Modeling the effects of health on economic growth.

This paper investigates the effects of health indicators such as adult survival rates (ASR) on GDP growth rates at 5-year intervals in several countries. Panel data were analyzed on GDP series based on purchasing power adjustments and on exchange rates. First, we developed a framework for modeling the inter-relationships between GDP growth rates and explanatory variables by re-examining the life expectancy-income relationship. Second, models for growth rates were estimated taking into account the interaction between ASR and lagged GDP level; issues of endogeneity and reverse causality were addressed. Lastly, we computed confidence intervals for the effect of ASR on growth rate and applied a test for parameter stability. The results showed positive effects of ASR on GDP growth rates in low-income countries.

International collective action in health: objectives, functions, and rationale.

To improve the performance of international health organisations, their essential functions must be agreed. This paper develops a framework to discuss these essential functions. Two groups are identified: core functions and supportive functions. Core functions transcend the sovereignty of any one nation state, and include promotion of international public goods (eg, research and development), and surveillance and control of international externalities (eg, environmental risks and spread of pathogens). Supportive functions deal with problems that take place within individual countries, but which may justify collective action at international level owing to shortcomings in national health systems-such as helping the dispossessed (eg, victims of human rights violations) and technical cooperation and development financing. Core functions serve all countries, whereas supportive functions assist countries with greater needs. Focus on essential functions appropriate to their mandate will better prepare international health organisations to define their roles, eg for WHO to focus on core functions and for the World Bank to focus on supportive ones.

Poverty and mortality among the elderly: measurement of performance in 33 countries 1960-92.

This paper analyses the effect of income and education on life expectancy and mortality rates among the elderly in 33 countries for the period 1960-92 and assesses how that relationship has changed over time as a result of technical progress. Our outcome variables are life expectancy at age 60 and the probability of dying between age 60 and age 80 for both males and females. The data are from vital-registration based life tables published by national statistical offices for several years during this period. We estimate regressions with determinants that include GDP per capita (adjusted for purchasing power), education and time (as a proxy for technical progress). As the available measure of education failed to account for variation in life expectancy or mortality at age 60, our reported analyses focus on a simplified model with only income and time as predictors. The results indicate that, controlling for income, mortality rates among the elderly have declined considerably over the past three decades. We also find that poverty (as measured by low average income levels) explains some of the variation in both life expectancy at age 60 and mortality rates among the elderly across the countries in the sample. The explained amount of variation is more substantial for females than for males. While poverty does adversely affect mortality rates among the elderly (and the strength of this effect is estimated to be increasing over time), technical progress appears far more important in the period following 1960. Predicted female life expectancy (at age 60) in 1960 at the mean income level in 1960 was, for example 18.8 years; income growth to 1992 increased this by an estimated 0.7 years, whereas technical progress increased it by 2.0 years. We then use the estimated regression results to compare country performance on life expectancy of the elderly, controlling for levels of poverty (or income), and to assess how performance has varied over time. High performing countries, on female life expectancy at age 60, for the period around 1990, included Chile (1.0 years longer life expectancy), China (1.7 years longer), France (2.0 years longer), Japan (1.9 years longer), and Switzerland (1.3 years longer). Poorly performing countries included Denmark (1.1 years shorter life expectancy than predicted from income), Hungary (1.4 years shorter), Iceland (1.2 years shorter), Malaysia (1.6 years shorter), and Trinidad and Tobago (3.9 years shorter). Chile and Switzerland registered major improvements in relative performance over this period; Norway, Taiwan and the USA, in contrast showed major declines in performance between 1980 and the early 1990s.

Investing in health wisely. The role of needs-based technology assessment.

Countries worldwide spend huge sums on health--about $1,700 billion a year, or roughly 8% of global income. But the World Development Report 1993: Investing in Health shows that these monies could be spent much more wisely, in the process doing a great deal to help the world's 1 billion poor. Essential national public health and clinical packages are proposed based on assessment of the burden of disease (measured in disability adjusted life years) and the cost-effectiveness of interventions. Governments can play a central role in improving the health of their citizens: they can foster an environment that enables households to improve health and they can also improve their own spending on health, targeting it to support universal access to essential national public health and clinical packages based on the above methods. This is a good example of the concept of needs-based technology assessment, combining the disciplines of epidemiology, economics, and policy formulation. When applied, it should lead to improved effectiveness, efficiency, and equity.

The global burden of disease in 1990: summary results, sensitivity analysis and future directions.

