Health

1. Health

2. Health • Specific topics of interest are: • Infant and child mortality • Adult mortality • Infectious diseases • – new interest in Neglected Tropical Diseases • Inherited diseases • Serious injuries • Health and Pregnancy/Childbirth • Nutritional Status of both children and adults • Mental Health • New interest in research related to child mental health from children left behind by parents who migrate to work (China)

3. Basic Facts about Death in Developing Countries • Almost ½ of low life expectancy is due to high infant and child mortality. • Vaccinations to children and infants can reduce infant mortality • UNICEF and WHO had a huge campaign in 1980's and 1990's that did this, resulting in much lower infant and child mortality rates. (vaccines were measles, diphtheria, pertussis, tetanus, polio) • 45% of deaths are due to infectious diseases or parasites in developing countries (5% in developed countries) • Oral rehydration therapy (ORT) dramatically reduces deaths due to infant diarrhea. Source: 1993 World Development Report

4. Leading Causes of Child < 5 Death • Difference by income: Source: 2011 World Health Report

5. Leading Causes of Adult Death • Differences by income Source: 1993 World Development Report

6. Role of Government in Health Care • Observation: Technological developments in health care are increasing. However - the cost of providing some kinds of "high-tech" health care can be very expensive. • Observation: Continuing problem that diseases evolve to become resistant to treatments (e.g. tuberculosis), and new diseases emerge (e.g. AIDS) • Reasons for Government Intervention (in terms of economic theory) • Distributive: i.e. basic health care is a right (question: why not just redistribute money?) • Externalities from communicable diseases • Other market imperfections, e.g. lack of markets for health insurance • Lack of information on the part of many households

7. Potential Health Policies • Provision of public health services • immunization campaigns, visits by health workers to homes and schools, construction of sewage treatment plants, reduce pollution, public education campaigns • Pricing policies • subsidization of “essential” drugs and health services, price controls on private providers, prices of all services offered by government health facilities, reducing distance to health facilities, prices of goods that effect health - alcohol and tobacco • Research on new methods to treat health problems (research is a public good). • Most research is done in developed countries. • Policies that promote equitable economic growth • Increase education, especially education of women

8. Potential Health Policies Source: 1993 World Development Report

9. MDGs and Targets • Goal 4: Reduce child mortality • Target 4.A. Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate    • 4.1 Under-five mortality rate • 4.2 Infant mortality rate • 4.3 Proportion of 1 year-old children immunized against measles http://www.mdgmonitor.org/index.cfm

10. Goal 4: Reduce child mortality • Target 4.A. Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate    • 4.1 Under-five mortality rate • 4.2 Infant mortality rate • 4.3 Proportion of 1 year-old children immunized against measles

11. Goal 4: Reduce child mortality • Target 4.A. Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate    • 4.1 Under-five mortality rate • 4.2 Infant mortality rate • 4.3 Proportion of 1 year-old children immunized against measles

12. Goal 4: Reduce child mortality • Target 4.A. Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate    • 4.1 Under-five mortality rate • 4.2 Infant mortality rate • 4.3 Proportion of 1 year-old children immunized against measles

14. Goal 4: Reduce child mortality • Target 4.A. Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate    • 4.1 Under-five mortality rate • 4.2 Infant mortality rate • 4.3 Proportion of 1 year-old children immunized against measles

15. Goal 4: Reduce child mortality • Target 4.A. Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate    • 4.1 Under-five mortality rate • 4.2 Infant mortality rate • 4.3 Proportion of 1 year-old children immunized against measles

16. MDGs and Targets • Goal 5: Improve maternal health • Target 5.A. Reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio • 5.1 Maternal mortality ratio • 5.2 Proportion of births attended by skilled health personnel • Target 5.B: Achieve, by 2015, universal access to reproductive health • 5.3 Contraceptive prevalence rate • 5.4 Adolescent birth rate • 5.5 Antenatal care coverage (at least one visit and at least four visits) • 5.6 Unmet need for family planning http://www.mdgmonitor.org/index.cfm

