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Journal of Pediatric Gastroenterology & Nutrition:
doi: 10.1097/MPG.0b013e318272af3b
Special Feature

The Economics of Health Care Delivery

Winter, Harland S.*; Mossialos, Elias; Naci, Huseyin; Chandra, Amitabh; Salojee, Haroon||; Yamashiro, Yuichiro§; Bhutta, Zulfiqar A.; Uauy, Ricardo#; Corvalan, Camila**

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*Massachusetts General Hospital, Boston, MA

Aga Khan University, Karachi, Pakistan

Harvard Kennedy School of Government, Harvard University, Cambridge, MA

§Probiotics Research Laboratory, Juntendo University Graduate School of Medicine, Tokyo, Japan

||Division of Community Paediatrics, University of the Witwatersrand, Johannesburg, South Africa

London School of Economics and Political Science, London, UK

#Division of Pediatrics, School of Medicine, Pontifical Universidad Catolica de Chile

**Instituto de Nutricion y Technologia de Alimentos (INTA), Universidad de Chile, Santiago.

Address correspondence and reprint requests to Harland S. Winter, MD, Massachusetts General Hospital, 175 Cambridge St, CRPZ 5-560, Boston, MA 02114 (e-mail: HWINTER@partners.org).

Received 30 August, 2012

The authors report no conflicts of interest.

Contributors from Europe, Africa, Asia, South America, and North America were invited by regional representatives to comment on the economics of health care for children because it relates to their region. The series of articles that follow this introduction reflect what each author believed was relevant. Two of the articles are written by economists at The London School of Economics and the Harvard Kennedy School of Government and delineate the role of health care in economic development; whereas, the other articles express the views of physicians in specific regions about the effects of economic development on individual or community health issues. Although it is true that intellectual genius is not related to economic or social status, societies benefit when the abilities of children are recognized and supported through education and opportunity, access to affordable health care for all children increases individual productivity, and economic empowerment of women improves children's health, there are no data to support the hypothesis that investing in children's health ultimately improves a country's economy. It would seem reasonable to believe that improving health care for children would result in their becoming better educated, reaching their intellectual potential, and being more productive, all of which in turn would result in economic improvement. Physicians who, by training, focus on the needs of an individual child find this worldview to be consistent with their beliefs, but economists who have a broader view of factors that affect economic development realize that health care for children is but one factor of economic success. Although investment in children's health has not yet been shown to directly affect economic growth, such an investment may not demonstrate benefit for decades. Allocation of modest resources to childhood health care may not be sufficient to affect an economy. The experiment may require a bold and comprehensive program to maximize impact. Both physicians and economists agree that the argument to support health care for children and to empower women need not be justified by an economic benefit to society, but rather is laudable on its own merits. Additional studies may be needed to convince governments that investing in health care for children and women will “trickle up” to improve the lives of all of the citizens and validate the expression once used by President John F. Kennedy, “A rising tide lifts all boats.”

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Elias Mossialos and Huseyin Naci

Children's health is influenced by socioeconomic status as well as physical and socioemotional environments. To promote and improve children's health in Europe, the World Health Organization (WHO) emphasizes a life-course approach, which aims to address the health challenges at each stage of development from prenatal life to adolescence (1). This translates to 7 areas for action, including maternal and newborn health, nutrition, communicable diseases, injuries and violence, physical environment, adolescent health, and psychosocial development and mental health.

Meeting the objectives of a life-course approach poses significant challenges to health systems because it necessitates multisectorial commitment, which spans across agriculture, education, transport, and social care sectors. Improving policies to promote children's health in Europe requires a different philosophy, or a reconfiguration of the health system, to allow for better coordination with other sectors. Health systems have traditionally favored the treatment of illness and disease rather than the promotion of future health. The failure to address the risk factors in early life of serious chronic illnesses such as obesity is likely to increase the medical costs associated with these conditions later on. Children who are obese, for instance, are likely to be obese adults, substantially increasing their risk for costly comorbidities such as type II diabetes mellitus (2).

A multisectorial life-course approach is justified on the basis that promoting children's health would have the potential of reducing the future costs not only to health care, but also to education and social welfare systems. Intuitively, there are pathways that provide a link between children's health status and educational and economic outcomes. Improvements in children's health can lead to improvements in educational outcomes, the prevention of irreversible harm to future economic contribution to society, and given the strong relation between poor health and income level, the mitigation of the intergenerational transmission of poverty (3).