A basic requirement for evaluating the cost-effectiveness of health interventions is a comprehensive assessment of the amount of ill health (premature death and disability) attributable to specific diseases and injuries. A new indicator, the number of disability-adjusted life years (DALYs), was developed to assess the burden of disease and injury in 1990 for over 100 causes by age, sex and region. The DALY concept provides an integrative, comprehensive methodology to capture the entire amount of ill health which will, on average, be incurred during one's lifetime because of new cases of disease and injury in 1990. It differs in many respects from previous attempts at global and regional health situation assessment which have typically been much less comprehensive in scope, less detailed, and limited to a handful of causes. This paper summarizes the DALY estimates for 1990 by cause, age, sex and region. For the first time, those responsible for deciding priorities in the health sector have access to a disaggregated set of estimates which, in addition to facilitating cost-effectiveness analysis, can be used to monitor global and regional health progress for over a hundred conditions. The paper also shows how the estimates depend on particular values of the parameters involved in the calculation.

PIP: Evaluating the cost-effectiveness of health interventions requires a comprehensive assessment of the amount of ill health attributable to specific diseases and injuries. Unlike previous attempts at global and regional health situation assessments which have been generally less comprehensive in scope, less detailed, and limited to relatively few causes, the disability-adjusted life year (DALY), a new indicator, was developed to assess the burden of disease and injury in 1990 for more than 100 causes by age, sex, and region. The measure provides an integrative, comprehensive methodology to capture the entire amount of ill health which will, on average, be incurred during one's lifetime because of new cases of disease and injury in 1990. This paper summarizes the DALY estimates for 1990 by cause, age, sex, and region, giving those responsible for deciding health sector priorities access to a disaggregated set of estimates. The paper also shows how the estimates depend upon particular values of the parameters involved in the calculation.

Disease control priorities in developing countries: health policy responses to epidemiological change.

Health systems in developing countries are facing major challenges in the 1990s and beyond because of a growing epidemiological diversity as a consequence of rapid economic development and declining fertility. The infectious and parasitic diseases of childhood must remain a priority at the same time the chronic diseases among adults are emerging as a serious problem. Health policymakers must engage in undertaking an epidemiological and economic analysis of the major disease problems, evaluating the cost-effectiveness of alternative intervention strategies; designing health care delivery systems; and, choosing what governments can do through persuasion, taxation, regulation, and provision of services. The World Bank has commissioned studies of over two dozen diseases in developing countries which have confirmed the priority of child survival interventions and revealed that interventions for many neglected and emerging adult health problems have comparable cost-effectiveness. Most developing countries lack information about most major diseases among adults, reflecting lack of national capacities in epidemiological and economic analyses, health technology assessment, and environmental monitoring and control. There is a critical need for national and international investment in capacity building and essential national health research to build the base for health policies.

The distribution and impact of health resource availability in China.

Since 1949, China's progress in mortality reduction has far exceeded that experienced by other developing countries with comparable levels of national income. This achievement has taken place in the context of a development strategy oriented, in part, to the elimination of the worst aspects of poverty. Using recent cross-section data, this paper provides a statistical assessment of the extent to which health resources are evenly distributed in contemporary China, and the degree to which improvements in health resource availability may account for the observed variation in mortality levels. Contrary to expectation, the analysis finds that substantial inequalities do remain in the distribution of health resources, and that these differentials are principally associated with levels of urban income and urbanization. However, these differences in health resource availability do not appear to explain the significant variation which also persists in mortality levels, a finding consistent with the results of similar analyses for developed countries.

Radio for formal education and for development communication.

PIP: A substantial body of literature documents the successful use of open radio broadcasting, radio campaigns, and radio-listening groups in nonformal education and other aspects of development communication. The 4 alternative strategies for using radio in formal education -- using radio to enrich learning, direct instruction, extending in-school education, and distance learning -- need to be assessed in terms of users' needs. The use of radio to enrich in-school education holds little promise for major improvements, but the potential for the use of radio in direct instruction in 1 or more subjects is promising and presents a strong challenge to educators. Case studies of 2 Mexican projects to extend school in order to expand the rural population's access to information and schools were disappointing. Both projects showed that radio could teach about as effectively as traditional elementary school teachers, but neither expanded beyond the pilot stage. Better financing and a firmer government commitment might have made a difference. The use of radio in formal education as a component of a distance-learning system has been successful in Kenya and the Dominican Republic, among other places. The best use of open broadcast is to transmit an interesting message; the most appropriate use of listening-group strategies -- radio schools, farm forums, and radio animation -- are to promote more complex and longterm changes. Communication planners need to be aware that radio can be used in numerous ways in response to a variety of goals. 4 projects are reviewed to illustrate instances in which radio has realized its goals with special success -- the Kenyan health broadcasts, the radio program that used nutrition "ads," the Guatemalan agricultural information programs, and the Tanzania radio campaigns. These projects show that the development goals being promoted and the special characteristics of the project determine the strategy, its effects, and its transferability.^ieng