Joke #1: “Officer, I lost my watch,” says the drunk wandering around a lamppost. “Where did you lose it?” asks the officer.
“Across the street.”
“Then why are you looking for it here?”
“Because there’s more light here.”
Child mortality rates in India and Pakistan, already very high, are not falling very fast, despite rapid economic growth in both countries. The determinants of child mortality in poor countries lie mostly outside the health sector—water, sanitation, mother’s education, even transport, as countries such as Bangladesh that have made impressive strides in child survival have shown. Health inputs have only a weak relationship with child mortality. Yet health ministries rarely promote safe water, better sanitation, girls’ education and rural road construction as the major components of a program of child survival. Instead, they focus on health inputs. Why? Because there’s more light there.
Mariam Claeson
Wed, 01/09/2008 - 02:47 Does your giving a link of the bloomberg article here mean that you, even partly, approve of the focus on contraceptives as suggested by the author? If yes, in a situation of pitiably low level of well-being, how effective would latex be, if mere statistical reduction of poverty is not the only goal? I found the following line, which appeared right after a quote from your blog, highly offensive, if not arrogant. "The fewer the number of children born in extreme poverty, the smaller will be the problem of their neglect." Is it that easy, sir? Rather, should it be that easy?
Mon, 12/17/2007 - 10:33
One approach to this "street light" problem is for a donor or central government to “pay for progress” (http://www.cgdev.org/section/initiatives/_active/pbaedu), leaving it up to local actors to decide how to achieve that progress. In the case of health, this would allow funds to be used for “buying” mothers’ education, better roads or...yes, more health clinics.
Thu, 12/06/2007 - 11:53 I recall a comment along the lines that investment in sanitation infrastructure has done more to prevent serious illnesses / deaths by preventing the build up and spread of diseases than any post-symptom treatments (i.e. medical care, hospitalization, etc.) have done. Interest in infrastructure solutions to improving the quality of life seem to ebb and flow depending upon the success of previous projects. Infrastructure takes time to be built, and can take time to influence health (and other) statistics. The benefits of that investment are also put at risk by challenges faced in maintaining the infrastructure, and therefore sustaining the benefits originally obtained. The solution, as I see it, is working with communities to determine what infrastructure can be built and, more importantly, maintained (think of this as maintaining the services the infrastructure enables to be provided, not maintaining the physical assets); and, working in parallel with governments to institutionalize the benefits being obtained. Governments are part of the solution to sustainably managing infrastructure over the long term. The private sector has a role - more on that another time. In cities the role of the government is predominant as a sense of community may be more fragmented or more difficult to engage efficiently and effectively.
Thu, 12/06/2007 - 04:19 In child survival research, socioeconomic factors (household and community variables) are considered distal determinants, which in turn, operate through proximate determinants such as maternal factors (age, parity, birth interval), environmental contamination, nutrition, injury and personal illness control that directly influence the disease process and health outcomes of children [1]. Globally, two-thirds of child deaths can be prevented by interventions that address the proximate determinants including simple low-cost interventions such as immunization, treatment of infectious diseases such as diarrhea, malaria, pneumonia, sepsis and tetanus [2]. These interventions can only be delivered through the health sector. You make a point about the ineffectiveness of public health spending in a related comment. A cross-national study on child survival demonstrates that even though public health spending does not have an association with under-5 mortality, the quality, accessibility, and utilization of basic health care services does and the challenge “may be less to raise overall public health spending, or even the share of public health spending devoted to basic services, than to assure that a very small absolute amount of revenue is spent effectively to raise access to, or improve the quality of, maternal and infant health care” [3]. It is erroneous therefore to suggest that health inputs have little impact on child survival and that the child survival efforts should mainly focus on girl’s education, rural road construction, etc. No doubt these are desirable goals and may have an indirect (distal) impact on child survival in the long-term. However, we need more immediate (proximate) and effective (quality) solutions for preventing child mortality and this can only be accomplished by strengthening the health sector. 1. W. Henry Mosley and Lincoln Chen, An analytical framework for the study of child survival in developing countries. Population and Development Review,10 Supp: 25-45, 1984. 2. Gareth Jones, Richard W Steketee, Robert E Black, Zulfiqar A Bhutta and Saul S Morris, How many child deaths can we prevent this year?, The Lancet 362(9377):65-71, 2003. 3. James W. McGuire, Basic health care provision and under-5 mortality: A Cross-National study of developing Countries, World Development 34(3): 405-425, 2006.
Fri, 12/07/2007 - 18:50
Thanks for the thoughtful comment, Mona. I agree that health interventions, by addressing the proximate causes of child mortality, can have a profound effect on child survival. The problem is that spending on public health often doesn't translate into those health interventions. The question is how we can make sure that "a very small absolute amount of revenue is spent effectively to raise access to, or improve the quality of, maternal and infant health care". I submit that, by focusing on increasing public health spending, we reduce the chances that we can get this improvement in effective health care.