Sebastian Vollmer

Association between economic growth and early childhood undernutrition: evidence from 121 Demographic and Health Surveys from 36 low-income and middle-income countries

BACKGROUND Economic growth is widely regarded as a necessary, and often sufficient, condition for the improvement of population health. We aimed to assess whether macroeconomic growth was associated with reductions in early childhood undernutrition in low-income and middle-income countries. METHODS We analysed data from 121 Demographic and Health Surveys from 36 countries done between Jan 1, 1990, and Dec 31, 2011. The sample consisted of nationally representative cross-sectional surveys of children aged 0-35 months, and the outcome variables were stunting, underweight, and wasting. The main independent variable was per-head gross domestic product (GDP) in constant prices and adjusted for purchasing power parity. We used logistic regression models to estimate the association between changes in per-head GDP and changes in child undernutrition outcomes. Models were adjusted for country fixed effects, survey-year fixed effects, clustering, and demographic and socioeconomic covariates for the child, mother, and household. FINDINGS Sample sizes were 462,854 for stunting, 485,152 for underweight, and 459,538 for wasting. Overall, 35·6% (95% CI 35·4-35·9) of young children were stunted (ranging from 8·7% [7·6-9·7] in Jordan to 51·1% [49·1-53·1] in Niger), 22·7% (22·5-22·9) were underweight (ranging from 1·8% [1·3-2·3] in Jordan to 41·7% [41·1-42·3] in India), and 12·8% (12·6-12·9) were wasted (ranging from 1·2% [0·6-1·8] in Peru to 28·8% [27·5-30·0] in Burkina Faso). At the country level, no association was seen between average changes in the prevalence of child undernutrition outcomes and average growth of per-head GDP. In models adjusted only for country and survey-year fixed effects, a 5% increase in per-head GDP was associated with an odds ratio (OR) of 0·993 (95% CI 0·989-0·995) for stunting, 0·986 (0·982-0·990) for underweight, and 0·984 (0·981-0·986) for wasting. ORs after adjustment for the full set of covariates were 0·996 (0·993-1·000) for stunting, 0·989 (0·985-0·992) for underweight, and 0·983 (0·979-0·986) for wasting. These findings were consistent across various subsamples and for alternative variable specifications. Notably, no association was seen between per-head GDP and undernutrition in young children from the poorest household wealth quintile. ORs for the poorest wealth quintile were 0·997 (0·990-1·004) for stunting, 0·999 (0·991-1·008) for underweight, and 0·991 (0·978-1·004) for wasting. INTERPRETATION A quantitatively very small to null association was seen between increases in per-head GDP and reductions in early childhood undernutrition, emphasising the need for direct health investments to improve the nutritional status of children in low-income and middle-income countries. FUNDING None.

The Impact of a Customs Union between Turkey and the EU on Turkey's Exports to the EU

This article investigates Turkeys sectoral trade flows to the EU based on panel data from the period 1988 to 2002. Turkeys 16 most important export sectors are analysed. Emphasis is placed on the role of price competition, EU protection and transport costs in the export trade between Turkey and the EU. The empirical model used is an extended version of the gravity model. This study is also a contribution to the current discussion of whether Turkey should be granted full EU membership or a privileged partnership with the EU, which for Turkey would mean improved access to the EU market for its products, among other benefits. Our investigation focuses on the latter policy outcome: the impact of deepening the customs union between Turkey and the EU and applying the common agricultural policy (CAP) to Turkish agricultural exports. To this end, the impact of the 1996 customs union covering most industrial goods and processed agricultural goods, is evaluated on a sectoral level. We also perform simulations to quantify the impact of the potential inclusion of agricultural goods, as well as iron and steel and products thereof, into the full customs union between Turkey and the EU which is still to come.

An African Growth Miracle? Or: What do Asset Indices Tell Us About Trends in Economic Performance?

Using changes in the possession of household assets over the past 20 years, several recent papers have argued that economic performance in Arica was substantially better than suggested by national income data and income poverty statistics, who suffer from well-known weaknesses. We scrutinize these claims and first argue that trends in assets provide biased proxies for trends in incomes or consumption. In particular we show that the relationship between growth in assets and growth in incomes or consumption is extremely weak; instead, we find evidence of asset drift using macro and micro data, which is consistent with the claims we make about possible biases in the use of asset indices. As a result, we find no evidence supporting the claim of an African growth miracle that extends beyond what has been reported in GDP/capita and consumption figures.