17. Goal 5: Improve maternal health • Target 5.A. Reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio • 5.1 Maternal mortality ratio • 5.2 Proportion of births attended by skilled health personnel

18. Goal 5: Improve maternal health • Target 5.A. Reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio • 5.1 Maternal mortality ratio • 5.2 Proportion of births attended by skilled health personnel

19. Goal 5: Improve maternal health • Target 5.B: Achieve, by 2015, universal access to reproductive health • 5.3 Contraceptive prevalence rate • 5.4 Adolescent birth rate • 5.5 Antenatal care coverage (at least one visit and at least four visits) • 5.6 Unmet need for family planning

20. Goal 5: Improve maternal health • Target 5.B: Achieve, by 2015, universal access to reproductive health • 5.3 Contraceptive prevalence rate • 5.4 Adolescent birth rate • 5.5 Antenatal care coverage (at least one visit and at least four visits) • 5.6 Unmet need for family planning

21. MDGs and Targets • Goal 6: Combat HIV/AIDS, malaria, and other diseases • Target 6.A. Have halted by 2015 and begun to reverse the spread of HIV/AIDS   • 6.1 HIV prevalence among population aged 15-24 years • 6.2 Condom use at last high-risk sex • 6.3 Proportion of population aged 15-24 years with comprehensive correct knowledge of HIV/AIDS • 6.4 Ratio of school attendance of orphans to school attendance of non-orphans aged 10-14 years • Target 6.B Achieve, by 2010, universal access to treatment for HIV/AIDS for all those who need it • 6.5 Proportion of population with advanced HIV infection with access to antiretroviral drugs • Target 6.C.Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases   • 6.6 Incidence and death rates associated with malaria • 6.7 Proportion of children under 5 sleeping under insecticide-treated bednets • 6.8 Proportion of children under 5 with fever who are treated with appropriate anti-malarial drugs • 6.9 Incidence, prevalence and death rates associated with tuberculosis • 6.10 Proportion of tuberculosis cases detected and cured under directly observed treatment short course http://www.mdgmonitor.org/index.cfm

22. Goal 6: Combat HIV/AIDS, malaria, and other diseases • Target 6.1. Have halted by 2015 and begun to reverse the spread of HIV/AIDS   • 6.1 HIV prevalence among population aged 15-24 years • 6.2 Condom use at last high-risk sex • 6.3 Proportion of population aged 15-24 years with comprehensive correct knowledge of HIV/AIDS • 6.4 Ratio of school attendance of orphans to school attendance of non-orphans aged 10-14 years http://ddp-ext.worldbank.org/ext/GMIS/home.do?siteId=2

23. Goal 6: Combat HIV/AIDS, malaria, and other diseases • Target 6.1. Have halted by 2015 and begun to reverse the spread of HIV/AIDS   • 6.1 HIV prevalence among population aged 15-24 years

24. Goal 6: Combat HIV/AIDS, malaria, and other diseases • Target 6.1. Have halted by 2015 and begun to reverse the spread of HIV/AIDS   • 6.1 HIV prevalence among population aged 15-24 years • 6.2 Condom use at last high-risk sex • 6.3 Proportion of population aged 15-24 years with comprehensive correct knowledge of HIV/AIDS • 6.4 Ratio of school attendance of orphans to school attendance of non-orphans aged 10-14 years http://ddp-ext.worldbank.org/ext/GMIS/home.do?siteId=2

25. Goal 6: Combat HIV/AIDS, malaria, and other diseases • Target 6.B Achieve, by 2010, universal access to treatment for HIV/AIDS for all those who need it • 6.5 Proportion of population with advanced HIV infection with access to antiretroviral drugs http://ddp-ext.worldbank.org/ext/GMIS/home.do?siteId=2

26. Goal 6: Combat HIV/AIDS, malaria, and other diseases • Target 6.B Achieve, by 2010, universal access to treatment for HIV/AIDS for all those who need it • 6.5 Proportion of population with advanced HIV infection with access to antiretroviral drugs http://ddp-ext.worldbank.org/ext/GMIS/home.do?siteId=2

