Information about Asia and the Pacific Asia y el Pacífico

2 Achieving Better Results in Human Development

International Monetary Fund
Published Date:
April 2008
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Information about Asia and the Pacific Asia y el Pacífico
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The world has made steady progress toward meeting the numerical targets for the human development Millennium Development Goals (MDGs). Achievements have been impressive in some cases, and even in countries that are lagging, progress is measurable. The glass is, at the very least, half full. Nonetheless, significant challenges still exist as the global community approaches the halfway point of the MDG goals, and some countries and regions are seriously off track for successfully meeting the goals. This chapter provides an overview of the key issues and trends that underpin the human development indicators of the MDGs, with an explicit focus on inequity in spending and access, health care quality, and child malnutrition. The chapter also documents environmental problems that pose barriers to the achievement of the human development MDGs.

One challenge for reaching the health and education MDGs relates to equity: uneven access to resources and the exclusion of marginalized groups mean that the benefits associated with progression toward the MDGs are not widely shared by all. These inequalities are closely related to quality concerns, because the costs of low-quality education and health care are likely to be disproportionately borne by the poor. Moreover, poor quality discourages the use of services even if they are free. The quantitative nature of the MDGs masks important variations in quality, which in turn holds up the attainment of the MDGs in education and in health.

For education, while several regions are on track to meet the targets of universal primary completion and gender parity (MDGs 2 and 3), neither of these goals necessarily translates into learning or human capital development. The quality of education is as important, if not more so, as its quantity, as the Global Monitoring Report 2007 emphasized. In addition, addressing the issue of quality in public health care provision can make a significant contribution toward combating malnutrition, reducing child mortality, improving maternal health, and limiting the spread of HIV/AIDS, malaria, and tuberculosis (MDGs 1, 4, 5, and 6).

Malnutrition—“the forgotten MDG”—has received limited attention and investment, and it continues to be a major concern in many countries, especially in South Asia and Sub-Saharan Africa.1 Malnutrition lowers the immune system and undermines the individual’s ability to deal with adverse environmental hazards, in particular those associated with unsafe drinking water and lack of sanitation. Water, sanitation, and good hygiene are increasingly recognized as important for improving health and nutrition status.

Exposure to environmental health risks in early infancy can lead to stunting, wasting, lowered immunity, and increased mortality. Indoor air pollution stemming from reliance on biomass for energy raises morbidity, especially among children, and it is a major contributor to mortality. Outdoor air pollution increasingly places both children and adults at risk, a problem particularly acute in urban areas of fast-growing economies. Climate change is expanding the exposure to tropical vector-borne diseases, such as malaria, as average temperatures rise and as new areas become infested. All of these environmental hazards have a negative influence on health, and bringing these hazards under control will help not only to achieve environmental goals but also to improve the health status of children and infants.

Equity Considerations in Meeting the MDGs

Inequalities in access to health and educational services exist almost everywhere in the world: the poor tend to be less healthy and less educated than the rich. But income is not the only factor leading to unequal access. So too are differences in ethnicity, gender, and social status. In addition, the quality of education and health services is often unequally distributed. Nonetheless, poverty remains the largest roadblock to good health and education and can lead to a vicious cycle of deteriorating health, low demand for education, and increased poverty.

How equitable are countries’ education and health systems?

Analyzing health inequality requires some measures of living standards along with objective measures of the quality of health services provision, which can be disaggregated and also collected for different groups of the population. Three commonly employed outcome measures are child survival rates, anthropometric indexes, and an aggregated measure of adult health.2 Education inequality is analyzed by examining outcome measures such as school completion rates and student achievement on standardized tests. There are also input-based measures, such as public expenditure in health and education. These measures can be used to understand the current state of inequities in health and education, as well as their evolution over time.

There are a few places in the developing world, such as Sri Lanka or Kerala, India, where disparities in income and educational attainment are small, where health access is equal, and where outcomes are similar across the population. Virtually everywhere else, however, and by almost any available measure, the richest quintile is healthier than the poorest on an aggregate regional basis, and the disparities can be sobering (table 2.1). For example, in Latin America and the Caribbean, a child born in the poorest quintile is almost three times as likely to die before his or her fifth birthday, almost six times as likely to be malnourished, and about two-thirds as likely to receive medical attention for a fever as is a child born in the richest quintile. In all regions, the concentration indexes—which are a measure of the extent of socioeconomic-related inequality in health outcomes—suggest the existence of inequalities that are detrimental to the poor (box 2.1). Health inequalities tend to be the most acute in upper-middle-income countries, consistent with patterns of income inequality worldwide.

Table 2.1Selected measures of health inequality, by region and income group, 2000–present


Ratio of poorest

to richest quintile

Under-five mortality rate (per 1,000 live births)
Latin America & the Caribbean86.534.82.95-0.17
Middle East & North Africa101.044.02.27-0.13
South Asia131.765.82.10-0.12
East Asia & Pacific96.137.92.89-0.18
Europe & Central Asia78.941.31.97-0.11
Sub-Saharan Africa171.1100.51.86-0.09
Low-income countries166.496.71.84-0.09
Lower-middle-income countries78.930.82.76-0.16
Upper-middle-income countries91.135.82.81-0.18
Medical treatment of fever (% of under-five child population)
Latin America & the Caribbean37.258.70.660.10
Middle East & North Africa26.636.20.720.09
South Asia31.659.80.490.17
East Asia & Pacific35.354.20.650.07
Europe & Central Asia15.236.40.420.09
Sub-Saharan Africa27.849.30.540.14
Low-income countries27.248.80.540.14
Lower-middle-income countries36.455.40.680.08
Upper-middle-income countries30.356.10.530.12
Medical treatment of adult illnesses (% of female population)
Latin America & the Caribbean23.537.00.870.07
South Asia17.249.60.350.20
Europe & Central Asia32.651.80.630.06
Sub-Saharan Africa39.463.70.610.12
Low-income countries35.861.60.570.13
Lower-middle-income countries23.935.20.890.06
Upper-middle-income countries52.373.30.720.07
Source: Adapted from Gwatkin and others 2007 based on DHS data.Note: Averages are unweighted means for latest available years.
Source: Adapted from Gwatkin and others 2007 based on DHS data.Note: Averages are unweighted means for latest available years.

Educational outcomes also appear to reflect this same inequality. With the exception of Europe and Central Asia, school participation and completion rates are significantly higher for the richest quintile of the population (figure 2.1). In regions such as the Middle East and South Asia, where intraquintile female completion rates are already significantly lower than male completion rates, the difference in the likelihood of completion for a boy in the richest quintile compared with a girl in the poorest is particularly acute. While inequalities in participation rates apply across regions, they are especially dramatic in South Asia and Sub-Saharan Africa.

figure 2.1Regional disparities in primary school completion and participation, 1990–2005

Source: World Bank calculations, based on DHS data.

Note: Regional values are unweighted averages.

Much of the concern about the role of equity in reaching the MDG goals for health and education revolves around the skewed allocation of public resources for programs in these areas. Although there are variations across countries, public spending on health care and education tend to be skewed toward high-income segments of the population.3 With the exception of Latin America and the Caribbean, public spending on health services consistently favors the rich (figure 2.2), while spending on public education favors the rich across all regions (figure 2.3). In Sub-Saharan Africa, for example, the highest quintile receives more than twice as much public funding for health care and education as the lowest quintile. This is typically also the case when countries are grouped by income.

figure 2.2Incidence of public health spending on poorest and richest quintiles, 1989–2001

Source: Filmer 2003 and World Bank calculations.

