For countries with higher quality of governance i. For life expectancy, countries with higher quality of governance i. These results suggest that the same amount of resources is twice as effective in improving health outcome in countries with higher quality of governance as in those countries with lower quality of governance. These findings provide one possible explanation for the surprising result that public spending on health often does not yield the expected improvement in health outcomes.
As highlighted in the literature review, some studies, including the influential paper by Filmer and Pritchett [ 14 ], have found insignificant or an extremely small impact of public spending. Our findings show that the quality of governance may be the explanation and this is supported by Rajkumar and Swaroop [ 30 ], who studied the impact of public spending on development outcomes, including under-five mortality, at different levels of quality of governance.
Their findings show that while public spending on health is effective in reducing U5M in well-governed countries, it has virtually no impact in poorly governed countries. Probable explanations for this observation is that improving QoG leads to better allocation of resources, better targeting and enhances more efficient use of available resources.
As Wagstaff and Claeson [ 5 ] point out, better governance leads to better policies and more efficient institutions, hence strengthening the link between PSH and health outcomes. Similarly, Lewis [ 29 ] concludes from a study of developing countries that governance is important in ensuring effective health care delivery and that returns to investments in health are low where governance issues are not addressed.
The importance of quality of governance for health is echoed in the literature by Kaufmann et al. Population health can be related to QoG in several ways. Secondly, quality health care service delivery is dependent on quality of policies and administrative institutions, both of which improve with QoG. Higher QoG should result in more efficient use and better-targeting of resources in healthcare delivery and thus better population health.
Public health spending improves health outcomes. Its impact is mediated by quality of governance, having the higher impact on health outcomes in countries with better governance and lower impact in countries with poor governance. This provides one possible explanation for the insignificant or extremely small impact of public spending observed in some studies, namely; that inefficiency of public spending may be, in actual fact, a result of poor governance.
Governance is important in ensuring effective health care delivery and returns to investments in health are low where governance issues are not addressed.
It is therefore imperative that SSA governments improve the quality of governance as one way of improving health outcomes. We used public and freely available data, ethical approval was not required. Competing interests.
IM and BOH had the concept of the paper. IM did the analysis. Both authors wrote the first draft, revised the paper and the final draft. Both authors read and approved the final manuscript. Availability of data and materials.
Innocent Makuta, Email: moc. National Center for Biotechnology Information , U. BMC Public Health. Published online Sep Author information Article notes Copyright and License information Disclaimer. Corresponding author. Received Oct 16; Accepted Sep This article has been cited by other articles in PMC. Methods Using two staged least squares regression technique on panel data from 43 countries in SSA over the period —, we estimated the effect of public spending on health and quality of governance U5M and LE, controlling for GDP per capita and other socio-economic factors.
Results Public spending on health has a statistically significant impact in improving health outcomes. Discussion Public spending on health improves health outcomes. Literature review Economic growth and health outcomes The search for major socioeconomic determinants of good health has been a preoccupation of researchers and policy-makers for decades.
Public spending on health, quality of governance and health outcomes PSH has long been viewed as a potential complement to economic growth in improving health status. Methods Measures of quality of governance Governance refers to the manner in which public officials and institutions acquire and exercise the authority to shape public policy and provide public goods and services [ 33 ].
Table 1 Definitions of dimensions of governance. Open in a separate window. Demand for health capital: a simplified Grossman model Health outcomes can be seen as outcomes of a health production process or function. Results Based on the Hausman specification tests, the fixed effects model was favoured over the random effects model. Table 2 Regression results for Under-five mortality. Table 3 Regression results for life expectancy.
Table 4 Instrumental Variable Regression results for Under-five mortality - with interactions. Table 6 Instrumental Variable Regression results for Life expectancy- with interactions. GDP per capita 2. Lower a Mean b Upper c Control of corruption 3. Discussion On the whole, the results show that public spending on health is an important determinant of health outcomes in SSA. The same increase in PSH is twice as effective in reducing U5M and increasing LE in countries with higher QoG as with lower QoG, as shown in the table above Notes: a elasticity computed at one standard deviation below the sample mean score; b semi-elasticity computed at one standard deviation above the sample mean score; c semi-elasticity computed at one standard deviation below the sample mean score; d semi-elasticity computed at one standard deviation above the sample mean score.
Conclusions Public health spending improves health outcomes. Ethics approval We used public and freely available data, ethical approval was not required. Acknowledgements We thank the reviewers whose excellent reviews helped us to improve the manuscript. Funding No external funding was used for this study. Footnotes Competing interests The authors declare that they have no competing interests. Availability of data and materials Not applicable. Contributor Information Innocent Makuta, Email: moc.
References 1. United Nations. The Millennium Development Goals Report Wagstaff A, Claeson M. Gupta S, Verhoeven M. The efficiency of government expenditure Experiences from Africa.
J Policy Mak. Grigoli F, Kapsoli J. Comparative efficiency of national health systems: cross national econometric analysis. Jayasuriya and Q. Efficiency in Reaching the Millennium Development Goals.
World Bank Working Paper, vol. Herrera S, Pang G. Pritchett L, Summers L. Filmer D, Pritchett L. The impact of public spending on health: does money matter? Soc Sci Med. Government health expenditures and health outcomes.
Health Econ. Income and child mortality in developing countries: a systematic review and meta-analysis. J R Soc Med. Anyanwu J, Erhijakpor A. The effectiveness of government spending on education and health care in developing and transition economies. Eur J Polit Econ. Akinkugbe O, Afeikhena J. In Applied macroeconomics and economic development. Edited by Adenikinju A, Olaniyan O. Ibadan: Ibadan University Press; Determinants of life expectancy in eastern mediterranean region: a health production function.
