This document summarizes a presentation on two papers that examine routes to low mortality in poor countries. The first paper by Caldwell in 1986 used data from 99 third world countries to analyze the relationship between mortality, income, and other factors. The second paper by Kuhn revises Caldwell's analysis using updated data and indicators. Kuhn finds that while some original superior and poor health achievers have converged, education, gender equality, health spending, poverty, and governance continue to influence countries' health achievement relative to their income levels. The discussion considers ways to improve analysis of factors driving health outcomes in developing nations.

1. Arip Muttaqien
JPEG Fellow
Paper Presentation:
Routes to Low Mortality in Poor Countries Revisited
Randall Kuhn, Population and Development Review 36(4): 655-692

2. What we discuss today
• Caldwell paper (1986), little bit for background, especially basic concept.
• Revised paper by Kuhn.
• Discussion and conclusion.

3. Caldwell, John C. 1986. “Routes to Low Mortality in Poor Countries”,
Population and Development Review 12(2): 171-220
Keyword: infant mortality, health, income

4. Caldwell’s Paper
• Source: World Development Report
1984 (The World Bank).
• 99 third world countries: ranking from
the worst to the best.
• Indicator: infant mortality rate (IMR),
child mortality rate (CMR), life
expectation at birth, and level of income.
• Check table 1 and table 23 from the
WDR.

5. Caldwell: Logic of Ranking The worst
Rank 1 Low-income economies
Rank 99
China and India
Other low-income
(rank 1-34)
Middle-income economies
Oil exporters
Oil importers
Lower middle-income
(rank 35-72)
Upper Middle-income
(rank 73-94)
High-income oil exporters
(rank 95-99)
The best
Bangladesh,
Zaire, India,
China, Bhutan,
etc.
Sudan, Egypt,
Thailand,
Turkey,
Lebanon, etc.
Malaysia,
Portugal, South
Africa,
Venezuela, etc.
Libya, Saudi
Arabia, Kuwait,
UAE, Oman.

6. Caldwell: Logic of Ranking The worst
Rank 1
Rank 126
The best

7. Caldwell: Logic of Ranking
GNP per
capita ($)
(1982)
IMR per 1,000
live births
(1982)
Expectation
of life at birth
(yrs)
(1982)
Rank Rank Rank
Rank of IMR
relative to
rank of
income
320 23 32 85 69 84 +62
Rank of life
expectancy
relative to rank
of income
+61
Superior health achiever: ≥+25
1,330 62 10 99 73 94 +37 +32
16,000 97 108 99 56 47 -61 -50
SRI LANKA
JAMAICA
SAUDI ARABIA
Superior health achiever: ≥+25
Poor health achiever: ≤-25
Superior health achiever: IMR rank – Income rank ≥ +25
Poor health achiever: IMR rank – Income rank ≤ -25

8. Jack Caldwell
• Unique methods and aggressive hypothesis-formation.
• Inspired demographers to do mixed research in quantitative and qualitative.
• Addressed contextual, historical, and political condition.

9. Mortality levels
relative to income
level for 99 third
world countries,
1982
Superior health achiever
Poor health achiever
• Most significant achievement:
Costa Rica, Sri Lanka,
Kerala.
• Caldwell emphasized the
symbiosis between cultural &
health.
• Education as the catalyst.
• Substantial female autonomy,
dedication to education, open
political system, civilian
society without class
structure, and history of
egalitarianism & radicalism.
• Causality?

10. Revised Paper by Kuhn: National health indicators
• Caldwell drew measurement and data from the 1984 World Development
Report (99 countries with population greater than one million). Income was
measured in US$.
• Income measure has changed. Income is measured by PPP. Then, Kuhn
uses PPP adjustment.
• The 2009 WHO World Health Statistics Report.
• Child mortality rate (CMR) as standard indicator of national well-being. CMR
shows more variability than IMR due to lower IMR at the moment.
• Adult mortality rate (AMR).

