The Epidemiological Transition Policy and Planning Implications for Developing Countries (1993) / Chapter Skim
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DISTRIBUTIONAL IMPLICATIONS OF ALTERNATIVE STRATEGIC RESPONSES TO THE DEMOGRAPHIC-EPIDEMIOLOGICAL TRANSITION - AN INITIAL INQUIRY
DISTRIBUTIONAL IMPLICATIONS OF ALTERNATIVE STRATEGIC RESPONSES TO THE DEMOGRAPHIC-EPIDEMIOLOGICAL TRANSITION - AN INITIAL INQUIRY
Pages 197-228
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From page 197... ...
These changes raise the possibility that the time has come for a corresponding shift in developing countries health strategies. No longer can one simply assume that it remains adequate to continue stressing oral rehydration, immunization, and related approaches.
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From page 198... ...
THE OVERALL SITUATION Although most of this exploration focuses on the country level that is of particular interest, it can best begin with a brief look at the situation of the Third World as a whole and of the major regions within it. Such a look can provide both a sense of how central a place the demographic and epidemiological transitions deserve in designing health improvement strategies and an initial hint about the possible distributional consequences of these strategies.
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From page 199... ...
(70.0) Middle East and North Africa 0-14 51.6 54.5 34.725.8 15-64 28.2 23.9 33.937.2 65+ 20.3 21.6 31.436.9 Total 100.1 100.0 100.099.9 Life expectancy at birth (years)
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From page 200... ...
(68.0) (70.0 Middle East and North Africa Infectious and parasitic diseases 41.4 40.429.523.2 Neoplasms and circulatory disorders 19.1 22.032.740.8 Other 39.5 37.637.836.0 Total 100.0 100.0100.0100.0 Life expectancy at birth (years)
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From page 201... ...
This point appears to have been at least implicitly accepted within the international health profession in that calls for a review of health priorities seem to arise much more frequently with reference to the more advanced Latin American and Asian countries than with respect to high-mortality subSaharan African nations. What seems much less well recognized is the possibility that differences analogous to those just noted with respect to 2The figures presented are estimated from linear regression equations in which the percentage of deaths at a specific age or from a specific cause serves as the dependent variable, and a group's life expectancy at birth is the independent variable.
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From page 202... ...
To find out, it is necessary to turn to the information available about individual countries and about differences in health conditions among population groups within them. RANGE OF INTRACOUNTRY MORTALITY DIFFERENCES The best way to begin the examination is with a look at intergroup differences in overall mortality levels that is, at differences in mortality at all ages and from all causes together.
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From page 203... ...
of intergroup disparities. S The cross-sectional figures available cannot address the question of whether the differences cited have been widening or narrowing as countries' epidemiological transitions have proceeded: whether, in other words, the least healthy groups have benefited less or more from the transitions than the groups that were healthiest to begin with.
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From page 204... ...
However, an initial look at illustrative country situations based on composite data can be instructive both in introducing an approach of potential relevance for those national studies and in providing findings to guide policies in the interim prior to the studies' completion. For this purpose, two illustrative populations can serve as the basis for an examination of age- and cause-specific mortality patterns: one population with mortality and fertility levels characteristically found in societies of sub-Saharan Africa, the area of the Third World where overall mortality is highest; the other broadly representative of Latin America, the developing world's lowest-mortality region.
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From page 205... ...
Thus, for example, the age structure for the least healthy group in the high-mortality society is the unweighted average of those of the four African countries whose 1985-1990 life expectancies are closest to the 47.5 years of that group: Mali and Burkina Faso, whose life expectancies of 47.2 and 47.3 years, respectively, are just below 47.5 years; and Senegal and Mozambique, whose life expectancies of 47.6 and 48.1 years are just above. The population distributions of the other groups are determined in an analogous manner, by using data from Africa for the other group in the high-mortality society, and from Latin America and the Caribbean for the two groups in the low-mortality Q society.
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From page 206... ...
There are, however, model life tables or standardized compilations of age-specific mortality data from developed and advanced developing countries that are generally considered trustworthy. These have long been routinely used by the United Nations, the World Bank, and national statistical offices to assist demographic analyses in a wide range of developing countries with insufficient data of their own.
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From page 207... ...
(7) 0 148.80 62.49 2.38 74.45 13.31 5.59 1 20.15 5.58 3.61 7.37 0.44 16.79 5 4.50 1.61 2.80 2.00 0.23 8.54 10 3.37 1.24 2.72 1.53 0.20 7.58 15 4.73 1.96 2.42 2.35 0.39 6.04 20 6.39 2.71 2.36 3.24 0.55 5.95 25 7.13 3.00 2.38 3.60 0.58 6.18 30 8.15 3.44 2.37 4.12 0.70 5.92 35 9.43 4.19 2.25 4.96 0.97 5.13 40 11.16 5.42 2.06 6.27 1.55 4.04 45 13.42 7.43 1.81 8.34 2.77 3.01 50 17.97 10.75 1.67 11.87 4.70 2.53 55 24.00 15.76 1.52 17.05 8.10 2.11 60 35.09 24.06 1.46 25.80 13.42 1.92 65 50.31 37.03 1.36 39.16 23.19 1.69 70 75.49 58.64 1.29 61.35 40.08 1.53 75 115.04 93.60 1.23 97.06 69.09 1.40 80 175.81 146.80 1.20 151.54 112.60 1.35 85 270.64 231.02 1.17 237.54 183.27 1.30 90 413.43 360.62 1.15 369.37 295.78 1.25 95 626.93 557.93 1.12 569.41 472.27 1.21 100 949.35 860.99 1.10 875.70 751.40 1.17 SOURCE: Average figures for males and females from West model life tables in Coale and Demeny (1983:46, 50, 53)
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From page 208... ...
