Chapter one: why invest in women's health and nutrition?

Evidence from around the world has demonstrated that investment in health is fundamental to improving human welfare and economic growth, as well as to reducing poverty (World Bank 1993b). This report focuses on how public investment in women's health and nutrition, in particular, can contribute to sustainable economic growth by:

* Improving equity and the quality of life. Initiatives to improve women's health could save millions of women from needless suffering or premature death and enable them to lead fully productive lives. Women are at particularly high risk for certain health problems, largely because of their low socioeconomic status and reproductive role.

* Conferring widespread benefits. Investments in women's health have multiple payoffs. In addition to improving women's well-being and productivity, such investments also yield significant benefits for families, communities, and the national economy. In particular, women's health has a major impact on the health and productivity of the next generation.

* Improving efficiency. Redirecting public spending to highly cost-effective interventions improves allocative efficiency. Measures that address women's health problems are among the most cost-effective investments available in developing countries.

Differentials in Health

Fertility and infant and child mortality rates have dropped substantially in developing countries over the past three decades. From 1962 to 1992, infant mortality in the developing world decreased by 50 percent, and fertility rates fell by 40 percent (un 1993). Fertility regulation has contributed to women's health by reducing the number of pregnancies--and the associated risks--and giving women more control over their lives.

Progress has been much slower in other areas significant to women's health. Maternal mortality ratios and rates reflect the widest disparity in human development indicators between industrial and developing countries. (1) In SubSaharan Africa, for example, where the ratio is 700 maternal deaths per 100,000 live births, a woman runs a 1 in 22 risk of dying from pregnancy-related causes during her lifetime. In Northern Europe, the risk falls to 1 in 10,000 (un 1993; Herz and Measham 1987). Except in countries with relatively low maternal mortality ratios (fewer than 100 maternal deaths per 100,000 births), the World Health Organization (who) has found scant evidence of any progress in reducing maternal mortality in recent years (who 1992c). In Bangladesh, for example, although the total fertility rate declined by one-third and child mortality by almost one-half in just over two decades, the maternal mortality ratio remained virtually unchanged (Khan, Jan an, and Begum 1986; World Bank 1992; World Bank 1993a).

As it now stands, most women in the developing world lack ready access to a selection of fertility control methods and to basic maternity care. Many countries have largely neglected interventions that could control other problems to which women are particularly vulnerable, such as sexually transmitted diseases (STDs), malnutrition, and gender violence. Moreover, the women's health initiatives that are in place are inadequate and tend to focus on married women of childbearing age. Girls, adolescents, older women, and unmarried or childless women of reproductive age rarely receive the attention of public health administrators.

Women's health status is affected by complex biological, social, and cultural factors that are highly interrelated (Figure 1.1). To reach women effectively, health systems must take into account the biological factors that increase health risks for women and such sociocultural determinants of health as age at marriage, as well as psychological factors, such as depression arising from gender violence. Over the longer term, broader efforts--particularly increased female education--will help reduce many of the barriers to women's health.

[FIGURE 1.1 OMITTED]

Biological Determinants of Women's Health

Under optimal conditions for both men and women, a woman's life expectancy at birth is 1.03 times that of men (Coale and Demeny 1983; World Bank 1993b). In many parts of the world the statistics are even more favorable for females; in most industrial countries their life expectancy is more than 1.06 times that of men, and up to 1.10 times higher in Canada. In most developing countries, however, the ratio is much lower, dropping below 1.00 in parts of Asia with a low of 0.97 in Bhutan---a sign of socioeconomic conditions particularly inimical to women and girls (Keyfitz and Flieger 1990).

While the major health risks related to pregnancy are well known, other health problems associated with women's reproductive biology may be less recognized. Menstruation, for example, renders women more susceptible than men to iron-deficiency anemia. Certain conditions, including anemia, malaria, and tuberculosis, can be exacerbated by pregnancy. Complications of pregnancy may also cause permanent damage, such as uterine prolapse and obstetric fistulae.

Because of biological factors, women have a higher risk per exposure of contracting STDs, including MV, than do men. In addition, because women with STDs are more likely to have no symptoms, they may delay treatment until an advanced stage, with more severe consequences. Human papillomavirus infection results in genital cancer much more frequently in women than in men, and it is the single most important risk factor for cancer of the cervix, which accounts for more new cases of cancer each year in developing countries than any other type of cancer (Parkin, Laara, and Muir 1988). And although women of reproductive age are thought to receive some protection against cardiovascular disease from the hormone estrogen, their risk increases after menopause. By age 65, a higher proportion of women than men die as a consequence of cardiovascular conditions (Lopez 1993).

