Health, Human Capital, and Development

Assessing the Health and Welfare Benefits of Interventions Using the Wider Societal Impacts Framework

OBJECTIVES

Health technology assessment bodies advocate capturing the value of interventions in terms of their benefits to health and broader welfare. The wider societal impacts (WSI) framework considers how changes in health alter a person's net contribution to society-that is, what they produce minus what they consume. In this research, we review this framework and explore the scope to differentiate WSI by equity-relevant sociodemographic characteristics.

METHODS

This research updates previous calculations using publicly available data from population-based surveys in the United Kingdom. We then estimate for 199 chronic conditions: (1) WSI for the average person with the condition and (2) gain in WSI for an improvement of 0.1 in health-related quality of life score.

RESULTS

The nature and availability of information varied across population-based surveys and precluded analyses to examine WSI by population subgroup. Our updated estimates mirrored earlier findings that consideration of the broader societal impacts of health would reprioritize interventions compared with assessment on health alone. For example, for the same improvement in health, a woman experiencing diseases of the circulatory system has the highest potential gain in WSI (£354/month) whereas a man experiencing HIV has the lowest potential gain (£233/month).

CONCLUSIONS

The WSI framework provides a simple, indirect method to inform resource allocation decisions. Understanding the equity implications of this approach was hindered by differences in the information collected across population-based surveys. Findings demonstrate the potential reprioritization that may occur if the broader welfare benefits of health interventions were used to inform coverage decisions.

Estimating and Rewarding the Value of Healthcare Interventions Beyond the Healthcare Sector: A Conceptual Framework

BACKGROUND

Evaluating healthcare interventions for their impacts beyond health outcomes may result in recognition of changes in human capital, income level, tax revenue, and government spending, which could affect economic growth and population health. In this paper, we document instances where current health technology assessment (HTA) practices fail to account for the impacts of healthcare interventions on broader society beyond the healthcare sector.

METHODS

We propose a novel conceptual framework, highlighting its three components (distributional cost-effectiveness analysis [DCEA], input-output model, and voting scheme) and their contributions to capturing the economic and societal ripple effects of healthcare interventions. This manuscript also outlines a case study in which the framework is applied to the reassessment of a previously evaluated digital health therapeutic for the treatment of opioid use disorder (OUD) compared with standard of care, demonstrating its practical application.

RESULTS

The DCEA health value metric indicates that digital therapeutic is more equitable, favoring socioeconomically disadvantaged groups, while standard of care exacerbates health inequality by benefiting the already advantaged. Additionally, digital therapeutic shows potential for boosting productivity, raising income, and creating jobs, supporting its consideration by employer-sponsored health plans to optimize resource allocation for treating OUD.

CONCLUSION

The conceptual framework provides insights for enhancing HTAs to incorporate the broader economic and societal impacts of healthcare interventions. By integrating DCEA, extended HTA analysis with input-output modeling, and a voting scheme, decision makers can make informed choices aligned with societal priorities, although further research and validation are necessary for practical implementation across diverse healthcare contexts.

Health and Economic Growth: Reconciling the Micro and Macro Evidence

Economists use micro-based and macro-based approaches to assess the macroeconomic return to population health. The macro-based approach tends to yield estimates that are either negative and close to zero or positive and an order of magnitude larger than the range of estimates derived from the micro-based approach. This presents a micro-macro puzzle regarding the macroeconomic return to health. We reconcile the two approaches by controlling for the indirect effects of health on income per capita, which macro-based approaches usually include but micro-based approaches deliberately omit when isolating the direct income effects of health. Our results show that the macroeconomic return to health lies in the range of plausible microeconomic estimates, demonstrating that both approaches are in fact consistent with one another.

The impact of health on economic growth: A narrative literature review

The nexus between health and economic growth is a dynamic and complex relationship. This article reviews the empirical evidence that has sought to assess the causal impact of health on growth, understood as growth in GDP per capita, and focusing on cross-country and selected single country studies. The review largely provides evidence in favour of a positive effect of population health on economic growth. However, the multitude of the factors at play and the possible bidirectional relationship between health and growth pose a challenge for the quantification of the effect and for the relative importance of the underlying mechanisms. There is notable heterogeneity between studies in the magnitude and, in some cases, even in the sign of the effect. The evidence suggests that the health-growth relationship may depend on three main factors: the sample composition (i.e. a country's demographic stage or GDP per capita); the health dimension considered (e.g. health improvements at different life stages may affect productivity differently); and the model specification (e.g. whether or not initial life expectancy is controlled for in the analysis or the quality of the instrument). These findings advocate for a policy approach that integrates health considerations into economic strategies and emphasizes intersectoral collaboration to maximize the economic returns from improved health outcomes.

Health and health system effects on poverty: A narrative review of global evidence

Ill-health causes poverty. The effect runs through multiple mechanisms that span lifetimes and cross generations. Health systems can reduce poverty by improving health and weakening links from ill-health to poverty. This paper maps routes through which ill-health can cause poverty and identifies those that are potentially amenable to health policy. The review confirms that ill-health is an important contributor to poverty and it finds that the effect through health-related loss of earnings is often larger than that through medical expenses. Both effects are smaller in countries that are closer to universal health coverage and have higher social safety nets. The paper also reviews evidence from low- and middle-income countries (LMICs) and the United States (US) on the poverty-reduction effectiveness of public health insurance (PubHI) for low-income households. This reveals that PubHI does not always deliver financial protection to its targeted population in LMICs. Countries that have succeeded in achieving this goal often combine extension of coverage with supply-side interventions to build capacity and avoid perverse provider incentives in response to insurance. In the US, PubHI is effective in reducing poverty by shielding low-income households with children from healthcare costs and, consequently, generating long-run improvements in health that increase lifetime earnings. Poverty reduction is a potentially important co-benefit of health systems.

National, regional, and global estimates of low birthweight in 2020, with trends from 2000: a systematic analysis

BACKGROUND

Low birthweight (LBW; <2500 g) is an important predictor of health outcomes throughout the life course. We aimed to update country, regional, and global estimates of LBW prevalence for 2020, with trends from 2000, to assess progress towards global targets to reduce LBW by 30% by 2030.

METHODS

For this systematic analysis, we searched population-based, nationally representative data on LBW from Jan 1, 2000, to Dec 31, 2020. Using 2042 administrative and survey datapoints from 158 countries and areas, we developed a Bayesian hierarchical regression model incorporating country-specific intercepts, time-varying covariates, non-linear time trends, and bias adjustments based on data quality. We also provided novel estimates by birthweight subgroups.

