Economic Value Of Health Valor Econômico Da Saúde
Gavetas e prateleiras Drawers & Shelves Acknowledgements
This work was prepared with the inten-
Economic value of health
tion as of contributing to the debates dur-
ing the conference of the V World Health
Valor econômico da saúde
Assembly to be held in Geneva during May
1952.
The enormous effort to select, collect,
discuss and write in the short time available
would not have been possible without the
tireless cooperation of the personnel of
Paulo de Assis Ribeiro’s Technical Office
and of the Serviço Especial de Saúde Pública
(SESP) under whose auspices, this paper is
presented.
We cannot neglect to make special ref-
erence and express our deep gratitude for
the effort of Vera de Assis Ribeiro and
Dorothéa Viot de Albuquerque. They have
gone up to the boundaries of their strength
during all phases of the work.
To Mathilde Kastrup, in charge of the
English translation we are, not only deeply
thankful but also, on the obligation to
present our excuses for the many errors and
defects due to the hurry of revising, typing
and printing.
The graphs, so many times corrected
and redrawn by Heriberto Alves de Albu-
querque as well as the preparation of the
cover and designs of symbols and formula
by Sebastião M. Silva, contribute to give a
better presentation to “Economic Value of
Health”.
Paulo de Assis Ribeiro
The pressure of time was a heavy bur-
Manoel José Ferreira
den on Clélio Ximenes Carneiro and
Ernani Braga
Roberto Martins Costa in charge of the
Published under the auspices of the Serviço Especial de Saúde Pública
printing.
Rio de Janeiro
We are also not less thankful to a num-
Brazil - 1952
ber of others not mentioned by name.
The Serviço Especial de Saúde Pública, created on July 17, 1942 by
Rio de Janeiro, April 28, 1952
virtue of the contract between the Governments of the United States
of Brazil and of the United States of America, signed respectively by
PAULO DE ASSIS RIBEIRO
the Ministry of Health and Education to which it is subordinated,
MANOEL JOSÉ FERREIRA
and the Institute of Inter-American Affairs, is maintained on a co-
ERNANI BRAGA
operative basis by the governments of booths countries.
ETPAR - 1952
303
Rev. Bras. Epidemiol.
Vol. 1, Nº 3, 1998
Contents
CHAPTER I - GENERAL ASPECTS ............................................................................. 305
1) Principles of Measuring the Economic Value of Health ................................................................................... 305
A) Economic Factors Function of Health ............................................................................................................. 305
B) Basic Concepts ...................................................................................................................................................... 305
2) Principles of Individual Productivity and Consumption According to Age .............................................. 306
3) Principles of the Productivity and Consumption of Population According to Composition by Age
Groups ............................................................................................................................................................................. 308
4) Fundamental Principles of Life Span; Representative Rates and its Evolution ........................................ 311
A) Various Principles of the Life Span ................................................................................................................... 311
B) Evolution of the Rates of Human Life Span ................................................................................................... 314
5) The Value of Man and the Economically Productive Life Span - Need for Demo-Econometric Investi-
gations ............................................................................................................................................................................. 317
CHAPTER II - THE COST OF MORBIDITY .................................................................. 319
1) The Causes of Morbidity and its Economic Importance .................................................................................. 319
2) Influence of Morbidity on the Maintenance of Public Health Systems ..................................................... 323
3) Method of Determining the Cost of Morbidity ................................................................................................... 325
A) General Considerations ...................................................................................................................................... 325
B) General Morbidity ................................................................................................................................................ 325
C) Annual Individual Specific Consumption on Account of Morbidity ........................................................ 325
D) Annual Total Production Lost on Account of Morbidity ............................................................................. 326
E) Annual Total Consumption Increased on Account of Morbidity ............................................................... 326
CHAPTER III - COST OF MORTALITY ........................................................................ 328
1) Natural Death and Premature Death in the Moral Field and in the Financial Field ............................... 328
2) Method of Determining the Cost of Death .......................................................................................................... 334
A) General Considerations ...................................................................................................................................... 334
B) Number of Premature Deaths ........................................................................................................................... 334
C) Annual Specific Individual Consumption on Account of Premature Death ........................................... 334
D) Total Potential Production Lost Annually on Account of Premature Deaths ........................................ 335
E) Specific Total Annual Consumption Increased on Account of Premature Death .................................. 336
F) Total Potential Consumption Reduced Annually on Account of Premature Deaths ............................ 336
CHAPTER IV - CONCLUSIONS .................................................................................. 338
1) The Value of Health and Some Representative Rates ....................................................................................... 338
A) General Considerations ...................................................................................................................................... 338
B) Balance of Potential Values of Production and Consumption of a Population .................................... 338
C) Total Influence of Morbidity on the Economic Value of Heath .................................................................. 338
D) Total Influence of Mortality on the Economic Value of Health ................................................................. 339
E) Total Production Lost by Virtue of Morbidity and Mortality ....................................................................... 339
F) Total Consumption Augmented Because of Morbidity and Mortality .................................................... 340
G) Representative Rates .......................................................................................................................................... 340
2) Organization of Health Systems Based on the Value of Health .................................................................... 340
BIBLIOGRAPHY ....................................................................................................... 342
Rev. Bras. Epidemiol.
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Vol. 1, Nº 3, 1998
Ribeiro, P. de A., Ferreira, M.J. & Braga, E.
CHAPTER I
-
Owing to social and economic
GENERAL ASPECTS
desiquilibrium in the communities
where they occur;
1) Principles of Measuring the
-
Owing to increased production cost
Economic Value of Health
of the population group reaching
adult age;
A) Economic Factors Function of Health
-
Owing to the reduction of the aver-
age value of the rate relating of du-
The purpose of this study is to explain
ration of the economically produc-
the value of health from the viewpoint of the
tive life; and consequently,
expenses and losses caused by disease and
-
Owing to increase of the relation be-
other physical deficiencies which, in all age
tween total consumption and total
groups, reduce or hinder the full normal
production of the population of the
productiveness of the healthy man in a spe-
region.
cific period; also losses in productivity-re-
Attention should also be given to reduc-
sulting from premat\ure deaths and caus-
tion in the normal total consumption, re-
ing a reduction in the number of individu-
sulting from the reduction of the number
als in each age group in ages below the nor-
of consumers eliminated from the popula-
mal age of Lexis for the region under con-
tion by premature death.
sideration - throughout the period between
Values relating to death will be dis-
the age when death occurred and the re-
cussed for the period included between the
spective normal Lexis ages.
age at which death occurred and the nor-
An analysis will be made elsewhere of
mal Lexis age for the region.
the cost of disease and the cost of death.
This study will frost define the fundamen-
B) Basic Concepts
tal concepts followed.
In analyzing the cost of disease, an exami-
It will therefore be necessary to define
nation will be made of the expenses and losses
some basic concepts used in fixing mea-
incurred by diseases and physical lesions:
surement units for the value of health.
-
Directly, in private economy - indi-
These are to determine the total value of all
vidually and of in each family group
expenses and losses referred to and also to
- and in the general economy - of the
establish rates relating to each region. Such
state;
rates should represent the value of health
-
Indirectly, by reducing individual
in relation to the balance of total reproduc-
productivity rates and the various
tion for the population considered and in
age groups of the population in the
relation to each age group of that popula-
region under consideration;
tion, both as instantaneous values and for
-
Indirectly, by an increase of the
determining the variation of these in the
population groups of low productiv-
course of time, inclusively by the influence
ity; and finally,
of growth rates to be considered.
-
By a growth in the relation between
Throughout this work, it is admitted that
total consumption and total produc-
the well being of a given population is in di-
tion of the population of the region
rect proportion to the average productivity
under consideration, owing to the
of its members. Productivity, in turn, de-
duration of disease and the effects
pends on the rate of heath of the region and
of physical lesions.
grows as the rate improves. The rate is de-
In analyzing the cost of death, special
termined by the conditions of morbidity in
consideration will be given to the losses
general and by the characteristic death
consisting in increase of goods and services
curve.
which should normally be consumed:
In a general way, all the factors that have
Economic Value of Health
305
Rev. Bras. Epidemiol.
Ribeiro, P. de A., Ferreira, M.J. & Braga, E.
Vol. 1, Nº 3, 1998
a bearing on calculating the value of health,
fication for each group of the average val-
according to the principles followed in this
ues of productivity and of production, as
study, are of completely different values for
well as of average consumption in goods
each region considered. Moreover, in one
and services, for each individual in these
and the same region these values undergo
age groups.
noticeable change as time goes on, and this
It would also be advisable to classify, for
will taken into consideration in the analy-
each of the cases, the average values appli-
sis of each of the following chapters.
cable to individuals of both sexes, but the
lack of statistical data does not permit car-
2) Principles of Individual Productivity
rying the study this far.
and Consumption According to Age
In this respect, there is also one other
necessary approximation, referring to the
Jean Dayre (1), Technical Consultant of
unit of production: individual, family, or
the French National Productivity Commit-
family group.
tee, has stated, in a parody of the title of
In the present day social organization,
Alexis Carrel’s book, “Man, the Unknown”,
with the gradual disappearance of the pa-
that in the modern world the idea of pro-
triarchal family, it is difficult to adopt the
ductivity is another unknown.
average family as a unit of production and
In 1911, Albert Aftalion (2), in an article
of consumption in a population. It would
published in the Revue d’Economie
be easier to study the family groups which,
Politique, entitled “The Three Notions of
in modern society, constitute the social and
Productivity and Rent”, pointed out the
economic unit and which are formed not
confusion existing in economic literature on
only of closely related members but of sym-
productivity: global productivity (in natura);
biotic association.
the special productivity of each agent (in
However, approximations of the same
nature); and the special productivity of each
order will be arrived at more easily by de-
agent (in value). These agents are the three
termining the average values for each indi-
groups of classical factors of economy: land,
vidual of the various age groups.
work, and capital.