Although the reasons are not well understood, women tend to have fewer injuries than men. The behavior patterns of men, including higher alcohol consumption, place them at a higher risk for most injuries, but biology may also play a role (Stansfield, Smith, and McGreevey 1993).

Socioeconomic Influences on Women's Health

The cultural and socioeconomic environment affects women's exposure to disease and injury, their diet, their access to and use of health services, and the manifestations and consequences of disease. Indoor cooking, for example, is one of the most serious occupational health and environmental hazards in the developing world because of the acute and chronic--and sometimes fatal-consequences of inhalation of smoke and toxic gases, as well as accidental burnings (WHO 1986; World Bank 1992).

Women's disadvantaged social position, which is often related to the economic value placed on familial roles, helps perpetuate poor health, inadequate diet, early and frequent pregnancy, and a continued cycle of poverty. From infancy, females in many parts of the world receive less and lower-quality food and are treated less often when sick, and then only at a more advanced stage of disease. In countries where women are less educated, receive less information than men, and have less control over decisionmaking and family resources, they are also less apt to recognize health problems or to seek care. Cultural factors, such as restrictions in some Middle Eastern countries on women's traveling alone or being treated by male health care providers, inhibit their use of health services.

Women's low socioeconomic status can also expose them to physical and sexual abuse and mental depression. Unequal power in sexual relationships exposes women to unwanted pregnancy and STDs, including HIV and acquired immunodeficiency syndrome (aids). With changing social values and economic pressures, girls are engaging in sexual relationships at earlier ages. The worst manifestation of this phenomenon is the growing number of young girls forced into prostitution, especially in Asia.

The general level of underdevelopment may pose additional health risks for women. For example, poor roads and lack of transport, as well as inadequate obstetric facilities, hinder women from receiving timely medical treatment for pregnancy-related complications. Inadequate water supply, lack of electricity, and poor sanitation impose extra burdens on women because of their household responsibilities, such as fetching water and fuelwood.

Women's disproportionate poverty further curtails their access to health services. Their wages for the same or similar work are substantially lower than men's, and much of their work is outside the formal sector and not financially remunerated. Furthermore, because of their multiple tasks and responsibilities, women face high opportunity costs for time spent on health care. Girls begin working at an earlier age than boys and spend more hours working each day (paid and unpaid) throughout their lives in all regions (UN 1991). Studies in Kenya and Peru confirm that distance and user fees are a larger obstacle to women than to men in seeking medical care (Mwabu, Ainsworth, and Nyamete 1993; Gertler and van der Gaag 1990).

The strongest evidence of gender differentials in health status and the use of health services has been documented for both children and adults in South Asia. A study in India found that protein-energy malnutrition was four to five times more prevalent among girls, and yet boys were fifty times more likely to be hospitalized for treatment (Das Gupta 1987). Studies in other countries have also found that even where there is no apparent gender difference in the prevalence of infectious disease, women may be less likely than men to seek care. In Colombia and Thailand, for example, about six times as many adult men as women attend malaria clinics for treatment (Vlassof and Bonilla 1992; Ettling and others 1989).

The Widespread Impact of Women's Health

Improving women's health has significant benefits not only for women but also for their children and the national economy. Standard cost-effectiveness calculations often fail to take these effects into account.

Child Survival and Family Welfare

To a large extent, the well-being of children depends on the health of their mothers. In developing countries, a mother's death in childbirth means almost certain death for the newborn and severe consequences for her older children. A recent study in Bangladesh of children up to age 10 found that a mother's death sharply increases the chances that her children, especially her daughters, will die within two years. Children whose mothers die are three to ten times more likely to die within two years than those with living parents (Figure 1.2). A father's death only has a significant effect on the survival prospects of his children between the ages of 5 and 9, and the impact is just half that of the mother's death (Strong 1992).

When mothers are malnourished, sickly, or receive inadequate care in pregnancy, their children face a higher risk of disease and death. The effect on perinatal outcomes is particularly strong. Each year, 7 million infants die within a week of birth and more than 20 million low-birthweight babies are born. The prospects for many of these babies could be bettered by improving women's health and nutrition and providing good maternity care (WHO 1993a; WHO and UNICEF 1992).