11. Growth and mortality progress of original superior and poor health achievers,
1982 - 2007
Strong forces of economic and epidemiologic convergence

12. CMR and GDP per capita (131 countries, 2007)
AMR and GDP per capita (131 countries, 2007)
Superior health achiever: CMR rank – Income rank ≥ +30
Poor health achiever: CMR rank – Income rank ≤ -30
Superior health achiever: AMR rank – Income rank ≥ +30
Poor health achiever: AMR rank – Income rank ≤ -30

13. Discussion
• Today’s poor health achievers still include oil-rich states.
• Caldwell: relationship between majority-Muslim population and poor
achievement.
• Kuhn: Today, the situation looks quite different as mortality reductions in a
wide range of Muslim countries in last 25 years.
• Kuhn: Religious identity must be interpreted with care. In 1986, Caldwell used
‘Islam’ term, not Muslim countries. He also discussed Buddhism in Sri Lanka,
Thailand, Vietnam, and Myanmar (enlightenment principle).
• My opinion: Religious definition. For example: Islam and Muslim countries are
debatable for exact definition, it can be defined as formal definition, cultural
definition, or principle definition. Ex: Islamicity Index measures how well the
country adhere with principle of Islam. In 2014, the top country: Ireland,
Denmark, and Luxembourg. Saudi Arabia is rank 91.

14. Exceptional mortality levels relative to income levels for 121 low and middle-income
countries with adult HIV/AIDS prevalence below than 15% (2007)
Superior health achiever: Mortality rank – Income rank ≥ +28
Poor health achiever: Mortality rank – Income rank ≤ -28

15. Determinant of Exceptional Health Achievement
• Education and gender.
• Substantial advantage of primary school enrollment (gross enrollment
ratio).
• Women’s schooling.
• Health system spending.
• Poverty.
• Governance and society.

16. Determinant of Exceptional Health Achievement
• Education and gender.
• Health system spending.
• Health spending demonstrated a societal commitment to welfare for
better outcomes.
• Total health spending is not a strong correlate of health achievement. It is
primary related only to poor health achiever.
• Challenge of the policy focus on public health expenditures as
determinant of health outcomes.
• Poverty.
• Governance and society.

17. Determinant of Exceptional Health Achievement
• Education and gender.
• Health system spending.
• Poverty.
• Poverty is important dimension of health achievement, perhaps more
significant than health expenditure, but it is related with poor health
achiever.
• Governance and society.

18. Determinant of Exceptional Health Achievement
• Education and gender.
• Health system spending.
• Poverty.
• Governance and society.
• The role of democracy, social activism, and social solidarity or
consensus.
• Indicators: efficacy, corruption, and democracy.

19. Conclusion
• The result of superior and poor are not stable.
• Two routes to low mortality:
• Direct route involving women’s schooling
• Involving the interplay between governance, social consensus, and
empowerment.
• Education has a causal effect on mortality, especially for children. But it is
overshadow by factor relating to health system, poverty, and governance.
• Health policy itself is important, rather than health spending.
• Superior achievers are identified by success on some development indicators and by
the lack of abject failure on all dimensions. They are also distinguished by performing
well on at least one governance indicator and avoiding extremely poor performance at
all.
• Substantial reduction as emerging patters: Latin America and Muslim world.
• Cost-effective primary health care and increasing democratic inclusion in Latin
America.
• For Muslim world case, human capital dependency. Complex relationship
between social solidarity, democratic change, health system, and mortality.
• More ethnic homogenous (eg: Latin America and Arabic countries), more success in
lowering mortality.

20. Discussion
• What is the best health indicator? And causality among indicators? The
next research can focus on causality. Eg: health service indicators,
morbidity statistics, and demographic indicator?
• Definition of superior and poor health achievers? The limit of +25 and -25,
what is the logic behind this?
• Definition of superior and poor health achievers? What about initial level
from each country? In this case, we can compare between two different
time (panel).
• Ranking is categorical variable. Let’s assume three countries: A, B, and
C. Life expectancy from three countries: 55 yrs (A), 57 yrs (B), and 75 yrs
(C). Then, ranking from three countries: A = 1st, B = 2nd, C = 3rd. In this
case, ranking system doesn’t reflect “the gap” among these countries.
• Other factor, eg: geographic.
• Challenge: source of data from developing countries.

21. Thank you!

22. Schooling and literacy
indicators

23. Schooling and literacy indicators

24. Poverty indicators

25. Governance
indicators