FINDINGS

An estimated 19·8 million (95% credible interval 18·4-21·7 million) or 14·7% (13·7-16·1) of liveborn newborns were LBW worldwide in 2020, compared with 22·1 million (20·7-23·9 million) and 16·6% (15·5-17·9) in 2000-an absolute reduction of 1·9 percentage points between 2000 and 2020. Using 2012 as the baseline, as this is when the Global Nutrition Target began, the estimated average annual rate of reduction from 2012 to 2020 was 0·3% worldwide, 0·85% in southern Asia, and 0·59% in sub-Saharan Africa. Nearly three-quarters of LBW births in 2020 occurred in these two regions: of 19 833 900 estimated LBW births worldwide, 8 817 000 (44·5%) were in southern Asia and 5 381 300 (27·1%) were in sub-Saharan Africa. Of 945 300 estimated LBW births in northern America, Australia and New Zealand, central Asia, and Europe, approximately 35·0% (323 700) weighed less than 2000 g: 5·8% (95% CI 5·2-6·4; 54 800 [95% CI 49 400-60 800]) weighed less than 1000 g, 9·0% (8·7-9·4; 85 400 [82 000-88 900]) weighed between 1000 g and 1499 g, and 19·4% (19·0-19·8; 183 500 [180 000-187 000]) weighed between 1500 g and 1999 g.

INTERPRETATION

Insufficient progress has occurred over the past two decades to meet the Global Nutrition Target of a 30% reduction in LBW between 2012 and 2030. Accelerating progress requires investments throughout the lifecycle focused on primary prevention, especially for adolescent girls and women living in the most affected countries. With increasing numbers of births in facilities and advancing electronic information systems, improvements in the quality and availability of administrative LBW data are also achievable.

FUNDING

The Children's Investment Fund Foundation; the UNDP-UNFPA-UNICEF-WHO World Bank Special Programme of Research, Development and Research Training in Human Reproduction; and the Bill & Melinda Gates Foundation.

Scoping review on the link between economic growth, decent work, and early childhood caries

BACKGROUND

Early Childhood Caries (ECC) is a prevalent chronic non-communicable disease that affects millions of young children globally, with profound implications for their well-being and oral health. This paper explores the associations between ECC and the targets of the Sustainable Development Goal 8 (SDG 8).

METHODS

The scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. In July 2023, a search was conducted in PubMed, Web of Science, and Scopus using tailored search terms related to economic growth, decent work sustained economic growth, higher levels of productivity and technological innovation, entrepreneurship, job creation, and efforts to eradicate forced labor, slavery, and human trafficking and ECC all of which are the targets of the SDG8. Only English language publications, and publications that were analytical in design were included. Studies that solely examined ECC prevalence without reference to SDG8 goals were excluded.

RESULTS

The initial search yielded 761 articles. After removing duplicates and ineligible manuscripts, 84 were screened. However, none of the identified studies provided data on the association between decent work, economic growth-related factors, and ECC.

CONCLUSIONS

This scoping review found no English publication on the associations between SDG8 and ECC despite the plausibility for this link. This data gap can hinder policymaking and resource allocation for oral health programs. Further research should explore the complex relationship between economic growth, decent work and ECC to provide additional evidence for better policy formulation and ECC control globally.

Human Capital Development Factors and Black Adolescent Tobacco and Cannabis Use

INTRODUCTION

This study examined the association of four domains of human capital development (cognitive development, social and emotional development, physical health, and mental health) and exclusive and concurrent tobacco and cannabis use (TCU) among black youth.

AIMS AND METHODS

Nationally representative annual cross-sectional data for black adolescents (12-17 years; N = 9017) in the National Survey on Drug Use and Health 2015-2019 were analyzed. Analyses examined the influence of human capital factors (cognitive development, social and emotional development, physical health, and mental health) on exclusive and concurrent TCU.

RESULTS

In total, 50.4% were males; prevalence of 12-month tobacco use fluctuated insignificantly between 5.6% and 7.6% across survey years. Similarly, prevalence of 12-month cannabis use remained relatively stable around 13%, with no significant linear change. Prevalence of concurrent TCU also fluctuated insignificantly between 3.5% and 5.3%. Investment in cognitive development decreased the odds of tobacco (aOR = 0.58, p < .001), cannabis (aOR = 0.64, p < .001), and concurrent tobacco and cannabis (aOR = 0.58, p < .001) use. Similarly, investment in social and emotional development reduced the odds of tobacco (aOR = 086, p < .001), cannabis (aOR = 0.83, p < .001), and concurrent tobacco and cannabis (aOR = 0.81, p < .001) use. Good physical health reduced the odds of tobacco (aOR = 0.52, p < .1), cannabis (aOR = 0.63, p < .05), and concurrent TCU (aOR = 0.54, p < .05). Major depressive episodes increased the likelihood of cannabis use (aOR = 1.62, p < .001).

CONCLUSIONS

Investment in cognitive, social, and emotional aspects of human capital development, and physical health among black youth is protective against TCU. Efforts to sustain human capital development among black adolescents may contribute to reducing TCU disparities.

IMPLICATIONS

This is one of few studies to examine human capital development factors and their associations with TCU among black youth. Efforts to eliminate tobacco/cannabis-related disparities among black youth should also invest in social, emotional, cognitive, and physical health development opportunities.

The effect of increasing health disaster risk and public spending on economy conditions: a DSGE perspective

Purpose

The main motivation of the present study is to understand the severity of the effect of health shock on Iran's oil economy and analyze the role of government under these conditions.

Design/methodology/approach

Dynamic stochastic general equilibrium (DSGE) models can show the precise interactions between market decision-makers in the context of general equilibrium. Since the duration of the virus outbreak and its effect on the economy is not known, it is more appropriate to use these models.

Findings

The results of the survey of hands-on policies scenarios compared to the state of hands-off policy indicate that the effect of government expending shocks on the economy under pandemic disease conditions has much less feedback on macroeconomic variables.

Originality/value

As a proposed policy, it is recommended that the government play a stabilizing role under pandemic disease conditions.

Key messages

Assessing the adaptive capacity of smallholder cocoa farmers to climate variability in the Adansi South District of the Ashanti Region, Ghana

This study assessed the adaptive capacity of smallholder cocoa farmers to address the adverse effects of climate variability in the Adansi South District of the Ashanti Region, Ghana. Specifically, the study sought to (i) assess the perception of the smallholder cocoa farmers to climate variability; (ii) determine the perceived effects of climate variability on cocoa production in the district; and; (iii) evaluate the adaptive capacity of the smallholder cocoa farmers to manage climate risks. The study used questionnaire surveys with 150 smallholder cocoa farmers, key informant interviews, and focus group discussions in three selected communities (Afiaso, Tonkoase, and Amudurase). A variety of capital assets (social, financial, human, physical, and natural) were utilized to conceptualize smallholder cocoa farmers' adaptive capacity. Results showed that the smallholder cocoa farmers reported changes in the onset and duration of rains, rising temperatures, and increasing windstorms in the selected communities. The farmers perceived increased incidence of drought and cocoa failure, the prevalence of diseases and pest invasion, and decreased farmer income as the key adverse effects on their cocoa production. Further, findings also revealed that cumulatively, all the selected communities in Adansi South District had a moderate adaptive capacity (0.531). It is recommended that appropriate policies aimed at enhancing the adaptive capacity of smallholder cocoa farmers must be formulated by policymakers to minimize their vulnerabilities to climate risks.

