vital statistics will support measurement efforts and help track progress towards reaching SDG 3.1. Among those countries with low overall maternal mortality, the next challenge is measuring and amending inequities among subpopulations. The new Global Strategy for Women’s, Children’s and Adolescents’ Health will spearhead an enhanced global collaborative response aimed at ending all preventable maternal deaths.” from the Trends in Maternal Mortality 1990 to 2015 Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division.
9
Some countries have substantial variation in health indicators across population groups.
Tend to be low- and middle-income countries or high-income countries with significant ethnic minorities.
Equity Within Countries
Under-5 Child Mortality Rates, for Selected States, India, 2005-2006.
Equity also exist within countries. The graph here shows under five mortality rates among five states of India. According to 2005-2006 data , Uttarpradesh had almost five times more child mortality than Kerala. What do you think are the reasons for such variance within countries?
10
Sources
Measure of America calculations using mortality counts from the Centers for Disease Control and Prevention, National Center for Health Statistics. Mortality – All County Micro-Data File, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. Population counts are from the CDC WONDER Database.
Equity Within Countries
This table shows data for life expectancy for different ethnicities in United States. This data is an example for you to see the inequity in health within a country.
11
Urban dwellers tend to enjoy better health status, coverage, and access to services than rural dwellers.
Rural people tend to have lower incomes, less education, less access to services, and weaker political voice.
Health and Equity-Equity and Location
We expect to see the variance in health by location. Urban dwellers enjoy better health as they have more access to health care, whereas rural dwellers are deprived of such care just because of the location. In Sub-Saharan Africa, the rural children are 33 times more likely to be stunted than urban children.
12
Large gap in access, coverage, fairness, and benefits between less well off and better off.
Equity and Income
Percentage of Births Attended by Skilled Personnel, by Income Quintile, Latest Data 2003-2009, for selected Regions
Health equity and income relationship has been examined in so many literature. The difference in variance in different health indictors according to income quintiles showed well off population enjoy the blessing of good health much more than poor population. For Example, In South Asia richest 20% of the population are almost 8 times more likely to have a birth attendant than poorest 20%. Similarly very few children of the richest 20% are underweight.
13
Equity and Gender
“Being born female is dangerous to your health”
Women face health concerns related to their diminished place in many societies.
Examples: female infanticide, less food for female children, lower enrollment in school, violence against women.
Think equal for Women and Girls (1:20)
http:// www.youtube.com/watch?feature=player_embedded&v=UaCwOdNeA7k
Equity and Ethnicity
Strong association between ethnicity and health status, access, and coverage.
Linked to strong association between ethnicity and power, education, and income.
Health and Equity
In many parts of the world just being born as female poses health risk. The discrimination starts from shorter duration of breastfeeding, less food for girl, less attention for healthcare needs for girls. Adult women also suffer from lack of health care, less power, lack of education and less voice in the society.
Ethnicity and health status correlation is a strong one and very evident in the form of access to health care and coverage. In the United States there is large gap between White people and Black people in health care services. Similar differences can also be seen in different health indicators between indigenous people and non-indigenous people, between majority and minority.
14
Substantial out-of-pocket costs for poor in low-income countries
Benefit of public subsidies often received by better off people
Get Well, Maya: Universal Health Coverage Ensures Healthy Futures (2:12)
http :// www.youtube.com/watch?v=6prBrGHI2Ws
Equity and Financial Fairness
In high income countries and some of the middle income countries have some type of mandatory and universal health insurance system that ensure access to health for all. However, for poor countries this is not the case at all. Other than the free or low cost provision from public sector or from NGOs whose services are questionable, most of the poor need to pay out of pocket for health service. Poor countries fail to protect their own population from health related catastrophic event.
15
Most high-income countries spend 9-12% of GDP and have higher life expectancies.
Most low-income countries spend 3-6% of GDP and have lower life expectancies.
Important outliers like Sri Lanka and Cuba spend relatively little, but achieve higher life expectancies.
Health Expenditure and Health Outcomes
The more you spend on health the more likely you expect to have better outcome. Most high income countries spend 9-12% of GDP and have higher life expectancy. Most low income countries spend 3-6% of their GDP and expect lower life expectancy. However, countries like Sri Lanka and Cuba spend less of their GDP and still have achieved life expectancies.
16
Source: http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS/countries?display=map
GDP and Health
National Income and Health Expenditure, Selected Countries, 2003/2004
Expenditure on Health as a Share of GDP, Compared to Life Expectancy, Selected Countries, 2003/2004
GDP and Health Example
As it can be seen from this figures, most high income countries cluster around 9-12 % of their national income on health and have a higher life expectancy for example Germany and Iceland.
Most low income countries cluster around 3-6% of their GDP and have a lower life expectancy as in the case of Mali, Kenya, and Nigeria. There are some outliers in these figures like Cambodia and Cuba who spent less of their GDP after health and still have higher life expectancy.
18
Public and Private Expenditure on Health
Private Expenditure: expenditure by sources other than the government such as a non-governmental organization
Out-of-Pocket Expenditure: expenditure by individuals that is not covered or reimbursed by an insurance program
Public Expenditure: expenditure by any level of government or government agency
Factors needed to consider in public expenditure
The investment should benefit society
Promote equity
Financial protection to the poor
Discuss this slide
19
The Cost Effectiveness of Health Interventions : Cost-effectiveness analysis
Amount of health is measured by life years saved/DALYs
Alternative approach
A specific goal
Cost and gain of different interventions
Investment choices
An important tool for setting priorities for public expenditure on health is cost effective analysis. This is a method that compares couple of things like it compares cost of an intervention with the amount of health that can be purchased with that investment and the amount of health is measured by life years saved/DALYs. It also compares alternative approaches to achieving a specific goal/intervention, such as TB drug therapy.
Finally, it compares different interventions to assist investment choices. Cost effective analysis can help to set priorities among different ways of achieving a health goal
20
Incidence & prevalence of the health condition considered for intervention
Cost of the intervention
Expected reduction in morbidity , mortality and disability
Effectiveness of intervention implementation
Factors influence cost effective analysis
The amount of health that can purchased with an investment depends on couple of factors like incidence & prevalence of the intervention in consideration, cost of the intervention, expected outcomes and the effectiveness of intervention implementation.
21
Good health promotes economic development.
For Example: A high prevalence of malaria is associated with a reduction of economic growth of 1%/year or more (Commission on Macroeconomics and Health. Macroeconomics and Health: Investing in Health for Economic Development. Geneva: World Health Organization,2001).
Higher levels of economic development also promote better health, but not quickly enough.
Therefore, low- and middle-income countries must adopt policies that speed achievement of health goals, even with constrained incomes.
Health and Development
Discuss this slide
22