The implications of this pattern can be seen by weighting the agespecific mortality rates that lie behind these curves by the proportion of the population in each age group shown in Table 2, to provide an estimate of the percentage of total deaths occurring at each age. These results appear in Table 4.
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From page 209... ...
Such a scenario needs to be distinguished carefully from an "equal-input" scenario, in which the per Capella allocation of resources to each health status or age group is equal. The equaloutput and equal-input scenarios will produce the same results only if the output-input ratios (i.e., the amount of mortality reduction produced per unit of resource invested)
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From page 210... ...
210 Ct .~ · _I Ct 4 o o o .~ so · _I a' o o an 4 ED ·_t sit ¢ Cal Cal o (1)
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From page 211... ...
As such an outcome indicates, what matters in determining the distributional impact of a policy change is not a society's overall health status, but rather the pattern of intergroup differences in demographic and health conditions within the society. The distributional consequences of changing priorities may be considerably more severe in a low-mortality society marked by large intergroup differences than in a high-mortality society where intergroup differences are relatively small.
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From page 212... ...
Even so, reliance on developed country data when assessing the Third World's evolution appears to be becoming an increasingly accepted practice in leading professional institutions, as demonstrated by the central role it has played in such major works as the two World Bank studies that represent the most careful extant examination of developing country trends (Feachem et al., 1992; Jamison and Mosley, 19931. This reliance and the importance of the topic suffice to justify at least a passing look at what the figures in current use have to say about the distributional consequences of alternate disease-specific foci.
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From page 214... ...
A decline in mortality from noncommunicable diseases would produce the opposite effect: the least healthy would gain only about one-half as much as the healthiest in each society, and the gap between the two groups would widen. According to the figures in Table 8, in other words, an emphasis on communicable diseases is progressive; a focus on the noncommunicable diseases is regressive.
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From page 216... ...
. The number of deaths suffered or prevented in a group is obviously important, but it is by no means a complete representation of the group's health status or of changes in it.
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From page 217... ...
The conclusions reached in the illustrations are valid only if the cost of preventing a death in the most 12At first glance, chronic diseases at older ages might seem to be particularly "morbidity intense" because of the extended period of disability and suffering that often precedes death. Yet such morbidity, while perhaps more visible than that caused by communicable diseases early in life, is not necessarily more prevalent.
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From page 218... ...
However, the costs of the traditional approaches to averting deaths among older people from chronic diseases are notoriously high, which raises the possibility that the illustrations in which such diseases emerge dominant overstate the case for according priority to them. 14 A fifth consideration concerns the existence of wide differences in the distributional implications of dealing with specific problems within each of the broad age and disease categories covered.
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From page 219... ...
Can guidance, however preliminary and provisional, be drawn from what is now known and presented here in order to help them decide how to respond to the demographic and epidemiological transitions? At the heart of any such guidance would have to be a warning against responding to overall trends such as those portrayed by the data presented in tables 1A and 1B by a general shift in health priorities toward a greater emphasis on problems caused by noncommunicable diseases among adults and the elderly.
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From page 220... ...
Vaughan 1983 Regional Model Life Tables and Stable Populations, 2nd ed. New York: Academic Press.
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From page 221... ...
IMR was 60.8 per 1,000 live births and eO was 62.2 years. IMR relative difference: 2.10 times; IMR absolute difference: 66.6 deaths per 1,000 live births.
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From page 222... ...
109. (Infant mortality and life expectancy derived through application of model life tables to figures for child deaths by age 2 per 1000 live births presented in text.)
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From page 223... ...
16. (Life expectancy derived through application of model life tables to infant mortality figures provided in text.
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From page 224... ...
3 (May/ June 19891. (Life expectancy derived through application of model life tables to infant mortality figures provided in text.)
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From page 225... ...
(Life expectancy derived through application of model life tables to infant mortality figures provided in text.) The highest mortality group for the period 1984-1987 is based on children of women with no education, representing 23.2 percent of the total population.
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From page 226... ...
(Life expectancy derived through application of model life tables to infant mortality figures provided in text.) The highest mortality group for the period 1981-1986 is based on children of women with no education, representing 77.2 percent of the total population.
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From page 227... ...
(Life expectancy derived through application of model life tables to infant mortality figures provided in text.)
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From page 228... ...
The missing life expectancy and/or infant mortality figures were estimated using the average of female and male figures taken from the Coale-Demeny West model life tables. An indication of which figures were calculated in this manner is provided in a parenthetical note accompanying each data source.
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