Patterns of Frailty in Older Adults: Comparing Results from Higher and Lower Income Countries Using the Survey of Health, Ageing and Retirement in Europe (SHARE) and the Study on Global AGEing and Adult Health (SAGE)

We use the method of deficit accumulation to describe prevalent and incident levels of frailty in community-dwelling older persons and compare prevalence rates in higher income countries in Europe, to prevalence rates in six lower income countries. Two multi-country data collection efforts, SHARE and SAGE, provide nationally representative samples of adults aged 50 years and older. Forty items were used to construct the frailty index in each data set. Our study shows that the level of frailty was distributed along the socioeconomic gradient in both higher and lower income countries such that those individuals with less education and income were more likely to be frail. Frailty increased with age and women were more likely to be frail in most countries. Across samples we find that the level of frailty was higher in the higher income countries than in the lower income countries.

The global economic burden of diabetes in adults aged 20–79 years: a cost-of-illness study

BACKGROUND Differences in methods and data used in past studies have limited comparisons of the cost of illness of diabetes across countries. We estimate the full global economic burden of diabetes in adults aged 20-79 years in 2015, using a unified framework across all countries. Our objective was to highlight patterns of diabetes-associated costs as well as to identify the need for further research in low-income regions. METHODS Epidemiological and economic data for 184 countries were used to estimate the global economic burden of diabetes, regardless of diabetes type. Direct costs were derived using a top-down approach based on WHO general health expenditure figures and prevalence data from the 2015 International Diabetes Federation Diabetes Atlas. Indirect costs were assessed using a human-capital approach, including diabetes-associated morbidity and premature mortality. FINDINGS We estimate the global cost of diabetes for 2015 was US

Does Access to Improved Sanitation Reduce Childhood Diarrhea in Rural India

1·31 trillion (95% CI 1·28-1·36) or 1·8% (95% CI 1·8-1·9) of global gross domestic product (GDP). Notably, indirect costs accounted for 34·7% (95% CI 34·7-35·0) of the total burden, although substantial variations existed both in the share and the composition of indirect costs across countries. North America was the most affected region relative to GDP and also the largest contributor to global absolute costs. However, on average, the economic burden as percentage of GDP was larger in middle-income countries than in high-income countries. INTERPRETATION Our results suggest a substantial global economic burden of diabetes. Although limited data were available for low-income and middle-income countries, our findings suggest that large diabetes-associated costs are not only a problem in high-income settings but also affect poorer world regions. FUNDING None.

Diabetes in sub-Saharan Africa: from clinical care to health policy

Almost nine million children under 5 years of age die every year. Diarrhea is considered to be the second leading cause of under-five mortality in developing countries. About one out of five deaths is caused by diarrhea. In this paper, we use the newly available data set District Level Household Survey 3 to quantify the impact of access to improved sanitation on diarrheal morbidity for children less than 5 years of age in India. Using propensity score matching, we find that access to improved sanitation reduces the risk of contracting diarrhea by 2.2 percentage points. There is considerable heterogeneity in the impacts of improved sanitation. We find statistically insignificant treatment effects for children in low or middle socioeconomic status households and for girls; however, boys and children in high socioeconomic status households experienced economically significant treatment effects. The magnitude of the treatment effect differs largely by hygiene behavior.

Diabetes diagnosis and care in sub-Saharan Africa: pooled analysis of individual data from 12 countries

Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA (Prof R Atun FRCP, Prof T Bärnighausen MD, I Postolovska ScD, S Vollmer PhD, B Ammon, A Annamreddi, A Awasthi, S Bhadriraju, J Chai MPH, J Ho BS, S S Kakarmath MBBS MS, R Kharel, M A Kyle, S C Lee MD, A Lichtman MD, J Manne-Goehler MD, M Nair MPH, O L O Okafor MPH, O Okunade MD, D Sando, A Sharma MPH, A S Syed MPH); Harvard Medical School, Harvard University, Boston, MA, USA (Prof R Atun, A Binagwaho MD, P Chipendo MD, J Manne-Goehler); Centre for Global Health, King’s College London, Weston Education Centre, London, UK (J I Davies MD); MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Education Campus, University of Witwatersrand, Parktown, South Africa (J I Davies); University of Bristol, Bristol, UK (E A M Gale FRCP); Muhimbili University of Health and Allied Sciences, and Abbas Medical Centre, Dar es Salaam, Tanzania (Z G Abbas MMed); Institute of Public Health, Faculty of Diabetes in sub-Saharan Africa: from clinical care to health policy