Note: Regional and income averages are unweighted averages.

figure 2.3Incidence of public education spending on poorest and richest quintiles, 1985–2001

Source: Filmer 2003 and World Bank calculations.

Note: Regional and income averages are unweighted averages.

Out-of-pocket payments by patients and parents for publicly provided services are also an equity concern. Fees for education and health, both formal and informal, can represent a significant portion of household income. In health, the proportion of out-of-pocket payments tends to be higher for countries with lower levels of national income. At the household level that leads to inadequate health care utilization and households being driven into poverty.4

box 2.1Comparing inequality in health in India and Mali

An examination of outcomes by income quintiles provides a crude summary measure of inequalities. A smoother measure can be obtained from “concentration curves” for health, which capture the distribution of a given health measure against living standards. The concentration index derived from this curve quantifies the magnitude of socioeconomic-related inequality in health (and education).a For example, using data for India and Mali, it is possible to cumulate the relative percentages of births for each quintile, order them by increasing wealth, and plot this against the cumulative percentage of under-five deaths. The resulting concentration curves show that child deaths are concentrated among the poor (since both curves exceed the line of equality), although there is relatively less inequality in Mali than in India (since the curve is less bowed outward).

Distribution of under-five mortality, India and Mali

Source: O’Donnell and others 2008.Note: Curves based on DHS 1982–92 (for India) and 1985–1995 (for Mali).a. The concentration index is analogous to the Gini index. An index of zero suggests no inequality, and since health outcomes can be measured as “bads,” such as ill health, negative values mean that ill health is higher among the poor. Inequality is greater the larger the absolute (positive or negative) value of the index.

Progress on gender equity in primary education has been dramatic over the past four decades, and in some regions, such as Europe and Central Asia and Latin American and the Caribbean, girls are surpassing boys.

But some inequities persist, even in successful countries, particularly among excluded groups and among rural populations. Girls in both of these communities tend to lag significantly behind boys.5 In Lao People’s Democratic Republic, for example, disparities continue to exist in the average years of school completion for boys and girls between urban and rural areas, and between the majority Lao-Tai population and minority groups, highlighting the importance of targeting rural areas and, within them, minority groups and girls (figure 2.4). The challenge is to reach marginalized groups and—if the gender education goals are to be met in each country—to focus efforts on girls. One effort that aims to help countries meet the twin equity goals of universal primary education and gender equality is the Fast-Track Initiative, which bundles donor funds to support the implementation of countries’ objectives of enrollment, gender parity, and primary school completion (box 2.2).

figure 2.4Differences in Laotian education achievement across age, gender, and ethnic group, 2002–03

Source: King and van de Walle (2007).

Note: Figures are drawn after taking three-year moving averages. Data for the urban non-Lao-Tai are not included because of lack of observations.

Although it could be expected that health and education inequality is related to income distribution within a country, this is not the case. Concentration ratios for health and education, reflecting the distribution of health and education outcomes, generally display a weak and statistically insignificant negative relationship with the income Gini coefficient (figure 2.5). In other words, countries that are more unequal in terms of income distribution do not necessarily have a more unequal distribution of health outcomes. The level of income per se does not affect health inequality either, although it is a highly significant predictor of education inequality (figure 2.6).6 This finding suggests that poorer countries, such as Bangladesh or Nepal, have more unequal outcomes in primary education than do middle-income countries such as Brazil and Colombia.

figure 2.5Relationship between health and education inequality and income inequality

Source: World Bank calculations, based on DHS and WDI data.

Note: The health concentration index is calculated as the average of seven health status measures: under-five mortality rate, percent of children with moderate and severe stunting, percent of children without all essential vaccinations, percent of children receiving medical treatment for fever, percent of women with births receiving antenatal care, percent of women with births with delivery attended by trained medical personnel, and percent of women receiving medical treatment for adult diseases. The education concentration index is the average of school participation and completion rates.

figure 2.6Relationship between health and education inequality and per capita income

Source: World Bank calculations, based on DHS and WDI data.

Note: For definitions of health and education concentration indexes, see figure 2.5.

Improving equity in education and health

Success in achieving the MDG goals in health and education will hinge on reaching out to poor and marginalized groups through targeted interventions. Tailored programs are often necessary to bridge language differences between marginal groups and the majority population, and cultural barriers often need to be accommodated to ensure participation in education and health programs.

In Argentina, for example, public health and nutrition programs are targeted to the poor even though their health coverage is universal. Argentina’s child-feeding programs deliver between 40 and 75 percent of their benefits to the poorest 20 percent of the population; similarly, between 20 and 50 percent of all government-administered immunizations were given to children from lower-income groups.7 In contrast, such clear progressive outcomes were not found in two reproductive health programs—mobile reproductive health camps and education sessions—conducted in the rural part of Gujarat state in India. In this case, program beneficiaries were clustered among middle-income groups, with smaller numbers among both the rich and the poor.8

box 2.2The Education for All Fast-Track Initiative

The Education for All Fast-Track Initiative (EFA–FTI) is a global partnership launched in 2002 to help low-income countries meet the education MDGs and the EFA goal that all children complete a full cycle of primary education by 2015. It is among the largest global partnerships (in which the Bank is a participant) and is a platform for collaboration at the global and country levels.

FTI Achievements. FTI is widely regarded as a partnership with promise for achieving development impact; its achievements include:

  • strengthening harmonization at both the global and country level around country plans
  • raising the political profile of education and deepened country commitment to reform
  • increasing domestic resource allocation for basic education (albeit unevenly across countries)
  • generating momentum for accelerating progress on primary education in terms of primary school enrollment (an increase of 4.4 percentage points in all countries and 8.2 percentage points in Sub-Saharan countries), gender parity (from .87 to .92 between 2000 and 2006 and from .82 to .89 in Sub-Saharan countries), and primary completion rates (an average increase of 12 percentage points, from 57 to 69 percent in all countries, and a 17 point increase, from 37 to 54 percent, in Sub-Saharan countries)
  • mobilizing external funding for education, through bilateral and multilateral channels as well as through the FTI Catalytic Fund, which grew rapidly in 2006-07 to over $1 billion in donor pledges.

FTI Catalytic Fund. The Catalytic Fund was established in 2003 to provide transitional financial assistance to FTI-endorsed countries. The fund was designed both to complement other bilateral and multilateral funding and to ensure that countries’ FTI-endorsed education sector plans could be adequately funded. As a joint agreement across 17 donor countries, the initiative puts into practice the harmonization and alignment goals of the Paris Declaration by:

  • fostering collaboration among donors, and
  • relying on local decision making to drive activity and ensure that countries’ needs are met flexibly and in a timely manner.

To date, fifteen donors have pledged $1.2 billion through 2009, and $301 million in grant agreements have been signed with 18 countries. Current requests for funding are estimated at $878 million and further pledges of funding are pending.

FTI’s Challenge. FTI’s challenge is to stimulate strengthened dialogue, decision making, and commitment in four critical areas:

  • enhancing local capacity to implement education sector plans more effectively to obtain results faster, more deeply, and more efficiently
  • introducing strategies, policies, and interventions in partner countries to provide education to children living in marginalized communities, children with disabilities, and children living in situations of fragility or conflict
  • aligning education reforms on the key objective of ensuring learning outcomes, and not just on school enrollment and completion
  • strengthening the international aid architecture to facilitate more reliable, robust, and harmonized financial and technical support.