Integrating water science, economics, and policy for future climate adaptation

Water science, water economics, and water policy issues continue to rise in importance internationally as elevated population, income growth, and climate change magnify scarcity, shortages, and injustices in water access. Based on the unique physical, institutional, and economic characteristics of water, this work's first contribution is to characterize a road forward for research innovations that enable better integration of water science, water economics, and water policy. Meeting water's sustainable development and justice goals calls for several research innovations that humanity awaits. The advances called for in this work include deep uncertainty management, red team reviews, innovative water rights design, accelerating SDG achievement, valuing water infrastructure, valuing natural water retention, incentivizing water conservation, improving financial performance of rural water systems, water network modularization, non-price scarcity signals, optimization model calibration, remote sensing, transboundary benefit sharing, optimal growth, and water valuation. The work's second contribution is to present a prototype scalable basin scale hydroeconomic analysis (HEA) as a framework for integrating these above innovations when they occur. Results of the HEA show that losses from a 50% shortage in the basin's surface water supply can continue to protect 93% of total economic benefits across economic sectors if an efficient water trading system is established to move water from lower to higher valued uses when shortages occur. The work concludes by noting that great advances remain needed for better and longer lives.

Prevalence, causes, and impact of self-reported vision impairment among older people in China: Findings from the China health and retirement longitudinal study

This article investigated the prevalence, causes, and impact of self-reported vision impairment among older people in China. A total of 12,910 participants aged ⩾50 years were included in this study from China Health and Retirement Longitudinal Study (CHARLS) over the periods of 2011, 2013, and 2015. All data were reported by participants via a self-reported questionnaire. Distance vision was assessed by asking if they could see the face of a person on the other side of the street. Near vision was assessed by asking if they could read ordinary newspaper. Depressive symptoms were evaluated by 10-item Center for Epidemiological Studies Depression Scale. The analysis method included the χ2 – square distribution test and multiple regression analysis. This article first found that prevalence of self-reported vision impairment was much higher in rural than in urban areas; in urban areas, females had a greater chance of being affected than males, and for both sexes, it increases with increasing age. Second, some factors found are significantly associated with increased vision impairment rates, include increasing age, female gender, rural residents, elementary-level education, unmarried individuals, and non-agricultural occupations. Third, the leading cause of vision impairment was a refractive error and the most common causes of vision impairment include cataracts and glaucoma. Fourth, vision impairment was significantly associated with falls and depressive symptoms and has a negative effect on the quality of life of older Chinese. The article concluded that older people with self-reported vision impairment were relatively low and it is majorly caused by refractive error. Older people with distance vision impairment and near vision impairment were more likely to report falls and depressive symptoms in the future. In line with these findings, a couple of policy recommendations for further research were made.

Inverted U-Shaped Relationship between Physical Activity and Academic Achievement among Chinese Adolescents: On the Mediating Role of Physical and Mental Health

We aimed to clarify the relationship between Chinese adolescents' physical activity and academic achievement, the mediating role of physical and mental health, and provide a scientific reference for the integration of sports and education. Based on baseline data from the China Education Panel Survey, we conducted a nationwide study of 12,960 adolescents. We used nonlinear models, mediation effect analysis, and other measurement methods. Three significant findings emerged: (1) adolescent physical activity duration and academic achievement showed an inverted U-shaped relationship. Moderate physical activity improves academic achievement. The inverted U-shaped inflection point is about 3.549 h/week; (2) physical activity among the male group has a stronger effect on promoting academic achievement, while the positive effect of physical activity among females is not significant. The difference in effectiveness between urban and rural youth groups is relatively small, but the inflection point of rural youth groups is higher, and (3) the level of physical and mental health effectively mediates the inverted U-shaped influence of youth physical activity on academic achievement. We recommend that governments and schools should implement physical activity appropriately and suggest the feasibility of using physical activity to narrow the growth gap between urban and rural youth.

Tobacco Taxes as the Unsung Hero: Impact of a Tax Increase on Advancing Sustainable Development in Colombia

Objective: Tobacco taxes are a well-established cost-effective policy to prevent Noncommunicable Diseases. This paper evaluates the expected effects of a tobacco tax increase on the Sustainable Development Goals in Colombia. Methods: We use microsimulation to build an artificial society that mimics the observed characteristics of Colombia's population, and from there we simulate the behavioral response to a tax increase of COP$4,750 (an increase that has been discussed by policy makers and legislators) and the subsequent effects in all SDGs. Results: The tobacco tax hike reduces the number of smokers (from 4.51 to 3.45 MM smokers) and smoking intensity, resulting in a drop in the number of cigarettes smoked in Colombia (from 332.3 to 215.5 MM of 20-stick packs). Such reduction is expected to decrease premature mortality, healthcare costs, poverty and people facing catastrophic expenditure on healthcare, to increase health, income and gender equity, and to strengthen domestic resource mobilization even in the presence of illicit cigarettes. Conclusion: Tobacco taxes are an effective intervention for public health and a powerful instrument to advance on the 2030 Sustainable Development Agenda. Relevance: A comprehensive analysis of the impact of tobacco taxes on all areas of Sustainable Development is missing in the empirical literature. Such perspective is needed to break the barriers for further tobacco tax increases by gathering wider societal support, especially from stakeholders and key decision makers from development areas other than health. SDG Nr: SDG3 (health), SDG 1 (no poverty), SDG 4 (education), SDG 5 (gender equality), SDG6 (water), SDG10 (inequality), SDG12 (responsible production and consumption), SDG17 (partnerships).

A Literature Review of Pandemics and Development: the Long-Term Perspective

Pandemics have been a long-standing object of study by economists, albeit with declining interest, that is until COVID-19 arrived. We review current knowledge on the pandemics' effects on long-term economic development, spanning economic and historical debates. We show that all economic inputs are potentially affected. Pandemics reduce the workforce and human capital, have mixed effects on investment and savings, but potentially positive consequences for innovation and knowledge development, depending on accompanying institutional change. In the absence of an innovative response supporting income redistribution, pandemics tend to increase income inequalities, worsening poverty traps and highlighting the distributional issues built into insurance-based health insurance systems. We find that the effects of pandemics are asymmetric over time, in space, and among sectors and households. Therefore, we suggest that the research focus on the theoretical plausibility and empirical significance of specific mechanisms should be complemented by meta-analytic efforts aimed at reconstructing the resulting complexity. Finally, we suggest that policymakers prioritize the development of organizational learning and innovative capabilities, focusing on the ability to adapt to emergencies rather than developing rigid protocols or mimicking solutions developed and implemented in different contexts.

