Health as output The reverse has also been argued, where wealth is seen to be a necessary input

Health as output The reverse has also been argued, where wealth is seen to be a necessary input

for the achievement of health (specifically infant mortality) outcomes. Indeed, Pritchett and Summers (1996) argue that ‘wealthier nations are healthier nations’, as demonstrated by the strong and consistent association between per capita income and child mortality. They suggest that the effect of income on health is causal (not accounted for by reverse causation or a third variable) and that, for every unit change in per capita income, there is a 0.2–0.4 drop in child mortality rates. So, they conclude, if we focus on economic growth, we will ultimately save children’s lives. Thus, economic growth assumes a central role in development objectives.

However, many have contested the centrality of economic growth to health. Sudhir Anand and Martin Ravallion (1993), for example, find the

HEALTH

relationship between GNP per capita and health to operate mainly through the impact of GNP on private incomes (particularly of the poor) and public expenditure on health care. When both factors are included in their statistical analysis, GNP alone explains very little about the relationship. While it is true that increased economic growth provides the resource base to develop and strengthen health systems, increases in GNP are not always translated into health improvements. Health improvements have more to do with public, as well as individual, resource allocation and priority setting. In other words, it is not only the absolute availability of resources, but rather how these resources are distributed and used.

Sen (1999, p620) describes GNP-induced health improvement as ‘growth- mediated’ health development. This takes place, he argues, when fast economic growth is broad and highly employment-oriented, as well as when economic growth results in the expansion of social services, including health care, education and social security. This argument has been empirically verified by Ranis et al (2000). By cross-country regression analysis, they find that economic growth contributes to human flourishing (improved health and education) only if it is followed by a shift in resource-allocation towards health and education, equitable distribution of income, and extensive employment programmes for the unemployed (see Chapter 4 for a lengthier discussion on their study). Recently, Angus Deaton (2006) has also concluded that many contributions to health do not depend on economic growth or income. Indeed, there are numerous cases where health achievements have been made without high incomes (e.g. Sri Lanka, Cuba, Costa Rica), as well as reverse cases, where the expected level of health outcomes are not realized despite high levels of economic growth (e.g. Saudi Arabia). Deaton argues that there is likely a third factor relating both to economic growth and health, which explains the relationship (e.g. education, governance). Moreover, he emphasizes the need to recognize that health measures used for such macro level analysis often come from incomplete or inaccurate vital registries, particularly in poor countries, and life-expectancy figures come from model life tables which, by design, give more weight to infant and child death.

It is therefore clear from the discussion above that economic growth does not automatically translate into improved health. Instead, there is a set of social policies required to promote health; in the absence of such policies, fast economic growth may only benefit a few. The so-called ‘trickle-down effect’ never quite happened in much of the developing world, despite occasionally impressive cases of economic growth (see Chapter 4).

Whether we consider wealth to be the input and health the output – or the reverse, where health is the input for economic growth outputs – we are confined by our own conventional conceptions of inputs and outputs that relate to one another in a predictable and reliable fashion. Health necessarily improves wealth and wealth invariably improves health. Such approaches lead us to the critical question of whether economic growth is necessary for improving health. Sen (1999) asserts that this is not always the case. It is not

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always necessary to wait for high economic growth to take place before focusing on improving health. Indeed, the success of pre-reform China, Costa Rica, Sri Lanka and the Indian state of Kerala in improving the health and life expectancy of their citizens without substantial increases in income, supports the claim that economic growth is not a pre-condition for health improvement. Sen describes this health improvement as ‘support-led’ processes of health development, which result from priority being given to the provision of social services, particularly health care and basic education. These support-led processes, he argues, are economically viable since the required social services (i.e. health care and basic education) are labour-intensive and developing countries have cheap labour. Thus, low wages provide opportunities for improving health without requiring economic growth.

Health in the context of the human development and capability approach