In some cases, the results of health interventions are potentially regressive even where absolute improvements are achieved. A program to expand the use of maternal health services in the Matlab subdistrict of Bangladesh increased the number of facility-based births among the population as a whole but did not improve service usage by the very poor.9 As a result, the distribution of health benefits across income groups remained essentially unchanged between 1997 and 2001, and in the most unequal years service usage by the poor was so low that a woman in the richest quintile of the population could be up to 3.5 times as likely to be a beneficiary of the program as a woman in the poorest quintile.

The success of health equity interventions varies according to country, strategy, disease, or service. The large-scale delivery of primary health care services by nongovernmental organizations (NGOs) generated improved services for the poor in Cambodia and Nicaragua, but the same medium of delivery led to more mixed results in Gujarat state in India.10 Similarly, while a campaign to distribute insecticide-treated bednets in conjunction with measles immunization in Ghana and Zambia was successful in raising bednet ownership rates among the poor, the long-term sustainability of bednet programs in reducing malaria incidence and transmission is not so clear.11 In some cases, these contextual factors may even be region specific. In rural Guatemala, different models of delivery of government health services provided mixed results, depending on the service area and population served.12 Overall, trends in health equity vary across countries and time periods.

Educational interventions to promote equity can improve enrollment, completion, and test scores for the poor. However, targeted interventions do not always achieve the intended outcome of increasing access for disadvantaged groups for a number of reasons.

For example, recent evidence suggests that when preschool and compulsory education is more extensive—in terms of enrollment and duration—equality of opportunity in education is increased.13 Achieving such an outcome is not simply a result of increasing educational spending and resources for students from targeted groups, whether at the class or school level.14 One recent finding of relevance to countries striving to meet the MDGs is that neglect of nutrition and cognitive stimulation in the first six years of life permanently affects an individual for life. Longitudinal studies show the serious behavioral, health, and income effects of neglect in early life.15 Access to early childhood interventions is highly specific to the income and education of parents, partly because infants and small children are kept at home.

Where financially feasible, targeted conditional cash transfers (CCTs), whereby parents are paid to ensure that their children receive education and health services, have been shown to be highly effective in encouraging school enrollment and completion and in ensuring child health checkups.16 Among the most challenging aspects of CCTs are the administrative difficulties, especially in remote areas, and the supply of services that are often insufficient to meet the demand triggered by CCT programs.

Health Care Quality Critical to Reaching the MDGs

The quality of health care services matters because it reflects the extent to which investments in national health care systems are able to raise both human capital and individual welfare. Efficient and accountable health care systems provide good returns on such investments, and in the long run the quality of health care matters more to improving health outcomes than increases in health care spending per se.

Health care quality can be defined as the “proper performance (according to standards) of interventions that are known to be safe, that are affordable to the society in question, and that have the ability to produce an impact on mortality, morbidity, disability, and nutrition.”17 This definition is broad, and the specific dimensions or criteria chosen can influence assessments of the quality of health care.

Health Care Quality Measurement: Complex.

The measurement of the quality of health care provision is complicated and not standardized across countries and diseases. Unlike the case of education quality, there is an absence of a small number of universally agreed-upon indicators for the quality of health care delivery, and existing measures are often not systematically available for all countries.

Inherent in the definition of health care quality is the notion that quality can be evaluated from the perspective of inputs, processes, or outcomes.18 Input measures are often aspects of structure; for example, whether medical facilities possess and maintain medical equipment, or the extent to which they are stocked with essential drugs. Indicators of process attempt to gauge service delivery from the supply-side—such as whether doctors correctly diagnose medical conditions and prescribe the appropriate treatment—or the demand side, such as patients’ subjective evaluations of the quality of care received. Measures of outcomes, such as mortality rates, are indirect; moreover, they often capture quantity as well as quality aspects of health care. Nonetheless, outcome indicators are typically correlated with health care quality in other dimensions and can serve as important complements to these measures of health care quality.

Why Improve Quality?

By almost any measure, improvements in health care quality benefit not only the individual but households and society more broadly. Better-quality health care may positively affect nutritional and mortality outcomes, infant health, and usage rates among the underserved.19 Moreover, health quality improvements need not be entirely precluded by cost considerations: there is ample evidence that even low-income households are willing to pay higher user fees, if they obtain improved access to, and enhanced reliability of, health care services in return. Most important, higher one-time costs incurred as a result of receiving higher quality care may mean lower costs in the long run, since post-consultation complications are less likely to arise when the initial quality of care is high.20 The fact that formal and informal out-of-pocket payments are so widespread in low-income countries suggests a willingness to pay for perceived failures in public services, either in terms of limited access or poor quality.21

In Ghana, improvements in public health care services and infrastructure led to improvements in child nutritional status, as captured by anthropometric measures.22 Children were taller in communities where there were more doctors, lower consultation fees, and basic drug availability. In addition, these health services had a positive impact on the probability of child survival. These results were particularly strong for children living in rural areas, although there was no distinguishable effect between the quality of health services received by the poor versus nonpoor. This last result stands in contrast to a similar study of the Côte d’Ivoire, which—while echoing the findings that doctor and drug availability positively influences child health—also notes that the quality of health services received were systematically different between children in poor and nonpoor households.23

Within countries, health care quality tends to depend on socioeconomic status, ethnicity, and whether the medical provider is public or private. Doctors treating the poor tend to be of lower quality than those treating the better off, even after taking into account differential abilities to pay. In India, the generally lower-quality medical training of physicians in the private sector—relative to the public sector—was more than offset by higher effort in performance. As a result, the private sector in India delivers an overall higher quality of care. 24 Racial inequalities may also be operative, as in the case of Mexico, where a large and significant difference was found in the quality of health care provided to indigenous versus nonindigenous patients.25

Well-trained doctors can make a dramatic difference in improving health care quality. In a study of doctors in India, Indonesia, and Tanzania, more competent doctors—as measured by an index of competency—were more likely to ask the right questions during treatment.26 For example, doctors in the top quintile of competence more frequently performed common diagnostic procedures for diarrhea—such as checking for blood or mucous in stools, or for fever—as compared to doctors in lower quintiles.

One measure of effort (or lack of it) is absenteeism, which is both chronic and pervasive in primary health care facilities in many developing countries.27 In Bangladesh, absenteeism by physicians in larger clinics was 40 percent, while the rate was much higher, 74 percent, in smaller subcenters with a single doctor. Meanwhile, absenteeism rates were lower for other health care professionals, such as nurses and paramedics. The absence rates across five developing countries averaged 35 percent between 2002 and 2003 (figure 2.7), and it is possible that this figure underestimates the severity of the problem, because health care personnel can be present without actually providing medical care.

figure 2.7Absenteeism among primary health care workers, 2002–03

Source: Adapted from Chaudhury and others 2006.

Note: Absenteeism was defined as not being found in the facility for any reason at the time of the unannounced random visit.