A multisectorial approach that embraces the life-course approach is increasingly the focus of policymaking across European settings. The Finnish government, for example, prioritizes health promotion that spans across physical and socioemotional environments, that is, lifestyles, living environment, and quality of products (4). Similarly, the “Healthy Lives, Brighter Futures” framework, the UK government's children's health strategy, aims to achieve easier access to health services to improve not only physical health but also psychosocial well-being in the form of universal, targeted, and specialist support across 3 life stages: early years and pregnancy, school-age children, and young people (5).

An important challenge facing decision makers in Europe is coordinating the efforts of various stakeholders and ensuring that they share the same incentives around the common goal of promoting and improving children's health. So far economic incentives, such as those in place for family practitioners in the UK, have been constrained to the health system. These so-called quality indicators (eg, screening for high blood pressure) are generally not applicable to children, and those that are (eg, management of type 1 diabetes mellitus) do not always address the greater social context. Extending the reach of these incentives to other sectors, and aligning the objectives across multiple stakeholders, remains an important policy objective in Europe.

Given the complex methodologies required to evaluate interventions that span multiple sectors, there are inevitable limitations of the research efforts exploring the relation between children's health and wider economic and social outcomes (3,6). Reflecting the limitations of the existing data sources, studies adopt a short-term view, without taking into account the long-term costs and benefits; and often neglect important cost dimensions such as social benefits.

To inform evidence-based policies, accurately capturing both costs and benefits associated with multisectorial interventions is essential. In this context, a number of country- or regional-level cohorts are collecting a wealth of longitudinal information on children's health and its determinants in Europe. Examples include the Amsterdam-born Children and their Development cohort in the Netherlands, the Norwegian Child and Mother Cohort study (7) in Norway, and the Newcastle Thousand Families Study in the UK. In an attempt to coordinate these efforts, a Europe-wide research strategy is emerging as a result of CHICOS (Developing a Child Cohort Research Strategy for Europe) (8). Funded by the European Commission, this effort is striving to develop a strategy for future research within European children's cohorts designed to improve evidence-based policy. These efforts provide an opportunity to measure the longitudinal effects of policy initiatives, and allow for a careful evaluation of the relation between children's health status and wider societal outcomes.

A multisectorial life-course approach is needed to promote children's health and align system-wide incentives. Recent efforts to mobilize country- and regional-level data collection mechanisms will offer valuable evidence to evaluate policy initiatives in European countries.

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Amitabh Chandra

This section reviews the relation between investing in health and later economic outcomes. Causal empiricism reveals 2 observations: healthier people are richer and richer countries are healthier, leading many commentators to believe that investments in health, especially in children, will yield economic benefits that are analogous to investments in schooling. As with early investments in human capital such as childhood enrichment programs, health capital is believed to pay off in the form of longer, healthier, and more productive lives. A child's intellectual and physiological development occurs early in life, suggesting that early setbacks may have deleterious effects on the ability to make future investments. The evidence on so-called critical periods for certain dimensions of development amplifies these concerns. Finally, there is a long tradition of assuming that what is true for individuals can be applied to larger aggregates such as states or countries. Distinguished commentators have argued that countries who pursue pro-natalist and pro-child investments would see large economic payoffs from their efforts to combat early insults such as malnutrition, diarrhea, and polio (9). The logic behind such reasoning is simple and intuitive, but the theoretical arguments and empirical evidence in support of it are far less obvious.

Let us first focus on the child as an individual and ignore the arguments surrounding aggregating his or her experience to the nation. The first reason that the link between early health investments and later health is not immediate is the problem of competing risks. Put simply, there are multiple health risks that a child faces, and eliminating the most prevalent risk will not guarantee that a child will survive to adulthood—a child who is free of polio may still succumb to malaria, a child who is cured of polio and malaria may still contract hepatitis. Therefore, if policies that target children's health target individual diseases, as many efforts by developing countries and WHO do, the salubrious effects of health investments will be diluted. The dilution depends on the presence of these competing risks, which are likely more prevalent in poorer parts of the globe. This is also 1 reason why investing in slightly older children may yield higher health benefits than investing in infants, who are subject to more competing risks because of their inherent frailty.