Graphic representation of average val-
Although contemporary specialists still
ues of production and individual consump-
use these distinctions in economic studies,
tion, during the statistical period of one
there is a tendency, pointed out by Jean
year, for individuals of the various ages, may
Dayre, to group the three classical factors
be taken to present forms, for each region
of productivity into one element, human
considered, similar to those presented in
work. This specialist also proposes that, for
Figures 1 and 2.
the needs of the measure, productivity be
Absolute values of the ordinates of these
defined as the relation between production
curves, however, will vary greatly according
and work.
to productivity rates. In one the same re-
In this study, except for the approxima-
gion, these will vary in the course of time
tions necessary to reduce the complexity of
with the economic progress, but the forms
practical evaluations of the values of pro-
indicated in the figures will be maintained
ductivity, adopted by economic technique,
with slight changes.
consideration will not be given to certain
In Figures 1 and 2, the values of the or-
factors bearing on the precision of those
dinates represent an empirical estimate,
values but of little significance to the objec-
with a primary approximation, for drawing
tives in view.
the curves relating to individual average
In addition to the global average values
production and consumption, at each age,
for a nation, region, or city, we should also
for Brazil. There are represented, respec-
know the average values for each age group
tively, by π and γ .
x
x
in the respective populations, with a classi-
E. Engel (3), who dedicated his latter life
Rev. Bras. Epidemiol.
306
Economic Value of Health
Vol. 1, Nº 3, 1998
Ribeiro, P. de A., Ferreira, M.J. & Braga, E.
to systematizing statistical investigations on
has considerable influence, from birth to
consumption, proposed the adoption at the
the 25th year for men and to the 20th year for
end of the 19th century of the unit of indi-
women.
vidual consumption, justifying this a fol-
“Detailed investigations on the cost of
lows: “It was necessary for me to introduce
man in the most numerous class warrant
this new expression. Since the constitution
evaluation of expenses for a newborn infant
of families varies greatly, and its members
of this class, prior to birth and during birth,
increase, grow, move, etc., it is clear that
of 100 marks. It seems advisable to use this
family consumption can not remain always
amount as an initial reference figure, in-
the same. Attention should be given to the
creasing it, according to the results of inves-
age of consumers, because this condition
tigations, at the arithmetic annual rate of
Economic Value of Health
307
Rev. Bras. Epidemiol.
Ribeiro, P. de A., Ferreira, M.J. & Braga, E.
Vol. 1, Nº 3, 1998
10% until the respective ages of 25 to 20
Giorgio Mortara and V. Pareto to determine
years”.
the cost of production of adult man, it should
After presenting a table for ages 0 to 25,
be noted that the values obtained increase
he continues:
to the limits of the ages under consideration.
“I do not claim that the figures on this
In applying these to the present study, it is
scale are irrefutable. On the contrary, they
necessary to take into account the fact that
may be questioned for the reasons I pointed
after a certain age, coefficients of consump-
out in my study on the cost of man. How-
tion in relation to age again decrease.
ever, they suffice perfectly for the purpose.
“The degree of consumers is therefore
3) Principles of the Productivity and
determined by the average amount of an-
Consumption of Population According
nual consumption expense. Upon reaching
to Composition by Age Groups
the age of 5, this represents 1.5; at 10 years,
2.0; at 25 years, 3.5 units. A family composed
The composition of populations by age
of father, mother, and six children aged 11,
groups may present three classical types:
9, 7, 5, 3 and 1 represents 16.1 units (father,
progressive, stationary, and regressive.
3.5; mother, 3.0; child of 11 years, 2.1; 9
For the three types, however, all indi-
years, 1.9; 7 years, 1.7; 5 years, 1.5; 3 years,
viduals from 15 to 50 years represent ap-
1.1; and 1 year, 1.1.
proximately 50% of the total population,
The introduction of this unit makes the
and the percentages of the number of indi-
composition of family independent from
viduals from 0 to 15 and from 50 to w are
the valuation of the balances of consump-
characteristic of the three types.
tion. The field of choice for families to be
According to Sundbärg (6) the charac-
studied is greatly increased, since its com-
teristically progressive type of population
position is inconsequential and its is suffi-
would have 40% individuals from 0 to 15
cient to know the number, sex, and age of
years, and 10% 50 to w years; the stationary
its members”.
type, 26.5% to 15 years and 23% 50 to w
It can be seen that Engel introduced a
years; the repressive type, 20% 0 to 15 years
unit of individual consumption based on
and 30% 50 to w years. Sundbärg establishes
prenatal and natal expense and established
the percentages for the three large age
that the variation of individual consump-
groups in a standard type of population: 0
tion, with the years, could be represented
to 15 years group - 33.3% 15 to 50 years -
by arithmetic progression.
50%, 50 to w group - 16.7%.
Giorgio Mortara (4) suggests substitut-
Accordingly, the population of Brazil
ing arithmetic progression for geometric
would be immediately included in the
progression and also presents the possibil-
clearly progressive type, and the distribu-
ity of a more general form of representation.
tion curve of the population by ages is rep-
He pointed out, however, that the lack of
resented in Figure 3, with approximate av-
numerical values to determine the func-
erage values for the population in 1950.
tions for expressing variation of consump-
R. R. Kuczynski (7) shows that is neces-
tion, according to age, discourages the
sary to know the death and birth rates and
adoption of these general functions.
the immigration data in order to reach a
On the other hand, Vilfredo Pareto (5)
definite conclusion on whether the popu-
drew up a method for substituting the dis-
lation is of the stationary, regressive, or pro-
continuous functions of Engel’s formulas by
gressive type.
continuous functions, using infinitesimal
For evolutive studies of the composition
calculation and substituting the totalities by
by ages for the population of a determined
integrals.
region, it is obviously necessary to use pre-
When using the coefficients established
cise methods to measure the tendency of
by E. Engel as well as those proposed by
the natural movement of the population.
Rev. Bras. Epidemiol.
308
Economic Value of Health
Vol. 1, Nº 3, 1998
Ribeiro, P. de A., Ferreira, M.J. & Braga, E.
From this aspect, however, the develop-
heavily in the absorption of the production
ment of studies on the general theory of
by the economically producing group.
population have reached a point where it is
At times, in one and the same country,
possible to obtain approximation degrees
there is a great variation in the composi-
suitable for economic studies.
tions by age of the populations of its vari-
In addition to his general studies on the
ous regions. There are especially great dis-
subject, Alfred J. Lotka (8) made a special
crepancies in the economically productive
study of the fundamental types of popula-
ages. For the purposes of this study, this
tion: stationary, malthusian and logistic, in
requires a knowledge of regional data in
relation to effective populations. These con-
order to evaluate the value of health.
tributed decisively to the practical applica-
It is not sufficient, therefore, to know the
tion of demography in economic studies,
average values in a country, in a determined
especially with reference to the differential
period, representing results of components
rates of growth for the productive age groups
with various characteristics representative
in a population of each of these types.
of each one of its regions.
It is therefore possible to know the com-
It is true that all work of reducing avoid-
position of the population of a region by age
able mortality leads, at the end of a certain
groups and also to make an approximate
period, to a percentage increase of the
forecast to this composition in periods of
population over a certain age. This is the
time necessary for economic studies.
case with the population of the United
The economic aspect of the composition
States where, according to a recent study by
by ages of a population is of utmost impor-
Oscar R. Ewing (9), administrator of the Fed-
tance, since the percentage of individuals in
eral Security Agency, there were 18% over
the economically productive age groups is
45 years in 1900, increasing to 28% in 1945,
of itself an indication of the production ef-
with a forecast of 34% for 1975.
fort which individual of this group must
After overcoming the causes of death
make to maintain the population where the
from the most frequent diseases in child-
as yet non-producing age groups and those
hood and adolescence, we arrive at the
of advanced age, of very limited productiv-
problem of the increase of chronic disease
ity, constitute consuming groups weighing
such as heart disease, cancer, cerebral le-
Economic Value of Health
309
Rev. Bras. Epidemiol.
Ribeiro, P. de A., Ferreira, M.J. & Braga, E.
Vol. 1, Nº 3, 1998
sions, nephrites, etc. The control of these is
g
. For those products, will be used the
XPX
not only more costly but also less efficient
symbols: R and C .
x
x
with the resources available.
The production balance of a population
In the economic study of the value of
indicated by the curves in Figures 1, 2 and
heath, this represents a substantial modifi-
3 may be expressed, using the indicated
cation in the forms of the characteristic
symbols
curves presented in this study, without,
however, altering the degree of validity of
ω
ω
= Σπ
− Σ γ
the method presented.
(1) S
p
p
p
x x
x x
On the other hand, in a country with
0
0
varying regions of economic development,
or
population groups of low production con-
ω
ω
tribute to a decrease in average rates of na-
S = Σ p
p
− ΣC
x
x
tional productivity. It is therefore of general
0
0
national interest to go to work in these re-
where Sr indicates the production balance,
gions, intensifying the means of production,
and w the most advanced age in the popu-
providing the population with instruction
lation under study.
according to the environment, and lastly
An analysis of Figure 4 shows how the
providing economic recuperation by all
increase of Sr balance may be obtained.
means in order to raise the average rates of
Theoretically, in order to increase the Sr
productivity.
value, we should try to increase the values
Figure 4 shows the forms of the curves
of pc in all ages, those of rc in the phases
of total production and of total consump-
where pc is greater than gc, and reduce the
tion, as well as the zones where there are
values of gc in all ages, and those of rc in
balances and deficits of production, accord-
the phases where gc is greater than pc.
ing to age. These curves are obtained by the
However, these changes should not be for
product of the ordinate of the curves shown
the purpose obtaining purely economic
on Figures 1 and 2 and the ordinates of the
data. The aim should be:
curve shown on Figure 3. The values of
-
to increase the values of gc, repre-
these ordinates are respectively p
and
XPX
senting a better standard of living for
Rev. Bras. Epidemiol.