Productivity, obesity, and human capital: Panel data evidence

The consequences of obesity for adults and children are well documented in the extant literature. We use panel data of 105 countries from 1990 to 2019 to estimate the effect of obesity on economic performance. We predict obesity using lagged values of child obesity as instruments. Predicted obesity has a negative and significant effect on productivity. This effect is independent of the effect of human capital and other macroeconomic determinants of economic performance. There is only weak evidence that this effect operates through the deterioration of human capital formation caused by childhood obesity.

Disaster risk management during COVID-19 pandemic

Disaster causing threats and damages to human lives and properties leading toward economic losses can be classified as natural, biological, technological, and societal disasters. Disaster risk management primarily include (i) limiting exposure to hazardous preagents and reducing vulnerabilities and, therefore, chances for disaster to occur; (ii) formulating strategies and preparedness in terms of gathering resources and making a blueprint of actions; (iii) real-time response during a disaster, and (iv) recovery and rehabilitation of affected people. The current pandemic in the form of COVID-19 has given rise to integrating health into the overall disaster risk management strategies. The current chapter aims to develop a framework for integrating health or biological disaster management into the overall disaster risk management protocols and principles. It also suggests a shift from the traditional approach of reactive response after the outbreak/occurrence of the health disaster to a more proactive approach of health risk mitigation by building capabilities across the nation through the development of healthcare services and infrastructure to combat health disasters. Health emergencies or disasters occur due to outbreaks of diseases and indirectly due to other natural calamities or disasters, causing disruption and collapse of healthcare facilities and limiting the access of the majority of people to healthcare services. Sustainable Development Goal-13 mentions the need of urgent actions to be taken and sets targets to combat the impact of climate change causing natural disasters. It is also discussed how to minimize risk and losses during COVID-19 and the required preventive measures to be taken during pandemic in the light disaster risk reduction (DRR) framework. Therefore the guidelines developed in this chapter aim at building a resilient healthcare infrastructure alongside assuring the supply of basic needs viz. water, medicine, food, electricity, and communication during emergencies. It also estimates cost relative to the country’s budget or Gross Domestic Product (GDP) required to build an appropriate healthcare infrastructure for disaster management and performs an economic analysis of cost and benefit.

Wrong place, wrong time: The long-run effects of in-utero exposure to malaria on educational attainment

This paper investigates the long-term relationship between early life exposure to malaria and human capital accumulation in Brazil. The identification strategy relies on exogenous variation in the risk of malaria outbreaks in different states and seasons of the year to identify in utero exposure according to the timing and location of birth. I find consistent negative treatment effects of in utero exposure to malaria on educational attainment. The effects are stronger for exposure during the first trimester of pregnancy than during other periods of gestation. Effective anti-malaria policies can, thus, be an important factor contributing to reducing the educational inequality by targeting pregnant women, especially those in their first months of gestation.

La Dolce Vita in times of harshness: Prevalence of health-related behaviors during the great recession in Italy

The current work investigates the heterogeneous effect of the 2008 recession on health outcomes in the Italian population across the main geographic areas. Health outcomes were proxied by individual-level information on healthy/risky behaviors, such as individual fruit and vegetable consumption, frequency of bodyweight monitoring, smoking, and alcohol intake. These health outcomes were employed as dependent variables in the empirical model that included some socioeconomic individual aspects (e.g., age, gender, education, and income source), as well as consumer price index data for tobacco products, alcoholic beverages, and fruit and vegetables. In this work, we used twelve years of data (2005-2016) from the Italian Multipurpose Household Survey (MHS), which collects individual self-reported characteristics, augmented with information on unemployment rates at the regional level, as well as with consumer price indexes for the goods analyzed. The results indicated that the 2008 economic crisis lowered the probability that individuals engage in healthy behaviors, such as self-monitoring their bodyweight, mostly among individuals in northern and central areas. Likewise, the economic downturn increased the probability of smoking regardless of the geographic area, with a larger magnitude in individuals in northern and central areas, whose health outcomes were more impacted by the economic downturn than individuals living in the southern and island areas.

Socio-economic inequalities in children's nutritional status in Democratic Republic of the Congo in 2017-2018: an analysis of data from a nationally representative survey

Objective:

The Democratic Republic of the Congo (DRC) has one of the highest levels of child undernutrition globally; however, little information exists on the underlying socio-economic inequalities resulting in undernutrition. This study aims to examine the differences in the nutritional statuses of children across different wealth quintiles and explores the association between malnutrition in children and related factors.

Design:

We utilised the 2018 Multiple Indicator Cluster Survey data. We estimated the prevalence of malnutrition across all twenty-six provinces. The study used the WHO 2006 child growth standards to measure stunting, underweight and wasting. We employed a mixed-effect linear model to analyse the association between nutritional status and healthcare accessibility, domestic sanitation, and socio-demographic factors.

Setting:

Twenty-six provinces in the DRC.

Participants:

21 477 children under 5 years of age and 21 828 women of childbearing age in the DRC.

Results:

The national prevalence of underweight, stunting and wasting was found to be 23·33 %, 42·05 % and 5·66 %, respectively. Household wealth and mother’s education level were significantly positively associated with the nutritional statuses of children. Among households in the lowest wealth quintile, residence in urban areas was a protective factor against undernutrition.

Conclusion:

The findings of this study indicate considerable socio-economic inequalities in the nutritional statuses of children under 5 years of age in the DRC, highlighting the need for nutrition promotion as part of maternal and child healthcare. Interventions and policies should include improving nutrition education for less-educated mothers, in particular, in the central provinces of the DRC.

Value-based focused global population health management

In 2018, approximately 18 million people worldwide were diagnosed with cancer and are predicted to double by 2040. The global quality chasm in improving health care worldwide requires "systems thinking" as the key to success. Aligning the goal around person-centered care captures the total needs of care of a population and not just disease categories. The integration of the Institute of Medicine's (IOM) six aims of quality termed "value-based focused" and population health management (PHM) provides all health care leaders grappling with improving the health care of the populations a framework for the communities they serve. In this context, the question becomes finding solutions to providing high quality, compassionate and patient-centered health care delivery. Over the last two decades, three paradigms have emerged; the six aims of quality, outcome-focused population health, and the "Quadruple Aim". We have termed the intersection of these concepts as Value-based focused Population Health Management (VBPHM). This review applies VBPHM across the geographic county and community levels in the United States. Specifically, we examine VBPHM at the county or county-equivalents and community levels within the United States. Lastly, the potential role of Community-based Participatory Research and it is applicability to our framework is discussed. VBPHM can comparably be applied globally to improve population health, especially in preventing and treating cancer better.

