588 2259 1 PB
588 2259 1 PB
588 2259 1 PB
DOI: 10.5455/2349-3291.ijcp20140808
Research Article
1
Department of Pediatrics, Father Muller Medical College, Mangalore-575002, Karnataka, India
2
Department of Obstetrics and Gynecology, Kasturba Medical College, Mangalore-575002, Karnataka, India
*Correspondence:
Dr. Anil Shetty,
E-mail: anilshettyk@hotmail.com
Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Background: Infant Mortality Rate (IMR) is one of the most vital health indicators. A number of factors impact and
influence IMR. One of the most important ones could be public health spending. Health spending however is not
uniform throughout Asia and varies from region to region.
Methods: Data obtained from the World Health Organization and World Bank Databases were used to assess the
effect of state health spending on IMR. Factors such as per capita spending on health, proportion of GDP directed at
health and private spending as a percentage of total health spending and their influence on IMR were also studied.
Results: Data from 34 Asian countries was included in the study. Singapore (2) and South Korea (3) had the least
IMR in the region. Afghanistan (71) had the highest IMR and also the least per capita governmental spending on
health and Qatar the highest spending on health.
Conclusion: Per capita state spending on health was the most important determinant of IMR in our study and
countries with higher per capita spending on health had significantly lower levels of IMR.
International Journal of Contemporary Pediatrics | July-September 2014 | Vol 1 | Issue 2 Page 100
Shetty A et al. Int J Contemp Pediatr. 2014 Aug;1(2):100-105
METHODS
International Journal of Contemporary Pediatrics | July-September 2014 | Vol 1 | Issue 2 Page 101
Shetty A et al. Int J Contemp Pediatr. 2014 Aug;1(2):100-105
low level of private spending but that is probably because Table 3 shows total and private health spending in the
of the high state spending on health in the monarchy. Middle East, not surprisingly a significant amount of the
oil wealth is channeled towards health spending. Health
spending as a percentage of GDP is highest for Iraq,
probably because that nation is rebuilding its resources.
The least private health spending on health is seen in
Oman. Countries in the Gulf subsidize health to a high
extent and this is reflected in low levels of private
spending in those countries.
Private spending
Health spending
Countries on health as % of
as % of GDP
all spending
Iran 5.6 59.9
Figure 2: Government health spending and infant Iraq 8.4 18.8
mortality rate for south East Asian countries.
Jordan 8.0 32.3
Kuwait 2.6 19.6
Table 2: Total health spending and private health
spending in South East Asian countries. Lebanon 7.0 60.8
Qatar 1.8 22.5
Private spending Saudi Arabia 4.3 37.1
Health spending
Countries on health as % of Syria 3.4 54.0
as % of GDP
all spending UAE 3.7 25.6
Brunei 2.8 15.1 Yemen 5.2 75.8
Cambodia 5.6 62.8 Oman 2.8 19.9
Indonesia 2.6 50.9
Laos 4.5 66.7 Figure 4 shows the IMR and per capita government
Malaysia 4.4 44.5 spending on health in U.S. dollars for the Central Asian
Myanmar 2.0 87.8 Region. South Korea spends the highest per capita on
Philippines 3.6 64.7 health and therefore benefits from the lowest IMR and
Singapore 4.0 63.7 Vietnam which spends the least has the highest IMR in
the region. China, the most populous country in the world
Thailand 3.9 25.0
benefits from a rapid acceleration of economic growth
and has a relatively low IMR.
Figure 3 shows the IMR and per capita government
spending on health in U.S. dollars for the Middle East.
There is a clear divide here between the countries which
have access to a valuable resource like oil and countries
which are devoid of such a blessing. Qatar has the highest
spending on health and enjoys the best IMR while Yemen
which spends the least has the highest IMR in the region.
International Journal of Contemporary Pediatrics | July-September 2014 | Vol 1 | Issue 2 Page 102
Shetty A et al. Int J Contemp Pediatr. 2014 Aug;1(2):100-105
Table 4: Total health spending and private health Malawi for instance between 2000 and 2010 NMR
spending in South Asian countries. reduced 3.5% annually.12 This indicate that IMR has
declined globally and the rate of decline is similar in third
Private spending world countries. In our study what is clearly visible is
Health spending
Countries on health as % of that the per capita spend on health had a much larger
as % of GDP
all spending impact on IMR than percentage of GDP budgeted for
China 5.1 46.4 health. Qatar and Oman’s health spend was only 1.8%
Kazakhstan 4.3 40.6 and 2.8% of GDP, but when translated into per capita
Mongolia 5.4 44.9 spending the figures were 1257 and 479 dollars.
