Abstract
The main aim of this article was to analyze the relationship of income inequality and government effectiveness with differences in efficiency in the use of health inputs to improve the under-five survival rate (U5SR) in developing countries. Robust Data Envelopment Analysis (DEA) and regression analysis were conducted using data for 47 developing countries for the periods 2000–2004, 2005–2009, and 2010–2012. The estimations show that countries with a more equal income distribution and better government effectiveness (i.e. a more competent bureaucracy and good quality public service delivery) may need fewer health inputs to achieve a specific level of the U5SR than other countries with higher inequality and worse government effectiveness.
Similar content being viewed by others
Notes
It is worth noting the kind of institutions these authors refer to. They consider key public sector institutions, including public service provision, the bureaucracy, and the legal and tax system, sharing the view of Knowles and Owen [12], among others.
The U5MR and Infant Mortality Rate (IMR) are the most used outcome indicators of health achievements in developing countries. However, the U5MR is preferable to the IMR as a measure of survival mainly because the indirect techniques employed to estimate it are less sensitive to assumptions about underlying mortality patterns than are the techniques used to estimate the IMR [23]. In contrast to adult or old-age mortality, child mortality is the one indicator that is based on a comparably large amount of empirical data in low-income and middle-income countries, which makes it unique from a monitoring perspective [1]. In addition, the U5MR has three substantial advantages over life expectancy at birth [7]: under-five deaths are more often due to preventable causes, and thus should be easier to reduce through appropriate policies; the death of a child represents more years of life foregone than does the death of an older person; a new cohort of babies is born every year, so the U5MR is more sensitive than life expectancy to new socioeconomic circumstances and to changes in social service delivery.
Health outcomes refer to the health consequences brought about by the treatment of a health condition or as the result of an interaction with the healthcare system. Thus, health outcomes encompass a wide range of health-related consequences of healthcare interventions and programs (i.e. health outputs) [25].
Three reasons justify the use of this indicator as a measure of health output:
-
Immunization is considered to be a good proxy for the use of basic maternal and infant health services [7], which are strong predictors of the U5MR. In addition, vaccinations are strongly associated with further vaccinations: people who get one are likely to get another [55].
-
Measles is one of the most important causes of child death in poor countries despite the availability of a safe and effective vaccine. In addition, the between-country distribution of alternative indicators, such as DPT (diphtheria, tetanus, and pertussis) vaccination coverage, is similar to that in countries employing measles vaccination coverage.
-
Given the potential of measles vaccination to reduce child mortality and that measles vaccination coverage can be considered to be a marker of access to child health services, routine measles vaccination coverage was also selected as an indicator for monitoring progress towards MDG 4.
-
References
You D, Hug L, Ejdemyr S, Idele P, Hogan D, Mathers C, Gerland P, New J, Alkema L (2015) Global, regional, and national levels and trends in under-5 mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Inter-agency Group for Child Mortality Estimation. Lancet Glob Health Collect. doi:10.1016/S0140-6736(15)00120-8
Jayasuriya R, Wodon Q (2003) Development targets and efficiency in improving education and health outcomes in Mexico’s Southern States. World Bank MPRA Paper No. 10577. The World Bank, Washington
Gupta S, Verhoeven M, Tiongson E (2002) The effectiveness of government spending on education and health care in developing and transition economies. Eur J Polit Econ 18(4):717–737
Gupta S, Verhoeven M, Tiongson E (2003) Public spending on health care and the poor. Health Econ 12:685–696
World Health Organization (2010) Health systems financing: the path to universal coverage. WHO, Geneva
Bokhari F, Gai Y, Gottret P (2007) Government health expenditures and health outcomes. Health Econ 16:257–273
McGuire J (2006) Basic health care provision and under-5 mortality: a cross-national study of developing countries. World Dev 34(3):405–425
Farag M, Nandakumar A, Wallack S, Hodgkin D, Gaumer G, Erbil C (2013) Health expenditures, health outcomes and the role of good governance. Int J Health Care Finan Econ 3:33–52
Cutler D, Deaton A, Lleras-Muney A (2006) The determinants of mortality. J Econ Perspect 20(3):97–120
Mehrotra S, Vandemoortele J, Delamonica E (2000) Basic services for all? Public spending and the social dimensions of poverty. Innocenti Research Centre. United Nations Children’s Fund, Florence
