Creating Effective and Sustainable Links: Addressing the Health and Social Needs in Developing Countries Dr. Maria Sophia Aguirre Department of Business and Economics The Catholic University of America International Forum on the Social Science - Policy Nexus UNESCO Argentina / Uruguay February 20-24, 2006

 There is a positive correlation between human capital, infrastructure and economic growth healthy institutions and economic development health and income per capita  These positive correlations reflect an essential causal link running from human capital to healthy institutions (social capital) infrastructure and technology  Life expectancy is a significant predictor of economic growth We know from economic analysis that in economic development

People face serious health and poverty problems, especially in the developing world Lack of income and assets to attain basic needs: Human assets Natural assets Physical assets Financial assets Social assets Aging security Vulnerability to adverse shocks are linked to an inability to cope with them

Environmental Health, Welfare and Living Conditions in Low Income vs. Developed Countries Indicator% access House Connection: water48 / 99 House Connection: sewerage46 / 99 House Connection: electricity62 / 100 Water consumption (liter per person)30 / 600 Wastewater treated29 / 97 Solid waste disposal: landfill or incinerated31 / 78 Solid waste disposal: other (dump,recycled,etc.)66 / 22 Paved Road15/ 19 / 94 Literacy51/ 49 / 100 Under-five mortality (per 1000)178/ 107 / 6 Public Expenditures on Health (%GDP)1.5/ 1.3 / 6.2

People face serious health problems, especially in the developing world  The main health risks and causes of death for men and women are:  Cardiovascular diseases (kills 16.7 million) (AF 1.1, LA 1.9)  Malignant neoplasms (cancer) (kills 7.1 million per year) (AF 0.41, LA 1.1)  Injuries (kills 5.2 million) (AF 0.74, LA 0.51)  Respiratory diseases (kills 3.7 million) (AF 0.26, LA 0.39)  Perinatal conditions (kills 2.5 million) (AF 0.55, LA 0.17)  Respiratory infections (kills 3.9 million) (AF 1.1, LA 0.23)  HIV/AIDS (produces 5 million new cases and kills 2.8 million) ( AF 2.1, LA 0.1)  Diarrhoeal Diseases (kills 1.8 million per year) (AF 0.71, LA 0.06)  Tuberculosis (produces 8 million new cases per year and kills 1.8 million people per year) (AF 1.6, LA 0.05)  Malaria ( produces million new cases per year and kills 1.2 million) (AF 1.2, LA 0.001)  Maternal condition (kills 510,000 per year) (AF 0.23, LA 0.017)  In developed countries these diseases are rare and treatment is accessible and their cost is remarkably low. WHO, World Health Report, 2005, Annex Table 3.

Statistics of HIV/AIDS per Region, 2005 RegionsBegin- ning Persons Infected with HIV New persons Infected with HIV Rate of Adults infected with HIV Rate of women infected with HIV Modes of Transmission Sub-Sahara AfricaEnd 70s 25.8 million 3.2 million7.5%55% Hetero Northern Africa and Middle East End 80s 540,000 67,0000.2%40% Hetero, IDU South AsiaEnd 80s 7.4 million 990,0000.6%35% Hetero East and Pacific Asia End 80s 870, ,0000.1%20% IDU,Hetero, MSM Latin-AmericaEnd 70s 1.8 million 200,0000.6%30% MSM, IDU, Hetero CaribbeanEnd 70s 300,000 30,0002.3%50% Hetero, MSM Central Asia and Europe Begin. 90s 1.6 million 270,0000.6%20% IDU Western EuropeEnd 70s 720,000 22,0000.3%25% MSM, IDU North AmericaEnd 70s 1.2 million 43,0000.6%20% MSM, IDU, Hetero Australia and New Zeeland End 70s 74,000 8,2000.2%10% MSM Total 40.3 Million 4.9 million1.1%48%

Low Cost Effective Interventions Cost of Treatment and (annual cost per capita) US Dollars TreatmentCostsEffectiveness Chemotherapy for TB (6 months )$20.00 ($0.60) 95% Contraceptives (HIV)$14.00 ($1.90) 99% (85%-95%) Hydration salts for Diarrhea$0.33 ($1.60) 95% Pneumonia Antibiotics (5 days antibiotics)$0.27High Measles (1 dose of vaccine)$0.26 ($0.50) 98% Malaria$10 ($0.05) 100% Sources: CDS, WHO

 Cost of malaria to African countries is 1-5% of GDP, productivity of the worker is reduced by 60%. Direct and indirect costs of malaria in sub-Saharan Africa exceed $2 billion.  75% of TB infections and deaths occur in the year age group (the most productive group).  AIDS places seventh among the leading causes of death. The main modes of transmission are homosexual and heterosexual promiscuity and injected- drug-use (IDU) (all high risk behavior).  Majority of maternal deaths are due to poor access to health care (1.9% of female death).