310
Economic Value of Health
Vol. 1, Nº 3, 1998
Ribeiro, P. de A., Ferreira, M.J. & Braga, E.
the population;
The main principles are:
-
to increase the values of rc, at ad-
a) empiric idea of the life span;
vanced ages, representing a greater
b) maximum or potential span;
average life span for the population,
c) man’s average effective span;
an ideal of civilization throughout
d) median life;
time.
e) average life;
-
two reduce pc in advance ages, a so-
f) normal life.
cial ideal also being gradually at-
tained with modern labor legislation,
a) Traditionally, the empiric idea of the
by means of retirement pensions.
life span shows that the human life, in the
These ideals, apparently at variance
various regions of the earth, may be con-
with the purposes of increasing total pro-
sidered to have a duration between 70 and
duction balances, must be arrive at simul-
80 years. Considered globally, this empiric
taneously with a strong increase of pc and
notion has not varied throughout the cen-
rc in the economically productive ages, by
turies and even in the Bible (10) - with the
means of greater efficiency in the organi-
exception of life spans of ante and post-
zation of labor. This is being accomplished
diluvial patriarchs - the life spans registered
in countries of better economic situation,
show that the common period of the life
especially by means of a well organized sys-
span did not vary greatly above or below
tem of public health, by planning tech-
those figures.
nique, by the development of mechaniza-
In this analysis, however, this empiric
tion in general, and by well supervised in-
idea of the human life span is of little inter-
dustrialization.
est, although the numerical rates are the
An attempt should be made to obtain for
most uniform in time and space.
the general population a greater relative
b) The second principle to be consid-
number of persons in the economically pro-
ered in the life span is the maximum or po-
ductive ages, and multiply for the produc-
tential span. Numerical values relating to
tion capacity of these by means of the avail-
this span do not permit a strict limit on hu-
able techniques.
man life. Most of the data registered in the
general and specialized literature on lon-
4) Fundamental Principles of Life Span;
gevity are legendary and do not possess suf-
Representative Rates and its Evolution
ficient documentation to be accepted sci-
entifically. Specialists in demography and
A) Various Principles of the Life Span
insurance risks refuse to accept as fact the
existence of cases of life span much over 115
The lack of a uniform terminology for
years. However, references have been made
questions relating to the life span requires
of individuals much older than 120 years,
that we first define the terms to be used in
such as Thomas Parr (11), said to have been
this analysis in order that data and conclu-
152 years and 9 months; Joseph Surrington
sions may be better interpreted. Various
(11), who died in 1797, at the reported age
terms are used in the study of the human
of 160 year; Henry Jenkins (12) said to have
life span and, according to the point of view
been 169 years; Countess of Desmond (12)
taken, ideas are expressed in such varying
140 years; José Martins Coutinho (13), who
manners that data and numerical rates dif-
was still living on December 4, 1872, in Cabo
fer greatly. This makes comparative stud-
Frio, State of Rio de Janeiro, Brazil, having
ies difficult, whether for the same popula-
been born in Saquarema in 1694, and was
tion in a determined period or what is still
therefore 178 years old, according to “The
more difficult - in cases of comparison of
British Brazilian Times” of that date. Figures
the conditions in various regions, over vari-
higher than these are found only in Biblical
ous periods.
texts, especially where reference is made to
Economic Value of Health
311
Rev. Bras. Epidemiol.
Ribeiro, P. de A., Ferreira, M.J. & Braga, E.
Vol. 1, Nº 3, 1998
the life span of patriarchs prior to the flood.
In view of the inaccuracy of the decla-
Literature of Hebrews, Samaritans, and of
rations and following a conscientious de-
the Setenta, although differing in the life
mographic analysis, Professor Giorgio
spans of theirs patriarchs, all refer to spans
Mortara reduces the figure of 7.889 to a
much higher than 100 years. The Latin
probable value of 70 to 140 cases of cente-
Vulgate (10) follows the chronology of the
narians in Brazil at the time of the 1940 cen-
Hebrew text, and in the latter the life spans
sus. Even so, this gives Brazil a rate per
of ante-diluvian patriarchs varied from 777
1.000.000 of 1.69 to 3.38, much higher than
(Lamech - Father of Noah) to 969 years
has been found for Germany, Japan, Swit-
(Methuselah - who died the year of the
zerland, Finland, Italy, and Holland.
flood), without taking into consideration
Kuczynski (quoted by Giuseppe Levi
the life span of Henoch (365 years) since,
(11) in a study on the limits of growth and
according to the Bible, this period does not
aging in metazoans), after carefully exam-
refer to Henoch’s life span as he was taken
ining data referring to a person who was
from the midst of men in the year 987 of the
said to be 118 years old, concluded that his
world but did not die on that date.
age was not greater than 106 years. S. Hirsch
In the censuses of various countries,
[apud 11], based on statistical studies and
there are frequent references to a large num-
especially those of Pütter, concluded that
ber of centenarians. Specialists in demogra-
the existence of men over 110 years is highly
phy do not accept these statistical data as
improbable, since studies relating to per-
being entirely true, especially since they are
centages of centenarians in cases of death
not based on civil registration, which is be-
found in Germany showed that for each in-
ing used only a little over a century, and not
dividual of 105 years there would be a cor-
in all countries. In the 1940 census in Brazil,
responding 1.1 million deaths, for each in-
there were several thousand declarations of
dividual of 115 years there would be a cor-
age over 100 years. In a recent study, Profes-
responding 6.550 million deaths, and there-
sor Giorgio Mortara attempted to correct the
fore the probability of a person dying at the
census data, showing numerous causes of
age of 115 years would occur only once ev-
error in such declarations.
ery 160 years.
Declarations of centenarians in the 1940
Therefore, the statistical principle of
census numbered 7.889, of whom 2.854
maximum or potential human life span is
were men and 5.035 women. In addition to
taken as being the period of one century for
many inaccuracies pointed out in these dec-
the normal limit in vital statistical studies.
larations by Professor Giorgio Mortara (14)
c) The third principle to be considered
in his work on “Centenarians in the Brazil-
is that of man’s effective average span, vary-
ian Census of 1940”, which leaves no doubt
ing according to the region, especially in
as to the inexacteness of the declarations,
relation to health indices, and therefore
it is curious to note that there were 213 cases
varying also for each era under consider-
of childbirth when the woman had already
ation. The numerical rate of this span is
passed her 50th birthday, since the age at
obtained by taking a simple average of the
which she could have had her youngest
real life spans found for individuals of a de-
child would be:
termined group born in the same period.
For Europe this value varies normally from
50 to 59 years
- in 33 cases
35 to 45 years, with the exception of some
60 to 69 years
- in 97 cases
places where the figure is higher than 50.
70 to 79 years
- in 49 cases
In the United States, this average reaches
80 to 89 years
- in 19 cases
values equal to or higher than 70 years. In
90 to 99 years
- in 9 cases
Brazil, the rate is normally between 35 and
100 to 109 years
- in 3 cases
45 years.
110 years and over
- in 3 cases
These figures are of slight significance
Rev. Bras. Epidemiol.
312
Economic Value of Health
Vol. 1, Nº 3, 1998
Ribeiro, P. de A., Ferreira, M.J. & Braga, E.
for the purposes of this study, but are very
ies at each age of the person under consid-
representative of the global characteristics
eration. In comparative studies, it is cus-
of health conditions in a determined region.
tomary to take the rate referring to the ages
d) another characteristic index of a new
of 0 to 1 year, although the tables are orga-
principle of the life span is that covered by
nized for all ages. The following examples
the median life (sometimes incorrectly
(16) of average life at age 0 give a good idea
called probable life), which corresponds to
of these rates:
the age at which the initial figure of 100.000
survivors, considered as having been born
Brazil ................ (1920) - 38
in the same period, is reduced to 50.000, or
United States ... (1940) - 63
half. This rate is very former of the health
Italy ................... (1930) - 56
conditions in a determined region.
Chile ................. (1930) - 38
In order to have an idea of the approxi-
Australia ........... (1947) - 68
mate numerical value of this index, we
New Zealand .... (1938) - 67
quote a few examples taken from Giorgio
Mortara (15):
f) Finally, we have the principle intro-
duced by Wilhelm Lexis of the normal age
Brazil ................ (1920) - 43 years
corresponding to the age at which the num-
United States ... (1940) - 68 years
ber of deaths of adults, in 100.000 births of
Italy ................... (1930) - 43 years
the same period, attains the maximum. For
Chile ................. (1930) - 42 years
a better understanding of this rate, it is in-
dispensable to examine the general curve of
e) Another principle of the life span is
deaths, in the manner suggested by Lexis.
that indicated by average life, representing
For this rate to be significant, the age it indi-
the probable number of years a man still has
cates must be correlated with the frequency
to live at each age. This rate is determined
of deaths verified at that age (Figure 5).
in the calculations of the death rate tables,
Figure 5 was drawn in the basis of the
and the life span appears therein as factor
survival table, according to mortality in the
of statistical probability. It is of the greatest
period 1939-1941, organized by Giorgio
interest in economic studies of death rates
Mortara (15), with the Gompertz-Makehan
and is the basis for all actuarial calculations
adjustment, starting with age 20, for the
of insurance companies and social security.
Federal District, Brazil.
From its definition, we see that this rate var-
As examples of these, we have:
Economic Value of Health
313
Rev. Bras. Epidemiol.
Ribeiro, P. de A., Ferreira, M.J. & Braga, E.
Vol. 1, Nº 3, 1998
Federal District
a) Survival curve according to the hy-
Brazil ................ (1940) - 69
pothetical life table of L.I. Dublin
United States ... (1937) - 80
(1933);
b) Survival curve according to the table
In a general way, all these rates with the
calculated by H.L. Dunn for the
exception of that relating to the principle
United States of North America
of maximum or potential human life span,
(1946);
are studied separately for both sexes, since
c) Survival curve for the city of São Paulo
variations for all are very noticeable for the
(Brazil) according to the table calcu-
group of men and the group of women in
lated by Giorgio Mortara (1940);
one region, in a given period. However, the
d) Survival curve for the city of Recife
average values for both groups serve to es-
(Pernambuco-Brazil), according to
tablish influences relating to death rates in
the table calculated by Giorgio
the present economic studies.