Low absenteeism is correlated with well-functioning facilities—as measured by objective criteria such as whether the facility has potable water—and greater utilization. Chronic absenteeism leads to low usage, because health care personnel are not available, and dissuades future use because of unreliable service. Evidence for low-income, rural communities in Cameroon, Tanzania, and Uganda suggest that NGOs charging modest fees provide higher quality of care than free government clinics, as well as higher rates of utilization. This is true even for NGOs that pay their health care personnel less than the government rate. Greater accountability and more consistent and reliable health services result in higher quality care from NGOs.28

High Variability of Health Care Quality

Although health care quality is notoriously difficult to measure, there is little doubt that quality of care varies from country to country and within countries, raising equity concerns as well as health care concerns. The role that public spending plays in this variation is a matter of some controversy. Most studies have been unable to find strong links between health outcomes and government health spending, although some recent work has questioned this result.29 For example, the relationship between infant and under-five mortality rates and public health spending is weak overall, and may depend on the specific set of countries or variables being considered.30

This weak link between spending and health outcomes is consistent with strong evidence in education of an insignificant relationship between spending and learning. Even taking into account the one-time nature of mortality, the statistical insignificance of health care spending for mortality rates suggests that the quality of service delivery is likely to be low. However, variations in the quality of service delivery across countries are relatively large (table 2.2).

Table 2.2Selected proximate measures of health care quality for selected countriesby region, 2002–06
CountryYear of dataAssistance during

delivery by doctor

or health care


(% of all live births)
Receipt of

full set of

vaccinations in

first year of life
Children with

acute respiratory

infection treated

at health care facility

(% of all under-five children)
Treatment of diarrheic

children with oral

rehydration therapy
Sub-Saharan Africa
Burkina Faso200337.927.835.926.5
Regional average45.934.740.936.3
Middle East & North Africa
Egypt, Arab Rep. of200574.281.463.435.7
Regional average78.462.359.228.6
Europe & Central Asia
Regional average99.02.159.734.9
South Asia
Regional average18.
East Asia & Pacific
Regional average56.651.153.847.3
Latin America & the Caribbean
Dominican Republic200297.822.363.532.3
Regional average72.017.840.145.1
Source: Demographic and Health Surveys, various years.Note: Full range of vaccinations include BCG, diphtheria, polio, and measles.
Source: Demographic and Health Surveys, various years.Note: Full range of vaccinations include BCG, diphtheria, polio, and measles.

Measures of performance illustrate this point. The provision of assistance during delivery by a doctor or health care professional, for example, ranges from 78 percent of all live births in the Middle East and North Africa, to 18 percent in South Asia. In contrast, the use of oral rehydration treatment for children suffering from diarrhea in South Asia is almost double that in the Middle East and North Africa. Even within Sub-Saharan Africa, the vaccination coverage of children ages 1–2 years ranges from a low of 8.1 percent in Uganda to a high of 75.9 percent in Eritrea.

Despite this seemingly large cross-country variation, evidence suggests that cross-country differences may be smaller than intracountry variations. Studies have also found large intracountry variations by type of facility, medical condition, and domain of care.31

Relation of Quality to Income and Economic Growth

Ultimately, the goal of a quality health care system is improved health status. Healthy populations are more likely to invest in human capital via education, and this improves productivity, spurs greater overall economic growth, and raises incomes. Higher-quality health care is especially important for children, as healthy children are more likely to go to school, finish school, and learn more, which in turn has a positive effect on future productivity and household income.32 Cross-country evidence for education shows the insignificance of education spending in spurring economic growth, but the central importance of education quality (box 2.3).

While the quality of health is often multifaceted and can involve strong value judgments, aggregate measures of health quality, as captured by selected outcome indicators, provide some broad generalizations. Health quality is positively related to national income, but there is little relationship between public health spending levels and quality measures (figure 2.8). This apparent paradox—that income matters for health quality but health spending does not—suggests that other drivers of health quality are important.

figure 2.8Relationship of health quality to income and public health care expenditures

Source: World Bank calculations, based on DHS and WDI data.

Notes: Health quality includes 8 measures of health quality outcomes: percent live births with no antenatal care, percent live births with no tetanus injections, percent live births with no trained medics during delivery, percent children with no cocktail of essential vaccinations, percent women with births receiving key components of antenatal care, percent women with births receiving no postnatal care, percent children with acute respiratory infection not treated in a medical facility, and percent children with diarrhea with no treatment.

There are several possible factors accounting for this finding. As noted above, public health care expenditures are skewed toward expensive secondary and higher-level care that benefits higher-income quintiles. Second, health care expenditures are a proxy for structural measures such as whether a clinic has certain medical equipment or essential drugs, and these measures may be a relatively poor determinant of health care quality. For example, a study to assess the quality of clinics providing prenatal care in Jamaica found that clinic processes—such as examination and counseling procedures—exerted a positive, significant impact on birth weights, while structural factors alone did not.33 Failure to monitor health care delivery services adequately can also lead to poor outcomes.34 This combination of inequality of spending, poor governance, and difficulties in capturing meaningful measures of quality health care services may result in weak associations. More balanced spending and raising service performance therefore offer important tools for reaching the human development MDGs.

box 2.3Improving educational quality and stimulating growth

An emerging body of evidence shows the major role that the quality of learning and the skills acquired through the educational system plays in spurring growth. Recent work commissioned by the World Bank draws on the traditional human capital model to show the sizable effect that improvements in quality may have on long-term income growth. Using a set of international standardized test score for the last 40 years for a group of 50 countries, Hanushek and Wößmann reach two key conclusions. First, educational quality has a strong causal impact on individual earnings and economic growth. The authors find that one standard-deviation increase in international standardized test scores contributes to higher growth in long-term GDP per capita of 2 percent. Second, the role of educational quality in economic development differs between developing and developed countries. The payoff to increasing quality, per year of schooling of the population, is 80 percent higher for developing countries.

Hanushek and Wößmann also make a strong case that improving educational quality requires a focus on efficient education spending, bolstered by sound institutions that encourage competition, autonomy, and accountability. Simply increasing educational spending does not guarantee improved educational quality.

The long-term quality-of-education payoff

Source: Adapted from Hanushek and Wößmann 2007.

Quality of health care deserves greater attention and measurement if reaching the health MDGs is to be realized. As in education, quality matters to outcomes, but the tools in health are more complex and less comparable across countries, making meaningful comparisons difficult. This is clearly an area for additional effort and financing.

Child Malnutrition: Tackling Hunger and Mortality

Reducing child malnutrition is one area that holds great potential not only for improving child health but also for improving education outcomes and ultimately the welfare of individuals and families. A close epidemiological link exists between childhood malnutrition and mortality across a range of diseases, such as diarrhea, measles, and pneumonia; malnourishment not only increases the risk of contracting these diseases, it also influences the severity and likelihood that the outcomes resulting from them are fatal. Malnutrition is also closely related to performance in education; undernourished children display reduced school achievement and inferior cognitive abilities that diminish their lifetime accumulation of human capital. Child malnutrition also has consequences for adult health, because malnourishment in childhood can result in a higher disease risk in adulthood.35

Understanding the impact of malnutrition on early childhood and subsequent adult development is complicated by the presence of other factors in households with malnourished children, notably poverty, limited demand for education, and an adverse physical environment—all of which contribute to malnutrition. Because risks accumulate and are compounded over time, total accumulated risks are important,36 although there are certain sensitive periods of physiological development where the appropriate intervention can make a major difference. Of particular significance is the increasing evidence pointing to the narrow “window of opportunity” for preventing malnutrition, which starts at conception and ends at two years of age. Nutritional deficits during this period can lead to irreversible physical and cognitive impacts.37

The most readily available and observable indicators for malnutrition outcomes are based on the anthropometric criteria of height and weight. Two accepted measures are stunting (low height for age, a measure of chronic malnutrition) and wasting (low weight for height, which captures more transient episodes of malnutrition). In addition, intake of micronutrients—principally iron, iodine, and vitamin A—are increasingly being monitored as important metrics for gauging malnutrition. And the implications of inaction are serious. For example, sustained iron and iodine deficiencies in pregnant women can lead to reduced cognition in babies.38

Long-term Consequences of Malnutrition

Nutritional deficits in childhood interfere with human capital accumulation. Starting with primary education, malnutrition can result in lower enrollment levels, grade repetition, failure to complete grades, and inferior performance on cognitive tests. Evidence from country studies is instructive.