Determinants of psychological well-being during the Covid-19 pandemic among "people living with HIV/AIDS" in India

ABSTRACTUsing survey data on 647 "people living with HIV/AIDS" (PLHIV) respondents from India, we examine the association between human, economic, and social capital and psychological well-being during the Covid-19 pandemic, and whether pandemic-induced job and financial insecurity are significant stressors. We find that among human capital indicators, family health status results in a more positive mental state and fewer personal conflicts among PLHIV while having more working-age adults in the household results in more conflict. With regards to economic capital, PLHIV in salaried jobs and self-employment have a less positive mental state compared to those in daily wage work. Compared to daily wage workers, those in salaried jobs and self-employment exhibit lower addictive behavior. Self-employed PLHIV respondents also engage in fewer conflicts with their significant other. We do not find any correlation between social capital and psychological well-being. Job and financial insecurity are negatively associated with psychological well-being. While job insecurity is associated with an increase in addictive behavior, financial insecurity increases the likelihood of more frequent personal conflicts. We conclude that there is a need for greater economic and psychological support from institutions, community, and family to assuage the pandemic-induced psychological distress among PLHIV.ABBREVIATIONS: ART: antiretroviral treatment; GSNP+: Gujarat State Network of Positive People; MHI: mental health inventory; OBC: other backward castes; PLHIV: people living with HIV/AIDS; SC: scheduled castes; SD: standard deviation; ST: scheduled tribes.

The Health Status Transition and Medical Expenditure Evaluation of Elderly Population in China

(1) Background: Because of the rapid expansion of the aging population in China, their health status transition and future medical expenditure have received increasing attention. This paper analyzes the health transition of the elderly and how their health transition impacts medical expenditures. At the same time, feasible policy suggestions are provided to respond to the rising medical expenditure and the demand for social care. (2) Methods: The data were obtained from the China Health and Retirement Longitudinal Study (CHARLS) from 2011 to 2015 and analyzed using the Markov model and the Two-Part model (TPM) to forecast the size of the elderly population and their medical expenditures for the period 2020-2060. (3) Results: The study indicates that: (1) for the elderly with a mild disability, the probability of their health improvement is high; in contrast, for the elderly with a moderate or severe disability, their health deterioration is almost certain; (2) the frequency of the diagnosis and treatments of the elderly is closely related to their health status and medical expenditure; alternatively, as the health status deteriorates, the intensity of the elderly individuals' acceptance of their diagnosis and treatment increases, and so does the medical expense; (3) the population of the elderly with mild and moderate disability demonstrates an inverted "U"-shape, which reaches a peak around 2048, whereas the elderly with severe disability show linear growth, being the target group for health care; (4) with the population increase of the elderly who have severe disability, the medical expenditure increases significantly and poses a huge threat to medical service supply. Conclusions: It is necessary to provide classified and targeted health care according to the health status of the elderly. In addition, improving the level of medical insurance, establishing a mechanism for sharing medical expenditure, and adjusting the basic demographic structure are all important policy choices.

Is Pollution a Cost to Health? Theoretical and Empirical Inquiry for the World's Leading Polluting Economies

Making development sustainable in the long run is the goal of policy makers of countries all over the world. To attain such a goal, countries have to face the dynamics of pollution-income interactions in both the short and long run, which are observed along the well-known Environmental Kuznets Curve (EKC). In the short run stage of the EKC, rising income and rising health expenditure may lead to rising pollution, while in the long run, as pollution continues, health expenditures increase, besides conservation of capital investment. The former is a common phenomenon in developing economies and the latter in the developed economies. Hence, there are both theoretical and empirical questions on whether health expenditures are caused by environmental pollution or not. The present study has attempted to investigate the issue from the theoretical point of view, through the endogenous growth framework, and by considering empirical observations for the world’s top 20 polluting countries for the period 1991–2019. The results show that per capita health expenditure and per capita pollution are cointegrated in the majority of the countries. However, in the short run, pollution is the cause of health expenditures for many developed countries in the list, and health expenditures are the cause of pollution in some of the developing countries. The results justify the claim of the endogenous growth model incorporating pollution and health expenditure.

Mortality, morbidity and economic growth

The question of whether and how changes to population health impact on economic growth has been actively studied in the literature, albeit with mixed results. We contribute to this debate by reassessing–and extending–[1], one of the most influential studies. We include a larger set of countries (135) and cover a more recent period (1990–2014). We also account for morbidity in addition to mortality and adopt the strategy of providing bounding sets for the effects of interest rather than point estimates. We find that reducing mortality and disability adjusted life years (DALYs), a measure which combines morbidity and mortality, promotes per capita GDP growth. The magnitude of the effect is moderate, but non negligible, and it is similar for mortality and DALYs.

Inequality in the treatment of diabetes and hypertension across residency status in China

Objectives: This paper studies the institutional inequality that exists in the prevalence of diabetes and hypertension, as well as their diagnosis and medication management, between urban and rural residency status (hukou) holders in China.Methods: Exploiting the Chinese Health and Nutrition Survey, we primarily demonstrate that while a lower proportion of rural residency holders suffer from diabetes and hypertension, a larger proportion have never been diagnosed with these conditions and do not take medicine to control them. We explore the determinants of these disparities by the non-linear decomposition method.Results: Decomposition results illustrate that a large part of disparities in the prevalence of diabetes and hypertension can be explained by the differences in demographic structure and occupational socio-economic status. Regarding the ruralurban disparity in the under diagnosis and under-medication rates, the differences in demographic structure, household affluence, occupational socio-economic status and consumption patterns make the greatest contributions.Conclusions: This evidence suggests that improving the institutional economic inequality and enhancing the occupational mobility of rural residency holders are of paramount importance to mitigate any inequality in health and healthcare utilisation.

Dietary Diversity in Nepal: A Latent Class Approach

BACKGROUND

Nutritional status has important implications for labor productivity, lifetime earnings, and country-wide economic development. Dietary diversity is an important contributor to nutrition.

OBJECTIVE

To identify how patterns of food consumption are related to dietary diversity and to measure the potential for policy interventions to influence diet complexity.

METHODS

Household dietary diversity scores were constructed using data from 11 809 rural and urban households surveyed in Nepal between 2013 and 2016. Diversity scores were based on 7-day recall information on food purchases and food consumed directly from agricultural production. Reported consumption from 14 food groups was mapped into 4 distinct dietary patterns via latent class analysis. Ordered probit regressions were used to identify factors associated with observed diet patterns.

