Road Less Traveled

Four Developing Countries Blaze New Trails to Better Health

By Thomas W. Croghan

Tom Croghan directed this study as a senior natural scientist at RAND. He is now a senior fellow at Mathematica Policy Research, Inc., and a professor in the Departments of Medicine and Psychiatry at Georgetown University School of Medicine, both in Washington, D.C. Board certified in internal medicine and rheumatology, he practices primary care medicine at the Washington Free Clinic.

Worldwide, more than 10 million children die each year, with nearly three-quarters of these deaths attributable to just six causes: pneumonia, diarrhea, malaria, neonatal sepsis, premature birth, and suffocation during the birth process. Poor sanitation and inadequate nutrition add to the risk for these and other dangers.

We at RAND recently investigated the factors that appear to have ameliorated these conditions and improved the health status of children in Bangladesh, Ecuador, Egypt, and Indonesia, four developing countries that throughout the 1990s reduced child mortality at rates exceeding what might be expected from their poor economic circumstances. We sought to identify the common characteristics that could be associated with the ability of these countries to overcome their economic constraints. Our conclusions cast doubt on some long-held assumptions about the best approaches to improving health in developing countries.

AP PHOTO/PAVEL RAHMAN   A volunteer, right, administers polio vaccine to a boy as his mother looks on during a polio eradication drive in Dhaka, Bangladesh, on April 16, 2006.

In each country, the so-called contextual factors of economic development, good governance, and strong health care systems mattered less than did the amount of foreign aid and technical assistance provided and the effective implementation of targeted health interventions, such as vaccination programs and family planning. These findings contradict prevailing U.S. foreign policy regarding the circumstances in which progress toward health goals can be made.

Decades of Debate

During his inaugural address on January 20, 1949, President Harry S. Truman declared: “We should make available to peace-loving peoples the benefits of our store of technical knowledge in order to help them realize their aspirations for a better life.” Ever since Truman recognized the importance to U.S. interests of improving health in developing nations, there has been a lively debate about the most effective means to accomplish that goal.

To be sure, a great deal of theoretical and empirical research over the decades has confirmed the importance of contextual factors, such as a strong economy, better education, adequate nutrition, poverty reduction, equity, and effective government; a functioning public health system that provides sanitation, clean water, and infection control; and a comprehensive primary health care delivery system. However, some countries with ample resources and few barriers to health improvement, especially many oil-rich nations, have lagged behind. Meanwhile, other countries have made great strides despite resource limitations, tropical diseases, internal strife, and other obstacles. Thus, although context helps, we reasoned that it might not be the decisive factor associated with improved health in many cases.

Our conclusions cast doubt on some long-held assumptions about the best approaches to improving health in developing countries.

In our analysis, we focused on countries that saw sharp declines in child mortality of at least 40 percent between 1991 and 2000 — and where health expenditures in 2000 totaled no more than $150 per person (in U.S. dollars adjusted for purchasing power). We excluded countries with very small populations (such as Cape Verde and Vanuatu) and those with very large populations (such as India and China). Bangladesh, Ecuador, Egypt, and Indonesia met our criteria. Each achieved very significant reductions in child mortality despite remaining quite poor and spending less on health than did countries that saw much smaller reductions in child mortality.

All four countries face major obstacles on the road to health improvement. Bangladesh is the world’s most densely populated country and the eighth most populous, with 136 million people. It is among the world’s poorest countries and has few resources to devote to health, nutrition, education, and other public services. Ecuador, the least populous of the four, with 13 million people, has nearly 85 percent more income per person and spends two-thirds more per capita on health than does Bangladesh. But poverty has been a challenge — more than half of Ecuador’s population in 2000 lived on less than $2 a day. Egypt, with 66 million people, has a national income more than twice that of Bangladesh, about half the poverty, and little malnutrition, but Egypt’s illiteracy and other education measures are comparable to those of Bangladesh. In Indonesia, despite rapid economic development, less than half of all children under five have been vaccinated against measles, and malnutrition is very common.