[FIGURE 1.2 OMITTED]

Maternal anemia and small pelvic size among women whose growth has been stunted increase the risk of infant mortality. Iodine-deficient mothers are at greater risk of giving birth to infants with severe mental retardation and other congenital abnormalities. Pregnancy in early adolescence has additional harmful effects and sets in motion an intergenerational cycle of ill health and growth failure. Proper nutrition and health care can interrupt this cycle.

A woman's health status affects not only her children's health but also other aspects of their welfare. The preliminary results of a study in Tanzania suggest that a woman's death has an important influence on children's education, particularly at the secondary school level. In households where an adult woman had died within the past twelve months, children spent only one-half as much time in school as did children from households where such a death had not occurred. The effect did not appear significant when an adult male died (Ainsworth and Over 1994).

As the principal providers of family health care, women tend to the sick and disabled and protect children's health. Although not officially recognized as health workers, women are responsible for 70 to 80 percent of all the health care provided in developing countries. Therefore, improving their health status and educating them to prevent and detect infectious diseases and practice proper hygiene and nutrition is a cost-effective approach to improving family health (Leslie, Lycette, and Buvinic 1988).

Productivity and Poverty Reduction

Reducing fertility and improving women's health can improve individual productivity and family well-being and, particularly when combined with education and access to jobs, can also accelerate a nation's economic development Women's current contributions are substantial but only partially reflected in official economic statistics, and women's potential is underutilized. Women are responsible for up to three-quarters of the food produced annually in the developing world. In parts of Africa, women produce 80 percent of the food consumed domestically and at least 50 percent of export crops. Women also constitute one-third of the world's wage-labor force and one-fourth of the industrial labor force. Much of women's work--both within and outside the home--is unpaid and therefore not counted. If the gross domestic product (GDP) included domestic work, it would increase by 25 percent (UN 1991).

Poor health reduces women's capacity to carry out their multiple productive and reproductive responsibilities. Studies of women tea workers in Sri Lanka and cotton mill workers in China, for example, have documented the reduced productivity associated with iron deficiency and the positive effects of iron supplementation on work output (Edgerton and others 1979; Li and others 1994). Frequent pregnancies and poor health not only drain women's productive energy but also contribute to their poverty. A study in one area of India found that disability reduced the female labor force by 22 percent In addition, illness was found to be the second highest cause of indebtedness--with especially profound effects on women because they predominate among the poor (Chatterjee 1991).

Women's health is central not only to their wage earning but also to the performance of their many household tasks. Within the family, women bear the principal responsibility for maintaining the home and caring for society's dependents--children and the elderly. They collect water and fuel (Tanzanian women, for example, use up to 20 percent of their caloric intake collecting water), they cook and feed the family, and they perform other tasks essential to household maintenance. These familial responsibilities carry high opportunity costs, as reflected in absenteeism from the work force associated with pregnancy or the care of sick children, for example.

Evidence suggests that efforts to improve the health and nutritional status of women could be critical to the goal of poverty reduction. The weight of poverty falls more heavily on women than on men. In addition to low health and nutritional status, poor women have low education levels. In the developing world there are only 86 females per 100 males in primary school, 75 in secondary school, and 64 in tertiary education. Finally, women have less access to remunerative activities.

Female-headed households are becoming more prevalent and already represent 20 percent of all households in Africa and in Latin America and the Caribbean (un 1991). Among the poor, female-headed households are at a greater, economic disadvantage than male- or jointly headed households because of the lower earnings of women and the dual nature of their work burden, which imposes severe time constraints, restricting their access to social and health services (Rosenhouse 1989).

Despite these disadvantages, women contribute a large share of household income for family survival. Evidence from diverse country settings--Burkina Faso, Cameroon, India, Lebanon, Nepal, and the Philippines--suggests that when the time spent on home production is valued, women contribute between 40 to 60 percent of household income (World Bank 1994). Women are also more likely than men to spend their income on family welfare. In Guatemala it takes fifteen times more spending to achieve a given improvement in child nutrition when income is earned by the father than when it is earned by the mother (World Bank 1993b).