Economic theory offers another cautionary tale about the mechanism by which childhood health investments increase later earnings. The channel that economists emphasize is that better childhood health allows a child to learn faster and become stronger. In economic parlance, this is a productivity shock. Better health also may increase incentives to remain in school longer, but the gains from this channel will be second order relative to the direct effect of being healthier on earnings. This is because individuals select the number of years of schooling by comparing the benefits of more schooling to its costs. They may do so imperfectly, but better health only marginally alters their decision-making calculus. Moreover, better health can perversely increase incentives to drop out of school because of higher market wages, especially for physical work.

The third reason is that the extrapolation from the individual to the population is fraught with pitfalls. In high-mortality environments, disease restricts the ability of a population to grow, but when a population grows (because of improvements in health), it reduces the capital per worker, and through this channel, the productivity of labor and, consequently, earning. Therefore, although improvements in individual health may increase individual earnings, the same logic may not aggregate up to the country level. Indeed, this is the key finding of Acemoglu and Johnson (10), who found that major health improvements in the 1940s (the international epidemiological transition) stemming from the widespread use of penicillin, streptomycin, and DDT, were successful in improving life expectancy, but these improvements in life expectancy did not increase income per capita, largely because of the offsetting increase in population.

Taken together, these results lead economists to conclude that it is wrongheaded to argue that investments in health are a policy tool to improve economic outcomes. Rather, better health is an end in its own right and should be valued regardless of its effects on economic outcomes. In the spirit of this argument, Becker et al (11) demonstrate that the striking convergence in mortality between rich and poor countries, which is contrary to their income trajectories, did much to reduce the gap in human welfare between rich and poor countries. Good health means much more than higher incomes. It affects human capabilities and capacity to imagine, consume, and live. This is a sufficient motivation to invest in childhood health.

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Haroon Salojee

Sub-Saharan Africa makes up 11% of the world's population, accounts for 24% of the global disease burden, is home to only 3% of the global health workforce, but commands <1% of global health expenditure (12). Health care delivery infrastructure is inadequate, skilled health care workers and essential medicines are in short supply, and weak health information systems restrict appropriate responses. The health care financing system is as deficient as the health care delivery system it supports. It depends on a mélange of measly governmental spending, heavy (but dwindling) foreign donor assistance, and substantial reliance on user fees and out-of-pocket contributions that primarily disadvantage the poorest. With the lowest health spending in the world (averaging $24 per person annually in 2010 [WHO recommends at least $40]), countries cannot ensure universal access to even a limited set of health services. Africa's health care challenges are heightened by the sheer diversity of the continent.

Weak economic growth, inefficient budgeting and spending, poor accountability, and corruption are a few of the immediate causes of the fiscal crisis. Budgetary stringency under health sector reforms that accompany structural adjustment programmes instituted by institutions such as the World Bank and the International Monetary Fund have handicapped many African governments’ ability to respond appropriately to citizens’ health needs. At the same time, inadequate investment in the health sector has paralyzed service delivery. In 2001, African governments agreed to allocate 15% of their budgets to health; to date, only 6 countries have met this commitment. Undoubtedly, the continent's greatest challenge is narrowing the inequity in access to care for the “have's” (privileged) and the “have not's” (ordinary citizens).

Universal health schemes are returning to Africa. Countries such as Ghana, Rwanda, Gabon, and Senegal have led the way in pooling risk and transforming access to health care, with South Africa and Nigeria following suit. Ethiopia, for one, has demonstrated the power of strong political will to create a primary-care service virtually from scratch. Simultaneously, an emerging middle class, increasingly active private health care industry, and shifting disease burdens are transforming the way health care on the continent is being funded and delivered.

Africa accounts for more than half of global maternal and child deaths, with infectious diseases predominating. Ensuring access to clean water and sanitation, battling ongoing communicable diseases, and stemming the tide of preventable deaths still dominate the health care agenda in most African settings. The last decade has seen significant progress in marshalling resources to tackle human immunodeficiency virus (HIV)/acquired immune deficiency syndrome, malaria, and tuberculosis, as new donors and institutions have emerged; however, there is concern that this focus has negatively affected progress in other areas, such as diarrheal disease and malnutrition reduction. Although diseases such as HIV and malaria are inextricably linked to diarrhea and malnutrition, both causally and in their successful management, the fear that funds that primarily address the latter diseases have been diverted elsewhere needs to be allayed. The evidence for this is equivocal.

