Health Policy and Education 3 (1982) 109-112 Elsevier Scientific Publishing Company, Amsterdam - Printed in The Netherlands

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LITERACY, EDUCATION AND HEALTH DEVELOPMENT: POLICY IMPLICATIONS

DAVIDSON R. GWATKIN

Overseas Development Council, 1717Massachusetts Avenue, N. W., Washington, D.C. 20036, U.S.A.

ABSTRACT

The statistical evidence on the relationship between education and health is impressively strong, but a causal link remains to be established. Despite this weakness, however, the evidence is much more solid than that on which policy decisions concerning health and education are normally made. Although further research is needed, the findings currently available are adequate to support advocacy of a higher priority to education in development and health improvement strategies.

My assignment is not to deal with what more we need to know, but rather with what we already know and how adequate and useful that knowledge is for policy and program purposes. My principal conclusion is that, for all its very real shortcomings, the evidence about education and mortality pre- sented in this symposium provides an important further rationale for ad- vocating that a higher priority be given to education in development,

To explain how I arrive at this conclusion, I propose to begin by providing an interpretive summary of the evidence presented. I shall then describe the policy setting to which this evidence would be applied. I shall conclude by indicating what I think the evidence can and cannot legitimately and profit- ably be used to support in this setting.

The principal strength of the evidence available lies in the impressive econometric and statistical findings reported here in such papers as those by

The Evidence

Susan Cochrane, Jack Caldwell, Paul Schultz, and Mark Rosenzweig, and those findings appearing in earlier work by them and other symposium participants, especially Samuel Preston. The relationship between education and mortality appears unusually strong, regardless of the specification of the model used and regardless of what other variables are also employed.

Unlike so many econometric or statistical findings, these are by no means simply demonstrations of the intuitively obvious. When I first started looking at the relationship between education and development two or three

01652281/82/0000-0000/$02.75 0 1982 Elsevier Scientific Publishing Company

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years ago, I expected that nutrition, as represented by food availability and food consumption, would be dominant. It had never occurred to me that education might be of more than secondary importance, but things have not worked out this way. The relationship between nutritional variables and mortality has proven surprisingly difficult to establish econometrically. Education, on the other hand, has stood out in econometric study after econometric study, showing a close and strong relationship with mortality levels that cannot be ignored.

Even so, some would question the significance of such evidence with good reason because of the difficulty of going beyond the statistical association between education and mortality to a determination that education’s influence on mortality is the reason behind the relationship. After listening to Scarlett Epstein’s presentation, it would be difficult to argue that there is likely to be much in the content of conventional developing country educational programs of relevance for health or for anything else. This re- inforces the possibility, prompted by the intuitively improbable strength of the relationship as just noted, that no causal relationship exists; that educa- tion, rather than influencing mortality directly, is simply acting as a proxy for some other factor that is the true cause of both mortality decline and of educational levels themselves.

This possibility is not to be dismissed, but it is important to note that there are plausible hypotheses that suggest non-curricular ways in which education can influence mortality, which, if correct, would establish educa- tional programs as causal factors despite the curriculum problems to which several papers have referred. Jack Caldwell has described mechanisms by which education might work independently of its content to influence health, and others at the symposium have alluded to work in other fields which suggests that exposure to education can affect people’s aspirations and outlook on life despite that education’s irrelevant content. Thus, while the evidence available to indicate that education influences mortality can hardly be viewed as conclusive, I think it can be appropriately considered highly suggestive despite the difficulty in clearly establishing causality.

The Setting

In determining whether such suggestive evidence is adequate for policy purposes, it is necessary to consider the setting in which the evidence would be applied. If decisions about educational and health policies were being made only on the basis of overwhelming conclusive empirical evidence, and if the priority being accorded education was approximately in line with that indicated by such evidence, then there would be little basis for attaching much practical attention to the data that have been presented, but neither

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of these two conditions applies to the setting in which health and educa- tional policies are currently being formulated.

The lack of empiricism can be illustrated by the process through which resources are allocated in the health sector. At present, somewhere around fifteen to twenty billion dollars a year is being spent on governmental health services in developing countries, with practically no evidence to suggest that these expenditures are producing significant health gains. Nor has there been much more documentation of the potential effectiveness of the sharp reorientation toward primary health care that is currently being advocated and is, in some cases, occurring. This movement has at times seemed more religious than scientific. I remember, for example, some time ago asking one of the movement’s leaders a quantitative question: would the expenditure of the twenty billion dollars or so on primary health care between now and the end of the century, which he and his colleagues were advocating, be more likely to produce a five percent or a 50 percent reduc- tion in the typical country’s infant mortality rate, were things to go as well as might reasonably be expected? There was no response other than surprise that the question should have been asked.

While health services may be benefiting from this lack of empiricism, education is suffering. UNESCO figures point to a slowing in the increase in educational enrollments. There was a strong move last year to curtail sharply the amount of money allocated to education by the U.S. Agency for Inter- national Development. The Ford Foundation has largely moved out of the education sector with respect to its overseas development work. Other examples could be cited.

The Policy Implications

When such imperfections in the setting and the policy directions to which they have led are taken into account, the weaknesses of the evidence pre- sented at this symposium become less impressive. Despite its shortcomings, such evidence remains far superior to the professional predilections and vague impressions which are currently serving as the principal basis for health and educational policies, and the argument it makes for raising the priority accorded to a field that has been allowed to slide in recent years is one worthy of attention.

In any area, there comes a point as evidence accumulates where the social costs of not acting on that evidence approach and eventually outweigh the social costs of doing something: that is, when the cost that might result from sending people off on a wild goose chase in a new direction which later proves unfruitful becomes less than the likely cost of foregoing the benefits that action could produce. In my judgement, we have passed that point in

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our work on the relationship between education and mortality. I do not think we can yet be more specific than that. We do not have the

kind of evidence necessary to formulate policies with respect to the more specific issues that have been raised. I do not, for example, believe that we are in a position to say whether an additional dollar invested for the purpose of improving health can best be allocated to health services, to education, or to something else. We do not yet have a clear enough appreciation of the relationship between education and health services to know whether com- plementarities or trade-offs exist. I would be reluctant to argue on the basis of what I have heard that one kind or level of education is more or less important for mortality reduction than any other kind or level. Nor is there much that can be said about what kind of curriculum would be best for mortality declines.

I share the hope of all of us that the research necessary to provide concrete guidance in such specific areas - and also to establish firmly the causal nature of the education/mortality link - will proceed apace. But as we pursue such research, I also hope that we will take seriously the impor- tant policy implication of what we have learned thus far and that, unless and until evidence to the contrary appears from our further research, we will not hesitate to join with those who advocate a higher priority for education in overall development and health improvement strategies.