Int J Heal Policy Manag. Governance matters: an ecological association between governance and child mortality. Int Health. Kaufmann, A. Kray, and P. Statistics Access and download statistics Corrections All material on this site has been provided by the respective publishers and authors. You can help correct errors and omissions.
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For technical questions regarding this item, or to correct its authors, title, abstract, bibliographic or download information, contact: XML Conversion Team email available below. Please note that corrections may take a couple of weeks to filter through the various RePEc services. Economic literature: papers , articles , software , chapters , books. FRED data. There was a considerable degree of variation in the degree of active citizenship across the EU Member States: almost one third At the other end of the range, less than 1 in 10 of the adult population were active citizens in a majority 19 out of 27 of the Member States.
Of these, there were seven that recorded shares below 5. Figure 1 shows that the proportion of active citizens was generally higher for men than it was for women across the EU Member States. In , there were only four exceptions to this pattern: Lithuania, France, Sweden and Finland.
It is interesting to note that with the exception of Lithuania, each of these had high overall rates of active citizenship three out of the four highest rates. Finland had the widest gender gap for active citizenship, as the share of women who were active citizens was 4.
By contrast, the gender gap was generally in favour of men and among the 23 Member States where this was the case, the largest gender gaps were recorded in Greece 4. The information presented in Figure 2 extends the analysis by taking account of age: in , young women aged in the EU were more likely than young men to be active citizens; while there was almost parity between the sexes among the core working-age population years ; however, elderly men aged years were more likely than elderly women to be active citizens.
Although this pattern was not reproduced in each of the EU Member States it was relatively common to find that the lowest share of active citizenship among women was recorded among the elderly, whereas the opposite was true for men, with men aged years often recording the highest share of active citizenship among any of the different age classes.
A closer analysis reveals that Sweden recorded the highest rates of active citizenship in , irrespective of age or sex; note that the share of elderly women from France who were active citizens was the same as the proportion recorded in Sweden. Gender gaps for active citizenship were often more pronounced for either young adults or the elderly than they were for the core working-age population where rates of active citizenship were typically low for both men and women, likely reflecting work and family commitments for this age group.
The share of young adult women who were active citizens was Among the elderly population, Finland and Estonia were the only EU Member States to record a slightly higher share of active citizens among elderly women than among elderly men.
By contrast, in the remaining Member States where elderly men were more active, the gender gap widened to 7. The final analysis in this section focuses on active citizenship by income situation see Figure 3.
This pattern — a higher share of active citizens among the fifth rather than the first income quintile — was repeated in each of the EU Member States, although there was almost no difference in the level of active citizenship between these two subpopulations in Denmark and the difference was also relatively narrow in Sweden, the Netherlands, Finland and Malta.
By contrast, people in Cyprus in the fifth income quintile were 7. These figures suggest that the highest earners in society often have more interest or lower barriers to participate actively in cultural and social life, while people with the lowest incomes tend to be less active.
However, in the latest election, the voter turnout increased again to It is interesting to note that voter turnout was particularly low among the younger generation and was relatively high among the elderly.
Turnout is often used as a proxy for democratic legitimacy: across the EU it averaged The considerable variations witnessed in voter turnout may reflect, at least to some degree, the trust that people have in political systems.
In , on a scale of with 0 being the lowest and 10 the highest , the average rating given to trust in the political systems of the EU was 3. The highest levels of trust in political systems were recorded in the Nordic Member States , Malta and the Netherlands in ; none of the other EU Member States recorded a score that was above 5.
At the other end of the range, aside from Slovenia 1. As was the case for trust in political systems, the highest levels of trust in legal systems were also recorded in the Nordic Member States and the Netherlands where ratings were higher than for political systems. Note that the level of trust in the Maltese legal system was lower than for the political system, whereas elsewhere the reverse was true. An analysis by income situation is presented in Figure 4: it highlights that people in the fifth income quintile generally had a higher degree of trust in political systems an average score of 3.
This pattern — a lower score among people in the first rather than the fifth income quintile — was repeated in each of the EU Member States, with the exception of Malta, where there was no difference between these two subpopulations. The gap was widest in Germany, as people in the fifth income quintile gave an average rating of 5. The picture was even clearer when analysing the trust that people had in legal systems, with those in the fifth income quintile systematically recording a higher level of trust than those in the first income quintile.
These results may be somewhat disconcerting insofar as legal systems are generally intended to protect the rights of all citizens, yet there appears to be a clear divide in the degree of trust afforded to legal systems by citizens belonging to different income quintiles. This divide was widest in Germany, where people in the fifth income quintile gave an average rating of 6. The functioning of democratic institutions and civil society shape an important dimension in the quality of life for European citizens.
The rule of law should ideally be based on unambiguous legal provisions that provide for the equal treatment of all citizens, whether considered in terms of gender, sexual orientation, disability, race, ethnicity, religion or other characteristics.
That said, a range of different surveys across the EU reveal that a relatively high proportion of Europeans consider various forms of discrimination to be common, as can be seen from the specialized surveys on disadvantaged populations coordinated by the Fundamental Rights Agency. One example is discrimination in labour markets, be it in relation to the degree of female participation or the average earnings that women receive compared with men.
The indicators used within the Quality of life indicators framework to measure this are the gender employment gap and the gender pay gap. Most academics agree that self-perceived quality of life measures are enhanced when more women work, perhaps as a result of increasing levels of empowerment, economic security and social inclusion.
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