In the case of childhood diarrhea, in the face of remarkable decreases in mortality globally, diarrhea has superseded pneumonia as the number one cause of under-5 mortality in Africa. Improvements in access to safe drinking water and sanitation have also stalled in Africa, making it difficult to combat stubbornly high levels of water-borne illnesses. A staggering 80% of African countries are presently unlikely to meeting the Millennium Development Goal sanitation target. More costly but still important have been the reductions in HIV-related morbidity through improved prevention of mother-to-child transmission strategies and antiretroviral therapy access, particularly in southern and east Africa.

In the case of malnutrition, evidence of disease reduction is lacking. Underweight prevalence in sub-Saharan Africa has remained roughly the same during the last 2 decades. More than half of the children hospitalized with severe malnutrition in countries such as Malawi, South Africa, and Zambia are HIV infected. The difficulties of ensuring access to nutritious food for the most vulnerable in Africa have been compounded by a convergence of global trends: skyrocketing food prices; an increase in the number and intensity of weather-related disasters (eg, droughts); and an escalation of ongoing civil conflicts. Although billions of dollars of international assistance are labeled “food aid,” <2% is being spent on interventions targeted specifically at reducing malnutrition among children (13). Médecins Sans Frontières have raised the concern that wealthy countries are investing in long-term agriculture programmes at the expense of urgent measures to target food aid at the hungriest children (13).

Where lies salvation for Africa's children? Extending universal health care coverage to Africa's poorest offers the best prospect for addressing equity and other issues. It takes the focus of health systems away from providing expensive, hospital-centric, and disease-focused care and reestablishes the premier position of primary health care and the importance of community-based activities. Reducing reliance on international aid organizations and giving local communities more control over health care resources is crucial for meaningful change, but historically has been difficult to institutionalize. Nevertheless, community-based ambulatory treatment of severe malnutrition is an example of how this kind of change can occur. Inpatient care of malnutrition in many African settings is now reserved for the most severe cases, with many children being managed at outpatient or clinic nutrition centers, or at home. Costs of this ambulatory community-based treatment have been consistently lower than that for institution-based treatment, ranging between US$46 and $453 per child, depending on the type of care provided and the costing methods used (14). At this price, the intervention is cost-effective compared with other priority health interventions in low-income African countries.

Africa's health care systems are at a turning point. The crisis is as much political as fiscal. Governments must make tough choices and their decisions will be crucial to determining whether mortality rates remain crushingly high, or whether the “dark continent” illuminates a new path demonstrating how citizens’ basic needs, including health, can be met, and diseases such as diarrhea and malnutrition obliterated to clinical peculiarities.

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Yuichiro Yamashiro

In the last 2 decades, at least 3 major economic crises have occurred. The Asian currency crisis in 1997, the so-called Lehman Shock in 2008, and the present European market crisis. Globalization is rapidly influencing events worldwide. More than three-quarters of the countries belonging to the Organization for Economic Cooperation and Development have experienced a growing gap between rich and poor during this period.

Income inequality can damage health through 2 pathways. First, a highly unequal society implies that a substantial segment of the population is impoverished, and poverty is bad for health. Second, income inequality is thought to affect the health of not just the poor but also the better-off in society. The so-called spillover effects of inequality have in turn been attributed to the psychosocial stress resulting from social inequality (15). The fight by conservative forces in the United States against the bill to reform Medicaid is 1 example.

Health care delivery in highly developed countries can be roughly divided into 2 systems: the European type and the US type. The former is based on the principle of universal coverage. It is operated by tax-financed organizations such as the National Health Service in the UK (16). It is offered to all of the members of the population in times of health care need, and it provides largely free care at the point of use and lends itself to the principle of equal access for equal need. The latter relies on the incentive mechanisms of the purchasers and providers of health care and is based purely on economic notions of competition, rather than regulation by the government (17). Although the European type has been modified and reformed in each country, their health outcomes have been satisfactory. This is in contrast to that in the United States, where the lack of a national health care system to provide universal coverage, together with the lack of health insurance in a large segment of the population (>50 million, including even 7.5 million children in 2009), has led to a health crisis (17,18). It is worth keeping in mind the notion that health is not a game; it is a public good, and thus health services should not be about competition; they should provide equity for all people, irrespective of their socioeconomic or demographic position. Patients are not treated as merely consumers. This is especially true for children.