Investing in women is a major theme of the World Bank's two-pronged strategy for poverty reduction, which includes (a) the introduction of broadly based, labor-absorbing economic growth to generate income-earning opportunities for the poor and (b) improved access to education, health care; and other social services to help the poor take advantage of these opportunities (World Bank 1994). The adverse effects of ill health, both on income and on personal and household welfare, are greatest for the poor. There is evidence that improved health and nutrition reduces infant and child mortality and contributes to demand for smaller families. Smaller family size in turn helps reduce poverty by saving household resources. A growing body of research also points to the positive effects of health and nutrition on the labor productivity of the poor (Behrman 1990). Therefore, to the extent that women are overrepresented among the poor, interventions for improving women's health and nutrition are critical to efforts for poverty reduction.

The Cost-Effectiveness of Women's Health Interventions

An analysis of the eighteen most cost-effective interventions that affect the leading causes of death and disability for both sexes found that childhood interventions have similar benefits for males and females. Men benefit more than women from the treatment of tuberculosis after age IS and from prevention of conditions related to tobacco and alcohol consumption after age 45. From age 5 onward, however, females benefit more than males from the prevention and treatment of STDs and iron-deficiency anemia. In addition, women derive substantial benefits from interventions that target health problems exclusive to women, such as cervical cancer.

For the major causes of death and disability for males and females by age group in developing countries, there is a greater convergence of the relative disease burden and cost-effective interventions for females than for males (Table 1.1). Highly cost-effective interventions--those costing less than $100 per disability-adjusted life year (DALY) saved--can benefit more females than males between the ages of 5 and 44. The health problems of women aged 15 to 44--especially those related to reproduction--are particularly responsive to cost-effective prevention and treatment. For these reasons, many of the interventions included in the minimum package of health services considered essential by the World Bank (Box 1.1) either directly benefit girls and women or are targeted to them as a means of improving infant health. In low-income countries, for example, one-third of the cost of the recommended minimum

BOX 1.1 ASSESSING THE DISEASE
BURDEN AND INVESTING IN
INTERVENTIONS

Assessments of the relative importance
of different health problems are
usually based on how many deaths
they cause. Many health problems,
however, are notfatal but cause much
disability. As part of background work
for the the 1993 edition of its annual
World Development Report, the World
Bank, in collaboration with who, carried
out a comprehensive analysis of
the disease burden--the amount of
both premature death and disability
due to specific diseases and injuries,
measured in disability-adjusted life
years (DALYS).

The burden of disease was calculated
as the present value of future
DALYS lost as a result of death, disease,
or injury in 1990. The calculations
incorporated disability weights
(to value the severity of an illness relative
to loss of life), discounting (to
value future years of healthy life relative
to the present), and age weights
(to give years lost at different ages
different relative values). Using this
method, the disease burden was assessed
for more than 100 causes of
ill health, and the data broken down
by age, sex, and region. Preliminary
results appear in World Development
Report 1993 (World Bank 1993b). A
full accounting will be published jointly
by who and the World Bank.

Disease burden estimates can be
used to monitor global and country-level
progress in improving health,
and, in combination with information
on cost-effectiveness, to help set priorities
for the health sector. Following
this approach, the World Bank assessed
the costs and benefits of a
wide range of health interventions to
determine which were the most cost-effective.
It then proposed a minimum
package of essential health services
that included:

* Public health services--immunization,
school health, aids prevention,
tobacco and alcohol control, and other
public health programs (including family
planning, health and nutrition information).

* Clinical services--short-course
chemotherapy for tuberculosis, management
of the sick child, prenatal
and delivery care, family planning,
treatment of STDs, and limited care
for adults.

Where instituted, this minimum
package, which is estimated to cost
$12 per capita in low-income countries
and $22 per capita in middle-income
countries, could reduce the
burden of disease in low-income countries
by more than 30 percent and
about 15 percent in middle-income
countries. Public financing is needed
to ensure the availability of public
health interventions, given that such
services are so nearly public goods
that private markets will provide too
little of them. Governments must also
finance clinical services in the minimum
package for the poor. In middle-income
countries, where resources
are less constrained, additional public
expenditure can go either toward
extending coverage to the nonpoor or
toward expansion beyond the minimum
package to a national package
of health care that includes somewhat
less cost-effective interventions for
more diseases and conditions.
package is accounted for by family planning,
maternity care, and management
of STDs; in middle-income countries these interventions account for half
of the estimated costs (World Bank 1993b).

In sum, improvements in women's health increase personal and family well-being and productivity today and help to ensure healthier generations tomorrow. National economies, communities, and households--all of them highly dependent on women's paid and unpaid labor--benefit from investment in women's health.

