Source:Human Development Report (1993) – UNDP

1. Regional Disparities in Adult Chronic and Acute Health in Albania: A Multilevel Analysis of the Albanian Living Standards Measurement Survey 2002 Katie Bates (LSE), Dr Arjan Gjonça (LSE)

2. Introduction • North-south gradient in mortality • ‘Good health at low cost’ population • Albania e15 1989 - 57.8 • U.K. e15 1992 – 58.7 Source:Human Development Report (1993) – UNDP Gjonça, A – 2001 - Communism, health and lifestyle: the paradox of mortality transition in Albania, 1950-1990. Greenwood Press, Westport

3. Diet Hypothesis Figure 2. Geographical distribution of olive production in Albania, 1985 Gjonca, A., Bobak, M., - 1997 – ‘Albanian paradox, another example of the protective effect of Mediterranean lifestyle?’ Lancet Vol. 350: 1815–17 Gjonca, A., Wilson, C., Falkingham, J. – 1999 – ‘Can Diet and Life Style Explain Regional Differences in Adult Mortality in the Balkans?’ MPIDR WORKING PAPER WP 1999-003 Gjonça, A – 2001 - Communism, health and lifestyle: the paradox of mortality transition in Albania, 1950-1990. Greenwood Press, Westport • North-South Gradient in Mortality • Socioeconomic • Communist policies population-wide • Behavioural • Low smoking prevalence • Physical activity uniformly high • Difference in Age Structure • Unlikely systematic difference • Internal migration restricted • Diet Hypothesis • North-east – high in animal fats • South-west – ‘Mediterranean diet’ - Olive oil, fresh fruit and vegetables • CVDs

4. Rationale for Study • North-South gradient in mortality prevailed 1950-1989 • Social and economic changes during post-communist transition • Albania Living Standards and Measurement Survey 2002 provides opportunity to assess the relationship between region and health outcomes in Albania, post-1989, by drawing on correlation between ill-health and mortality

5. Research Questions • Hypothesis: Regional disparities in health remain despite changing socioeconomic conditions • Research Questions: Is region related to adult health outcomes in Albania? a) Is region related to chronic illness? b) Is region related to acute illness?

6. Data and Methods *p<0.05, ** p<0.01, *** p<0.001 INSTAT – 2003 – Albania Living Standard Measurement Survey 2002 Basic Information Document The World Bank, Albania Institute of Statistics (INSTAT) • Albania Living Standards Measurement Survey 2002 • Dichotomous Dependent Variables: Self-report chronic; Self-report acute • Multistage Sample design, violation of independence Table 1.  Log Likelihood Ratio Test: Between-Cluster Variance • Logistic Variance Components Models

7. Data and Methods • Explanatory Variables (individual and household level) • Age • Marital Status • Education (years) • Income (percentiles) • Water source (inside/outside HH) • Toilet (inside/outside HH) • Distance to doctor • Region as fixed effect • Step-wise Model Selection Fig. 3: Regions of Albania

8. Results: Chronic Illness

9. Results: Acute Illness

10. Results and Regional Disparities Fig. 6: Geographic Distribution of Odds of Reporting Chronic Illness Fig. 7: Geographic Distribution of Odds of Reporting Acute Illness • Coastal region highest odds of reporting chronic illness • Internal migration as key factor? • Northeast region highest odds of reporting acute illness

11. Discussion/Conclusion • Acute Illness: north-south gradient persists • Chronic Illness: change in regional pattern • Change in behavioural risk factors • Internal migration - ‘the Coastal region is [an] important absorbing area. The Mountain and the Centre regions…, are strong expellers’ (Carletto et al. 2004: 7) • Future Research: control for migration since 1990 Carletto. G., Davis. B., Stampini. M., Trento. S., Zezza. A, - 2004 - "Internal Mobility and International Migration in Albania," Working Papers 04-13, Agricultural and Development Economics Division of the Food and Agriculture Organization of the United Nations (FAO - ESA)

12. Questions

13. Model Adequacy and Interpretation: Chronic Figure 21: Predicted Probabilities of Reporting Chronic Illness Against Observed Probabilities:

14. Model Adequacy and Interpretation: Acute Figure 24: Predicted Probabilities of Reporting Chronic Illness Against Reported Acute Illness:

15. Odds Ratios for Random Intercept Logistic Regression Models for Reporting Chronic/No Chronic illness in the last three years: 2002 Albania LSMS:

16. Odds Ratios for Random Intercept Logistic Regression Models for Reporting Acute/No Acute illness in the last four weeks: 2002 Albania LSMS:

17. CEE context 2001

18. Good Health at Low Cost • Caldwell ‘Routes to low mortality’ (1986) • Political will, egalitarianism, radicalism • Government commitment to education • Government commitment to health care • Health care free and accessible to all • Maternal and child health care • Universal vaccination • Education (particularly female) • Female autonomy Caldwell, J., - 1986 - Routes to Low Mortality in Poor Countries - Population and Development Review Vol. 12, No. 2 (Jun., 1986), pp. 171-220 Published by: Population Council http://www.jstor.org/stable/1973108