Rodgers G (2002) Income and inequality as determinants of mortality: an international cross-section analysis, 1979. Int J Epidemiol 31(3):533–538
Knowles S, Owen D (2010) Which institutions are good for your health? The deep determinants of comparative cross-country health status. J Dev Stud 46(4):701–723
Wagstaff A, Claeson M (2004) The millenium development goals for health: rising to the challenges. The World Bank, Washington
Rajkumar A, Swaroop V (2008) Public spending and outcomes: does governance matter? J Dev Econ 86:96–111
Gauri V, Khaleghian P (2002) Immunization in developing countries: its political and organizational determinants. World Dev 30(12):2109–2132
Ottersen O, Dasgupta J, Blouin C, Buss P et al (2014) The political origins of health inequity: prospects for change. Lancet 383:630–667
Drèze J, Sen A (2011) Putting growth in its place, Outlook
Mushtaque A, Chowdhury R, Bhuiya A, Chowdhury M, Rasheed S, Hussain Z, Chen L (2013) The Bangladesh paradox: exceptional health achievement despite economic poverty. Lancet 382:1734–1745
Rodrik D, Subramanian A (2003) The primacy of institutions (and what this does and dos not mean). Fin Dev 40(2):31–34
Chaudhury N, Hammer J, Kremer M, Muralidharan K, Rogers FH (2006) Missing in action: teacher and health worker absence in developing countries. J Econ Perspect 20(1):91–116
Deaton A (2013) The great escape. Health, wealth, and the origins of inequality. Princeton University Press, Princeton
Rodrik D (2013) The past, present, and future of economic growth. Working Paper 1 Global Citizen Foundation
Ahmad O, Lopez A, Inoue M (2000) The decline in child mortality: a reappraisal. Bull World Health Organ 78:1175–1191
Joumard I, André C, Nicq C (2010) Health care systems: efficiency and Institutions. OECD Economics Department Workings Papers, No. 769. OECD Publishing
Lee A, Leung S (2014) Health outcomes. In: Michalos AC (ed) Encyclopedia of quality of life and well-being research. Springer Reference, Heildelberg
Worthington A (2004) Frontier efficiency measurement in health care: a review of empirical techniques and selected applications. Med Care Res Rev 61(2):135–170
DeLellis N, Ozcan YA (2013) Quality outcomes among efficient and inefficient nursing homes: a national study. Health Care Manag Rev 38(2):156–165
Coppola MN, Ozcan YA, Bogacki R (2003) Evaluation of performance of dental providers on posterior restorations: does experience matter? A data envelopment analysis (DEA) approach. J Med Syst 27(5):445–456
Akazili J, Adjuik M, Jehu-Appiah C, Zere E (2008) Using data envelopment analysis to measure the extent of technical efficiency of public health centres in Ghana. BMC Int Health Human Rights 8:11. doi:10.1186/1472-698X-8-11
Renner A, Kirigia JM, Zere EA, Barry SP, Kirigia DG, Kamara C et al (2005) Technical efficiency of peripheral health units in Pujehun district of Sierra Leone: a DEA application. BMC Health Serv Res 5:5-11
Tandon A (2005) Measuring efficiency of macro systems: an application to millennium development goal attainment. Asian Dev Rev 22(2):108–125
Tanzi V, Schuknecht L (1997) Reconsidering the fiscal role of government: the international perspective. Am Econ Rev 87(2):164–168
Tanzi V, Schuknecht L (2000) Public spending in the 20th century: a global perspective. Cambridge University Press, Cambridge
Adler N, Yazhemsky E, Tarverdyan R (2010) A framework to measure the relative socio-economic performance of developing countries. Socio Econ Plan Sci 44:73–88
Abdelfattah B, Ablanedo-Rosas J, Gemoets L (2011) Developing country efficiency assessment by means of a comprehensive model based on data envelopment analysis. Int J Soc Syst Sci 3(1/2):58–80
Musgrove P (1996) Public and private roles in health: theory and finance patterns. World Bank Discussion Paper No. 339. The World Bank, Washington
Filmer D, Pritchett L (1997) Child mortality and public spending on health: how much does money matter? World Bank Policy Research Working Paper No. 1864. The World Bank, Washington
Filmer D, Hammer J, Pritchett L (1998) Health policy in poor countries: weak links in the chain. World Bank Policy Research Working Paper No.1874. The World Bank, Washington
Filmer D, Pritchett L (1999) The impact of public spending on health: does money matter? Soc Sci Med 49:1309–1323
Anand S, Ravallion M (1993) Human development in poor countries: on the role of private incomes and public services. J Econ Perspect 7(1):133–150
Bidani B, Ravallion M (1997) Decomposing social indicators using distributional data. J Econ 77(1):125–139
Bhalotra S (2007) Spending to save? State health expenditure and infant mortality in India. Health Econ 16:911–928
Farahani M, Subramanian S, Canning D (2010) Effects of state-level public spending on health on the mortality probability in India. Health Econ 19:1361–1376
Hu B, Mendoza R (2013) Public health spending, governance and child health outcomes: revisiting the links. J Human Dev Capabilities 14(2):285–311
Anand S, Bärnighausen T (2007) Health workers and vaccination coverage in developing countries: an econometric analysis. Lancet 369:1277–1285
