Economics and health
1999; Elsevier BV; Volume: 354; Linguagem: Inglês
10.1016/s0140-6736(99)90363-x
ISSN1474-547X
Autores Tópico(s)Global Health Care Issues
ResumoAmartya Sen is Master of Trinity College, Cambridge, UK, and Lamont Professor Emeritus at Harvard University. His research has ranged over a number of fields in economics and philosophy, including social-choice theory, welfare economics, and moral and political philosophy. In 1998, he won the Nobel Prize for Economics.There is a gross story, but there are also some finer ones. The glaring connection between economic prosperity and good health is one of strong positive association. People of richer countries typically suffer less from diseases of one kind or another, and live longer. Richer people in the same country also typically have fewer illnesses and live longer. Economic prosperity can thus be seen to be a good way of living better and living longer. As we move from one millennium to another, that gross story can indeed be a good starting point for analysis. But it would be a mistake to take this to be the main wisdom to emerge from empirical studies on the relation between economic prosperity and good health.Let me begin with discussing a statistical connection. Consider the important statistical analysis presented by Sudhir Anand and Martin Ravallion on inter-country comparisons between less-developed countries (Human development in poor countries: on the role of private incomes and public services. Journal of Economic Perspectives 1993; 7: 133–50). They found that life expectancy does indeed have a significantly positive correlation with gross national product (GNP) per head, but that the former also links closely with the incomes specifically of the poor, and with public expenditure particularly in health care. Furthermore, once these two variables are included on their own in the statistical exercise, no extra explanation can be obtained by also including the GNP per head as an additional explanatory variable. Indeed, with poverty and public-health expenditure as variables on their own, the statistical connection between GNP per head and life expectancy seems to vanish altogether.What does this result show? Not that GNP per head or a country's average economic opulence is irrelevant to longevity, but that the influence of economic opulence on longevity may work mostly through the relation between opulence and two crucial policy variables (poverty removal, public health-care). Much would thus depend on how the fruits of economic growth are used. This helps to explain why some economies (such as South Korea and Taiwan, among others in east and southeast Asia) have been able to raise life expectancy so rapidly through economic growth, whereas others with a similar record in fast economic growth (such as Brazil) have not achieved correspondingly rapid longevity expansion.There is a further issue in not taking the gross account to be the final one. Even though for all the countries put together, the richer ones do indeed show greater achievement in life expectancy, the outliers may tell us something quite important about public policy. Indeed, we can get a "sub-story" in separating out some countries with very different extents of activism in public health-care, and notice that the ones more committed to public healthcare do very much better than the ones not so committed. Study the GNP per head and life expectancy at birth of six countries (China, Sri Lanka, Namibia, Brazil, South Africa, Gabon) and Kerala, a sizeable state in India with 30 million people—large enough to count as a country, but with a much better record of public education and health care than the Indian average. Despite their very low levels of income, the people of Kerala, China, and Sri Lanka enjoy much longer life expectancy than do the much richer populations of Brazil, South Africa, Namibia, and Gabon (figure). Health and longevity does respond to greater care, despite the barrier of low income. The fact that health care, basic education, and other crucial components of social opportunity are highly labour-intensive activities make them affordable even in poorer economies, where labour is also cheaper.FigureGNP per capita (US$) and life expectancy at birth, 1994View Large Image Figure ViewerDownload Hi-res image Download (PPT)A related lesson emerges also from the observed fact that in the USA, African Americans as a group—men and women—have a lower chance of reaching advanced age than do men and women born in the immensely poorer economy of the Indian state of Kerala, and (in the case specifically of men) than do the Chinese as well. The shorter lives of African Americans relate not to their low incomes (they are, in fact, very much richer in per-capita income than the Chinese or the Keralite), but to the lack of guaranteed health care (with big gaps in medical insurance), blighted educational arrangements, and other problems of social malaise and disruption. Indeed, the average African American man in New York, or San Francisco, or the District of Columbia has a lower life expectancy than does even the average man in India or Pakistan.So what do we conclude? The gross story stands, but it needs to be supplemented by the finer aspects of the relation between economics and health. Economic prosperity certainly helps, taking the rough with the smooth. It is, however, up to us to build more smoothness in the rough terrain. The fact that public policy makes