In rural Pakistan between 1986 and 1990, school enrollment rates rose as a result of improvements in nutrition. By one estimate, an increase of 0.25 of a standard deviation in average nutrition translated into an increase of 5.5 percent in the probability of school enrollment for the entire cohort. This would mean an increase in average productivity equal to a 0.65 percent increase in lifetime earnings. Moreover, this nutrition effect was seven times greater for girls than for boys.39 A similar study that tracked Filipino children born between 1983–84 and 1994–95 found that an increase of one standard deviation in nutrition would lead to enrollment improvements equivalent to between 11 and 21 months of school attendance.40

In rural Zimbabwe, nutritional deficits sustained by children—as a result of civil war in the late 1970s and two episodes of drought between 1982 and 1984—led to delayed school entry by five months and an estimated reduction in lifetime earnings of 14 percent.41 A study of a randomized, community-level nutritional intervention in rural Guatemala that ran from 1969–77 found persistent effects from the intervention. Twenty-five years after the program, women who received nutritional supplements as children had up to 1.2 years of additional schooling compared with those who had not received the supplement, as well as higher levels of economic productivity.42

Nutritional deficits also exert a direct effect on lifelong cognitive abilities and well-being. In Jamaica a study that followed a cohort of children from ages 9–24 months into adolescence found that the beneficiaries of childhood nutritional interventions significantly outperformed those without the interventions in 11 of 12 cognitive and educational tests.43

Steady Progress in Reducing Malnutrition

Nutrition outcomes have been steadily improving over time, as reflected in the downward trend in the incidence of stunting in most developing regions (table 2.3).44 Today just 36 countries account for 90 percent of all stunted children worldwide.45 Since the mid-1990s, the prevalence of stunting has fallen throughout Asia, with notable reductions in East and Southeast Asia. The notable exception to the trend is Sub-Saharan Africa, where declines have been modest, at best.

Table 2.3Downward trends in under-five malnutrition, 1990–2005
Moderate and severe stunting

(as a % of under-five children)
Latin America & the Caribbean18.015.313.011.1
Middle East & North Africa26.
South Asia50.845.239.734.5
East Asia & Pacific35.929.223.518.9
Sub-Saharan Africa36.735.834.934.1
Developing countries37.933.529.626.5
Developed countries2.
Source: Adapted from de Onis and others 2004, based on WHO data.
Source: Adapted from de Onis and others 2004, based on WHO data.

This steady progress can potentially be derailed by increases over the past four years in the worldwide prices of commodities (see chapter 1). Rising food and fuel prices lower the real income of households that do not produce these products, which may lead to substitution toward less food or cheaper, but less nutritious, substitutes for current diets. That could raise malnutrition levels, especially among the poorest households.

Post-2000 data on stunting from the World Health Organization (WHO) suggest that reductions in child malnutrition vary significantly from country to country (figure 2.9). Income is clearly correlated with the prevalence of malnutrition, as measured by stunting outcomes. The incidence of moderate and severe stunting in low-income countries exceeds that in high-income countries by a factor of 16. Much of this difference stems from the high incidence of severe stunting among children under age five in Sub-Saharan Africa. South Asia actually has a slightly higher incidence than Sub-Saharan Africa of moderate stunting, but a lower incidence of severe stunting.

figure 2.9Stunting and wasting for under-five children, 2000–present

Source: WHO Global Database on Child Growth and Malnutrition, various years.

Stunting prevalence differs between males and females. Using severe stunting as the measure of malnourishment, under-five females are less malnourished than males. In countries in the Middle East and North Africa and in South Asia—regions where gender discrimination against females is often perceived to be more common—the difference between male and female child malnutrition does not appear to be statistically significant.

Moderate and severe wasting is far less pervasive than stunting. In fact, wasting in middle-income countries as a whole is statistically indistinguishable from that of high-income countries, which suggests worldwide progress in improving child malnutrition among those countries. Unfortunately, the gap in wasting prevalence remains between middle- and low-income countries, and pockets of malnutrition persist even in the upper-middle-income countries.46

Worldwide, patterns of micronutrient deficiencies are very similar to the pattern for stunting and wasting. Vitamin A deficiency is concentrated in Sub-Saharan Africa and South Asia. High-risk areas for zinc deficiency are, likewise, mainly in those two regions.47 Finally, anemia prevalence is highest in South Asia and Sub-Saharan Africa, with little evidence of improvement over time.48

Two of the main factors contributing to the notable differences in malnutrition prevalence across regions and countries are income and education. Empirically there is a strong positive association between poverty rates and malnutrition and a strong negative correlation between levels of female education and malnutrition (figure 2.10), and this is the case even when controlling for other factors.49 A country with a high poverty rate, such as Rwanda or Zambia, is much more likely to have a high child malnutrition rate compared with those with lower rates of poverty, such as Colombia and the Islamic Republic of Iran. Similarly, countries such as Niger and Rwanda that have low primary education completion among females tend to demonstrate higher rates of child malnutrition.

figure 2.10The relationship between malnutrition, poverty, and education

Source: World Bank calculations, based on WHO and WDI data.

Note: Partial regression plots of bivariate regression of height two standard deviations below median on: (a) poverty headcount ratio ($2 day PPP adjusted basis) as percentage of population; and (b) female primary education completion rate, as percentage of relevant age group.

The importance of education and income as determinants of child malnutrition has been confirmed by household and cross-country empirical evidence.50 Education improvements seem particularly important. Household analyses suggest that insufficient maternal schooling is frequently the main constraint to adequate child nutrition. For example, higher levels of maternal education influence feeding practices, which directly affect child health. In Ghana, the most highly educated mothers were more than three times as effective in reducing child malnutrition as the least educated mothers.51

Other evidence from household surveys underscores the importance of income growth for reductions in child malnutrition. Assuming an annual per capita income growth rate of 2.5 percent from the 1990s to 2015 for 12 countries, projections of reductions in child malnutrition range from a low of 13 percent (for Romania) to as much as 63 percent (for Peru).52 However, these simulation results are likely to be overoptimistic because, in reality, only 3 of the 12 countries actually met the study’s assumption of a 2.5 percent per capita income growth during the 1990s.

While the influence of income growth is positive and statistically significant, the magnitude of the effect can be relatively small. The impact of economic growth on malnutrition is tempered by the relatively low income elasticity of nutrition, so that changes in income have a relatively limited impact on nutrition outcomes. The estimated decrease in a given measure of malnutrition is dramatically affected by estimates of this elasticity, and current evidence suggests a range from –0.01 to –0.82 (figure 2.11). For example, assuming an annual income growth rate of 5 percent and an elasticity of –0.5 percent, it would still take Tanzania until 2026 to meet the MDG malnutrition goal.53

figure 2.11Relation of reductions in under-five malnutrition to increases in income

Source: World Bank 2006c.