In other Organization for Economic Cooperation and Development signatory nations, however, core objectives of the system also have not been performed smoothly. This is mainly because of income inequality. Care is no longer entirely free at the point of use for all health services because of various reasons, including the increasing cost of health care management. Health inequality is a serious and growing problem worldwide, even in Japan (19), where wealth inequality is still lower than in other highly developed countries, according to the Gini coefficient. Indeed, cost performance for health care service in Japan is extremely good. For example, in 2008 the total expenditures for health/capital, in US dollars, were 7720 in the United States, 3644 in Sweden, 3280 in the UK, and 2878 in Japan (20). Furthermore, the lowest infant mortality rate, the longest life expectancy, and the lowest obesity rate among both adults and children were in Japan.

In highly developed countries, a lower level of education is associated with health inequalities. Lower education levels can lead to insecure income, hazardous work conditions, poor housing, and even psychosocial stresses, all of which can have a bad influence on children's environments for healthy growth. These factors cause higher rates of premature babies and of infant and child mortality, along with lower breast-feeding rates, leading to poor school performance, child abuse, and obesity with metabolic syndrome.

There is no valid argument against giving a high priority to the health of mothers and children, yet women and children are particularly vulnerable to socioeconomic inequalities. Medicaid in nearly half of the states of the United States is almost collapsing (21). This is threatening children with chronic diseases and leading to a widening health gap between different social groups. What world medicine needs today to avoid the sacrifice of children's health is a new and stronger political voice. Medical professionals working for children's care should strengthen their professional moral responsibilities because they know that a more involved and motivated profession will lead to better outcomes for children with diseases, throughout the world.

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Zulfiqar A. Bhutta

Although there has been remarkable progress during the last decade in reducing the burden of child mortality, the rates of reduction in child deaths globally vary considerably. From an estimated 10 million deaths among children younger than 5 years annually in 2000 (22), now corrected to 9.6 million deaths, present figures indicate that there are 2.0 to 2.4 million fewer deaths ever year (23,24). There have been major reductions in childhood diarrhea-, pneumonia-, and measles-related deaths, and despite variations in malaria estimates (25), there has also been progress in reducing malaria-associated deaths; however, despite the reduction in the under-5 global mortality rate in children younger than 5 years to 57.1 from 73/1000 live births, progress across the globe remains variable. There are some varied estimates of gains over time and trends largely depending upon methodology used to derive estimates. The recent Countdown to 2015 initiative (26,27) reports that of 75 countries with >95% of the global burden of maternal, newborn, and child mortality, only 22 are on track to achieve Millennium Development Goal 4 and 13 (17%) have made little or no progress.

Of the 7.6 million under-5 child deaths globally, despite progress there are still close to 2 million deaths due to diarrhea and pneumonia annually. In 2010, 64% (4.875 million) of all of the child deaths were attributable to infectious causes, and pneumonia (14%, 1.068 (uncertainty range [UR] 0.972–1.173 million) and diarrhea (10%, 0.748 (UR 0.532–1.026) million) accounted for almost one-quarter of all deaths. There were notable regional variations. The southeast Asia region was also heavily affected by childhood pneumonia, which was responsible for 22% (0.455 million, UR 0.357–0.550 million) of child deaths in the neonatal and postneonatal periods. In India alone, of the 1.682 million under-5 children child deaths in 2010, newborn deaths accounted for 52% of these deaths, whereas pneumonia (0.394 million, UR 0.301–0.483 million, 23%) and diarrhea (0.208 million, UR 0.179–0.274 million, 12%) accounted for another third (3). For pneumonia and diarrhea, the 5 countries with the most deaths include India, Pakistan, Nigeria, Democratic Republic of the Congo, and Ethiopia (28).

Although challenges and inequities remain (29), there has been progress. Of the 2 million fewer deaths seen between 2000 and 2010, 41% of the lives saved were related to diarrhea and pneumonia. Pneumonia deaths fell from 1.846 (UR 1.608–2.124 million) to 1.393 million (UR 1.185–1.639 million), with the pneumonia-specific mortality rate dropping by an average of 3.1% (UR 2.6%–3.4%) per year. Diarrhea deaths fell from 1.160 (UR 0.911–1.574 million) to 0.798 million (UR 0.550–1.176 million), a 4.0% (UR 2.5%–5.6%) decline; however, the present rate of reduction of these deaths is insufficient to attain Millennium Development Goal 4. Despite reduced mortality, there is evidence that morbidity rates have hardly reduced during the last 2 decades (30), reflecting relatively sparse attention paid to preventive strategies and social determinants of health. Child undernutrition trends show some improvement, but unequal progress (31) and rates of reduction in stunting in Africa and parts of south Asia remain extremely slow.