Solutions often Proposed  Outlined in the 8 UN Millennium Development Goals.  Population control Aging population trap  “Safe sex” and antiretroviral drugs. Although condoms give the “best” protection against HIV for men, the risk reduction for women is not as high (Davis and Weller,1999) Use of condoms increases the risk of contracting AIDS (UNAIDS 1996 and NACHHD 1999) Not a solution for IUD and Heterosexual transmission Access to family planning increases sexual promiscuity (Kaiser 2000, Paton 2002, USAID 2002)

ABC APPROACH Abstaining from sexual activity, mutual monogamy or being faithful, and correct and consistent condom use, especially for casual sexual activity and other high-risk situations. There is growing body of evidence that supports the ABC approach as the best approach. By adopting this approach, Uganda AIDS prevalence declined from 15% in the early 90's to 5 % by 2001.

ABC strategies were rooted in a community- based national campaign: government worked closely with community and faith-based organizations. The effect was to create what researchers call a "social vaccine" against HIV: a set of cultural values that encouraged more responsible sexual attitudes and behaviors. The best evidence suggests that the crucial factor was a national campaign to discourage risky sexual behaviors that contribute to the spread of the disease.

Educational Approach to AIDS vs. Sexually Active Single Persons Sources: HIV/AIDS Survey Education Data Base. Based on last survey available

The most significant of the ABC elements appears to be faithfulness or partner reduction behaviors. Data shows a decline by well over 50 percent. This conclusion is supported by comparisons with other African countries.

The message is clear, the only way to avoid acquiring HIV through sexual contact is abstinence from sexual involvement or restricting sexual activity to a mutually faithful, monogamous, life-long relationship with a similarly uninfected heterosexual partner. In most cultures and for all recorded history, this relationship is known as marriage

Thailand Case: “100 percent condom programme” Over half of the prevalence of HIV in Thailand is due to injected-drug-use (IDU’s). The other is prostitution. Measures taken to mitigate the prevalence of HIV/AIDS include an automated dispensing of condoms with cash at ATM machines. Instead of fighting prostitution or discouraging it, the “[a] generally tolerant approach was taken toward sex work”, by supporting it through the strong push for condom use. (UNDP, 2004) Mental illness as well as divorce, common indicators of social health, are on the rise. Condoms will not help.

Allocation of Funds  World Bank lending for malaria amounted to $300 million and for tuberculosis it amounted to $560 million.  The WHO funds totaled $369 million in  For HIV/AIDS, the World Bank allocated $1.5 billion in grants, loans, and credits to fight HIV/AIDS over the past five years.  Cost of Antiretroviral regimen has decreased significantly ($12,000 per year to $500).  Annual population assistance levels reached $2 billion a year.  The misuse of funds does not only affect health but also other fundamental elements of economic growth.

Expenditure on Grant-Financed Development Activities of the United Nations System by Sector (Percentage of Total)

Expenditures on Grant-Financed Development Activities of the United Nations System by Sector Source: Compiled from Comprehensive Statistical Data on Operational Activities for Development, years

Aging Trap  Social security system funding: the family cannot support the elderly  Competition between the younger and older people  Early retirement  To provide for the economic needs of the elderly, there is a reduction of funding allocated to training new generations  The transmission of cultural, scientific, technical, artistic, moral, and religious goods is endangered: "moroseness” results. Add to this immigration.  Saving rates are affected by a society's age structure, mirroring the change in an individual's saving rate over the life cycle.

Speed of Population Aging Number of years for % of population aged 65 and over to rise from 7% to 14% Source: US Census Bureau, 2000

How Could Government Policies and Civil Societies Help to Effectively Address the Health Needs of Developing Countries ?  Address the real health needs of developing countries: research and funds allocation.  In terms of AIDS, support programs that promote and foster healthy sexual lives such as the ABC program instead of the “save-sex” message. This carries political as well as moral implications: Failure to confront the pandemic in nations ravaged by AIDS is a recipe for economic decline and social chaos.  Engage Civil as well as Faith-Based Initiatives in these efforts.  Develop Legislation that Promotes and Supports families vis a vis other types of living styles.