Rising nutrition levels can lead to a virtuous cycle of improvements in health and increases in income. Evidence from northwestern Tanzania between 1991 and 1994 on the role of supplementary child feeding programs found that such nutritional interventions would allow the income poverty MDG to be attained at an annual income growth rate of 1.5 percent, lower than the 2.2 percent rate required in the absence of such a policy.54

Making a Difference in Child Malnutrition

Malnutrition is often assumed to be caused by food insecurity. Recent evidence suggests that household behavior and assets are equally important (or perhaps even more important) determinants. Food security, while necessary, is not sufficient to guarantee positive nutrition outcomes. The potential for interaction and feedback effects between child nutrition, education, and income suggest a role for policy interventions in child health that work concomitantly with other investments.55 Addressing nutrition reinforces other efforts to improve child health.

Several interventions to stem both short- and long-term malnutrition are well known and simple to achieve—examples are oral rehydration therapy and the promotion of exclusive breastfeeding. Ensuring adequate levels of iron, iodine, vitamin A, and zinc for pregnant women, infants, and children can often be effectively achieved through fortifying common foods such as flour and salt with micronutrients, and promoting the use of iron cookware.56 These offer inexpensive but effective means of implementation as they harness the private sector in distribution. Except where subsistence is the norm and consumption of commercial foods rare, such efforts are highly effective and deserve to be priority interventions.

Recent evidence on the importance of nutrition during pregnancy and during the first two years of life suggests that focusing investments on nutrition supplements for pregnant women and children under age two would have a high payoff over the long term. Maternal education makes a big difference in ensuring adequate nutrition, as does rising household income, but shorter-term efforts such as teaching mothers about hygiene and sound feeding practices have been shown to be effective even among uneducated women.57 Availability of fortified snack foods at home or school can compensate for poor nutrition without leading to substitutions for meals, which is a common practice in some countries. Community nutrition interventions can also have an impact on how communities compensate for inadequate food for children and mothers.

As with health care quality, these interventions will be effective only to the extent that they are targeted to the populations in need. The quality of the delivery of these services will also affect their success.

The Environment and Health Goals

The interrelationships among environmental factors, child health, nutrition status, and education are strong and multifaceted, and together significantly influence progress toward the MDGs. Environmental risk factors such as access to water and sanitation play a role in many diseases. It has been estimated that 23 percent of all deaths are principally attributable to environmental factors. Children are among those most vulnerable and adversely affected. Diarrhea, malaria, and lower respiratory infections are most closely linked to environmental factors.

Malnutrition is among the most important determinants of child mortality, together with respiratory infection (largely caused by indoor air pollution), diarrheal diseases (mostly from inadequate water, sanitation, and hygiene), and malaria (from inadequate environmental management and vector control).58 Lack of food and nutrients, along with the consequences of lack of access to clean water, poor hygiene and sanitation, and repeated infections, lowers resistance to disease, which in turn, leads to a cycle of illness and chronic malnutrition.59 The WHO estimates that the environment—in particular poor water, sanitation, and hygiene—accounts for about half of the health burden of malnutrition.60 Recent evidence also points to the negative effects on child growth of infections and of exposure to environmental health risks in early infancy that lead to permanent growth faltering, lowered immunity, and increased mortality.61

Impacts of Environment on Health

Environmental health refers to all the physical, chemical, and biological factors external to a person, as well as to all the related factors affecting individuals’ behaviors, and encompasses the assessment and control of those environmental factors that can potentially affect health status.62 Modifiable environmental risks are deemed to be those that are “reasonably amenable to management or change” and that can be classified into either traditional or modern forms.63 Traditional hazards are those environmental health risks closely linked with poverty and development: lack of access to clean water, poor sanitation, poor waste disposal, indoor air pollution, and vector-borne diseases such as malaria. Modern hazards include environmental health risks such as urban air pollution, agro-industrial waste, and toxic chemicals. The sources of these environmental challenges vary widely, their implications are broad, and interventions range from highly private goods and services (such as cleaning up indoor air pollution) to public goods (such as provision of sanitation).

Environmental risk factors play a role in more than 80 percent of diseases globally. An estimated 24 percent of the global disease burden from all causes is attributable principally to environmental factors (box 2.4). In developing countries, 25 percent of all deaths were found to be attributable to environmental risk factors, compared to 17 percent in developed countries (figure 2.12).64

figure 2.12Environmental disease burden in DALYs per 1,000 of population, 2002

box 2.4Indicators of environmental risk factors—DALYs

The disability-adjusted life year (DALY) is a measure used to quantify the burden of disease by combining years of life lost due to premature death and years of healthy life lost due to morbidity, with one DALY representing the loss of one year of equivalent full health. The use of the DALY measure allows quantification and comparison of the impact of different environmental risk factors on health. In calculating the burden of disease attributable to an environmental risk factor, it is often not practical to assume that exposure to the risk factor can be reduced to zero. Instead, the contribution of environmental risk factors is estimated by how much the disease burden would decline if exposure to a given factor were reduced to a certain achievable baseline level.

In addition, the poorest and most vulnerable populations—women, children, migrants, people living with HIV/AIDS—are generally the most adversely affected by environmental risk factors as they tend to reside in areas with the worst environmental conditions or have greater exposure to risk factors. Moreover, these populations typically have lower resistance to infection. Among children under five, over 40 percent of the global disease burden is linked to environmental risk factors: an estimated 4.7 million children under five died in 2000 from illness related to unsafe environments.65

For the lowest-income countries striving to reach the MDGs, the diseases estimated to have the largest epidemiological burden attributable to environmental factors include diarrhea, lower respiratory infections, and malaria. These diseases also constitute the greatest burden on children ages 0–14 years. Together, the three conditions account for 24 percent of all deaths in children under age 15 (figure 2.13).66

figure 2.13Environmental contribution to disease burden

Source: Prüss-Üstün and Corvalán 2006.

a. COPD = Chronic obstructive pulmonary disease.

b. DALYs represents a weighted measure of death, illness, and disabilities.

c. The environmental disease burden is measured in DALYs.

Roughly 94 percent of diarrheal cases worldwide can be attributed to the environment, primarily to unsafe drinking water, poor sanitation, and hygiene, resulting in 1.5 million deaths annually, many of them children. Another estimated 1.5 million deaths annually result from respiratory infections caused by environmental factors. In developing countries alone, approximately 24 percent of upper respiratory infections and 42 percent of lower respiratory infections were attributable to environmental risk factors, such as outdoor and indoor air pollution, and contributing risk factors, such as tobacco smoke, solid fuel use, and housing conditions.67

Roughly two-fifths of global malaria cases could be prevented through improved environmental management, such as modifications to the natural environment or to human habitation. Behaviors, such as the consistent use of bed nets, can also enhance prevention.68 Climate change, which raises malaria incidence through meteorological effects on pathogens and vectors, is expected to expand the geographical distribution of several vector-borne diseases, including malaria, and may even come to extend transmission seasons in some regions. Even small temperature increases could potentially cause large relative increases in the risk of malaria.69

Environmental effects on health status also affect incomes. The economic burden on society caused by poor environmental health has been estimated at approximately 1.5–4 percent of GDP annually (figure 2.14).70

figure 2.14Economic burden associated with poor environmental health

percentage of GDP

Source: World Bank Country Environmental Analyses, various years, and Baris and Ezzati (2007).