Mortara (1940).
Figure 7 shows the five following types
B) Evolution of the Rates of Human Life
of average life curves, at various ages:
Span
a) Representative curve, drawn accord-
ing to the hypothetical life table of
The most common graphic forms for rep-
Dublin (1933);
resenting data referring to death rates for a
b) Representative curve, according to
population are the probability curves of sur-
the table calculated by H.L. Dunn for
vival, of average life, and of general deaths.
the United States of North America
Figures 6, 7 and 8 give several examples
(1946);
of these three types of graphic representa-
c) Representative curve, according to
tion of death rates.
the data of W. R. Macdonell for the
Figure 6 shows the four following types
Roman colonies of Africa, 2.000
of survival curves:
years ago.
Rev. Bras. Epidemiol.
314
Economic Value of Health
Vol. 1, Nº 3, 1998
Ribeiro, P. de A., Ferreira, M.J. & Braga, E.
Economic Value of Health
315
Rev. Bras. Epidemiol.
Ribeiro, P. de A., Ferreira, M.J. & Braga, E.
Vol. 1, Nº 3, 1998
d) Representative curve, according to
Macdonell in 1902, analyzing data relative
the data of K. Pearson for Roman
to the populations of North Africa about
Egypt, 2.000 years ago;
2.000 years ago, when Egypt was under the
e) Representative curve for Recife
dominion of Rome, enable them to draw a
(Pernambuco-Brazil), according to
probability curve of live at each age, permit-
the table of Giorgio Mortara (1940).
ting a comparison of the conditions of life
Figure 8 shows the curves of general
at that period with those in various regions
deaths of Wilhelm Lexis for the United
of the world in modern times. Continuing
States of North America (1940).
the investigations initiated with Karl
In analyzing these, it is possible to make
Pearson, W. R. Macdonell, based on mate-
a general examination of how the life span
rial extracted from “Corpus Inscriptionum
rates have evolved over the last 2.000 years.
Latinarum” of the Academy of Berlin, se-
In the evaluative study, it is not possible
lected three groups of data which permit-
to consider the life spans registered in Bib-
ted the establishment of curves analogous
lical literature, since these have not as yet
to those organized for the Egyptian popu-
been interpreted to the satisfaction of all
lation of that era, for the inhabitants of
who believe in the truth of the historical
Rome, for the inhabitants of Spain and
book. In any event, we would find refer-
Lusitania under the dominion of Rome, and
ences useful only in studying maximum or
for the African colonies. These curve were
potential life span.
organized separately for each sex and per-
Scientific studies of value in determining
mit comparisons analogous to these re-
the conditions of life and death about 2.000
ferred to.
years ago are those of Pearson and
An observation of Figures 6 and 7 shows
Macdonell, continued by Macdonell (17,18).
how in some regions of the world sanitary
The oldest known probability tables (19) are,
and economic conditions have permitted
those of Prefect Pretorian Ulpiano and of
life span rates to approach, and sometimes
Jurisconsult Aemelius Macer, originated in
surpass the theoretical rates of the hypo-
the third century of the Christian era, but
thetical table of Dublin, which has therefore
these are of purely historical interest. Lists
been reviewed on account of that fact.
of life spans of eminent personages of an-
On the other hand, we note that in cer-
cient times give no evidence of evolution in
tain regions general rates of life span do not
the increase of the average life or of the nor-
show considerable progress when com-
mal life or of any other rate. For example, one
pared with the presumable sanitary condi-
list among many is the following:
tions in the world 2.000 years ago, expressed
by the curves drawn on the basis of the stud-
Alexander the Great ................... - 33
ies of Pearson and McDonnell.
Aristotles ..................................... - 62
Most basic studies, however, were pos-
Cicero .......................................... - 64
sible only commencing with the Nineteenth
Demosthenes .............................. - 62
Century, and even so with data referring to
Herodotus ................................... - 59
few countries, since statistics that could
Hippocrates ................................ - 85
supply sufficient documentation for stud-
Horace ......................................... - 57
ies on a scientific basis were rare and still
Ovid ............................................. - 60
are for a great number of countries. In or-
Plato ............................................ - 80
der to have an idea of the evolution of the
Pythagoras .................................. - 82
rates of life span during recent times, a few
Thales .......................................... - 94
examples of average life at age 0 are given
Virgil ............................................ - 51
on the following page.
The average life span is 67 years
After listing these data, it should be
pointed out that the situation from 1929 to
Investigations of Pearson and
1932 for Chile was indicated by the rate of
Rev. Bras. Epidemiol.
316
Economic Value of Health
Vol. 1, Nº 3, 1998
Ribeiro, P. de A., Ferreira, M.J. & Braga, E.
37.88 for men and 39.76 for women, and the
Gradually, however, the financial value
situation for some cities in Brazil from 1939
of man was again considered, taking into
to 1941 was, for São Paulo, 46.71 for men
account the goods produced by the popu-
and 51.77 for women; Federal District, 39.75
lation.
for men and 45.24 for women; Salvador
The creation of the primitive insurance
32.49 for men and 37.88 for women; Recife,
systems required the organization on tables
28.4 for men and 32.47 for women.
for the value of human life. These are being
continuously perfected in all countries, but
5) The Value of Man and the
the values are proportional to the premi-
Economically Productive Life Span -
ums. Their evaluations of the value of hu-
Need for Demo-Econometric
man life are gradually becoming more an a
Investigations
priori personal estimate rather than the
evaluation of the average values of man in
Following the abolition of slavery the
each region.
idea of attributing a financial value to man
The first attempts at a rational evalua-
was almost abandoned for a time. Under
tion of the economic value of man were
the former system, at least, a small part of
those of William Petty (1623-1687), who
the population was given a value in money
considered the value of a population as be-
and the free man was of less financial value
ing the equivalent of the capital which, at a
than the slave.
specific interest rate, would earn the total
goods produced by the population. The av-
TABLE
erage value of man would be the value of
that capital divided by the number of indi-
Average Life
viduals in the population under consider-
0 year
ation.
Countries
Periods
Men
Women
In addition to other errors in evaluation,
Australia
1881-1890
47.20
50.84
consideration was not given to the values
1946-1948
66.07
70.63
of consumption by the population in goods
Denmark
1835-1844
42.60
44.70
and services.
1941-1945
65.60
67.70
L. I. Dublin and A. J. Lotka (20) present
France
1817-1831
38.30
40.80
a study, which can be summarized in the
1946-1948
62.50
68.00
following steps.
Germany
1871-1880
35.58
38.45
In the Eighteenth century Adam Smith,
1932-1934
59.86
62.81
taking into consideration the relation be-
Finland
1901-1910
45.33
48.10
tween the productive capacity of nations
1941-1945
54.62
61.14
and the consumption necessary for their
Holland
1816-1825
29.32
35.12
populations, attempted to establish and
1947-1949
69.40
71.50
economic value for man.
New Zealand
1891-1895
55.29
58.09
Adam Smith, however, did not give an
1934-1938
65.46
68.45
intrinsic value to man himself, but gave
Italy
1876-1887
35.80
35.50
more weight to the productive capacities
1935-1937
54.00
57.49
such as knowledge acquired, abilities for
Sweden
1755-1776
33.20
35.70
work, since these contribute to an increase
1941-1945
67.06
69.71
of credits for determining production bal-
Brazil
1870-1890
33.86
33.86
ances, whereas man himself contributes to
1890-1920
39.25
39.25
increase the credits but contributes even
Russia
1874-1883
26.31
29.05
more strongly in increasing debits because
1926-1927
41.93
46.79
of goods and services he consumes.
United States
1850-
38.30
40.50
In the Nineteenth century, stricter inter-
(Massachusetts) 1939-1941
61.60
65.89
pretations were made and these resulted in
Economic Value of Health
317
Rev. Bras. Epidemiol.
Ribeiro, P. de A., Ferreira, M.J. & Braga, E.
Vol. 1, Nº 3, 1998
the studies of William Farr, T. Wittstein, R.
value of 20 years as being excessive since
Lüdtge, E. Engel, and V. Pareto.
individuals already produced special value
William Farr tried to determine the val-
for their subsistence starting at 16 years.
ues of each individual, taking into account
In the Twentieth century there have
the capacity for production at a specific age,
been many studies referring to the value of
determining the value at other ages by set-
man or of human life, the most important
ting interest rates and considering mortal-
of these being the studies of Louis I. Dublin,
ity tables. T. Wittstein attempted to deter-
Alfred J. Lotka, and Giorgio Mortara.
mine the value of man at various ages of life
During this century, the problem be-
by considering the value 0 at the date of
came even more significant. The knowledge
birth and establishing that, for a certain
of the value of human life has become in-
population group, total production
creasingly important for a perfect under-
throughout his entire existence would be
standing of economic problems.
the equivalent of the expenses for his main-
A historical analysis shows that all those
tenance. R. Lüdtge, studying specifically the
who took up the problem were limited in
value of man for the purpose of organizing
their studies by the deficiency of statistical
insurance tables, shows the relative nature
data, which alone shows the need for de-
of these values, since they do not have a fic-
veloping demo-econometric investigations.
titious average value but in each case have
In this study, we are trying to introduce
a real, physical significance of what the in-
into the analysis of the economic value of
dividual represents financially to his family
man the factors of greatest influence in its
or insurance beneficiary.
variation, summarized under the heading
E. Engel (3,21), a disciple of Quetelet and
of the economic value of health and taking
of Le Play, was the first to consider the ques-
into account disease rate in its many aspects
tion from a more ample viewpoint and he
in determining that value, a matter not yet
was the observer and initiator of various
duly estimated.
heretofore neglected elements among the
The study of the economically produc-
factors determining man’s value.
tive life span will be a result of investiga-
In addition to the data for determining
tions in each region for the coefficients re-
individual consumption according to age,
lating to individual production and con-
described above, Engel promised to com-
sumption, and also of the demographic
plete his investigations. His work, however,
analysis based on the death tables for the
remained unfinished, but he did have great
same regions.
influence on later investigations.