RESULTS

Diets are heterogeneous and map into 4 clusters along a continuum of complexity. Three identified diets are vegetarian and 1 is nonvegetarian. Diet complexity is associated with geography and socioeconomic features of the sample. On average, poor and agricultural households have less complex diets and households receiving remittances have more complex and higher quality diets. Road density is positively correlated with diet complexity. We find evidence of modest reductions in diet quality over the sample period.

CONCLUSIONS

Results confirm heterogeneous dietary behavior of Nepalese households. The identified patterns could be used to more effectively target policies directed at nutrition education or efforts to improve health by diversifying and improving the nutritional quality of household diets, for example, through supplemental feeding programs, home garden promotion, or targeted food assistance programs.

Poverty, depression, and anxiety: Causal evidence and mechanisms

Why are people who live in poverty disproportionately affected by mental illness? We review the interdisciplinary evidence of the bidirectional causal relationship between poverty and common mental illnesses-depression and anxiety-and the underlying mechanisms. Research shows that mental illness reduces employment and therefore income, and that psychological interventions generate economic gains. Similarly, negative economic shocks cause mental illness, and antipoverty programs such as cash transfers improve mental health. A crucial step toward the design of effective policies is to better understand the mechanisms underlying these causal effects.

Rainfall and child weight in Uganda

We combine data from the 2006 and 2011 Uganda Demographic and Health Surveys (UDHS) with rainfall data and two waves of the Ugandan National Household Survey (UNHS) to study patterns in child weight, as measured by weight-for-height z scores (WHZ), among 3492 rural children below age 5 in Uganda. We focus on rainfall as a nutrition driver along agriculture and disease pathways. We find a positive and significant association between crop yield and WHZ, but the magnitude of this association diminishes as we control for covariates, especially the use of productivity-enhancing agricultural inputs. We find diarrheal disease to have a negative and significant association with WHZ, and modifying effects of social and environmental factors along the disease pathway. Contemporaneous rainfall is associated with a lower likelihood of diarrheal disease in areas with excess rainfall and a higher likelihood of diarrheal disease in rainfall deficit areas. Our findings reinforce calls for targeted and situation-sensitive policies to promote child nutrition.

Healthcare Expenditure and Economic Performance: Insights From the United States Data

This research explores the association of public health expenditure with economic performance across the United States. Healthcare expenditure can result in better provision of health opportunities, which can strengthen human capital and improve the productivity, thereby contributing to economic performance. It is therefore important to assess the phenomenon of healthcare spending in a country. Using visual analytics, we collected economic and health data from the Bureau of Economic Analysis and the Bureau of Labor Statistics for the years 2003-2014. The overall results strongly suggest a positive correlation between healthcare expenditure and the economic indicators of income, GDP, and labor productivity. While healthcare expenditure is negatively associated with multi-factor productivity, it is positively associated with the indicators of labor productivity, personal spending, and GDP. The study shows that an increase in healthcare expenditure has a positive relationship with economic performance. There are also variations across states that justify further research. Building on this and prior research, policy implications include that the good health of citizens indeed results in overall better economy. Therefore, investing carefully in various healthcare aspects would boost income, GDP, and productivity, and alleviate poverty. In light of these potential benefits, universal access to healthcare is something that warrants further research. Also, research can be done in countries with single-payer systems to see if a link to productivity exists there. The results support arguments against our current healthcare system's structure in a limited way.

Wartime health shocks and the postwar socioeconomic status and mortality of union army veterans and their children

We investigate when and how health shocks reverberate across the life cycle and down to descendants in a manual labor economy by examining the association of war wounds with the socioeconomic status and older age mortality of US Civil War (1861-5) veterans and of their adult children. Younger veterans who had been severely wounded in the war left the farm sector, becoming laborers. Consistent with human capital and job matching models, older severely wounded men were unlikely to switch sectors and their wealth declined by 37-46%. War wounds were correlated with children's socioeconomic and mortality outcomes in ways dependent on sex and paternal age group.

The Effectiveness of Community Sports Provision on Social Inclusion and Public Health in Rural China

It is well known that increasing participation in physical activities is not only positive for individual health promotion, but also beneficial for community-level public health by enhancing the individual’s social well-being by facilitating social inclusion. Although the provision of community sports affects participation in physical activities, the magnitude and direction of this effect are still not clear. Under this circumstance, this paper examined the effects of community sports provision on social inclusion and public health using the micro-level data from a household survey conducted in eight provinces of rural China. For the purpose of this paper, the degree of social inclusion was proxied by participation in community sports, while public health was measured by the probability of getting ill for members of each household. The empirical results show that community sports provision was partially effective in promoting inclusion and health in rural areas. Specifically, constructing public sports facilities significantly increases participation in community sports and decreases the risk of getting ill. In contrast, organizing public sports activities increases the opportunity for households to play sports. Nonetheless, it does not promote public health. Equally important is that economic growth (reflected in the increase in income level) may enhance public health through advancing medical technologies and improving sanitary conditions instead of encouraging participation in community sports.

Unavoidable Risks: Local Perspectives on Water Contact Behavior and Implications for Schistosomiasis Control in an Agricultural Region of Northern Senegal

Human schistosomiasis is a snail-borne parasitic disease affecting more than 200 million people worldwide. Direct contact with snail-infested freshwater is the primary route of exposure. Water management infrastructure, including dams and irrigation schemes, expands snail habitat, increasing the risk across the landscape. The Diama Dam, built on the lower basin of the Senegal River to prevent saltwater intrusion and promote year-round agriculture in the drought-prone Sahel, is a paradigmatic case. Since dam completion in 1986, the rural population-whose livelihoods rely mostly on agriculture-has suffered high rates of schistosome infection. The region remains one of the most hyperendemic regions in the world. Because of the convergence between livelihoods and environmental conditions favorable to transmission, schistosomiasis is considered an illustrative case of a disease-driven poverty trap (DDPT). The literature to date on the topic, however, remains largely theoretical. With qualitative data generated from 12 focus groups in four villages, we conducted team-based theme analysis to investigate how perception of schistosomiasis risk and reported preventive behaviors may suggest the presence of a DDPT. Our analysis reveals three key findings: 1) rural villagers understand schistosomiasis risk (i.e., where and when infections occur), 2) accordingly, they adopt some preventive behaviors, but ultimately, 3) exposure persists, because of circumstances characteristic of rural livelihoods. These findings highlight the capacity of local populations to participate actively in schistosomiasis control programs and the limitations of widespread drug treatment campaigns. Interventions that target the environmental reservoir of disease may provide opportunities to reduce exposure while maintaining resource-dependent livelihoods.

