Health and development are positively correlated. Healthy populations are more productive, as they lose less time to illness. This allows for a more active economy and faster growth. People in healthy societies also live longer, reducing the costs to firms associated with constantly training new workers and allowing families to accumulate more wealth. People in these cultures can also use the money that they save on healthcare that is not invested or put into savings in the market which can stimulate the economy.
Beyond these indicators, and possibly most importantly, it seems that healthier populations would generally be happier ones. Thus it appears that not only does health correlate with development, but that it is a key component of it.
With this in mind, it appears as though making efforts to improve health outcomes would be an effective method of not only improving development, but also general quality of life. But how can health outcomes be improved in developing countries? Education and infrastructure are two potential fixes, but their success is dependent upon a number of exogenous variables.
Immunization, alternatively, has a direct impact on health outcomes, at a relatively low cost. This paper will examine the effectiveness of immunization through vaccination, as well as the impact incentivizing immunization on improving immunization rates.
Before a discussion about either vaccination or immunization can be had, it is important to first draw a distinction between the two. Healthdirect, an Australian government health service provides a succinct definition of both terms. Vaccination simply means getting a vaccine, usually through injection or orally.
Immunization, on the other hand, is a process that involves being vaccinated against a disease and subsequently becoming immune. A relatively simple process, immunization works by exposing an individual to a particular disease in a controlled way, either with dead bacteria or with a small amount of the live disease. The body is able to then develop a defense within the immune system. If the individual is exposed to the disease again in the future, the body can quickly deploy this countermeasure to avoid becoming sick.1
While some discussion of the merits of vaccination was provided in the introduction, it is useful to perform a more thorough analysis. This paragraph attempts to provide one. A previously mentioned, there are a number of alternatives when attempting to improve health outcomes in a population, all of which would ideally be administered in concert. However, this is not always possible or practical in a world of scarce resources. Improving health infrastructure faces a number of issues. It is theoretically the most expensive, as the materials, labor, and time required for such a project would be immense.
Additionally, decisions on where to place such infrastructure would be difficult, as they would likely be most effective in cities, but placing them there would create significant difficulty for rural individuals. Education does not face these issues, as education can be brought to the people rather than the people to it. That being said, it is a time consuming process with little immediate impact. Assuming people act as ration agents who discount the future, this makes their likelihood to participate in health education programs lower.
Additionally, education requires application. Even if education is received, the community must change their behavior to reflect what they have learned. If this means changing long standing traditions and practices, this could feasibly take months, years, or even generations. Both solutions also simply attempt to respond to issues that are already present, rather than prevent such issues in the first place.
Vaccination, on the other hand, does exactly that. According to the World Health Organization (WHO), only clean water is more effective at “reducing the burden or infectious disease.”2 The same WHO article notes many of the benefits of immunization. Immunized individuals are much less likely to contract the disease they were immunized against, and when they do it is usually less severe. Vaccination is an incredibly effective method of reducing childhood mortality, a key traditional indicator of health outcomes in a region.
Gunawardane et al’s explanation of the figure: “Correlation coefficients between U5MR (under 5 mortality rate) and DPT immunization rate for years 1960-2005. This world map depicts that U5MR is negatively correlated with DPT imm. for most countries as expected.”3 Lowering child mortality rates means there is less need for mothers to have high numbers of children to ensure the survival of at least a few. This in turn has positive health and economic impacts on mothers, by subjecting them to less pregnancy related risks and decreasing the child care related opportunity costs of working. The influx of women into the workforce should be beneficial to the economy. In the long run, immunization can eliminate diseases at the local level and potentially eradicate them at the global level. In addition to being medially and socially effective, immunization is similarly cost effective. A 2017 study by Wong et al found that in a comparison of 10 vaccination programs, 4 were cost saving as compared to the status quo, while the 3 of the remaining 6 fell well below the WHO willingness to pay threshold.4 This suggests that immunization is an economically efficient tool in addition to its medical and social efficiency.
Despite the immense benefits associated with immunization as a health improvement tool, immunization rates remain low in a number of regions. A study by Banerjee et al found that “in India only 44% of children aged 1-2 years have received the basic package. That drops to 22% in rural Rajasthan, the setting of the present study, and was less than 2% in our study area (a disadvantaged population in rural Udaipur) at baseline”.5 This is especially troubling given that immunization works best through a concept known as herd immunity. Herd immunity is the idea that as the proportion of the population which is vaccinated grows, it becomes more difficult for the disease vaccinated against to grow, as expressed in Figure 2.
FIGURE 2. 6
In this figure blue individuals are healthy but not vaccinated, red are sick, and yellow are vaccinated. As more people are vaccinated, there is less chance of a sick person interacting with a healthy but not vaccinated person, meaning that the disease spreads more slowly and infects less people in general. This is how the elimination and eradication of diseases (such as smallpox globally or polio in the west) has occurred. So why are vaccination rates so low? Herd immunity is ostensibly something to aim for, and proper herd immunity requires high rates of vaccination.
That being said, because of the nature of herd immunity, it may actually be disincentivizing people from vaccination. This is due to what is known as indirect effects. As the proportion of vaccinated individuals grow, the likelihood of infection lessens. This makes it relatively easy to reach a decent proportion of the population, but relatively difficult to reach the herd immunity threshold. This is because of a type of diminishing marginal returns. At first, the effect of a particular vaccination can be profound, but as the herd immunity threshold is approached, each individual vaccination makes less of a difference, rather the aggregate becomes more important.