Hay A (2010) Successes and challenges in global immunization efforts. Trans R Soc Trop Med Hyg 104:87–88
Dietrich S (2011) The politics of health aid: why corrupt governments have incentives to implement aid effectively. World Dev 39(1):55–63
Berkley S (2014) Improving access to vaccines through tiered pricing. Lancet 383:2265–2266
Wilkinson RG, Pickett KE (2006) Income inequality and population health: a review and explanation of the evidence. Soc Sci Med 62:1768–1784
Tandon A (2007) Measuring government inclusiveness: an application to health policy. Asian Dev Rev 24(1):32–48
Ghobarah H, Huth P, Russett B (2004) Comparative public health: the political economy of human misery and well-being. Int Stud Q 48:73–94
Davoodi H, Tiongson E, Asawanuchit S (2010) Benefit incidence of public education and health spending worldwide: evidence from a new database. Poverty Publ Policy 2(2):5–52
Wilkinson RG (2005) The impact of inequality: how to make sick societies healthier. New Press, NY
Feng X, Theodoratou E, Liu L, Chan K, Hipgrave D, Scherpbier R, Brixi H, Guo S, Chunmei W, Chopra M, Black R, Campbell H, Rudan I, Guo Y (2012) Social, economic, political and health system and program determinants of child mortality reduction in China between 1990 and 2006: a systematic analysis. J Global Health 2(1) doi:10.7189/jogh.02.010405
Hall A (2004) Vaccination and child mortality. Lancet 364:2156–2157
Hanf M, Nacher M, Guihenneuc C, Tubert-Bitter P, Chavance M (2013) Global determinants of mortality in under 5 s: 10 year worldwide longitudinal study. BMJ 2013(347):1–8
OECD (2015) Government at a Glance. OECD Publishing, Paris
Kaufmann D, Kraay A, Mastruzzi M (2011) The worldwide governance indicators: methodology and analytical issues. Hague J Rule Law 3:220–246
Charnes A, Cooper W, Rhodes E (1978) Measuring the efficiency of decision making units. Eur J Oper Res 2:429–444
Banker R, Charnes A, Cooper W (1984) Some models for estimating technical and scale inefficiencies in data envelopment analysis. Manag Sci 30:1078–1092
Fried H, Schmidt S, Yaisawarng S (1999) Incorporating the operating environment into a nonparametrtic measure of technical efficiency. J Prod Anal 12:249–267
Ruggiero J (2004) Performance evaluation when non-discretionary factors correlate with technical efficiency. Eur J Oper Res 159:250–257
Simar L, Wilson P (1998) Sensitivity analysis of efficiency scores: how to bootstrap in nonparametric frontier models. Manag Sci 44(1):49–61
Simm J, Besstremyannaya G (2015) Robust Data Envelopment Analysis (DEA) for R version 1.2-2, https://github.com/jaak-s/rDEA
Simar L, Wilson P (2007) Estimation and inference in two-stage, semi-parametric models of production processes. J Econ 136(207):31–64
World Health Organization (2006) Health systems profile-Jordan. Regional Health Systems Observatory-EMRO. Regional Office for the Eastern Mediterranean, WHO, Cairo
Pan American Health Organization (2008) Health systems profile Paraguay. PAHO, Washington
Turcanu G, Domente S, Buga M, Richardson E (2012) Republic of Moldova: health system review. Health Syst Transit 14(7):1–151
Harrison D (2009) An Overview of Health and Health care in South Africa 1994–2010: Priorities, Progress and Prospects for New Gains. A Discussion Document Commissioned by the Henry J. Kaiser Family Foundation to Help Inform the National Health Leaders’ Retreat
Marmot M, Friel S, Bell R, Houweling T, Taylor S (2008) Closing the gap in a generation: health equity through action on the social determinants of health. Lancet 372:1661–1669
McGuire J (2010) Wealth, Health, and Democracy in East Asia and Latin America. Cambridge University Press, Cambridge
Bloom G (2001) Equity in health in unequal societies: meeting health needs in contexts of social change. Health Policy 57:205–224
Makuta I, O’Hare B (2015) Quality of governance, public spending on health and health status in Sub Saharan Africa: a panel data regression analysis. BMC Public Health 15(932):1–11
Gisselquist RM (2012) Good governance as a concept, and why this matters for development policy. UNU-WIDER Working Paper No. 2012/30. World Institute for Development Economics Research, United Nations University, Helsinki
Dobson S, Ramlogan-Dobson C (2012) Why is corruption less harmful to income inequality in Latin America? World Dev 40(8):1534–1545
Marmot M (2005) Social determinants of health inequalities. Lancet 365:1099–1104
Klomp J, De Haan J (2008) Effects of governance on health: a cross-national analysis of 101 countries. Kyklos 61(4):599–614
Acknowledgments
We are grateful for the thoughtful comments from the three anonymous reviewers. We take responsibility for any remaining errors.
Author information
Authors and Affiliations
Corresponding author
Appendix
Appendix
Rights and permissions
About this article
Cite this article
Ortega, B., Sanjuán, J. & Casquero, A. Determinants of efficiency in reducing child mortality in developing countries. The role of inequality and government effectiveness. Health Care Manag Sci 20, 500–516 (2017). https://doi.org/10.1007/s10729-016-9367-1
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10729-016-9367-1