Note: The economic burden of health costs are typically measured as costs of poor health in terms of DALYs and adjusted by either human capital or value of statistical life methods. Since different methodologies and parameters may have been used for estimating costs across countries, these cross-country comparisons are only indicative.

Water and Sanitation

While wide agreement exists on the need for adequate water and sanitation, progress has been slow, particularly compared with progress on other MDGs.71 According to the WHO’s Joint Monitoring Programme for Water Supply and Sanitation, over a billion people do not enjoy reasonable access to a safe drinking water supply, and a staggering 2.6 billion people (40 percent of the world’s population) do not have access to basic sanitation. While these needs may appear basic, the challenges involved in meeting them are complex. Political, economic, and institutional demands have complicated efforts to close the gap. Facilities typically require large initial fixed costs. The economic and institutional costs of operating and managing them are relatively high and are best financed by users, and government has a necessary role in overseeing and regulating their operation. Clean water is vital and demand for it is high. But sanitation generates large externalities and low demand because the beneficiaries of sanitation are not only those who create the problem, but particularly those residing “downstream.” Hygiene entails behavior changes that are notoriously difficult to achieve rapidly.

Almost all diseases associated with the lack of drinking water supply and sanitation are transmitted by fecal material that has not been disposed of properly. Contamination from fecal material can occur through many transmission routes. Adequate water and sanitation can interrupt some of these routes but not all of them, and recent evidence suggests that behavioral changes are also needed. Changes in hygiene behavior must accompany infrastructure investments in water and sanitation systems if the full set of health benefits is to be realized.

The most recent assessment suggests that the world is roughly on target for reaching the MDG goal of halving the proportion of people without sustainable access to safe drinking water, but it is expected to miss the goal for access to basic sanitation by half a billion people (figure 2.15).72 The data also show that levels of access to improved water and sanitation in urban areas have been static, whereas access to water supply and sanitation in rural areas has been improving. Nonetheless, significant disparities continue to exist in urban and rural levels of access.

figure 2.15Trends and projections of access to water and sanitation in developing countries, 1990–2015

In addition, the summary global statistics are averages and conceal major disparities by income group. When disaggregated, it is clear that access to different levels of service varies with income quintile.73 As figure 2.16 shows for 32 countries in Africa, the distribution of access to clean water and proper sanitation is highly unequal: while less than 10 percent of the bottom expenditure quintile has access to improved water supply, nearly 70 percent of the top quintile has such access. Similarly, over half of the bottom quintile has no access to sanitation of any kind, while only 6 percent of the top quintile has no access to sanitation. Given the fundamental nature and cost of water and sanitation services, it is not surprising that service levels are linked to expenditure levels; that is, as incomes increase, many families will invest in these basic services, and they are willing and able to pay at least for water.

figure 2.16Access to clean water and sanitation by expenditure quintile, 32 African countries

Air Pollution

A major source of indoor air pollution in developing countries is the burning of solid fuels such as biomass (animal dung, wood, crop residues, and wastes) and coal for heating and cooking. Currently half of the world’s population relies on inefficient, highly polluting solid fuels for their daily energy needs.74 Many use solid fuels that are burned in open fires or simple stoves that release smoke into the home. These practices increase indoor air pollution, posing a serious health threat particularly for women and young children who spend more time indoors close to fires (box 2.5).

Approximately 32 percent of the global burden of disease caused by indoor air pollution occurs in Sub-Saharan Africa, 37 percent in South Asia, and 18 percent in East Asia and the Pacific. In developing countries, solid fuel use is the fourth most important environmental risk factor, and it accounts for approximately 3.7 percent of DALYs lost. Because of their reliance on solid fuels, the poorest regions of the world suffer the most, both in terms of deaths and DALYs (table 2.4). The specific health outcomes associated with indoor air pollution include acute lower respiratory infection, chronic obstructive pulmonary disease, and lung cancer.

Table 2.4Deaths and DALYs lost due to solid fuel use


Total burden

East Asia & Pacific5407,08718.4
Europe & Central Asia215441.4
Latin America & the Caribbean267742.0
Middle East & North Africa1183,5729.3
South Asia52214,23736.9
Sub-Saharan Africa39212,31832.0

Outdoor air pollution is caused mainly by the combustion of petroleum products or coal by automobiles, industry, and power stations. In some countries, major sources include wood or agricultural waste. Outdoor air pollution also stems from industrial processes that involve dust formation (such as that from cement factories and metal smelters) and the release of gases (such as that from chemical production). Outdoor air pollution is believed to contribute 0.6–1.4 percent of the total burden of disease in developing countries, and other forms of pollutants (such as lead in water, air, and soil) may contribute up to 0.9 percent.75

box 2.5Exposure to indoor air pollution: Evidence from Bangladesh

A recent study on Bangladesh analyzes individuals’ exposure to indoor air pollution at two levels: differences within households attributable to family roles; and differences across households attributable to income and education. The findings revealed high levels of exposure for children and adolescents of both sexes, with particularly high exposure for children under five, as would be expected. Among adults, men had half the exposure of women (women’s exposure was similar to that of children and adolescents). Elderly men also had significantly lower exposure than elderly women. Household choices of cooking fuel, cooking locations, construction materials, and ventilation practices were found to be significantly affected by family income and adult education levels (particularly for women).

Overall, the poorest, least-educated households had twice the pollution levels of relatively high-income households with highly educated adults. The study found that the typical household could cut their children’s pollution in half by adopting two simple measures: increasing children’s outdoor time from three hours a day to five or six hours; and concentrating that outdoor time during peak cooking periods.

Source: Dasgupta and others 2004.

Urban air pollution has become a growing concern for most large cities in developing countries. An estimated 800,000 people die prematurely every year from lung cancer and cardiovascular and respiratory diseases caused by outdoor air pollution.76 Other health effects from urban air pollution include chronic bronchitis, acute respiratory illness, asthma, and coronary diseases. Quantifying the adverse health effects caused by urban air pollution is difficult because of limited data availability, although this is beginning to change with the World Bank’s Country Environmental Analyses (CEAs), which highlight the need for ambient air quality monitoring stations, and for strengthened legal and policy frameworks for urban air quality management.77

The health effects of air pollution depend on the nature and level of exposure, as well as individuals’ activity patterns. Children are particularly susceptible to environmental risks given that greater exposure to air pollution can severely retard their growth and development. Overall, an estimated 5 percent of global lung cancer cases, 2 percent of deaths from cardiovascular and respiratory conditions, and 1 percent of respiratory infections are attributable to pollution caused by urban particulate matter, resulting in 7.9 million premature deaths.78 The potential savings from curbing health-related problems caused by urban air pollution can thus be substantial.

Climate Change

Climate change refers to human-induced (anthropogenic) change to the global climate system. Climate change constitutes an environmental risk that has global implications for health, but that requires local interventions to address the sources of the problem.79 However, a causal relationship between climate change and health is difficult to show, given the numerous factors driving both health outcomes and environmental conditions.

