Accounting for Health Gains
A host of factors account for the remarkable and widespread gains in human health during the 20th century, including changing demographics, rising productivity, urbanization, increased food supplies, medical science, sanitation, and institutional change. Some historical analyses emphasize one critical factor in a search for the one that underpins the rest, while other approaches emphasize the interplay of several factors. Efforts to understand the unprecedented changes in human health in the 20th century have involved exploration of theories of history and the nature of causation and how they have contributed to the study of epidemiology. Many different accounts are possible, but for our purposes—deriving lessons from this unprecedented historical trajectory—the following two clear messages emerge:
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Income growth by itself cannot account for the dramatic improvements in health in the last century, nor can it be relied upon as the only strategy for making progress on health in the future.
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Technical progress, in the broadest sense, works. It has been, and can be, the basis for substantial health gains, even when income growth is slow or stagnant.
"Technical progress, . . . has been, . . . the basis for substantial health gains, even when income growth is slow or stagnant."
While economic development and income growth are certainly among the factors that help explain the remarkable health gains of the 20th century, declining mortality in Europe was only weakly correlated with periods of economic growth in the 19th and early 20th centuries, and more recent experiences in many places, including Cuba, Sri Lanka, and the state of Kerala in India, demonstrate that dramatic improvements in health can occur without high or rapidly growing incomes. The pace of health improvements in so many different countries at different levels of economic development and with disparate rates of income growth demonstrates that other factors can and do play a leading role.
An increasing number of studies attribute last century's remarkable health gains not so much to increased wealth as to technical progress. In this context, technical progress refers to any advance in knowledge that leads to practical improvements. It includes the development and application of sophisticated treatments, such as organ transplants and angioplasty, and also simple treatments, such as oral rehydration therapy, whereby a child suffering from diarrhea is given liquids containing a few simple ingredients to drink to prevent death from dehydration. It includes progress in preventive care, such as new, more effective, or easier to administer vaccines along with simple behavioral changes, like keeping newborns warm and ensuring that their umbilical cords are clean and free of infection. It also includes innovative methods for delivering standard treatment, such as directly observed therapy short course (DOTS), an internationally disseminated strategy that has effectively combated the spread of tuberculosis (TB) in many countries.
Technical progress also comprises institutional and managerial innovations. These may include organizing and administering public health functions for the first time in a country or doing so in novel and more effective ways. They may involve identifying and training new cadres of health workers, developing new means of surveillance to track a disease and then target vaccination campaigns, or taking steps to improve the accessibility and quality of care.
In the sphere of economics and public policy, technical progress comprises improvements in allocating funds as a result of studying the efficacy of interventions and strategies and assessing their cost-effectiveness. It encompasses the development of new methods for financing health systems, such as mobilizing public resources or pooling existing financial resources, and new strategies for paying providers and purchasing health services. The creation of social security systems and national health services is another form of this kind of technical progress that helps to insure millions of families against the high costs of serious illnesses and injuries. DCP2 illustrates the many ways that collective action through public financing has led to substantial health gains for society.
"The creation of social security systems and national health services is another form of . . . technical progress . . ."
Technical progress outside the health sector has also contributed to improving health. Notably, rising agricultural productivity has improved nourishment for a large part of the world's growing population. In addition, improvements in such infrastructure as housing, sanitation, potable water, and safe roads have made significant contributions to health. Investments in education, which help increase literacy and thereby facilitate the diffusion of messages about healthy living, have had an important impact as well.
The boundary between institutional innovations and broader social change is not easily defined, and social changes have contributed substantially to progress in health. One of the most prominent of these social changes has involved women's status, including their political rights, education, and other forms of empowerment. These improvements in women's status have contributed to improving not only women's own health, but also the health of their families and societies.
When countries have adopted technical changes such as these, people's health has improved even in the absence of societal wealth or economic growth. Between 1950 and 1980, low- and middle-income countries such as Chile, Costa Rica, Cuba, and Sri Lanka adopted basic approaches to improving public health, including sanitation, routine immunization, and improved birth attendance, with remarkable reductions in infant, child, and maternal mortality. Countries with similar economic profiles that failed to adopt such measures lagged behind. A cross-country econometric analysis shows that countries that made rapid technical progress reduced infant mortality by as much as 5 percent annually compared with countries that made little or no technical progress.2 Even poor countries with weak public institutions, as well as those mired in violent conflict, have made important health gains through vaccination campaigns that eradicated smallpox worldwide, eliminated polio in most of the world, or controlled other endemic infectious diseases. By embracing technical progress in its myriad forms, progress in health is possible.
". . . countries that made rapid technical progress reduced infant mortality by as much as 5 percent annually compared with countries that made little or no technical progress."
Health gains in the last century were not only unprecedented but were dramatic relative to trends in economic growth and to local institutional capacity. Indeed, "income growth is neither necessary nor sufficient for sustained improvements in health. Today's tools for improving health are so powerful and inexpensive that health conditions can be reasonably good even in countries with low incomes" (DCP2, chapter 1, p. 8).