a difference is of interest not just for social activism, but also for good economic analysis. We reap as we sow. Amartya Sen is Master of Trinity College, Cambridge, UK, and Lamont Professor Emeritus at Harvard University. His research has ranged over a number of fields in economics and philosophy, including social-choice theory, welfare economics, and moral and political philosophy. In 1998, he won the Nobel Prize for Economics. There is a gross story, but there are also some finer ones. The glaring connection between economic prosperity and good health is one of strong positive association. People of richer countries typically suffer less from diseases of one kind or another, and live longer. Richer people in the same country also typically have fewer illnesses and live longer. Economic prosperity can thus be seen to be a good way of living better and living longer. As we move from one millennium to another, that gross story can indeed be a good starting point for analysis. But it would be a mistake to take this to be the main wisdom to emerge from empirical studies on the relation between economic prosperity and good health. Let me begin with discussing a statistical connection. Consider the important statistical analysis presented by Sudhir Anand and Martin Ravallion on inter-country comparisons between less-developed countries (Human development in poor countries: on the role of private incomes and public services. Journal of Economic Perspectives 1993; 7: 133–50). They found that life expectancy does indeed have a significantly positive correlation with gross national product (GNP) per head, but that the former also links closely with the incomes specifically of the poor, and with public expenditure particularly in health care. Furthermore, once these two variables are included on their own in the statistical exercise, no extra explanation can be obtained by also including the GNP per head as an additional explanatory variable. Indeed, with poverty and public-health expenditure as variables on their own, the statistical connection between GNP per head and life expectancy seems to vanish altogether. What does this result show? Not that GNP per head or a country's average economic opulence is irrelevant to longevity, but that the influence of economic opulence on longevity may work mostly through the relation between opulence and two crucial policy variables (poverty removal, public health-care). Much would thus depend on how the fruits of economic growth are used. This helps to explain why some economies (such as South Korea and Taiwan, among others in east and southeast Asia) have been able to raise life expectancy so rapidly through economic growth, whereas others with a similar record in fast economic growth (such as Brazil) have not achieved correspondingly rapid longevity expansion. There is a further issue in not taking the gross account to be the final one. Even though for all the countries put together, the richer ones do indeed show greater achievement in life expectancy, the outliers may tell us something quite important about public policy. Indeed, we can get a "sub-story" in separating out some countries with very different extents of activism in public health-care, and notice that the ones more committed to public healthcare do very much better than the ones not so committed. Study the GNP per head and life expectancy at birth of six countries (China, Sri Lanka, Namibia, Brazil, South Africa, Gabon) and Kerala, a sizeable state in India with 30 million people—large enough to count as a country, but with a much better record of public education and health care than the Indian average. Despite their very low levels of income, the people of Kerala, China, and Sri Lanka enjoy much longer life expectancy than do the much richer populations of Brazil, South Africa, Namibia, and Gabon (figure). Health and longevity does respond to greater care, despite the barrier of low income. The fact that health care, basic education, and other crucial components of social opportunity are highly labour-intensive activities make them affordable even in poorer economies, where labour is also cheaper. A related lesson emerges also from the observed fact that in the USA, African Americans as a group—men and women—have a lower chance of reaching advanced age than do men and women born in the immensely poorer economy of the Indian state of Kerala, and (in the case specifically of men) than do the Chinese as well. The shorter lives of African Americans relate not to their low incomes (they are, in fact, very much richer in per-capita income than the Chinese or the Keralite), but to the lack of guaranteed health care (with big gaps in medical insurance), blighted educational arrangements, and other problems of social malaise and disruption. Indeed, the average African American man in New York, or San Francisco, or the District of Columbia has a lower life expectancy than does even the average man in India or Pakistan. So what do we conclude? The gross story stands, but it needs to be supplemented by the finer aspects of the relation between economics and health. Economic prosperity certainly helps, taking the rough with the smooth. It is, however, up to us to build more smoothness in the rough terrain. The fact that public policy makes a difference is of interest not just for social activism, but also for good economic analysis. We reap as we sow.
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