27. Goal 6: Combat HIV/AIDS, malaria, and other diseases • Target 6.C. Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases   • 6.6 Incidence and death rates associated with malaria • 6.7 Proportion of children under 5 sleeping under insecticide-treated bednets • 6.8 Proportion of children under 5 with fever who are treated with appropriate anti-malarial drugs • 6.9 Incidence, prevalence and death rates associated with tuberculosis • 6.10 Proportion of tuberculosis cases detected and cured under directly observed treatment short course http://ddp-ext.worldbank.org/ext/GMIS/home.do?siteId=2

28. http://ddp-ext.worldbank.org/ext/GMIS/home.do?siteId=2

29. Goal 6: Combat HIV/AIDS, malaria, and other diseases • Target 6.C. Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases   • 6.9 Incidence, prevalence and death rates associated with tuberculosis

30. MDGs and Targets • Goal 7: Ensure environmental sustainability • Target 7.C. Halve, by 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation  • 7.8 Proportion of population using an improved drinking water source • 7.9 Proportion of population using an improved sanitation facility

31. Goal 7: Ensure environmental sustainability • Target 7.C. Halve, by 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation  • 7.8 Proportion of population using an improved drinking water source • 7.9 Proportion of population using an improved sanitation facility

32. Goal 7: Ensure environmental sustainability • Target 7.C. Halve, by 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation  • 7.8 Proportion of population using an improved drinking water source • 7.9 Proportion of population using an improved sanitation facility

33. Goal 7: Ensure environmental sustainability • Target 7.C. Halve, by 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation  • 7.8 Proportion of population using an improved drinking water source • 7.9 Proportion of population using an improved sanitation facility

34. Recent studies on one pathway between health and income: educationMiguel (2005) “Health Education and Economic Development” Chapter 6 in Health and Economic Growth • Child health-education linkages (2 studies) 1. Martorell, Habricht and Rivera (1995) INCAP nutritional project in Guatemala. • Basics: randomly chosen 4 villages were randomly assigned into 2 groups • Group 1 (2 villages): children and expecting moms got a high energy/high-protein drink called "Atole“ • children received a low energy/low protein drink called "Fresco". • Results: After a decade of following the children • children in Atole villages showed height/weight gains, greater work capacity (especially among boys) and gains in some cognitive measures that are likely to be linked to school performance • this was one of the most convincing studies to date that childhood nutrition and health affect subsequent life outcomes.

35. Recent studies on one pathway between health and income: educationMiguel (2005) “Health Education and Economic Development” Chapter 6 in Health and Economic Growth • Child health-education linkages (2 studies) 2. Miguel and Kremer (2004) “Worms and Schooling in Rural Kenya • Evaluated the Primary School Deworming Project (PSDP) in Busia, Kenya on education • Basics: 75 schools with 32,565 primary students (7-17 years old) • 90% of students were infected with helminths • Schools were randomly divided into 3 groups of 25 school

36. Recent studies on one pathway between health and income: educationMiguel (2005) “Health Education and Economic Development” Chapter 6 in Health and Economic Growth • Child health-education linkages (2 studies) 2. Miguel and Kremer (2004) “Worms and Schooling in Rural Kenya • Results: • treatment schools received ⇓in helminth infections, ⇓ in kids reporting being sick, ⇑ in HAZ scores, ⇓ in anemia. • ⇓ in absenteeism and increase in school participation among youngest primary school children (grade 4 and below). • deworming ⇓ worm burden and ⇑ school participation among untreated children in the treatment schools and among children in neighboring primary schools

37. Recent studies on one pathway between health and income: educationMiguel (2005) “Health Education and Economic Development” Chapter 6 in Health and Economic Growth • Child health-education linkages (2 studies) 2. Miguel and Kremer (2004) “Worms and Schooling in Rural Kenya • Points • failure to take into account these externalities into account would lead one to substantially underestimate the cost effectiveness of deworming • As a result of this study: most LDCs can receive donations of deworming medications for all (cost os $.02/pill 1-2x per year). • However: limited results on deworming effects on academic/cognitive test scores