Growing and Learning When Consumption Is Seasonal: Long-Term Evidence From Tanzania

This article shows that the seasonality of food consumption during childhood, conditional on average consumption, affects long-run human capital development. We develop a model that distinguishes differences in average consumption levels, seasonal fluctuations, and idiosyncratic shocks, and estimate the model using panel data from early 1990s Tanzania. We then test whether the mean and seasonality of a child's consumption profile affect height and educational attainment in 2010. Results show that the negative effects of greater seasonality are 30 % to 60 % of the magnitudes of the positive effects of greater average consumption. Put differently, children expected to have identical human capital based on annualized consumption measures will have substantially different outcomes if one child's consumption is more seasonal. We discuss implications for measurement and policy.

Childhood health shocks, comparative advantage, and long-term outcomes: Evidence from the last Danish polio epidemic

This paper examines the long-term effects of childhood disability on individuals' educational and occupational choices, late-career labor market participation, and mortality. We merge medical records on children hospitalized with poliomyelitis during the 1952 Danish epidemic to census and administrative data, and exploit quasi-random variation in paralysis incidence in this population. While childhood disability increases the likelihood of early retirement and disability pension receipt at age 50, paralytic polio survivors are more likely to obtain a university degree and to go on to work in white-collar and computer-demanding jobs than their non-paralytic counterparts. Our results are consistent with individuals making educational and occupational choices that reflect a shift in the comparative advantage of cognitive versus physical skills. We also find that paralytic polio patients from low socioeconomic status backgrounds are more likely to die prematurely than their non-paralytic counterparts, whereas there is no effect on mortality among polio survivors from more advantaged backgrounds.

How does birth weight affect health and human capital? A short- and long-term evaluation

In utero shocks have been shown to have long-lasting consequences. However, we hardly know whether these effects tend to fade out over time and whether they can be compensated by post-natal investments. This paper examines the effect of birth endowment over time by employing a long panel of individuals born in 1983 in Cebu (Philippines) that includes relevant information on the pregnancy. We build a refined health endowment measure netted out from prenatal investments. We find that initial endowments affect trajectories both through the human capital production function and subsequent parental investment. The effect of birth endowment remains until adulthood and the fading out is very limited for health outcomes but more pronounced for educational outcomes. We also find that parents tend to reinforce initial health endowments, but the effect of this behaviour has almost no effect on final outcomes.

The long run impact of early childhood deworming on numeracy and literacy: Evidence from Uganda

BACKGROUND

Up to 1.45 billion people currently suffer from soil transmitted helminth infection, with the largest burden occurring in Africa and Asia. Safe and cost effective deworming treatment exists, but there is a debate about mass distribution of this treatment in high prevalence settings. While the World Health Organization recommends mass administration of anthelmintic drugs for preschool and school-aged children in high (>20%) prevalence settings, and several long run follow up studies of an influential trial have suggested large benefits that persist over time, recent systematic reviews have called this recommendation into question.

METHODS AND FINDINGS

This paper analyzes the long-term impact of a cluster-randomized trial in eastern Uganda that provided mass deworming treatment to preschool aged children from 2000 to 2003 on the numeracy and literacy skills of children and young adults living in those villages in 2010-2015. This study uses numeracy and literacy data collected seven to twelve years after the end of the deworming trial in a randomly selected subset of communities from the original trial, by an education-focused survey that had no relationship to the deworming study. Building on an earlier working paper which used data from 2010 and 2011 survey rounds, this paper uses an additional four years of numeracy and literacy data (2012, 2013, 2014, and 2015). Aggregating data from all survey rounds, the difference between numeracy scores in treatment versus control communities is 0.07 standard deviations (SD) (95% CI -0.10, 0.24, p = 0.40), the difference in literacy scores is 0.05 SD (95% CI -0.16, 0.27, p = 0.62), and the difference in total scores is 0.07 SD (95% CI -0.11, 0.25, p = 0.44). There are significant differences in program impact by gender, with numeracy and literacy differentially positively affected for girls, and by age, with treatment effects larger for the primary school aged subsample. There are also significant treatment interactions for those living in households with more treatment-eligible children. There is no evidence of differential treatment effects on age at program eligibility or number of years of program eligibility.

CONCLUSIONS

Mass deworming of preschool aged children in high prevalence communities in Uganda resulted in no statistically significant gains in numeracy or literacy 7-12 years after program completion. Point estimates were positive but imprecise; the study lacked sufficient power to rule out substantial positive effects or more modest negative effects. However, there is suggestive evidence that deworming was relatively more beneficial for girls, primary school aged children, and children living in households with other treated children.

RESEARCH APPROVAL

As this analysis was conducted on secondary data which is publicly available, no research approval was sought or received. All individual records were anonymized by the data provider prior to public release.

The influence of the Community-based Health Planning and Services (CHPS) program on community health sustainability in the Upper West Region of Ghana

Ghana introduced Community-based Health Planning and Services (CHPS) to improve primary health care in rural areas. The extension of health care services to rural areas has the potential to increase sustainability of community health. Drawing on the capitals framework, this study aims to understand the contribution of CHPS to the sustainability of community health in the Upper West Region of Ghana-the poorest region in the country. We conducted in-depth interviews with community members (n = 25), key informant interviews with health officials (n = 8), and focus group discussions (n = 12: made up of six to eight participants per group) in six communities from two districts. Findings show that through their mandate of primary health care provision, CHPS contributed directly to improvement in community health (eg, access to family planning services) and indirectly through strengthening social, human, and economic capital and thereby improving social cohesion, awareness of health care needs, and willingness to take action at the community level. Despite the current contributions of CHPS in improving the sustainability of community health, there are several challenges, based on which we recommend, that government should increase staffing and infrastructure in order to strengthen and maintain the functionality of CHPS.

Accuracy and reliability of a low-cost, handheld 3D imaging system for child anthropometry

The usefulness of anthropometry to define childhood malnutrition is undermined by poor measurement quality, which led to calls for new measurement approaches. We evaluated the ability of a 3D imaging system to correctly measure child stature (length or height), head circumference and arm circumference. In 2016–7 we recruited and measured children at 20 facilities in and around metro Atlanta, Georgia, USA; including at daycare, higher education, religious, and medical facilities. We selected recruitment sites to reflect a generally representative population of Atlanta and to oversample newborns and children under two years of age. Using convenience sampling, a total of 474 children 0–5 years of age who were apparently healthy and who were present at the time of data collection were included in the analysis. Two anthropometrists each took repeated manual measures and repeated 3D scans of each child. We evaluated the reliability and accuracy of 3D scan-derived measurements against manual measurements. The mean child age was 26 months, and 48% of children were female. Based on reported race and ethnicity, the sample was 42% Black, 28% White, 8% Asian, 21% multiple races, other or race not reported; and 16% Hispanic. Measurement reliability of repeated 3D scans was within 1 mm of manual measurement reliability for stature, head circumference and arm circumference. We found systematic bias when analyzing accuracy—on average 3D imaging overestimated stature and head circumference by 6 mm and 3 mm respectively, and underestimated arm circumference by 2 mm. The 3D imaging system used in this study is reliable, low-cost, portable, and can handle movement; making it ideal for use in routine nutritional assessment. However, additional research, particularly on accuracy, and further development of the scanning and processing software is needed before making policy and clinical practice recommendations on the routine use of 3D imaging for child anthropometry.