Wealthier Means Healthier?

Much research has emphasized the critical nature of economic development in promoting health in developing countries. Some of this research suggests that income growth is not only necessary but is sometimes sufficient to improve health, prompting an oft-heard cry of “wealthier is healthier” in some U.S. foreign policy circles.

Money does help purchase medical supplies, cleaner water, and better food, of course, and could contribute to well-being in other ways. But the reverse could also be true: Good health has been proposed as a determinant of national wealth. In particular, better health at the national level results in an increased number of healthy workers, especially for labor-intensive industries. Costa Rica, now among the ranks of upper-income nations, is a case in point. This pattern is especially apparent in sub-Saharan Africa, where dramatic increases in life expectancy in the 1970s, followed by equally dramatic declines accompanying the HIV/AIDS epidemic, appear to have precipitated parallel swings in labor force participation and country-level gross domestic product.

Figures 1, 2, and 3 compare several measures of income and child mortality in the four countries of interest with four other countries from the same geographical regions. The comparison countries enjoyed considerably higher incomes and spent more on health yet experienced much lower reductions in child mortality. Specifically, we compare Bangladesh with Pakistan, Ecuador with Guyana, Egypt with Algeria, and Indonesia with Thailand.

Figure 1 — In Reducing Child Mortality Rates, Some Neighboring Countries Are More Successful Than Others . . .

SOURCE: Routes to Better Health for Children in Four Developing Countries.

Figure 2 — . . . Even Though the Comparatively Successful Countries Generate Less Income Per Capita . . .

SOURCE: Routes to Better Health for Children in Four Developing Countries.

Figure 3 — . . . Endure Higher Poverty Rates, and Exhibit Similar Levels of Income Inequality

SOURCE: Routes to Better Health for Children in Four Developing Countries.

The contrasts are clear. Bangladesh had nearly 15 percent less income per capita but three times the reduction in child mortality compared with Pakistan. Ecuador had 30 percent less income per capita but almost 2.5 times the reduction in child mortality compared with Guyana. Egypt had nearly 40 percent less income per capita than Algeria, where child mortality increased during the 1990s. And Indonesia’s reduction in child mortality was more than 50 percent greater than that in Thailand, despite having more than 50 percent less income per capita.

We also considered the possibility that income growth, less poverty, or greater economic equity was associated with better health. The rapid economic growth throughout Southeast Asia during the 1980s and 1990s could account for much of the improvement in health in Indonesia, but the economic growth there of 8.3 percent between 1975 and 2000 was no greater than the concurrent 9.2 percent growth in Thailand. And while Egypt had higher growth per capita than did Algeria, both Ecuador and Bangladesh had lower rates of growth than did Guyana and Pakistan, respectively.

In terms of poverty, the higher-achieving country in each case had a higher percentage of people living on less than $2 per day than did the comparison country, often dramatically so. And if greater income disparities were associated with higher child mortality rates, then the Gini coefficient — a common measure of economic equity — would be lower for the higher-achieving countries. Nevertheless, the coefficients were nearly identical across each comparison, except for Indonesia, where inequalities were less severe than those in Thailand.

We also found political development to be as dubious a determinant as economic development for improving health. Case studies by the Rockefeller Foundation in the 1980s examined three countries (Costa Rica, China, and Sri Lanka) and one state in India (Kerala) that had achieved good health despite great economic obstacles. The studies concluded that the single most important element underlying the health achievements in these cases was a strong political commitment to good health. The studies identified five elements of “political will”: historical commitment to health as a social goal, a social welfare orientation to development, widespread participation in political processes, equity in access and use of social programs, and effective intersectoral linkages allowing for coordination and cooperation.