38. Recent studies on one pathway between health and income: educationMiguel (2005) “Health Education and Economic Development” Chapter 6 in Health and Economic Growth • Parent health-education linkages (4 studies) • Case, Paxson and Ableidinger (2002): 10 SSA countries between 1992-2000 to estimate the impact of parent death on school enrollment. • Find that orphans are less likely to be enrolled in school than non-orphans. • Orphans are more likely to stay with distant relatives who may have less genetic incentives to care for these children • Gertler, Levine and Ames (2004): use panel data in Indonesia in the 1990s. • Find that parent death during past 12 months leads to a doubling of probability that child drops out of school that year.

39. Recent studies on one pathway between health and income: educationMiguel (2005) “Health Education and Economic Development” Chapter 6 in Health and Economic Growth • Parent health-education linkages (4 studies) • Ainsworth, Beegle and Koda (2002): Study children in northwestern Tanzania • Find that school enrollment is unaffected by parent death for non-poor households, whereas for poor households they find that enrollment is delayed for younger children and unaffected by older children. • Why mixed results?? 2 theories • when the local orphan rates surpass a critical level, the insurance networks breakdown. • it is possible that HIV/AIDs victims were somewhat better off (income wise) because they worked as: truckers, soldiers, teachers and prostitutes - relatively affluent jobs. Thus negative effects of death may be obscured...

40. Recent studies on one pathway between health and income: educationMiguel (2005) “Health Education and Economic Development” Chapter 6 in Health and Economic Growth • Parent health-education linkages (4 studies) • Evans and Miguel (2003): Kenya deworming dataset, look only at kids whose parents were alive in 1998 and compare those children whose parents died during 1998-2002 with those that did not die. Findings: • parent death has a large effect on school participation rate, it does not matter which parent dies • Participation rates drop sharply the year of the death and continue to fall for up to 3 years. • the magnitude of the effect is smaller than the magnitude of eliminating one worm infection a year • the effect of parent death is similar to the estimated impact of several measures of poverty (households without latrines/toilets have similar participation rates) • children from poorest households have greatest reduction in participation rates

41. Poor Economics Chapter 3: Low-Hanging Fruit for Better (Global) Health • Why is there little demand for health care among the poor? Visit: Udaipur District in western India • Rural, very poor village: 40% below the official poverty line • 46% males illiterate & 11% females illiterate • 21% have electricity • Health status: most had very low BMI • 80% were anemic • work functioning was poor (>30% could not walk 5k, draw water or work in the fields.) • People seemed worried about their health • See doctor about 0.5 visits per month per adult • 7% of personal consumption expenditures is on heath 60% of visits are to private doctor • 20% to public (government) doctor • 20% to bhopas (traditional healer) • Poorest 1/3 most likely to see bhopa and richest 1/3 most likely to see private doctor.

42. Poor Economics Chapter 3: Low-Hanging Fruit for Better (Global) Health • Why don’t they see public doctors? • Public (gov) doctors are closest to village, more qualified to treat and cheaper. Why little demand? • Supply side problems • the public facility is closed more than 1/2 of the time during regular hours and nurses don't show up to work • Demand side problems: • private doctors pander to what people want (medicine, shot or a drip). • Public doctors are said to provide less treatment and less injectables

43. Poor Economics Chapter 3: Low-Hanging Fruit for Better (Global) Health • Why don’t the poor see public doctors? • When do the poor see doctors? • fever, diarrhea, vomiting, upper abdominal pain (acute conditions that are likely to be self-limiting) • When do they not seek treatment? * • weakness, backache, pain during urination, hearing loss, chest pain, memory loss, weight loss (these are chronic conditions that are often life-threatening) • When do they see a bhopa? • chronic, potentially life-threatening conditions. • Why? Perhaps because the Bhopa provides some emotional support and comfort whenthey don't expect to get well. • Point: • The poor may spend money on the wrong conditions. • The poor get treatment, but incorrectly (lots of injections, antibiotics and steroids). • Since health care providers really might not have resources help the chronic conditions, the poor seek providers to get comfort about doing some thing about acute conditions.