Giorgio Mortara (22,23) made special
In his studies, he did not take into ac-
studies to determine the economically pro-
count the death rate or capital interest, al-
ductive life, published in a series of articles
though he was conscious of these deficien-
entitled “Demo-econometric Investiga-
cies, but he introduced the principle of the
tions”, for the purpose of developing knowl-
economically productive period of life.
edge of these two branches of social sci-
Vilfredo Paredo (15), starting with
ence, facilitating exploration of the zone of
Engel’s studies, not only introduced the fac-
common interest.
tor of infant mortality in the cost of the adult
The main result of this study may be to
man, but also established continuous for-
develop the interest of investigators to join
mulas to express the values at each age, us-
efforts in obtaining new methods to facili-
ing the mortality tables of Bódio. He also
tate not only the determination of the as yet
proposed that, in determining the cost of
deficient numerical coefficients but also to
adult man, consideration be given to the age
establish indices corresponding to the eco-
limit of 20 years instead of 25 years, as used
nomic value of health, fundamental for a
by Engel. He went so far as to question his
knowledge of economic questions.
Rev. Bras. Epidemiol.
318
Economic Value of Health
Vol. 1, Nº 3, 1998
Ribeiro, P. de A., Ferreira, M.J. & Braga, E.
CHAPTER II
normal activity of the individual during a
THE COST OF MORBIDITY
certain period an in the forms in which they
merely reduce the productivity of the indi-
1) The Causes of Morbidity and its
vidual at work. Consideration should also
Economic Importance
be given to physical lesions and traumatism
in general; whether they cause temporary
In the analysis covered by this chapter,
or permanent disability or whether they are
it is first necessary to establish a concept for
merely harmful to the worker by reducing
morbidity, since the determination of the
his output. We should also include all losses
characteristic elements of the general mor-
resulting from every and any physical or
bidity of a population vary greatly accord-
mental deficiency, or loss of productive ca-
ing to the concept adopted.
pacity, caused by diseases, in the broadest
Important characteristics for evaluating
sense of the term.
cost at each age are:
In examining the economic influence of
-the coefficient of morbidity
disease, it is also necessary to establish the
concept of what may be considered as tech-
nx
Zx =
nically avoidable morbidity and what may
px
be termed as residual morbidity of more
difficult control, in the population group
-the frequency of the disease or the pos-
considered.
sibility of becoming ill
This aspect of the problem was been
better studied with reference to death, but
f
cx
x= p
it is evident that premature deaths are the
x
final phase of a disease and everything in-
-the duration of the disease
dicates that it is by reduction or elimination
of these diseases that the more rapid reduc-
nx
δx =
tion or elimination of premature deaths is
cx
obtained.
were p , c and n represent, respectively;
Statistics, however, leave much to be
x
x
x
individuals, at age x, exposed to the risk of
desired in the majority of countries with
disease during the period of time under
respect to morbidity.
consideration; the number of individuals at
During this century some countries
age x, who in group rc were affected by the
have become concerned with the influence
disease during the period under consider-
of morbidity on the economic indices and
ation; and the total number of sickness-days
have undertaken special investigations and
for individuals of group p during the pe-
census-surveys to determine fundamental
x
riod under consideration.
coefficients, not only in order to institute
It is clear that for each concept adopted
sickness insurance but also to determine
for morbidity there are very different cor-
the orientation of public health systems for
responding numerical values for the char-
the improvement of production indices of
acteristic indices.
the population.
In calculating the cost of sickness, we
Edgar Sydenstricker (24) made a very
should, in a general way, include among the
valuable attempt to outline the “Age curve
diseases everything that represents harm-
of good health”, which was later developed
ful modification in the state of health and
by Isidor S. Falk, Margaret C. Klem, and
in the normal vigor of individuals at vari-
Nathan Sinai (25) following an analysis of
ous ages. Therefore, consideration should
8.500 families of the white race from vari-
be given to diseases in general, whether
ous regions of the United States.
those of chronic evolution or of acute evo-
In this study, disease was defined as
lution, both in the forms which hinder the
“any disorder which wholly or partly dis-
Economic Value of Health
319
Rev. Bras. Epidemiol.
Ribeiro, P. de A., Ferreira, M.J. & Braga, E.
Vol. 1, Nº 3, 1998
ables an individual for one or more days or
These evaluations did not include direct
any experience for which medical service of
expenses with medical care, such as those
any kind is received. Any condition, symp-
paid for by the patients, by the government
tom or disorder for which drugs costing 50
and public institutions, by philanthropic
cents or more are purchased is considered
institutions and by the employers, also rep-
an illness” (26).
resenting about 4 billions dollars.
It can be clearly seen that this concept
In order to give an idea of the known
is predominantly influenced by corporal
coefficients, tables 1, 2 and 3 show: Table 1
factors, whereas the present phase of medi-
- a survey of the Metropolitan Life Insurance
cine is daily becoming more firmly based
Co. made in 1915/17; Table 2 - an estimate
on a psychosomatic viewpoint.
for 1930 of the cases of diseases and condi-
The interrelation of a great number of
tions requiring medical diagnosis and treat-
pathological conditions of purely organic
ment; Table 3 - expenses with medical care
appearance, with alterations in the psycho-
for 1929, in the United States (26).
logical field, closely associates the clinical
It is clear that figures in the three tables
aspect of disease with the mental behavior
above vary considerably according to re-
of the patient.
gion. Variations correspond not only to the
This is the reason why medical care and
value of the rates for the various diseases
social assistance, in their broadest sense,
but also the occurrence of types of disease
are working on parallel levels and as parts
which are non-existent in one region and
of the same system.
predominant in others.
We therefore have an idea of the diffi-
culty of appreciating present statistics of the
Table 1 - Prevalence of Disabling Illness by
neuropsychological factor, not only in the
Age and Sex, Metropolitan Life Insurance Co.
origin of the sickness but also in the pro-
Surveys, 1915-17(1)
ductivity of the individual who has not yet
Percentage of persons sick
stopped work, but whose activities have
and unable to work
been affected.
Age
Both sexes
Male
Female
Although considerations of this aspect
0 - 14
1.1
1.1
1.1
of the problem are essential, we will go on
15 - 24
1.3
1.2
1.4
to examine morbidity with the concrete el-
25 - 34
1.6
1.4
1.8
ements available, in a effort to present its
35 - 44
2.1
2.0
2.2
economic significance in a rough manner.
45 - 54
3.0
3.3
2.8
Global and age rates, showing the eco-
55 - 64
4.8
5.4
4.2
nomic importance of sickness, have been
65 +
9.5
10.6
8.7
estimated in various countries, especially by
(1) From Sydenstricker, Edgar, Health and Environment
insurance companies.
(1933), p. 33. Bases on some recent morbidity data compiled
The United States was even established
by Margaret Looms Stecker from the reports of the
Community Sickness Surveys by Lee K. Frankel and Louis I.
average percentages of lost production, by
Dublin.
virtue of sickness and accidents, as well as
owing to tardiness, in the disorganization
In addition, direct expenses with medi-
of routines, in training time required for
cal care, in the various forms indicated in
substitutions, and by lowered production
Table 3, show very different rates accord-
resulting from other conditions of sickness.
ing to countries, since these expenses are
These percentages were estimated in 1929
related to the economic conditions of the
- taking into account the cost of living at
region and to the political plans of public
time - as being 4 billions dollars, corre-
health as adopted for each country.
sponding during that year to approximately
As stated, the concept for each region
the ordinary expenditure of the Federal
and each period of time of what should be
Government of the United States!
considered as technically avoidable mor-
Rev. Bras. Epidemiol.
320
Economic Value of Health
Vol. 1, Nº 3, 1998
Ribeiro, P. de A., Ferreira, M.J. & Braga, E.
Table 2 - Estimate of Cases of Disease and Conditions Requiring Medical Diagnosis and
Treatment (1)
Disease
Expectancy
Estimated
rates per
cases,
1.000 persons
United
all ages
States 1930
TOTAL
936.30
114.954.000
Respiratory system
459.00
56.354.000
Digestive system
117.00
14.365.000
Acute diseases
92.50
11.357.000
Injuries from external causes
54.00
6.630.000
Puerperal state
23.56
2.893.000
Syphilis and gonorrhoea
23.00
2.824.000
General diseases
21.00
2.578.000
Diseases of the skin
19.90
2.443.000
Nervous and mental conditions
16.29
2.000.000
Non venereal diseases of the female genital organs
16.00
1.964.000
Diseases of the ear
15.00
1.842.000
Neuralgia, nevritis
13.10
1.608.000
Neurasthenics nervous exhaustions
13.10
1.608.000
Diseases of muscles, bones
13.00
1.596.000
Diseases of the kidneys
12.10
1.486.000
Diseases of the heart
11.70
1.436.000
Diseases of the eye
8.50
1.044.000
Other diseases of circulatory system
6.80
835.000
Non veneral diseases of male genital organs
0.75
92.000
(1) Expectancy rates from Lee, Roger and Jones, Lewis W., The Fundamentals of Good Medical Care, Committee on the Cost of
Medical Care, Publication no 22 (1933), 97-100.
Table 3 - Total Expenditures for Medical Care(1) (in Millions of Dollars)
Sources of Funds
Service
Total
Patients
Governments
Philanthropy
Industry
Private physicians
1.090
1.040.0
...
...
50
Private dentists
445
445.0
...
...
...
Secretaries and practical secretaries
193
193.0
...
...
...
Private graduate nurses
142
142.0
...
...
...
Private practical nurses
60
60.0
...
...
...
Hospital operating expenditures
656
278.0
300.0
54.0
24
Hospital new constructions
200
...