In spite of this prior research, we found little evidence of political will or effective governance in the countries we studied that had achieved better child health. We did not find consistent evidence of political consensus on or a historical commitment to health, nor did we find much evidence of the types of social welfare orientation to development observed by the Rockefeller Foundation. Bangladesh, Ecuador, and Indonesia rank among the world’s most corrupt developing nations, and we found little evidence for participatory governance and decentralized decisionmaking. For example, crackdowns on extremists in Egypt and Indonesia had led to a tightening of central controls and authoritarian processes. The contrast between the four countries we studied and those highlighted in the Rockefeller case studies is dramatic and suggests that while the fundamental elements of political will might help, their absence can be overcome.

Remaining Clues

We did, however, uncover certain characteristics that the four countries of interest shared in common with respect to reducing child mortality. First, in each case, data that allowed for the identification of the specific health conditions associated with child mortality were available and appear to have been used effectively to target delivery of specific health interventions for those most in need of them.

Second, although each of the individual interventions probably accounted for only a small portion of the overall health improvements, multiple interventions were introduced in each country in a highly project-specific and targeted manner. The situation in Bangladesh, where the World Bank supported 128 individual health projects in 1998, is especially informative.

Third, none of the countries we studied had well-developed, accessible health care systems. In fact, the systems were not just underdeveloped and inaccessible, but also often unpopular.

Fourth, the four countries in our study appeared to form more effective relationships with donors than did less successful countries. Several key informants for our study suggested that Bangladesh is especially receptive to foreign aid and more willing and able than other countries to endorse the conditions or stipulations that often accompany such aid.

Finally, development partners in each of the four countries appear to have provided financial assistance that mitigated the effects of weak economies and of low levels of internal public and private health spending. It also appears that such financial aid may have increasingly bypassed government in favor of direct allocations to nongovernmental organizations.

Healthier Means Wealthier?

With regard to improving children’s health in developing countries, our findings suggest that targeted health interventions and foreign aid matter more than do economic development, good governance, and strong health care systems. The experiences of Bangladesh, Ecuador, Egypt, and Indonesia offer several important lessons for health and foreign policy.

The first lesson is that economic growth, poverty reduction, and economic equity are not necessary to reduce child mortality. But the reverse could very well be true and could explain the association between health and wealth. Tracking the economic development of these four countries in the coming decades will help us understand whether healthier could very well mean wealthier.

The second lesson is that the absence of political will or good governance does not doom efforts to reduce child mortality in developing countries. Violent political change, corruption, and ineffective government were common features in each of the four countries we studied, and participation in the political process was rare.

The third lesson is that foreign aid and technical assistance appear to be important. Each of the four countries received considerable financial assistance. Technical assistance in the form of disease surveillance was especially important for targeting interventions to those most in need.

The fourth lesson is that public health and medical services do not require the comprehensive framework, or the attendant level of coordination and bureaucracy, endorsed by the International Monetary Fund, the World Health Organization, and the World Bank. Comprehensive services could even be counterproductive. As a key informant from Pakistan told us, trying to accomplish everything dilutes resources and efforts, making it less likely that anything will be done well.

U.S. foreign policy, along with international trends in development assistance, emphasizes economic development and limited direct financial assistance in countries that meet certain criteria of government effectiveness, corruption control, and economic freedom. Much of the aid and debt relief from agencies such as the World Bank and the International Monetary Fund are also now tied to development strategies focusing on economic growth and poverty reduction.

This is not the route followed by the exemplary countries studied here, for which generous amounts of direct foreign aid supported the targeted introduction of effective interventions despite great poverty, weak economies, political turmoil, widespread corruption, and poor governance. The results favor an alternative approach that places a priority on setting explicit health goals and using targeted interventions to reduce child mortality.

Related Reading

“Routes to Better Health for Children in Four Developing Countries,” The Milbank Quarterly, Vol. 84, No. 2, June 2006, pp. 333–358, Thomas W. Croghan, Amanda Beatty, Aviva Ron.