There is considerable overlap between interventions to prevent and treat childhood diarrhea and pneumonia. Most of these interventions are inexpensive and well established, such as exclusive breast-feeding for 6 months, access to safe water, sanitation and hygiene, oral rehydration therapy, zinc supplementation, and community case management, yet their global coverage remains low, with huge differentials between various socioeconomic groups (29). Preventive interventions, some of which reduce the incidence of both diseases, include optimal breast-feeding practices and adequate nutrition, immunizations, hand washing with soap, and access to improved water and sanitation facilities. Lifesaving treatment options after a child becomes sick include antibiotics for bacterial pneumonia and oral rehydration salts and zinc for diarrhea; however, coverage of these interventions remains low, particularly among the most vulnerable children. In addition, many interventions requiring modifications of care seeking and household behaviors also do not have effective coverage, and if anything, overall coverage rates of oral rehydration for diarrhea have stagnated for the last decade.

In a previous estimation of costs for scaling up interventions for child survival, we assessed costs according to service delivery modes (community-based services, outreach programs, and facility-based clinical services) and suggested that a modest global investment of US$5.1 billion (UR US$3.1–8 billion) in new resources was needed annually to save 6 million child lives in the 42 countries responsible for 90% of child deaths in 2000 (32). These figures have been revised since to include a range of costs for integrated packages of maternal, newborn, and child health and include costs of training sufficient human resources, developing management capacity, and other aspects of the health system needed to scale up and sustain these coverage levels. A major cost-effective strategy for this is the development of cadres of community health workers for outreach and the development of strategies to reach those that are presently not being reached by existing programs (33). These community-based platforms have the potential to reduce maternal morbidity and newborn mortality and should be scaled up globally (34). They also have huge potential to reduce deaths caused by childhood diarrhea (35) and pneumonia (36) and should be an important part of the strategy options; however, efforts to do so are still slow (37). There is much that can be achieved by such task sharing with community-based outreach programs that can help address populations in greatest need. Similar approaches with targeting cost-effective interventions can also reach the urban poor (38) in some of the areas at highest need.

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Ricardo Uauy and Camila Corvalan

Stunting is defined by a low height relative to what is considered normal based on children of similar age and sex that have grown up under conditions that do not restrict growth; participants of the WHO multicenter growth reference study conform to the latter condition and therefore are valid to identify stunted children. Height provides a cumulative record of past and present restrictions affecting a child's skeletal growth: failure to reach one's genetic height potential. This is commonly because of inadequate nutrition compounded with frequent infections, inadequate care, poor sanitation, and limited access to health services; however, the true underlying causes are low socioeconomic status, unemployment, and poverty, commonly conditioned by social, economic, and political contextual factors (39). Presently, stunting is the most prevalent form of undernutrition. Estimates of stunting prevalence among children ages 5 years or younger in 2010 based on the WHO (2006) standards are 38.2% for Africa (60 million children), 27.6% in Asia (100 million children), and 13.5% (7 million children) in the Latin American region; more important, these figures, particularly in Africa, will not change substantially in the next 10 years (40). Recent analyses of surveys from 54 countries using WHO growth standard reference indicate that the fall in mean height-for-age z score in early life occurs early in most regions of the world. Growth faltering takes place soon after birth and increases thereafter reaching its lowest value close to 24 months of age (41). These results support the concept that the intrauterine periods and the first 2 years of postnatal life are critical for preventing malnutrition; once stunting is established, the lost length typically persists, unless there are specific nutritional disorders that delay bone age maturation (41). Tracking height from early life into adulthood is further supported by analyses of several large cohorts from developing countries that show that gaining 1 z score of height-for-age at 2 years (∼3.2 cm) is associated with a similar increase in attained adult height (42).