For individuals in this range with lower marginal benefit, it may actually be the rational choice not to vaccinate. This is because it is likely that persons in this range typically live in poorer, rural areas (such as Rajasthan), where the costs associated with traveling to receive a vaccination are much higher. Additionally, many immunizations require several applications to become effective over a long period of time. This further increases the costs and significantly decreases the likelihood of full herd immunity. In spite of this, evidence still shows that herd immunity is the ideal situation. In fact, a study by Sanchez et al finds that herd immunization can have profound impacts on immunization’s aforementioned cost effectiveness.
As seen here, the cost of 1 LYS, or life year saved, decreases exponentially as the percent of the herd which has been immunized increases. This means that the benefits of reaching the herd immunity threshold far outweigh any costs to society to reaching the threshold.
It appears that the benefits associated with herd immunity are such that it is a goal that society should aim for. Despite this, high individual costs mean that this goal is often not attained. This raises the question of how best to improve immunization rates. As with improving health outcomes overall, education and infrastructure are both potential options. Education attempts to increase the valuation of immunization to a point where the perceived benefits outweigh the perceived costs.
Infrastructure improvement alternatively attempts to decrease costs to a point where they are less than benefits. Unfortunately, both alternatives once again fail to adequately address the issue education fails for much similar reasons as in the case of healthcare overall, as does infrastructure improvement.
Much like immunization itself provided a more direct alternative to education and infrastructure improvement, the previously cited study by Banerjee et al provides an effective alternative within the discussion of immunization:
The results of the study were startling, immunization rates in the control group were 6%, while Group A (no incentives) saw 18% immunized and Group B (Small incentives) saw a rate of 39%. This study shows that while access to vaccinations is important, incentivizing them can significantly increase the rate at which children are immunized. The study also found that children in surrounding areas to group B villages were more likely to be immunized than those around Group A villages. This is evidence that the incentives provided in Group B villages were enough to outweigh the costs associated with traveling to an immunization camp.5
So how effective were the incentives used in Group B? Group A immunizations cost around $28 each, with an immunization rate of 18%. Group B saw a cost of $56 per immunization (includes costs of incentives) and a rate of 39%.
In economics, a common metric used to determine the viability of a practice is it returns to scale. These returns are determined by examining the impact on output when inputs are doubled. Firms can experience increasing returns to scale ( a factor > 2), constant returns to scale (a factor =2), or decreasing returns to scale (factor < 2). Conveniently, in the case of the Banerjee study, the input price of Group B was exactly double that of Group A. As we can see, when inputs double from $28$56, outputs increase by a factor of 2.167, showing increasing returns to scale. Economic theory tells us that a firm should operate whenever it experiences increasing or constant returns to scale, meaning that the practice of incentivizing immunizations should be continued. Beyond the financial implications, using incentives of lentils and metal dishes such as those in the experiment can also improve health outcomes by providing high protein food to reduce hunger and providing easily cleanable dishware which can further prevent the spread of disease. These effects of additional benefits were not measured by the study as they were out of its scope, but there is theoretical justification to assume that the effects were positive.
The question still remains whether or not health outcomes should be the target of organizations aimed at improving international development in the first place. Seemingly, health and health related goods and services are normal rather than inferior, meaning that their consumption should increase with income.
However, this may not always be the case. While these goods may be normal, this does not account for extreme degrees of income inequality, which the approach of letting health follow development rather than vice versa at best ignores and at worst increases. In other words, when national income increases, health expenditure will likely also increase, but if income is unequally distributed, this may just mean that the rich are buying more healthcare while the poor buy the same or less. This is undesirable exactly because of health’s correlation with development. If the poor buy less healthcare than the rich, they reap fewer benefits of health as well, this makes them less productive, which effectively keeps them trapped in their impoverished state. Furthermore, a study by Subramanian and Deaton finds that in the case of caloric consumption (another key health indicator), it is unreasonable to assume that income is constrained by nutrition rather than the other way around.
By simply extrapolating the data on caloric consumption to health outcomes as a whole, it becomes clear that income constraining health outcomes has negative implications for policies which only target growth. Doing so may reasonably be expected to have negative health outcomes on the poor, which could develop into a feedback loop in which this poor health led to even poorer incomes and so on. Thus, it appears that while both targeting growth and targeting healthcare have the potential to improve development, targeting healthcare directly has the potential to have a profound impact medically and socially as well, whereas growth targeting will mostly see an economic impact. With this in mind, it is up to policy makers and voters to decide which alternative is preferable to them.
Health is positively correlated with development. Improving the health outcomes in a society has great economic and social impacts, and can be done at relatively low costs. Vaccination and the herd immunity associated with it have the potential to positively impact millions of lives at low costs, as well as stimulate the economies of developing countries by empowering women and increasing general productivity. Despite this, immunization rates in many areas remain dangerously low. This occurs because though the costs to society are typically low, the costs to individuals can be high. This can be overcome through various avenues, one of the most effective of which is by providing incentives. Along with being highly effective, incentives for immunizing children are likely to have positive secondary and tertiary benefits to communities and individuals.
Doing so appears succeed in allowing providers to overcome the sometimes high nonmonetary costs of having one’s child vaccinated. However, immunization alone cannot fix the world’s health and development problems. While vaccinating children is incredibly effective, such practices must be used in conjunction with proper education, resource management and the improvement of current health infrastructures to ensure that the maximum returns are generated. Though they may not be a fix all, incentivized vaccination camps such as those used in Rajasthan appear to be a cheap, effective start to addressing the low vaccination rates and work towards a healthier and more prosperous future.