(1.) The maternal mortality ratio is the number of women who die in pregnancy and childbirth per 100.000 live births. It measures the risk women face of dying once pregnant. The maternal mortality rate is the number of women dying in pregnancy or childbirth per 100,000 women aged 15-49. The rate reflects both the maternal mortality ratio and the fertility rate.

TABLE 1.1 MAJOR HEALTH PROBLEMS WITH INTERVENTIONS OF HIGH TO
MEDIUM COST-EFFECTIVENESS, IN DEVELOPING COUNTRIES, 1990

                                  Cost-effectiveness
                                    of intervention

                                Diseases     Diseases
Age group/                      affecting     greater
main causes                      females       among
of disease                        only      females (a)

Ages 0-4
  Respiratory infections           --           --
  Perinatal causes                 --           --
  Diarrheal disease                --           --
  Childhood cluster/1              --           --
  Malaria                          --           --
  Protein-energy malnutrition                   --
  Vitamin A deficiency             --           --
  Iodine deficiency                --           --
  STDS and HIV                      --           --
Ages 5-14
  Intestinal helminths             --           --
  Childhood cluster *              --           --
  Respiratory infections           --           --
  Diarrheal disease                --           --
  Tuberculosis                     --          High
  Malaria                          --           --
  Anemias                          --          High
  STDS and HIV                     --          High
Ages 15-44
  Maternal causes                 High          --
  STDS                             --          High
  Tuberculosis                     --           --
  HIV                              --           --"
  Depressive disorders             --         Medium
  Respiratory infections           --           --
  Anemia                           --          High
Ages 45-59
  Tuberculosis                     --           --
  Ischemic heart disease           --           --
  Cataracts                        --          High
  Chronic obstructive
    pulmonary diseases             --           --
  Diabetes mellitus                --         Medium
  Cancer of the cervix             --           --
  Malignant neoplasm (liver)       --           --
Ages 60+
  Ischemic heart disease           --           --
  Respiratory infections           --           --
  Diabetes mellitus                --         Medium
  Tuberculosis                     --           --
  Cataracts                        --           --
  Malignant neoplasms
    (trachea, bronchus, lung)      --           --

                                    Cost-effectiveness
                                     of intervention

                                    Diseases       Diseases
Age group/                          similar         greater
main causes                       among males        among
of disease                      and females (b)    males (c)

Ages 0-4
  Respiratory infections              High            --
  Perinatal causes                    High            --
  Diarrheal disease                   High            --
  Childhood cluster/1                 High            --
  Malaria                             High            --
  Protein-energy malnutrition         High            --
  Vitamin A deficiency                High            --
  Iodine deficiency                   High            --
  STDS and HIV                        High            --
Ages 5-14
  Intestinal helminths                High            --
  Childhood cluster *                 High            --
  Respiratory infections              High            --
  Diarrheal disease                   High            --
  Tuberculosis                         --             --
  Malaria                             High            --
  Anemias                              --             --
  STDS and HIV                         --             --
Ages 15-44
  Maternal causes                      --             --
  STDS                                 --             --
  Tuberculosis                        High            --
  HIV                                  --            High
  Depressive disorders                 --             --
  Respiratory infections              High            --
  Anemia                               --             --
Ages 45-59
  Tuberculosis                         --            High
  Ischemic heart disease               --           Medium
  Cataracts                            --             --
  Chronic obstructive
    pulmonary diseases               Medium           --
  Diabetes mellitus                    --             --
  Cancer of the cervix                 --             --
  Malignant neoplasm (liver)           --            High
Ages 60+
  Ischemic heart disease             Medium           --
  Respiratory infections              High            --
  Diabetes mellitus                    --             --
  Tuberculosis                         --            High
  Cataracts                           High            --
  Malignant neoplasms
    (trachea, bronchus, lung)          --            High

Note: The causes of disease shown here have been chosen from the ten
main causes among women and the ten main causes among men based on
the availability of an intervention of high or medium
cost-effectiveness. Interventions of high cost-effectiveness are
those that can be implemented for less than $100 per disability-adjusted
life year (DALY) saved: those of medium cost-effectiveness,
for $100-999 per DALY saved.

(a.) For which the ratio of female to male burden of disease is 0.8 or
less.

(b.) For which the ratio of female to male burden of disease is
between 0.8 and 1.2.

(c.) For which the ratio of male to female burden of disease is 0.8 or
less.

d. Vaccine-preventable diseases of childhood

Source: World Bank 1993b.