1. Regional Disparities in Adult Chronic and Acute Health in Albania: A Multilevel Analysis of the Albanian Living Standards Measurement Survey 2002 Katie Bates (LSE), Dr Arjan Gjonça (LSE)

2. Source:Human Development Report (1993) – UNDP Gjonça, A – 2001 - Communism, health and lifestyle: the paradox of mortality transition in Albania, 1950-1990. Greenwood Press, Westport Introduction North-south gradient in mortality ‘Good health at low cost’ population Albania e 15 1989 - 57.8 U.K. e 15 1992 – 58.7

3. North-South Gradient in Mortality Socioeconomic – Communist policies population-wide Behavioural – Low smoking prevalence – Physical activity uniformly high Difference in Age Structure – Unlikely systematic difference – Internal migration restricted Diet Hypothesis – North-east – high in animal fats – South-west – ‘Mediterranean diet’ - Olive oil, fresh fruit and vegetables – CVDs Gjonca, A., Bobak, M., - 1997 – ‘Albanian paradox, another example of the protective effect of Mediterranean lifestyle?’ Lancet Vol. 350: 1815–17 Gjonca, A., Wilson, C., Falkingham, J. – 1999 – ‘Can Diet and Life Style Explain Regional Differences in Adult Mortality in the Balkans?’ MPIDR WORKING PAPER WP 1999-003 Gjonça, A – 2001 - Communism, health and lifestyle: the paradox of mortality transition in Albania, 1950-1990. Greenwood Press, Westport Diet Hypothesis Figure 2. Geographical distribution of olive production in Albania, 1985

4. Rationale for Study North-South gradient in mortality prevailed 1950-1989 Social and economic changes during post-communist transition Albania Living Standards and Measurement Survey 2002 provides opportunity to assess the relationship between region and health outcomes in Albania, post-1989, by drawing on correlation between ill- health and mortality

5. Hypothesis: Regional disparities in health remain despite changing socioeconomic conditions Research Questions: Is region related to adult health outcomes in Albania? a) Is region related to chronic illness? b) Is region related to acute illness? Research Questions

6. Albania Living Standards Measurement Survey 2002 Dichotomous Dependent Variables: Self-report chronic; Self-report acute Multistage Sample design, violation of independence Table 1. Log Likelihood Ratio Test: Between-Cluster Variance Logistic Variance Components Models INSTAT – 2003 – Albania Living Standard Measurement Survey 2002 Basic Information Document The World Bank, Albania Institute of Statistics (INSTAT) Data and Methods ModelDependent VariableChi-Square Test StatisticP-Value Chronic Illness Suffers from chronic illness ‘Yes/No’ 97.37***<0.0000 1 Acute IllnessHas had sudden illness or injury in last 4 weeks ‘Yes/No’ 591.69***<0.0000 1 *p<0.05, ** p<0.01, *** p<0.001

7. Data and Methods Explanatory Variables (individual and household level) Age Marital Status Education (years) Income (percentiles) Water source (inside/outside HH) Toilet (inside/outside HH) Distance to doctor Region as fixed effect Step-wise Model Selection Fig. 3: Regions of Albania

8. Results: Chronic Illness

9. Results: Acute Illness

10. Results and Regional Disparities Fig. 6: Geographic Distribution of Odds of Reporting Chronic Illness  Coastal region highest odds of reporting chronic illness  Internal migration as key factor?  Northeast region highest odds of reporting acute illness Fig. 7: Geographic Distribution of Odds of Reporting Acute Illness

11. Carletto. G., Davis. B., Stampini. M., Trento. S., Zezza. A, - 2004 - "Internal Mobility and International Migration in Albania,"Internal Mobility and International Migration in Albania Working Papers 04-13, Agricultural and Development Economics Division of the Food and Agriculture Organization of the United Nations (FAO - ESA)Working Papers Discussion/Conclusion Acute Illness: north-south gradient persists Chronic Illness: change in regional pattern Change in behavioural risk factors Internal migration - ‘the Coastal region is [an] important absorbing area. The Mountain and the Centre regions…, are strong expellers’ (Carletto et al. 2004: 7) Future Research: control for migration since 1990

12. Questions

13. Model Adequacy and Interpretation: Chronic Figure 21: Predicted Probabilities of Reporting Chronic Illness Against Observed Probabilities:

14. Model Adequacy and Interpretation: Acute Figure 24: Predicted Probabilities of Reporting Chronic Illness Against Reported Acute Illness:

15. Odds Ratios for Random Intercept Logistic Regression Models for Reporting Chronic/No Chronic illness in the last three years: 2002 Albania LSMS:

16. Odds Ratios for Random Intercept Logistic Regression Models for Reporting Acute/No Acute illness in the last four weeks: 2002 Albania LSMS:

17. CEE context 2001

18. Caldwell, J., - 1986 - Routes to Low Mortality in Poor Countries - Population and Development ReviewPopulation and Development Review Vol. 12, No. 2 (Jun., 1986), pp. 171-220 Published by: Population Council http://www.jstor.org/stable/1973108Population Council Good Health at Low Cost Caldwell ‘Routes to low mortality’ (1986) Political will, egalitarianism, radicalism Government commitment to education Government commitment to health care Health care free and accessible to all Maternal and child health care Universal vaccination Education (particularly female) Female autonomy