Methods for describing and measuring the health effects of climate change remain in the early stages of development. Estimates of the health effects of climate change are therefore based on measures of current and past effects of climate variation (and other influences) on health, and these derived relationships are then applied to projections of likely changes in future climatic conditions.80

Climate change has the potential to affect a variety of health outcomes (table 2.5). It directly effects heat waves, floods, and storms and indirectly affects the distribution and transmission intensity of infectious diseases and the availability of fresh water and food. In addition, climate change affects exposure to various communicable and noncommunicable diseases. A global estimate measured the burden of disease in 2000 attributable to climate change at 925 DALYs per million, with strong regional variations exhibited. The largest burdens were found in Sub-Saharan Africa, Asia, and the Eastern Mediterranean.81 These regions are generally located at lower latitudes, where the most important climate-sensitive health outcomes—such as malnutrition, diarrhea, and malaria—are already pervasive, and where vulnerability to climate change is greatest. Changes in climate are believed to have caused over 150,000 deaths, or the loss of over 5.5 million DALYs annually, since the year 2000.

Table 2.5Projected health effects of climate change
Health effectConfidence
Increased malnutrition and consequent disorders, including those related to child growth and developmentHigh
Increased number of people dying and suffering from disease and injury due to heat waves, floods, storms, fires, and droughtsHigh
Continued change in the range of some infectious disease vectorsHigh
Mixed effects on malaria; in some places the geographical range will contract, elsewhere it will expand, and the transmission season may changeVery high
Increased burden of diarrheal diseasesMedium
Increased card iorespiratory morbidity and mortality associated with ground-level ozoneHigh
Some increased benefits to health, including fewer deaths from cold. These benefits are expected to be outweighed by the negative effects of rising temperatures worldwide, especially in developing countriesHigh
Source: Confalonieri and others 2007.Note: The Intergovernmental Panel on Climate Change assigns confidence levels according to the scientific evidence available.
Source: Confalonieri and others 2007.Note: The Intergovernmental Panel on Climate Change assigns confidence levels according to the scientific evidence available.

Addressing Environmental Health Risks

Addressing environmental health risks is challenging because of the political, financial, and implementation difficulties. Simple investments, such as bed nets, can produce large benefits at modest cost relative to more complex interventions (table 2.6). However, the manner in which bed nets are obtained, treated, and used varies widely across countries, which accounts for some of the observed ineffectiveness of this simple and cheap technology. Poor governance, for example, can raise the costs significantly. Breastfeeding promotion is relatively inexpensive, but this is an awkward intervention because demand is uncertain and reaching the right mother is not always straightforward, particularly in rural areas. Residual spraying, if done consistently, is inexpensive and can protect households without any behavioral shift.

Table 2.6Cost per DALY of alternative interventions for addressing environmental hazardsUS$ per healthy year gained
InterventionCost per DALYAssumptions/Comments
Insect-treated bed nets9–31Two net treatments with insecticide per year
Insecticide residual spraying11–34Two rounds of spraying per hear
Breastfeeding promotion and diarrhea treatment930Two interventions during first year of life
Measles immunization981
Cholera immunization2,945
Water and sanitation upgrading
Hand pump or standpost94
House connection224
Sanitation construction and hygiene promotion< 270
Acute respiratory disease in children (pneumonia)398Four case management interventions

Measles immunization is also relatively inexpensive; moreover it has a positive effect on reducing morbidity and mortality from diarrhea, so its effects are quite powerful beyond simply preventing measles. Thus, there are options for preventing and treating the major environmentally driven diseases that plague the lowest-income countries. The challenge is devising effective programs that actually reach families and investing in the education that helps households prevent illness and use treatment options.

Water supply and sanitation.

Water and sanitation infrastructure investments are not cheap, and although health benefits are likely to be significant, they are only part of the considerable economic and environmental benefits that accrue to households and society from these investments. An estimated US$30 billion in annual investments is needed to reach the MDG targets of halving the fraction of the population without basic access to water and sanitation, and these costs do not include wastewater treatment, which is particularly expensive. Currently only US$15 billion is spent globally per year.

The high costs and other problems associated with building and maintaining water and sanitation infrastructure suggest that future investments should be subjected to the following considerations. First, institution building should accompany infrastructure construction, something that has been achieved even in small rural areas through local professional operators (a local entity willing to handle the operations and maintenance for a fee). The World Bank has found such programs to be effective in Rwanda, and programs are currently being tested in Haiti, Mali, and Madagascar.82 Second, urban water and sanitation networks need to be extended to peri-urban areas and smaller towns. Third, technical standards could be adjusted so that the standards of the developed world are not imposed on low-income countries that cannot afford the gold standard. Fourth, hygiene promotion should be included as part of the investment, as has been the case in recent World Bank water projects in China, Egypt, and Vietnam.

Of greatest concern, however, is the need to build the institutions that can ensure long-term operation and maintenance of water supply and sanitation systems. Not doing so during the “Drinking Water Supply and Sanitation Decade” of the 1980s led to the failure of the costly initiative. Part of the challenge is ensuring an adequate financial base through charges on users, something that often succumbs to political pressures and leads to deterioration of the physical infrastructure and water and sanitation services. Thus a strengthening of the institutional and policy framework must accompany water supply and sanitation investments if they are to have a sustainable impact.

Indoor air pollution.

A study that compared the differences in healthy years gained for four alternative solid fuels found that cleaner fuels yielded the greatest gains across all regions, but that improved stoves also had a significant impact.83 In Sub-Saharan Africa and South Asia, regions with the largest burden of disease attributable to solid fuel use, an improved biomass stove was the most cost-effective intervention. Cleaner fuels, such as kerosene, were the most cost-effective in East Asia and the Pacific.


Halfway to 2015 the world has made serious, if uneven, progress in numerical outcomes toward achieving the MDGs for health and education. Stronger and more targeted efforts are needed to improve the access of the poor and underserved populations to these services. Greater attention also needs to be focused on the quality of education and health investments—and to the governance and accountability of public programs—if they are to meet MDG objectives. Many countries are falling short on the malnutrition goal, and new evidence is pointing to the need to reach pregnant women as well as young children if nutritional status is to improve and education goals are to be realized. Finally, it is clear that environmental hazards pose a major risk to health status. Efforts to mitigate the effects of climate change, reduce indoor and outdoor air pollution, and expand water and sanitation coverage have positive impacts on health that must be considered in weighing the value of such investments. Ultimately, there are positive synergies across the goals, and these synergies need to be exploited.84


For more details on progress on the various MDG targets, see Annex: Monitoring the MDGs.


Indeed, even in OECD countries, the inequality of health outcomes tends to exceed income disparities.


Peabody, Gertler, and Leibowitz 1998. The estimated magnitude of the impact of clinical process quality was large. Increasing the frequency of one element of a given clinical exam (such as checking blood pressure) from once in the prenatal period to checks at every visit would increase average birth weights by approximately 128 grams.


Multivariate analyses produce similar results: Even after the inclusion of various controls that affect malnutrition outcomes-such as the size of the rural population and the regulatory quality of the country-education and income per capita are both negative and significant predictors of child malnutrition outcomes.


This definition follows that of WHO (2007). Others have defined environmental health more broadly to include all those aspects of human health determined by social and psychosocial factors within the environment.


The terms sanitation and hygiene can unfortunately mean many different things. Within this chapter, sanitation refers to infrastructure and service provision required for the safe management of human excreta, as exemplified by latrines, sewers, and wastewater treatment. As such, important environmental health services, such as solid waste management, vector control, and surface water drainage, are not included, nor are they tracked by the UN system for measuring progress toward MDG Target 10. Hygiene refers to the set of human behaviors related to the safe management of human excreta, such as the washing of hands with soap at appropriate times and the safe disposal of child feces.


The CEA report for Pakistan is an example (World Bank 2006b).


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