100.0
100.0
...
Public health
121
...
93.5
27.5
...
Private laboratory(2)
3
3.0
...
...
...
Orthopaedics and other supplies(2)
2
2.0
...
...
...
Glasses(2)
50
50.0
...
...
...
Drugs(2)
665
665.0
...
...
...
Organized medical services
29
7.9
16.0
0.2
5
TOTAL
3.656
2.885.9
509.5
181.7
79
(1) Source: Medical Care for the American People; the Final Report of the Committee on the Costs of Medical Care (1932), p. 14. The data, with a few minor
exceptions, apply to the year 1929.
(2) Includes only those expenditures not included in other items.
Economic Value of Health
321
Rev. Bras. Epidemiol.
Ribeiro, P. de A., Ferreira, M.J. & Braga, E.
Vol. 1, Nº 3, 1998
bidity is a fundamental matter in the study
days worked but in the high reduction of
of the economic value of morbidity.
productivity of workers infested, but at
Climate conditions, basic economic
work.
conditions, the cultural development of the
In addition to the above examples, vari-
people, the degree of perfection of sanitary
ous other diseases contribute in a high de-
control, the stages of the main endemic dis-
gree to reduced productivity, but are not
eases, the financial, technical, and human
frequent causes of deaths registered or
resources available for the control of pos-
main causes of absenteeism. Some of these
sible epidemics, and lastly, genetic condi-
are syphilis, certain types of diseases of the
tions of the people result in a varied con-
respiratory system, brucellosis and defi-
ception for each region of what should be
ciency diseases. Under present conditions,
considered as avoidable morbidity.
public health services are in a better posi-
This can be seen in an incomplete but
tion to control these.
expressive manner by analyzing the “age
Another very interesting element in the
curve of good health” and the already
economic study of morbidity, which can be
known curves representing specific mor-
used until specific coefficients become
bidity tables, taking into consideration
available, is the relation between the esti-
modern resources of preventive medicine.
mated number of cases of death and the
The modern world has the following
number of deaths already determined for
means of reducing or eliminating avoidable
various types of diseases, at different ages,
morbidity: sanitation and sanitary engi-
in some countries. Tables 4 and 5 are ex-
neering in general; health education and
amples (26).
modern processes of health information;
These estimates, although constituting
immunizations; epidemiological controls;
values of little precision, are very important
chemotherapy; the antibiotics; residual in-
in studies tending to establish numerical
secticides; and lastly, the resources of men-
value of the cost of health and should be
tal hygiene and sociology.
used freely. Often - as occurred in Engel’s
Precisely in those regions where the
studies, when he detailed presumable val-
people have poor health rates, the control
ues of the expenses of consumption at suc-
of disease is most rapid and efficient, and
cessive ages (4) - progress in a determined
consequently financial results are most
field of applied statistics results from hy-
gratifying.
potheses and the fixing of empirical data for
Although, as has been pointed out, sta-
approximate solutions.
tistical investigations and surveys have not
determined exactly the influence of mor-
Table 4 - Deaths and Estimated Number of
bidity on individual productivity and con-
Cases of Certain Common Diseases of
sequently on the total production of a popu-
Childhood, USA, 1934(1)
lation. It is well known that morbidity can
Disease
Estimated
Deaths
reduce production over 50%.
cases
For example, this is the case in some
Whooping cough
1.500.000
7.518
regions where incidence is high for malaria,
Measles
1.800.000
6.986
trypanosomiasis, certain schistosomiasis,
Diphtheria
46.000
4.159
hookworm, etc. These diseases are of long
Scarlet fever
300.000
2.524
duration and gradually reduce the produc-
Mumps
1.440.000
...
ing capacity of morbidity, used in organiz-
Chickenpox
1.000.000
...
ing the tables for insurance firms, consid-
(1) For case-rate estimates, see Sydenstricker, Edgar, and
ers only the number of sick days which de-
Wheeler, Ralph E.. Whooping Cough in Surveyed
Communities. American Journal of Public Health, 26:582
prive the worker of activity. As we have seen,
(June 1936). Also Collins, Selwyn D., Age Incidence of the
in cases similar to those cited, the loss of
Common Communicable Diseases of Children. Public Health
Reports, 44:763-826 (April 5, 1929). Public Health in New York
production is not felt in the reduction of
State, State of New York, Department of Health (1932), 404.
Rev. Bras. Epidemiol.
322
Economic Value of Health
Vol. 1, Nº 3, 1998
Ribeiro, P. de A., Ferreira, M.J. & Braga, E.
Table 5 - Deaths and Estimated Number of
cover periods of inactivity caused by sick-
Cases of Tuberculosis, Malaria, and Typhoid
ness. In this study, it is also necessary to
Fever in the United States, 1934(1)
verify morbidity for ages 0 to 15 years and
over 80 years.
Disease
Deaths
Estimated
In a study by Carlo Pinghini (27) we find
cases(1)
the main morbidity tables of Italy, France,
Tuberculosis
71.609
644.000
England, Germany, and Switzerland, as well
Malaria
4.520
2.700.000
as one, by diseases, organized for commer-
Typhoid and
4.237
42.000
cial employees in Italy. However, as has
paratyphoid fever
been pointed out, these tables show coeffi-
(1) Basis for estimates supplied by L.L. Williams, Jr., M.D. of
cients much lower than those which must
the United States Public Health Services
be taken into account in calculating the cost
of sickness.
Data relating to rates for lesions result-
Other tables organized on the basis of
ing from accidents and traumatisms of all
surveys by the Metropolitan Life Insurance
kinds are very poor. This also contributes
Co., by the United States Public Health Ser-
in a pronounced manner to lowering pro-
vice, and by the Committee on Costs of
duction, whether in determining conditions
Medical Care also show the economic ef-
of partial or total disability, or in determing
fects of disease (20).
disturbances of lesser importance capable
It is interesting to note that, according
of reducing productivity in the normal field
to data of the “German Sickness Insurance”,
of work of the individual affected, requir-
the duration of illnesses resulting in inabil-
ing correction by the consumption of con-
ity to work tends to grow in proportion to
siderable financial resources for
the development of the work of insurance
readaptation to new activities.
companies which undertake early diag-
Therefore, in a general way, four forms
noses and prompt treatment. This increase
of economic influence of sickness may be
was also verified in the “British Health In-
considered:
surance System” (28).
-
Number of days lost to production
This apparent paradox is probably due
by absence of the worker;
to two basic causes:
-
Percentage reduction in productiv-
1st) Inclusion, among the disabling dis-
ity of individuals at work, which may
eases, of types which formerly did not nor-
also be computed as work days;
mally hinder work owing to lack of sickness
-
Percentage reduction in production
insurance;
because of individuals temporarily
2nd) Because the worker who is pro-
or permanently disabled, which may
tected by sickness insurance seeks treat-
also be computed as work days;
ment until he is completely well and does
-
Direct expenses with medical-social
not return to work while still convalescing
assistance necessary for the preven-
as was normally the case prior to the ben-
tion, reduction, or elimination of ef-
efits of insurance.
fects of disease.
2) Influence of Morbidity on the
In evaluating the cost of sickness, all four
Maintenance of Public Health Systems
forms will be computed during the annual
period referring to the evaluation.
Although the general principles of pub-
Examples of tables of general morbidity
lic health technique are the same for the
and by disease, usually set values for ages
most varied types of disease prevalence, of
15 to 80 years, since these are especially
economic level and cultural development,
used in calculating rates for premiums on
working methods must vary greatly accord-
sickness insurance taken out mainly to
ing to needs.
Economic Value of Health
323
Rev. Bras. Epidemiol.
Ribeiro, P. de A., Ferreira, M.J. & Braga, E.
Vol. 1, Nº 3, 1998
Starting with underdeveloped regions,
interrelated: sanitation and the control of
priority is given to the phase of sanitation,
communicable diseases. Many regions of
including the provision of safe drinking
the civilized world do not as yet enjoy the
water and proper excreta disposal.
benefits of the first and much less of the
Most of the efforts to control sickness
second, resulting in the enormous amount
without first instituting the above basic
of sickness which could be avoided by the
sanitation measures are ineffective.
already known and proven methods.
Sedgwick and MacNutt (29) gave the name
The existence of such possibilities has
of “Mills-Reinke Phenomenon” to the par-
originated in the concept pronounced by the
allel decline of typhoid fever and intestinal
World Health Organization (30) that “Health
infections resulting from water treatment,
is a state of physical, mental, and social well-
with accompanying lowering of general and
being and does not consist merely in the ab-
infant mortality excluded those causes of
sence of disease or infirmity”. Humanity is
disease. In regions of the rural type, no pub-
always looking to the future, in search of new
lic health measure is so effective and give
horizons, as obstacles are being overcome.
such quick results in reducing morbidity as
The great epidemics of the past did not per-
the proper establishment of water and
mit thinking in positive terms of health. The
sewer systems. Sanitation services contrib-
insecurity of life and the ignorance of the
uting to the reduction of morbidity in un-
causes of mass destruction concentrated all
derdeveloped regions must be maintained
efforts on scientific investigation in the
on constantly higher levels at the rate that
search for determining causes. Now that the
these regions are developed economically
barrier of plagues has been hurdled, man’s
and attain better health rates. Therefore, in
efforts turn to the wiping out of diseases pro-
large cities the most advanced services of
duced by other microparasites, still consti-
sanitary engineering guarantee the absence
tuting the most important causes of disease
of epidemics or of endemic diseases and
and of death. With a knowledge of the
should be considered as permanent factors
sources and modes of infection and the
of lowered morbidity.
methods for cutting these, attention is be-
Another circumstance which should be
ing directed to wider horizons, health is be-
given priority is the group of diseases pro-
ing given a positive meaning, and a new era
duced by microparasites, whether transmit-
is in the offing, appropriately called the era
ted by vectors or not.
of “hominiculture” or “anthropotechnique”
The discovery of the antibiotics and of
(31). This third phase corresponds to a much
residual insecticides makes the control of
more diversified system of public health,
disease a matter of simplicity and feasibil-
since it does not have to do with nature and
ity formerly unattainable by even the best
the correction of the environment nor with
equipped systems of public health. Previ-
parasites and their inability to resist the new
ously unsolvable problems, from the finan-
therapeutic methods, but with man himself
cial or technical point of view, were trans-
and the complexity of this physical and men-
formed fundamentally into matters of or-
tal formation and his adjustment to modern
ganization and the availability of normal
society. It is advisable to note that these three
resources of administration. Reduction al-
great stages which clearly mark the type of
ready obtained in this sector of sickness and
evolution of any human group considered
what can hopefully be expected in the near
from the viewpoint of health do not have
future will permit arriving at the type of re-
well-defined frontiers and frequently exist
sidual morbidity and consequently other
side in the same region, country, or even city.
and more complex systems of public health.