Health and economic growth: Evidence from dynamic panel data of 143 years

This paper re-examines health-growth relationship using an unbalanced panel of 17 advanced economies for the period 1870-2013 and employs panel generalised method of moments estimator that takes care of endogeneity issues, which arise due to reverse causality. We utilise macroeconomic data corresponding to inflation, government expenditure, trade and schooling in sample countries that takes care of omitted variable bias in growth regression. With alternate model specifications, we show that population health proxied by life expectancy exert a positive and significant effect on both real income per capita as well as growth. Our results are in conformity with the existing empirical evidence on the relationship between health and economic growth, they, however, are more robust due to the presence of long-term data, appropriate econometric procedure and alternate model specifications. We also show a strong role of endogeneity in driving standard results in growth empirics. In addition to life expectancy, other constituent of human capital, education proxied by schooling is also positively associated with real per capita income. Policy implication that follows from this paper is that per capita income can be boosted through focussed policy attention on population health. The results, however, posit differing policy implications for advanced and developing economies.

Constructing health capital in ecological systems: A qualitative evaluation of community-based health workshops in the refugee community

Refugee communities face numerous health and mental health concerns both during and after resettlement. Health issues, already deteriorated by chronic poverty, malnutrition and poor living conditions, are exacerbated by acculturative challenges, such as cultural and language barriers, stigma, and lack of resources and information. Since such needs in refugee communities affect both individual and collective capacity, it is important to consider policy environment and socioecological contexts for cultural adjustment and community resources for navigating systems, rather than individual health behaviours and communication skills only. To expand our understanding of health promotion capacity and resources, a broad and context-dependent concept will be necessary. Adopting a concept of health capital, this study aims to explore the impact of community-based health workshops, while expanding and redefining the framework in the context of health promotion efforts for the refugee community in resettlement. As part of community-based participatory research, this qualitative study conducted seven focus group discussions (FGDs) with 22 Bhutanese refugees in 2014. Using a hybrid thematic analysis, themes emerged from the FGD data were organised and categorised into health capitals in ecological systems. The participants reported enhanced confidence and capacity for health promotion at individual, family and community levels. Given the interdependent coping and lifestyles of refugee communities, impacts on the participants' interactions and relations with family and community were significant, which emphasises the importance of assessment of interventions beyond an individualistic approach. The findings of this study underscore the vital role of varied forms of health capital in promoting health in the refugee community and connecting members to needed health resources and information. Health capital is an old and yet still new concept with a great potential to broaden our understanding of health resources by elaborating the impacts and interactions in individuals, family and community for health promotion.

Economic Context and HIV Vulnerability in Adolescents and Young Adults Living in Urban Slums in Kenya: A Qualitative Analysis Based on Scarcity Theory

Urban slum adolescents and young adults have disproportionately high rates of HIV compared to rural and non-slum urban youth. Yet, few studies have examined youth's perceptions of the economic drivers of HIV. Informed by traditional and behavioral economics, we applied a scarcity theoretical framework to qualitatively examine how poverty influences sexual risk behaviors among adolescents and young adults. Focus group discussions with one hundred twenty youth in Kenyan's urban slums were transcribed, coded, and analyzed using interpretive phenomenology. Results indicated that slum youth made many sexual decisions considered rational from a traditional economics perspective, such as acquiring more sex when resources were available, maximizing wealth through sex, being price-sensitive to costs of condoms or testing services, and taking more risks when protected from adverse sexual consequences. Youth's engagement in sexual risk behaviors was also motivated by scarcity phenomena explained by behavioral economics, such as compensating for sex lost during scarce periods (risk-seeking), valuing economic gains over HIV risks (tunneling, bandwidth tax), and transacting sex as an investment strategy (internal referencing). When scarcity was alleviated, young women additionally described reducing the number of sex partners to account for non-economic preferences (slack). Prevention strategies should address the traditional and behavioral economics of the HIV epidemic.

A review of the evidence linking child stunting to economic outcomes

Background

To understand the full impact of stunting in childhood it is important to consider the long-run effects of undernutrition on the outcomes of adults who were affected in early life. Focusing on the costs of stunting provides a means of evaluating the economic case for investing in childhood nutrition.

Methods

We review the literature on the association between stunting and undernutrition in childhood and economic outcomes in adulthood. At the national level, we also evaluate the evidence linking stunting to economic growth. Throughout, we consider randomized controlled trials (RCTs), quasi-experimental approaches and observational studies.

Results

Long-run evaluations of two randomized nutrition interventions indicate substantial returns to the programmes (a 25% and 46% increase in wages for those affected as children, respectively). Cost-benefit analyses of nutrition interventions using calibrated return estimates report a median return of 17.9:1 per child. Assessing the wage premium associated with adult height, we find that a 1-cm increase in stature is associated with a 4% increase in wages for men and a 6% increase in wages for women in our preferred set of studies which attempt to address unobserved confounding and measurement error. In contrast, the evidence on the association between economic growth and stunting is mixed.

Conclusions

Countries with high rates of stunting, such as those in South Asia and sub-Saharan Africa, should scale up policies and programmes aiming to reduce child undernutrition as cost-beneficial investments that expand the economic opportunities of their children, better allowing them and their countries to reach their full potential. However, economic growth as a policy will only be effective at reducing the prevalence of stunting when increases in national income are directed at improving the diets of children, addressing gender inequalities and strengthening the status of women, improving sanitation and reducing poverty and inequities.

The effect of economic development on population health: a review of the empirical evidence

BACKGROUND

Economic growth is considered an important determinant of population health.

SOURCES OF DATA

Relevant studies investigating the effect of economic growth on health outcomes were identified from Google Scholar and PubMed searches in economics and medical journals.

AREAS OF AGREEMENT

Additional resources generated through economic growth are potentially useful for improving population health.

AREAS OF CONTROVERSY

The empirical evidence on the aggregate effect of economic growth on population health is rather mixed and inconclusive.

GROWING POINTS

The causal pathways from economic growth to population health are crucial and failure or success in completing the pathways explains differences in empirical findings.

AREAS TIMELY FOR DEVELOPING RESEARCH

Future research should investigate how additional resources can more effectively reach those in need and how additional resources can be used more efficiently. It is particularly relevant to understand why preventive health care in developing countries is very price elastic whereas curative health care is very health inelastic and how this understanding can inform public health policy.