Testing for heterogeneous treatment effects in experimental data: false discovery risks and correction procedures

BACKGROUND Despite widespread recognition that the burden of diabetes is rapidly growing in many countries in sub-Saharan Africa, nationally representative estimates of unmet need for diabetes diagnosis and care are in short supply for the region. We use national population-based survey data to quantify diabetes prevalence and met and unmet need for diabetes diagnosis and care in 12 countries in sub-Saharan Africa. We further estimate demographic and economic gradients of met need for diabetes diagnosis and care. METHODS We did a pooled analysis of individual-level data from nationally representative population-based surveys that met the following inclusion criteria: the data were collected during 2005-15; the data were made available at the individual level; a biomarker for diabetes was available in the dataset; and the dataset included information on use of core health services for diabetes diagnosis and care. We first quantified the population in need of diabetes diagnosis and care by estimating the prevalence of diabetes across the surveys; we also quantified the prevalence of overweight and obesity, as a major risk factor for diabetes and an indicator of need for diabetes screening. Second, we determined the level of met need for diabetes diagnosis, preventive counselling, and treatment in both the diabetic and the overweight and obese population. Finally, we did survey fixed-effects regressions to establish the demographic and economic gradients of met need for diabetes diagnosis, counselling, and treatment. FINDINGS We pooled data from 12 nationally representative population-based surveys in sub-Saharan Africa, representing 38 311 individuals with a biomarker measurement for diabetes. Across the surveys, the median prevalence of diabetes was 5% (range 2-14) and the median prevalence of overweight or obesity was 27% (range 16-68). We estimated seven measures of met need for diabetes-related care across the 12 surveys: (1) percentage of the overweight or obese population who received a blood glucose measurement (median 22% [IQR 11-37]); and percentage of the diabetic population who reported that they (2) had ever received a blood glucose measurement (median 36% [IQR 27-63]); (3) had ever been told that they had diabetes (median 27% [IQR 22-51]); (4) had ever been counselled to lose weight (median 15% [IQR 13-23]); (5) had ever been counselled to exercise (median 15% [IQR 11-30]); (6) were using oral diabetes drugs (median 25% [IQR 18-42]); and (7) were using insulin (median 11% [IQR 6-13]). Compared with those aged 15-39 years, the adjusted odds of met need for diabetes diagnosis (measures 1-3) were 2·22 to 3·53 (40-54 years) and 3·82 to 5·01 (≥55 years) times higher. The adjusted odds of met need for diabetes diagnosis also increased consistently with educational attainment and were between 3·07 and 4·56 higher for the group with 8 years or more of education than for the group with less than 1 year of education. Finally, need for diabetes care was significantly more likely to be met (measures 4-7) in the oldest age and highest educational groups. INTERPRETATION Diabetes has already reached high levels of prevalence in several countries in sub-Saharan Africa. Large proportions of need for diabetes diagnosis and care in the region remain unmet, but the patterns of unmet need vary widely across the countries in our sample. Novel health policies and programmes are urgently needed to increase awareness of diabetes and to expand coverage of preventive counselling, diagnosis, and linkage to diabetes care. Because the probability of met need for diabetes diagnosis and care consistently increases with age and educational attainment, policy makers should pay particular attention to improved access to diabetes services for young adults and people with low educational attainment. FUNDING None.

The association of parental education with childhood undernutrition in low- and middle-income countries: comparing the role of paternal and maternal education.

We review the statistical models applied to test for heterogeneous treatment effects in the recent empirical literature, with a particular focus on data from randomised field experiments. We show that testing for heterogeneous treatment effects is highly common, and likely to result in a large number of false discoveries when conventional decision rules are applied. We demonstrate that applying correction procedures developed in the statistics literature can fully address this issue, and discuss the implications of multiple testing adjustments for power calculations and experimental design.