The numerical data and the graphs used
We therefore have two stages where the
throughout this study make it possible
aspects of morbidity and of the public
sketch the profile of morbidity in various ex-
health systems for combating morbidity are
amples and consequently of eliminating
Rev. Bras. Epidemiol.
324
Economic Value of Health
Vol. 1, Nº 3, 1998
Ribeiro, P. de A., Ferreira, M.J. & Braga, E.
straying from the tendency toward residual
economic significance in determining the
morbidity, in many cases practically
value of health.
achieved and in others still far distant. There
Hence the necessity for developing
is not doubt that for each type or stage of
demo-econometric studies, by means of
morbidity there is an appropriate public
general surveys and specific sampling in
health system.
order to more precisely determine the
Having examined the tendencies of the
losses, by period and region, which should
life curves, according to the various stages
be attributed to avoidable sickness, in the
of mortality and of morbidity, it may be -
total production of the population.
theoretically at the present moment - as-
In this study, we suggest adopting the
serted that the abolition of the present pre-
following method to determine the cost of
dominant diseases would give place to the
morbidity.
purely degenerative or deteriorating dis-
eases.
B) General Morbidity
This fourth phase will require true
knowledge of life and of aging, which would
It first becomes necessary to determine
determine improvement of the potential life
the characteristic Z , representing the total
x
span.
number of sickness-days, verified in the in-
dividuals of the population group under
3) Method of Determining the Cost of
consideration in the period of one year.
Morbidity
In order to determine this, consider-
ation must be given to the three first forms
A) General Considerations
of economic influence of morbidity sum-
marized in item 1 of this Chapter, wherein
The above evaluations of the economic
morbidity is described as any disturbance,
influence of disease by means of global in-
whether reducing productivity or causing
dices may be summarized in three groups
specific consumption.
of estimates:
Until it becomes possible to determine
-
Expenses with medical care in all
numerically the limits of cases of avoidable
forms, such as that undertaken by
morbidity and those that may be consid-
government public health services,
ered residual morbidity we may first use the
that financed by semi-official and
symbol Z in calculating from the age 0 to
x
philanthropic agencies, and also
the age w, the highest occurring in the
that sought directly by patients.
population under consideration.
-
Loss of production owing to absen-
The curve indicated in Figure 9 shows
teeism caused by diseases and acci-
the general form of the curve obtained by
dents and also by tardiness by dis-
determining Z , in accordance with the
x
organization of routines, and by low-
above principle.
ered output of all types, indirectly
caused by absenteeism.
C) Annual Individual Specific
-
Reduction caused by sub-normal
Consumption on Account of Morbidity
states of health in individual produc-
tivity and consequently in the total
Following the determination of the gen-
production of population groups.
eral morbidity curve, we should determine
This last item has been given the least
the curve representing average annual in-
consideration in statistics, resulting in the
dividual consumption by a patient at age x,
impression that it is of minimum influence
owing to sickness in its broadest meaning.
on the losses caused by morbidity whereas,
This curve, whose ordinates will be indi-
at least in determined regions, it may be
cated by the general sign g , varies in form
x
stated that the part it plays is of the greatest
according to the economic conditions of the
Economic Value of Health
325
Rev. Bras. Epidemiol.
Ribeiro, P. de A., Ferreira, M.J. & Braga, E.
Vol. 1, Nº 3, 1998
region under consideration and especially
Figure 11 shows the form of this curve
with the policy of public health adopted in
for ordinates σ , based on the values taken
x
each region.
for drawing the curve of ordinates π (Fig-
x
In regions where the economy is not
ure 1) and those for the curve of ordinates
highly developed, this curve should have a
Z (Figure 9).
x
form similar to that of Figure 10. Statistical
determination of the numerical values of
E) Annual Total Consumption Increased
this curve offers no greater difficulties than
on Account of Morbidity
determination of the values of Z .
x
Having arrived at the curve of values for
D) Annual Total Production Lost on
g , the values of total specific annual con-
x
Account of Morbidity
sumption added, at each age, by virtue of
sickness, will be obtained by drawing the
Having arrived at the curve of values for
curve of ordinates j , for the various ages,
x
Z , the values of total annual production lost
according to the formula:
x
at each age x, owing to sickness, will be found
Z .p
by drawing the curves of ordinates s for the
x
x
ϕ =
γ
x
)
3
(
. '
x
x
various ages, according to the formula:
300
Z .p
( )
2 σ =
x
x .
x
πx
If we divide the values of Z .p by 300 we
x
x
300
will have for each age a figure equivalent to
the number of individuals who, during one
If we divide the values of Z .p by 300 we
year, will consume a value equal to ϕ .
x
x
x
will have for each age a figure equivalent to
Figure 12 shows the form of this curve
the number of individuals who, during one
for ordinates γ’ , based on the values takes
x
year, will not produce a value equal to π ,
for drawing the curve of ordinates γ’ (Fig-
x
x
the annual individual production assumed
ure 10) and those for the curve of ordinates
in this study for 300 days of effective work.
Z (Figure 9).
x
Rev. Bras. Epidemiol.
326
Economic Value of Health
Vol. 1, Nº 3, 1998
Ribeiro, P. de A., Ferreira, M.J. & Braga, E.
Economic Value of Health
327
Rev. Bras. Epidemiol.
Ribeiro, P. de A., Ferreira, M.J. & Braga, E.
Vol. 1, Nº 3, 1998
CHAPTER III
with lines consists of deaths due to abnor-
COST OF MORTALITY
mal causes, especially those resulting from
insufficiency of sanitary conditions. There
1) Natural Death and Premature Death
therefore represent premature deaths, the
in the Moral Field and in the Financial
majority of which can be avoided by im-
Field
provement of the health rates. Figures 13, 14
and 15 show regions varying greatly from the
Observations throughout the centuries
viewpoint of health rates and show the cor-
have shown that pluri-cellular organisms
responding ordinates at the respective ages
have a limited life. The death of these or-
when premature deaths occur.
ganisms is normally preceded by phenom-
A simple analysis of these graphs, con-
ena given the global denomination of ag-
structed for each region, show how, from
ing. This aging consists essentially in a de-
the financial point of view, priorities should
crease of physiological activity and in a
be established for the main activities of
modification of the morphological ele-
public health services in each region.
ments making up the body. It reduces the
Theses graphs, however, can and should
individual’s capacity for reproducing the
be drawn as detailed as possible, breaking
species and makes him less resistant to ex-
down each ordinate into the parts applicable
terior harmful agents.
to each cause of death. For example, Figures
Science has not yet definitely established
16 and 17 emphasize the main causes of
whether aging is part of the pathological pro-
death in each of those regions. An analysis
cesses. This point is of limited interest in this
of these graphs shows the fields in which the
study since an attempt is being made to es-
control of premature mortality, and conse-
tablish the concepts of natural death and of
quently of its causes, should be most intense.
premature death, independent of the pri-
In addition to the differences found for
mary causes of death. It therefore suffices to
the various regions and for the various pe-
know the data of causes of death and the ages
riods of time, as well as the variations in
at which death occurs.
rates by sex, other aspects require an analy-
Hence it is proposed to give a statistical
sis of mortality for good interpretation of
meaning to premature death. Applying this
economic characteristics by using the cus-
at each period in a determined region, vary-
tomary indices.
ing rates will be maintained that are spe-
Such investigations have been made of
cific for those conditions.
the variations in mortality for urban and
Drawing the distribution curve of the
rural populations, for populations with a
number of deaths in a region, by age, for
greater or less degree of industrialization,
100.000 persons supposedly born at the
for the professional groups of each specialty
same time, on the basis of survival tables,
of work, in other words, all variations relat-
the age corresponding to the maximum or-
ing to the conditions of human life in mod-
dinate over age 10 is considered as the nor-
ern society. However, the analysis of most
mal span of life, according to a denomina-
interest in the economic studies of mortal-
tion introduced by Wilhelm Lexis. By draw-
ity are those relating to the characteristics
ing to the left of the maximum ordinate a
of each of the causes of death, in order to
branch symmetrical to the right descend-
determine the forms of the partial compo-
ing branch (see Figure 5), a curve is con-
nents of the general mortality curve. Each
structed in the form of a bell, of the type of
cause is especially characterized by the pe-
accidental error curve.
riod of age at which it occurs and by the fre-
This latter curve, according to Lexis, out-
quency of the deaths at each of these ages.
lines the area of deaths where life was ter-
For each region and for each period of time
minated mainly by natural exhaustion of the
the limits of those periods and the maxi-
vital capacity. The remaining area shadowed
mum rate are characteristic of each cause.
Rev. Bras. Epidemiol.
328
Economic Value of Health
Vol. 1, Nº 3, 1998
Ribeiro, P. de A., Ferreira, M.J. & Braga, E.
Economic Value of Health
329
Rev. Bras. Epidemiol.
Ribeiro, P. de A., Ferreira, M.J. & Braga, E.
Vol. 1, Nº 3, 1998
2.270
Rev. Bras. Epidemiol.
