Arip MuttaqienJPEG Fellow

Paper Presentation:

Routes to Low Mortality in Poor Countries RevisitedRandall Kuhn, Population and Development Review 36(4): 655-692

What we discuss today• Caldwell paper (1986), little bit for background, especially basic concept. • Revised paper by Kuhn.• Discussion and conclusion.

Caldwell, John C. 1986. “Routes to Low Mortality in Poor Countries”, Population and Development Review 12(2): 171-220

Keyword: infant mortality, health, income

Caldwell’s Paper

• Source: World Development Report 1984 (The World Bank).

• 99 third world countries: ranking from the worst to the best.

• Indicator: infant mortality rate (IMR), child mortality rate (CMR), life expectation at birth, and level of income.

• Check table 1 and table 23 from the WDR.

Caldwell: Logic of Ranking The worst

The best

Rank 99

Rank 1 Low-income economiesChina and IndiaOther low-income(rank 1-34)

Middle-income economiesOil exportersOil importersLower middle-income(rank 35-72)

Upper Middle-income(rank 73-94)

High-income oil exporters(rank 95-99)

Bangladesh, Zaire, India, China, Bhutan, etc.

Sudan, Egypt, Thailand, Turkey, Lebanon, etc.

Malaysia, Portugal, South Africa, Venezuela, etc.

Libya, Saudi Arabia, Kuwait, UAE, Oman.

Caldwell: Logic of Ranking The worst

The best

Rank 1

Rank 126

Caldwell: Logic of Ranking

GNP per capita ($)(1982)

IMR per 1,000 live births(1982)

Expectation of life at birth (yrs)(1982)

Rank Rank Rank

Rank of IMR relative to rank of income

320 23 32 85 69 84 +62

Rank of life expectancy relative to rank of income

+61

1,330 62 10 99 73 94 +37 +32

16,000 97 108 99 56 47 -61 -50

SRI LANKA

JAMAICA

SAUDI ARABIA

Superior health achiever: ≥+25

Poor health achiever: ≤-25

Superior health achiever: ≥+25

Superior health achiever: IMR rank – Income rank ≥ +25Poor health achiever: IMR rank – Income rank ≤ -25

Jack Caldwell

• Unique methods and aggressive hypothesis-formation.

• Inspired demographers to do mixed research in quantitative and qualitative.

• Addressed contextual, historical, and political condition.

Mortality levels relative to income level for 99 third world countries, 1982

Superior health achiever

Poor health achiever

• Most significant achievement: Costa Rica, Sri Lanka, Kerala.

• Caldwell emphasized the symbiosis between cultural & health.

• Education as the catalyst.• Substantial female autonomy,

dedication to education, open political system, civilian society without class structure, and history of egalitarianism & radicalism.

• Causality?

Revised Paper by Kuhn: National health indicators

• Caldwell drew measurement and data from the 1984 World Development Report (99 countries with population greater than one million). Income was measured in US$.

• Income measure has changed. Income is measured by PPP. Then, Kuhn uses PPP adjustment.

• The 2009 WHO World Health Statistics Report. • Child mortality rate (CMR) as standard indicator of national well-being. CMR

shows more variability than IMR due to lower IMR at the moment.• Adult mortality rate (AMR).

Growth and mortality progress of original superior and poor health achievers, 1982 - 2007

Strong forces of economic and epidemiologic convergence

CMR and GDP per capita (131 countries, 2007)

AMR and GDP per capita (131 countries, 2007)

Superior health achiever: CMR rank – Income rank ≥ +30Poor health achiever: CMR rank – Income rank ≤ -30

Superior health achiever: AMR rank – Income rank ≥ +30Poor health achiever: AMR rank – Income rank ≤ -30

Discussion

• Today’s poor health achievers still include oil-rich states.• Caldwell: relationship between majority-Muslim population and poor

achievement. • Kuhn: Today, the situation looks quite different as mortality reductions in a

wide range of Muslim countries in last 25 years. • Kuhn: Religious identity must be interpreted with care. In 1986, Caldwell used

‘Islam’ term, not Muslim countries. He also discussed Buddhism in Sri Lanka, Thailand, Vietnam, and Myanmar (enlightenment principle).

• My opinion: Religious definition. For example: Islam and Muslim countries are debatable for exact definition, it can be defined as formal definition, cultural definition, or principle definition. Ex: Islamicity Index measures how well the country adhere with principle of Islam. In 2014, the top country: Ireland, Denmark, and Luxembourg. Saudi Arabia is rank 91.

Exceptional mortality levels relative to income levels for 121 low and middle-income countries with adult HIV/AIDS prevalence below than 15% (2007)

Superior health achiever: Mortality rank – Income rank ≥ +28Poor health achiever: Mortality rank – Income rank ≤ -28

Determinant of Exceptional Health Achievement

• Education and gender.• Substantial advantage of primary school enrollment (gross enrollment

ratio).• Women’s schooling.

• Health system spending.• Poverty.• Governance and society.

Determinant of Exceptional Health Achievement

• Education and gender.• Health system spending.

• Health spending demonstrated a societal commitment to welfare for better outcomes.

• Total health spending is not a strong correlate of health achievement. It is primary related only to poor health achiever.

• Challenge of the policy focus on public health expenditures as determinant of health outcomes.

• Poverty.• Governance and society.

Determinant of Exceptional Health Achievement

• Education and gender.• Health system spending.• Poverty.

• Poverty is important dimension of health achievement, perhaps more significant than health expenditure, but it is related with poor health achiever.

• Governance and society.

Determinant of Exceptional Health Achievement

• Education and gender.• Health system spending.• Poverty.• Governance and society.

• The role of democracy, social activism, and social solidarity or consensus.

• Indicators: efficacy, corruption, and democracy.

Conclusion• The result of superior and poor are not stable. • Two routes to low mortality:

• Direct route involving women’s schooling • Involving the interplay between governance, social consensus, and

empowerment.• Education has a causal effect on mortality, especially for children. But it is

overshadow by factor relating to health system, poverty, and governance.• Health policy itself is important, rather than health spending. • Superior achievers are identified by success on some development indicators and by

the lack of abject failure on all dimensions. They are also distinguished by performing well on at least one governance indicator and avoiding extremely poor performance at all.

• Substantial reduction as emerging patters: Latin America and Muslim world.• Cost-effective primary health care and increasing democratic inclusion in Latin

America.• For Muslim world case, human capital dependency. Complex relationship

between social solidarity, democratic change, health system, and mortality. • More ethnic homogenous (eg: Latin America and Arabic countries), more success in

lowering mortality.

Discussion

• What is the best health indicator? And causality among indicators? The next research can focus on causality. Eg: health service indicators, morbidity statistics, and demographic indicator?

• Definition of superior and poor health achievers? The limit of +25 and -25, what is the logic behind this?

• Definition of superior and poor health achievers? What about initial level from each country? In this case, we can compare between two different time (panel).

• Ranking is categorical variable. Let’s assume three countries: A, B, and C. Life expectancy from three countries: 55 yrs (A), 57 yrs (B), and 75 yrs (C). Then, ranking from three countries: A = 1st, B = 2nd, C = 3rd. In this case, ranking system doesn’t reflect “the gap” among these countries.

• Other factor, eg: geographic. • Challenge: source of data from developing countries.

Thank you!

Schooling and literacy indicators

Schooling and literacy indicators

Poverty indicators

Governance indicators