Stunting is associated with increasing mortality and morbidity particularly because of infectious diseases such as diarrhea, measles, pneumonia, and malaria. The Lancet Series on Malnutrition reported that in 2004, stunting accounted for 1.5 million deaths and for almost 55 million disability-adjusted life-years in low- and middle-income countries (39). These numbers correspond to almost 15% of the total amount of deaths in children younger than 5 years and close to 13% of the total global disability-adjusted life-years. These data serve to demonstrate the relevance of nutrition–infection interactions as a risk factor for death and disability in children younger than 5 years. There is also evidence demonstrating that stunting is associated with impaired cognitive development and that this association is not just restricted to settings where the prevalence of stunting is extreme (43,44). Impaired motor development and exploratory behavior may further compromise and potentiate the early damage with consequences at later stages in terms of learning and school performance (45); however, the consequences of stunting are not restricted to the first few years of life; they extend throughout childhood and beyond (46). Stunting has also been associated with lower school performance, poorer attention in class, increased rates of repetition, higher drop-out from school, and lower graduation rates. These are likely because of the combined effect of deprived environments as well as the persistence of early functional and behavioral damage (44,45). Long-term economic consequences of stunting include lower earnings per workday and low family income, affecting men and women. In case of physical labor, there is a documented decrease in the capacity for physical work, likely because of reduced lean body mass and lower productivity in manual jobs. Analyses from the COHORTS study indicate that an increase of 1 standard deviation in height-for-age in early childhood in India was associated with an 8% increase in income as well as in assets (42). Birth length is also positively associated with attained adult height and fat-free mass, and therefore, has long-term consequences on body composition. Finally, it has been suggested that stunted children have a higher predisposition to develop obesity and metabolic complications later in life because of decreased energy expenditure; however, these associations have been replicated in some but not in all studies (47–50). In the case of adults, maternal short stature (height <1.45 m) is highly prevalent in south/southeast Asia and in some Latin American countries such as Guatemala. Given the actual rapid nutrition transition observed in developing countries, maternal short stature is now compounded with maternal obesity. Short stature and obesity act in synergy to increase the risks of cesarean deliveries (51), gestational diabetes as well as of delivering low- or high-birth-weight babies (52,53). The detrimental effects of the nutrition transition in developing countries will likely be amplified because of the transgenerational transmission of risks, unless we intervene to break the chain of events. These results support examining the consequences of stunting cumulatively with a life-course perspective.

Stunting may exacerbate poverty perpetuating the vicious cycle as vulnerability to malnutrition and disease grows. From a population perspective, the evidence summarized here demonstrates that stunting in early life not only has negative effects on children's health and educational performance but also imposes an added burden of disease across the life course affecting health expenditures and reducing overall productivity. Thus, the total cost of undernutrition is a function of higher health care spending, inefficiencies in education, and lower productivity. A recent study from the Economic Commission for Latin America and the Caribbean provides estimates of the economic costs associated with undernutrition in the Central American region (54). The analysis focuses on the consequences of infant and child malnutrition on economic development with a life course perspective. Given the rapidly evolving nutritional and epidemiological situation of these countries, the study provides present estimates based on extrapolations derived from previous studies from countries at early stages of the transition, as well as projected costs in the future predicted from costs and savings scenarios if interventions to control or eradicate undernutrition are effectively implemented. The first model using the retrospective approach includes the social and economic consequences of undernutrition for a given year for different cohorts that have been affected by undernutrition considering estimates of health costs for preschool children that are affected by undernutrition in the year of analysis; educational costs of 6- to 18-year-old children who experienced undernutrition during the first 5 years of life; and economic costs derived from lost productivity of working-age individuals who experienced undernutrition in early life. The second model used a prospective approach considering the projected present and future losses incurred as a result of medical treatment, repetition of grades in school, and projected lower productivity derived from undernutrition among children under the age of 5 in each country, in a given year. The models serve to estimate potential savings derived from actions to reduce malnutrition (eg, reducing undernutrition by 50% in 2015). Results indicate that the economic effect of undernutrition represents 1.7% to 11.4% of gross domestic product depending on the country studied (average 3.4% gross domestic product). Higher mortality and lower level of education accounted for >90% of the costs, whereas costs owing to illness or other health consequences accounted for only 6% and school repetition for <1%. These results support policies by governments in the region to eradicate hunger and undernutrition; significant economic and major social benefits will be accrued. In fact all of society would benefit from dropping malnutrition; investments in nutrition in early life will benefit not only the present group of children but also future generations.

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