44. Poor Economics Chapter 3: Low-Hanging Fruit for Better (Global) Health • Policy Research Question: What do we gain from supply side intervention (will demand follow?) Or what do we gain from demand side intervention? • Two studies: • Problem of non- attendance of government nurses. There was no incentive to come to work because no one monitors them. Organization (SevaMandir) proposed to monitor. • Intervention: a program to required monitoring of nurse attendance at public health facilities (treatment facilities). • Result: In the first 6 months, the results showed that the program was initially quite effective; the rate of presence increased from 25% to 40%. Result: Monitoring had no effect on demand for services • Perhaps change is slow • Result: program failed after 6 months (system did not work well because nurses protested... other internal problems).

45. Poor Economics Chapter 3: Low-Hanging Fruit for Better (Global) Health • Policy Research Question: What do we gain from supply side intervention (will demand follow?) Or what do we gain from demand side intervention? • Two studies: • Problem of lack of child immunizations. A baseline study revealed only 2.63% of children between ages 1-5 were fully immunized. Also 57.7% never received any vaccines. • Intervention: To increase parent demand for vaccines, a program gave 1 kg of dal (dried lentils, peas or beans) for each immunization and set of plates for completing immunization. • Result: It worked, affecting demand was easier in this case and might provide a basis for affecting supply.

46. Poor Economics Chapter 3: Low-Hanging Fruit for Better (Global) Health • We question again: Why is there a low demand for health? In particular, a low demand for preventative health care? • There exist technologies that are known to be effective and cheap ways to promote good health • Bed nets for malaria, immunization, breast feeding, ORS (oral rehydration salts), bleach for water • Further studies have shown that a child not exposed to malaria in Childhood would have an income 50% higher for all their life-time than a child exposed to malaria • Investments in malaria control measures seem highly cost effective • Why are the poor not spending on preventative health care?

47. Poor Economics Chapter 3: Low-Hanging Fruit for Better (Global) Health • Why are the poor not spending on preventative health care? • Is it that people really don't care about their health care? • They do care, recall in the Udaipur survey they spent 7% per month on health care. • Most of this was spent to cure (not to prevent) • Is it that governments are to blame? • To some degree yes. • Nurses are often absent • Governments doctors and nurses do not treat patient very well: 3 minutes, 3 questions, 3 medicines! • When services are good, people do not always get them: for example in the immunization camps, only 12% of people got all the shots: there is something about demand, not only about supply!

48. Poor Economics Chapter 3: Low-Hanging Fruit for Better (Global) Health • 2 Problems with demand for preventative care • It is difficult for the poor to know what works • For example: many diseases are ‘self-limiting’. They get better on their own after being worst. • Thus if you believe you need a shot (and can get a doctor to give you one) and you eventually get better. Tendency to attribute the health to a shot, when really it would have gotten better on its own. • Tendency to overmedicate! But that is not what really works! • Benefits are in the future and the cost is now. • With Preventative care, you are taking action (vaccines) to prevent something from happening….a long time after the fact. For many drawing the link is difficult. • Human tend to put too much weight on the present, relative to the entire future. Parents may intend every month that they will get the immunization next month…. But something else comes up, and they don't end up doing it.

49. Poor Economics Chapter 3: Low-Hanging Fruit for Better (Global) Health • Policy: Large benefits from making things easy/automatic for people: • Free Chlorine dispenser right where you collect your water • Small incentives for immunization/compulsory immunization if you can pull it off • In many cases, the superficial cost benefit analysis gives you the wrong answer. • Charging a small amount may be counter-productive • Giving people small incentives may save you money • The role of learning and trust is key • Because preventive care is hard to teach, need to maintain trust: important for governments to chose their battles. India lost credibility by lying to people about sterilization, and recovering from this is very difficult.