Effective health care interventions are underutilized in the developing world, and income-related disparities in use are large. The evidence concerning this access problem is summarized and its demand side causes are identified. Broad strategies that have been proposed to tackle the access problem through changes in economic incentives are considered. It is argued that there is a need to go beyond the identification of broad strategies to the design and evaluation of specific policy measures. Only through experimentation and evaluation will we learn what works in raising health care utilization, particularly among the poor in the developing world.

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Access to health care in developing countries: breaking down demand side barriers

Self-reported health status (SRHS) is an imperfect measure of non-fatal health, but allows examination of how health status varies over the life course. Although women have lower mortality than men, they report worse health status up to age 65. The SRHS of both men and women deteriorates with age. There are strong gradients, so that at age 20, men in the bottom quartile already report worse health than do men in the top quartile at age 50. In the bottom quartile of income, SRHS declines more rapidly with age, but only until retirement age. These facts motivate a study of the role of work, particularly manual work, in health decline with age. The Grossman capital-stock model of health assumes a technology in which money and time can effect complete health repair. As a result, declines in health status are driven, not by the rate of deterioration of the health stock, but by the rate of increase of the rate of deterioration. We argue that such a technology is implausible, and we show that people in manual occupations have worse SRHS and more rapidly declining SRHS, even with a comprehensive set of controls for income and education. We also find that much of the differences in SRHS across the income distribution is driven by health-related absence from the labor-force, which is a mechanism running from health to income, not the reverse.

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Broken down by work and sex: how our health declines

The World Health Report 2000

There is surprisingly little information about the delivery of health care in rural India and about the relationship if any between health care and health status. Some such as the Commission on Macroeconomics and Health of the World Health Organization (2001) have argued that better health care is the key to improving health as well as economic growth in poor countries but there is little systematic evidence that gives us a sense of how easy it is to impact the quality of health care delivery in developing countries and through these improvements to impact the health of the population. This paper reports on a recent survey in a poor rural area of the state of Rajasthan in India intended to shed some light on this issue where we use a set of interlocking surveys to collect data on health and economic status as well as the public and private provision of health care. (excerpt)

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Health care delivery in rural Rajasthan.

Background: Aquatic and land based exercise are frequently prescribed to maintain function for people with arthritis. The relative efficacy of these rehabilitation strategies for this population has not been established. This review investigated the effects of aquatic compared to land based exercise on function, mobility or participants’ perception of programs for people with arthritis. Methods: Medline, CINAHL, AMED and the Cochrane Central Register of Controlled Clinical Trials were searched up to July 2010. Ten randomised, controlled clinical trials that compared land to aquatic exercise for adults with arthritis were included. Study quality was assessed with the PEDro scale. Data relevant to the review question were systematically extracted by two independent reviewers. Standardised mean differences between groups for key outcomes were calculated. Meta-analyses were performed for function, mobility and indices that pooled health outcomes across multiple domains. Results: No differences in outcomes were observed for the two rehabilitation strategies in meta-analysis. There was considerable variability between trials in key program characteristics including prescribed exercises and design quality. Components of exercise programs were poorly reported by the majority of trials. No research was found that examined participant preferences for aquatic compared to land based exercise, identifying this as an area for further research. Conclusion: Outcomes following aquatic exercise for adults with arthritis appear comparable to land based exercise. When people are unable to exercise on land, or find land based exercise difficult, aquatic programs provide an enabling alternative strategy.

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Systematic review and meta-analysis comparing land and aquatic exercise for people with hip or knee arthritis on function, mobility and other health outcomes

One of the World Health Organization's longest standing mandates is the collection and routine reporting of information on population health. In addition to estimates of mortality and disease, assessment of health status from population based surveys contribute to estimates of population health. The first section of the paper briefly introduces the conceptual and operational basis to measure health, where health is measured through six domains (affect, cognition, pain, mobility, self-care and usual activities). The second section briefly notes that the main objective of this paper is to report on the average levels of health by age and sex groups for each domain of health across 66 population based surveys. The third section of this paper describes how we have applied the hierarchical ordered probit (HOPIT) model using vignettes to calibrate responses across survey populations, to self-reported levels of health on six domains. The data comes from the WHO Health Survey Study 2000-2001, from 66 population based surveys in 57 countries, representative of individuals 18 years and older. The fourth section provides results on comparable levels of health for each domain across populations, by age groups and sex. In order to further facilitate comparisons across countries, age-standardized aggregated results across all age groups, by sex, are also presented and compared to external data, such as GDP per capita (PPP) and life expectancy. The fifth section discusses the information content of the surveys, the added-value of the multi-dimensional approach and the comparability of responses across countries. The final section recommends additional analyses to be conducted. Comments on this discussion paper are most welcome and should be forwarded to: Dr. Ritu Sadana Evidence and Information for Policy World Health Organization Avenue Appia 20 CH-1211 Geneva 27 Switzerland Email: sadanar@who.int

https://www.who.int/healthinfo/paper43.pdf

Irina Serdobova

Papers

Describing population health in six domains: comparable results from 66 household surveys