Uzbekistan 5.8 52.5 Conversely Afghanistan, Cambodia and Iraq spent 7.6,
Vietnam 6.8 62.2 5.6 and 8.4 percent of GDP on health, but per capita
figures were 545 and 276 US dollars and the IMR for
South Korea 6.9 41.0
these countries was among the highest in the region. It is
not just Health spending that determines the IMR and
DISCUSSION there are various other factors involved. In a study done
in 16 Arab countries, the infant mortality rate in 1978 and
In the present study Asian countries with a higher per 1998 were studied, the impact of social, demographic and
capita state spending on health had a lower IMR and economic factors on the IMR was also studied and IMR
generally had a higher proportion of their GDP directed was inversely related to literacy status, annual gross
at health needs. Countries with higher per capita income national product per capita and access to safe drinking-
like Singapore, South Korea and Arab nations like Qatar water and adequate sanitation facilities.13 In another
and the UAE could afford higher health budgets and study, cross-national data was used to examine the impact
generally performed better than their peers. Health of both public spending on health in determining child
budgets have generally burgeoned globally. In a study and infant mortality and the study revealed that 95% of
funded by the Bill and Melinda Gates foundation and cross-national variation in mortality can be explained by
published in the Lancet, showed that from 1995 to 2006 a country's income per capita, inequality of income
in all developing countries, public financing of health in distribution, extent of female education and level of
constant US$ from domestic sources increased by nearly ethnic fragmentation.14 National-level data from 152
100% .8 Canada has one of the best health system and is countries based on World Development Indicators 2003
the envy of most countries. In Canada, about 70% of total were used for multivariate linear regression analyses and
health expenditure comes from the general tax revenues public health spending, gross national income/capita,
of the federal, provincial and territorial governments. 9 poverty, inequality and female illiteracy were the
Countries with small populations such as Qatar and socioeconomic predictors listed in order of importance
Brunei spent a lower proportion of their GDP on health determining mortality.15 In infants and children there are
but when translated into per capita spending it still ranked other factors that may also influence mortality, these
as the highest in their regions. Middle Eastern countries factors may include cultural and social practices
had a lower private spending on health but this was including gender preference. Health manpower may also
because of the state subsidizing health to a higher degree. play a significant role. A study in Lancet examined the
Poorer countries had a higher proportion of private role of human resources for health and determined that
spending on health and this is due to the lack of access to health worker density was significantly associated with
quality public health care. Democracies outspent coverage vaccinations.16
monarchies and one party regime’s in terms of proportion
of GDP directed at health spending and this is probably There are many studies that show public health spending
because of greater accountability and incumbent having a major influence on IMR, a recent study done in
governments having to periodically face the electorate. the Eastern Mediterranean Region assessed the impact of
The returns on investment on health are not uniform for public and private health expenditure on infant mortality
all age groups. Adults and older children benefit more rate and concluded that public health expenditures in the
from health investment and health infrastructure for Eastern Mediterranean countries improved health
example, in the Indian subcontinent, in Bangladesh, the outcome, while the private health expenditures did not
national neonatal mortality rate has undergone an annual have any significant relationship with health status.17 In a
decline of 4.0% since 2000, reflecting greater progress similar study covering 44 countries in Sub Saharan Africa
than both the regional and global averages, but the the results showed that both public and private health
mortality reduction for children 1-59 months was double care spending showed strong positive association with
this rate, at 8.6%.10 Bangladesh spent 19 $ per capita or health status even though public health care spending had
3.5% of its GDP on health. Similarly in Nepal, neonatal relatively higher impact.18 In the present study too
mortality rate reduced by 3.6% per year, which was faster countries that had a relatively high percent of government
than the regional average (2.0%) but slower than national spending on health had better infant mortality indicators,
annual progress for mortality of children aged 1-59 on the other hand countries which had a high proportion
months (7.7%) and maternal mortality (7.5%). 11 Nepal of private spending on health did not necessarily have a
spent 22 $ per capita or 5.5% of its GDP on health. lower IMR. Governmental health spending on health in
Similar data and results are seen all over the world, in
International Journal of Contemporary Pediatrics | July-September 2014 | Vol 1 | Issue 2 Page 103
Shetty A et al. Int J Contemp Pediatr. 2014 Aug;1(2):100-105
terms of per capita was the most important determinant of dollars per individual on health. This results in dismal
IMR. South Korea, Qatar, Singapore and Maldives spent health outcome and indicators.
the highest amount per capita on health in their regions
and they also had the best IMR figures in their regions. CONCLUSIONS
Higher governmental spending determines that the
section most vulnerable, the poor and the lower middle The present study demonstrates that the benefits of a
class can avail the benefits of affordable or subsidized declining IMR accrue when the per capita health
health care. In the 1990s Italy privatized a significant spending is robust, even low income countries which
portion of its healthcare delivery system the authors of an allocate a reasonable proportion of state spending on
epidemiological study calculated the average rate of health enjoy a relatively lower IMR. In every region,
change in avoidable mortality rates in 19 of Italy's countries which allocate and apportion more towards
regions for a decade and concluded that public spending health have lower IMR than their peers. The proportion
was significantly associated with reductions in avoidable of GDP directed at health indicates that there is a scope
mortality rates, while greater private sector spending was among many countries for increased earmarking of funds
not.19 In the present study Afghanistan, Myanmar, Yemen for health. The gains of higher health budgets would be
and Vietnam had the highest proportion of private many- a rapid reduction in IMR would be one of the most
spending as a percentage of total spending and also had vital. In this study private spending on health did not
the highest IMR in their regions. This indicates that when have a significant benefit on IMR and this is probably
a good public health care system and infrastructure is not due to factors such as affordability and affluence
available or found wanting, then citizens have to depend impacting private health care. State health spending on
on private health care which may not be always the other hand is more focused at vulnerable sections of
affordable and consequently results in poorer health society and results in more perceptible and tangible gains
outcomes. In a study on achieving the millennium and outcomes.
developmental goals in India, the authors pointed out that
poverty, low literacy, poor nutritional status , urban-rural Funding: No funding sources
divide and lower budgetary allocations are the reasons Conflict of interest: None declared
most responsible for high IMR and increasing Ethical approval: The study was approved by the
governmental spending has started showing encouraging institutional ethics committee
results.20 A cross-country study in seven Pacific island
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Esmaeilzadeh F, Hadian M, Torabi Pour A.
Comparison of the effects of public and private DOI: 10.5455/2349-3291.ijcp20140808
health expenditures on the health status: a panel data Cite this article as: Shetty A, Shetty S. The correlation
of health spending and infant mortality rate in Asian
countries. Int J Contemp Pediatr 2014;1:100-5.
International Journal of Contemporary Pediatrics | July-September 2014 | Vol 1 | Issue 2 Page 105
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