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POLICY
RESEARCH
WORKING
PAP'ER
28
31
Health
Outcomes
in
'oor
Countries
and
Policy
Options
Empirical
Findings from
Demographic
and
Health
Surveys
Limin
Wang
The
World
Bank
Environment
Department
April
2002
Public Disclosure AuthorizedPublic Disclosure AuthorizedPublic Disclosure AuthorizedPublic Disclosure Authorized Public Disclosure AuthorizedPublic Disclosure AuthorizedPublic Disclosure AuthorizedPublic Disclosure Authorized
POLIcY
RESEARCH
WORKING
PAPER
2831
Abstract
Empirical
studies on health
at
a
disaggregate
level-by
population.
Given
that
the
poor
are
mainly
concentrated
socioeconcmic
group
or
geographic
location-can
in
rural
areas,
the
evidence
suggests
that
health
provide
useful
information
for
designing
poverty-focused
interventions
implemented
in
the past
decade
may
not
interventions.
Using
Demographic
and
Health
Survey
have
been
as
effective
as
intended
in
reaching
the
poor.
(DHS)
data,
Wang
investigates the
determinants
of
The
empirical findings
in
this
study
consolidate
results
health outcomes
in
low-income
countries
both
at
the
from
earlier studies
and
add new evidence.
Wang
finds
national
level,
and
for
rural
and urban
areas
separately.
that
at
the
national
level
access
to
electricity,
vaccination
DHS
data
from
more
than
60
low-income
countries
in
the
first
year
of
life,
and
public
health
expenditure
can
between
1990
and
1
999
reveal
two
interesting
significantly
reduce
child
mortality.
The
electricity
effect
observations.
First
is
the
negative
association
between
the
is
shown
to
be
independent
of
income.
In
urban
areas
level
and
inequality
in
child
mortality.
Second
is
the
only
access
to
electricity
has
a
significant
health
impact,
significant
gap
in
child
mortality
between
urban
and
while
in
rural
areas
increasing
vaccination
coverage
is
rural
areas,
with
the
rural
population
having
a
much
important
for mortality
reduction.
slower
reduction
in
mortality compared
with the
urban
This
paper-a
product
of
the
Environment
Department-is
part
of
a
larger
effort
in
the
department
to
better
understand
health-environment
linkages.
Copies
of
the
paper
are
available
free
from the
World
Bank,
1818
H
Street
NW,
Washington,
DC
20433.
Please
contact
Limin
Wang,
room
MC5-208, telephone
202-473-7596,
fax
202-522-1735,
email
address
lwangltC@worldbank.org.
April
2002.
(33
pages)
The
Policy
Research
Workmig
Paper
Series
disseminates
the
findings
of
work
in
proJgress
to
encourage
the exchange
of
ideas
about
development
issuies.
.4n
objective
of
the
series
is
to
get
the
findings
out
quickly,
even
if
the
presentations
are
less
than
fully
polished.
'-he
papers
carry the
names
of
the
auithors
and
should
be
cited
accordingly.
Thie
findings,
interpretations,
and
conclusions
expressed
in
this
paper
are entirely
those
of
the
authors,
They
do
not
necessarilY
represent
the
vieu'
of
the
World
Bank, its
Executive
Directors,
or
the
countries
they
represent.
Produced
by
the
Research
Advisory
Staff
Health
Outcomes
in Low-Income
Countries
and
Policy
Implications:
Empirical
Findings
from
Demographic
and
Health
Surveys
Limin Wang'
ENV,
ESSD
1.
I
am
grateful
to
Kirk
Hamilton,
the
task
manager
of
this
project,
who
has
provided
helpful
comments
and
suggestions for
this
study.
I
thank Julia
Bucknall,
Jan
Boj6,
Katherine
Bolt,
David
Coady,
Deon
Filmer,
Gordon
Hughes,
Janet
Hohnen, Jenny
Lanjouw,
Peter
Lanjouw,
Stefano
Pagiola,
Priya
Shyamsundar,
Jonathan Wadsworth,
and Adam
Wagstaff
for
their useful discussions
and
advice
on
this
paper.
Arati Belle
and
Sandra
Sears
provided
excellent
assistance
to
this
project.
1.
Introduction
To
improve
health
outcomes
in
poor
countries
and
for poor
people
within
these
counties,
efforts have
been
directed
in
two
areas.
First,
a
large
number
of
empirical
studies
have
focused
on
improving
our
understanding
of
the key
determinants
of
health
outcomes
and
identifying
the
principle
causes
of
the
health
gap
between
the poor
and
the better
off.
Secondly,
a
strong
emphasis
has
been
placed
on
translating
empirical
findings
into
effective
policy
interventions.
Gwatkin
(2000)
provides
a
critical
reflection
in these
two
areas
and
summarizes
key
policy actions
taken
by
nnajor
international
development
agencies.
Wagstaff
(2001)
presents
an
overview
of
the
research
findings
on
the
relationship
between
poverty
and
health,
with
special
attention
being
focused
on
how
to
explain
these
findings
and
how
to
design
polices
to
irnprove
health
outcomes
in
low-
income
countries.
There
is
a
renewed
focus
in
the
policy
debate
on
health
inequalities.
This
results
directly
from the increasingly
strong
advocacy
for
defining
poverty
in
the
context
of
human
development
to
broaden
the
traditional
income/consumption
definition
of
poverty.
Wagstaff
(2001)
reviews trends
in
health
inequalities
both
in
developed
and
developing
countries,
identifies
the causes
of
inequalities,
and
propcises
approaches
for
evaluating
the
impact
of
anti-inequality
polices.
The
World Bank
(2000)
has
compiled
the most
comprehensive
indicators
on
socioeconomic differences
in
health, nutrition,
and
population
based
the
Demographic
and
Health
Survey
(DHS)
data,
which
provide
useful
inequality
measures
in
health.
However, to
better
understand
the
determinants
of
health
outcomes,
it
is
essential
to
measure
health
outcomes
as
well
as
inequality
in health
using
reliable
data
sources.
One
of
the
major
concerns
in
carrying
out
a cross-country
analysis
on
health is
the reliability
as
well
as
comparability
of
data
sources,
both
across countries
and
over
time.
Srinivasan
(1994)
has
critically
reviewed
the
potential
problems
associated
with cross-county
data.
This
problem
is
particularly
acute for the
estimates
of
child
mortality
rates
as
their
measurement
is
sensitive
both
to
the
types
of
data
sources used and
the
estimation
methods.
Filmer
and
Pritchett
(1996)
summarize that
child
mortality estimates
completed
by
the
United Nations
show
substantial
discrepancies among
different estimates
for
the
same
county
and
same
period,
depending
on
data
source
and
the
choice
of
estimation
method.
This
implies
that
in
producing
credible
empirical evidence
on
health
issues
using
cross
county
data we
should pay
special
attention
to data
comparability and
estimation
method.
In this regard,
demographic and
health
surveys,
which
have been
conducted
for
over
60
low-income
countries
since
1985,
are
a
superior
data
source.
They
are
comparable
across
countries
and
use
the
same
methodology
to
estimate
health and
other
socio-economic
indicators,
both
at
the national
level, and
for
urban
and
rural
areas
separately.
Therefore,
empirical
studies
on
health
determination
based
on
the
DHS
data
are
expected
to
generate more reliable
results.
Moving
from research findings
to operational
actions
requires
designing policy
interventions
with
a
strong
poverty
focus.
These
interventions
should
be
effective
both
at
improving
the
overall
average
level
of
health
(ie.
efficiency) and at
narrowing
2