330
Economic Value of Health
Vol. 1, Nº 3, 1998
Ribeiro, P. de A., Ferreira, M.J. & Braga, E.
It is here necessary to distinguish the fi-
of public health in the field of medical-so-
nancial aspect and moral aspect resulting
cial assistance and in the field of health edu-
from the interpretation of this concept of
cation.
premature death.
The group of causes related to the nu-
Financially, in determined regions as
tritional diseases in general, diarrhea’s and
those of the type indicated in Figure 15, con-
entreaties, as well as those in which the fac-
trol of the causes of death prevalent at ages
tors appear as a highly significant contrib-
over 40 is practically non-productive. How-
uting causes, is of the greatest importance
ever, from the normal point of view it is clear
in determining the infant mortality rates in
that we can not neglect public health ser-
countries of a low economic level and defi-
vices tending to lessen the effects of the dis-
cient means available to public health.
eases causing those deaths.
These causes, however, have lost their sig-
In regions where the majority of prema-
nificance during the last few years in coun-
ture deaths at ages under 40 are reduced to
tries with a better standard of living and
almost negligible rates, it is justificable to
adequate public health equipment.
undertake specific and intensive sanitary
The causes included in the group of
control of the more difficulty avoided
communicable diseases, such as bronchi-
causes of death, including the group of the
tis, pneumonia, tuberculosis, etc., have
so called diseases of age.
been effectively controlled by modern re-
Experience has shown that as their
sources available with the chemotherapeu-
health systems are perfected, many coun-
tic and antibiotic drugs and have become
tries have accomplished gradual modifica-
less significant, especially in countries
tion of the curve of general deaths, reduc-
where their development is hindered by not
ing the area corresponding to premature
very severe climate conditions.
deaths to almost negligible percentages of
Finally, the group of causes most diffi-
the area of deaths considered to be natural.
cult to control includes the usually unavoid-
It is easy to see the economic scope of
able deaths of infants from congenital and
the reduction in deaths due to causes lo-
hereditary defects.
cated in the intervals of ages where ordi-
In a study of “Mortality of Childhood
nates are found partially or totally outside
and Adolescence and Survival at the Begin-
the zone represented by the bell-shaped
ning of the Adult Age” (32), Prof. Giorgio
curve, in the general mortality curve.
Mortara gives data for four countries, two
In the period from 0 to 10 years, the
with low infant mortality and two with high
causes of death are different from those
mortality, referring to the two-year period
occurring in the period of adolescence and
1935-36, compared in the table below with
maturity. From 0 to 10 years, the main
the same data for the Federal District (Bra-
causes of death are:
zil) for the period from 1939 to 1941, which
a) premature birth
confirms the above statement:
b) congenital debility
c) congenital abnormalities
Death in the first year of
d) obstetrical traumatism
Causes
life per100 life births
e) diarrheas and enterites
of Death
Holland
USA Rumania Chile
Federal
f) deficiency diseases
District
g) bronchitis and bronchopneumonia
(Brazil)
h) influenza and pneumonias
Congenital
2.22
2.95
6.03
7.35
2.53
i) tuberculosis
defects,
j) syphilis
congenital
k) diphtheria
debilities etc.
l) whooping cough
Other causes 1.72
2.69 11.46 17.81 11.25
The elimination of death due to these
causes is one of the most serious problems
Total
3.94
5.64 17.49 25.16 13.78
Economic Value of Health
331
Rev. Bras. Epidemiol.
Ribeiro, P. de A., Ferreira, M.J. & Braga, E.
Vol. 1, Nº 3, 1998
Recent statistics (1946) show much
The resources of public health have pro-
more favorable indices for the United
vided very efficient preventive and therapeu-
States. For the total population we have the
tic measures for all these causes. Their inci-
rate of 3.38; 2.33 for the first causes and 1.05
dence may be considerably lowered in coun-
for others. The rate of the white population
tries with suitable sanitary organization.
is 3.18 and for the population of other races,
Dublin, in the hypothetical table of mor-
4.95. For 1950 the average rate for the en-
tality which he prepared and published in
tire population was 2.92.
his study “Health and Wealth” in 1928 and
Demo-econometric studies are con-
brought up to date in the 1946 edition of the
stantly proving that infant mortality occurs
study “The money value of a man” by
especially among children fit to live and is
Dublin and Lotka, based on the study of
caused mainly by ignorance and poverty,
conditions already attained in New
especially in countries with deficient sani-
Zealand, established for mortality from 0 to
tary organization and a low economic and
1 year the rate of 2.500 x 100.000, a value
social level.
approaching the average verified in the
The application of the theory of natural
United States for the white population.
selection, no matter how respectable, to jus-
The economic aspects of mortality in
tify cases of high infant mortality rates, is er-
the period from 0 to 10 years is normally
roneous and without economic foundation.
figured by the addition in the cost of pro-
In addition to the above causes of mor-
duction of the adult man and by the reduc-
tality, we should consider for the period 0
tion of the total production of the popula-
to 10 years those occurring frequently in
tion by virtue of its numerical reduction in
infancy, such as:
the economically productive period of life.
a) Diphtheria
It is therefore necessary to give some rates
b) Measles
relating to mortality at these ages in vari-
c) Whooping cough
ous countries and in various periods of
d) Scarlet fever
time.
Death per 100 survivors at age 0
Sweden
USA (WP)
Italy
Federal
District
(Brazil)
Ages
816
931
900
939
881
930
920
939
(completd years)
840
935
902
941
882
932
921
941
0
16.0
5.0
12.0
4.2
20.0
11.0
15.2
13.9
1 to 4
8.0
1.3
5.6
0.9
16.2
5.6
9.2
9.7
5 to 9
2.8
0.6
1.7
0.4
3.6
1.1
1.7
1.5
In the period from 10 to 40 years, in the
It has already been pointed out how cer-
stages of adolescence and maturity, there
tain causes of disease show apparently low
is a predominance of deaths due to com-
death rates, since death registration is not
municable diseases and of deaths due to
yet sufficiently accurate. It is therefore im-
accidents and violence. The latter grow pro-
possible to reach conclusions with correct
portionately, especially in the large cities.
numerical values on the influence of these
Principal causes in the group of diseases
diseases in the study of the cost of specific
prevalent in this age group are tuberculosis
mortality.
and typhoid fever.
In a direct evaluation of the cost of spe-
This study can not examine in detail the
cific mortality, the following method has
specific influences on the economic indi-
been adopted (33): determination of the
ces of each of these principal causes.
normal evolution of the rate of specific mor-
Rev. Bras. Epidemiol.
332
Economic Value of Health
Vol. 1, Nº 3, 1998
Ribeiro, P. de A., Ferreira, M.J. & Braga, E.
tality is studied in the hypothesis of the ab-
public health services by means of similar
sence of measures indicated by public
but less precise studies.
health technique.
As an example of the latter, we tran-
Based on experiments in other coun-
scribe part of the table published by J.
tries, the probable evolution in the decline
Hanlon (34).
of the mortality rate is established on the
After age 40, the predominant causes of
hypothesis that adequate sanitary control
death are the diseases of age, the majority
is established.
or most significant being the degenerative
Determination of the normal growth of
and neoplastic diseases such as arterioscle-
the population of the region where the eco-
rosis and cancer.
nomic value of death which it is possible to
In this phase, there is a considerable reduc-
reduce or eliminate is realised.
tion in the economic importance of the results
With these figures, it is calculated the
obtained by improvements in public health.
number of deaths in both cases for the vari-
However, health conditions such as
ous ages during a pre-established period.
those shown in Figure 15 demonstrate that
Attributing for each age a potential value
between the ages of 40 and 50 many deaths
in money for the deceased, the balance of
are not caused by the so-called diseases of
the number of deaths in both hypothesis
old age. These deaths, however, will be au-
will determine the economic value of the
tomatically eliminated by the general mea-
reduction of avoidable mortality.
sures adopted in the public health systems
A posteriori, it has been also attempted
for the control of diseases prevalent during
the verification of the economic results of
adolescence and maturity.
Table - Estimated Saving in Lives and Their Value in Millions of Dollars During 1946 over 1900 as a Result of Public Health
Measures Taken Against Certain Diseases, USA
Approximate Mid-Value of
$1,500
$4,500
$11,000 $18,000 $22,000 $21,000 $20,000 $18,000 $13,000
Totals
Lives in Age Group
Age Groups
under 5
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
0-45
Typhoid & Paratyphoid
Lives saved
1,971
1,489
4,161
6,789
6.263
4,599
5,081
3,022
3,022
36,397
Estimated value
$3.0
$6.7
$45.8
$122.2
$137.8
$96.6
$101.6
$54.4
$39.3
$607,4
Diphtheria
Lives saved
34,562
14,471
3,840
890
612
223
334
111
111
55,154
Estimated value
$51.8
$65.1
$42.2
$16.0
$13.5
$4.7
$6.7
$2.0
$1.4
$203.4
Diarrhea & Enteritis
Lives saved
165,200
1,548
774
387
967
774
967
967
1,161
172,745
Estimated value
$247.8
$7.0
$8.5
$7.0
$21.3
$16.3
$19.3
$17.4
$15.1
$359.7
Measles, Scarlet Fever, Pertussis
Lives saved
37,364
5,057
1,545
749
421
328
375
187
187
46,213
Estimated value
$56.0
$22.8
$17.0
$13.5
$9.3
$6.9
$7.5
$3.4
$2.4
$138.8
Tuberculosis
Lives saved
17,444
3,355
4,473
14,313
29,744
29,297
29.744
19,680
20,351
168,401
Estimated value
$26.2
$15.1
$49.2
$257.6
$654.4
$615.2
$594.9
$354.2
$246.6
$2,831.4
TOTAL
Lives saved
256,541
25,920
14,793
23,128
38,007
35,221
36,501
23,967
24,832
478,910
Estimated value
$384.8
$116.7
$162.7
$416.3
$836.3
$739.7
$730.0
$431.4
$322.8
$4,140.7
Economic Value of Health
333
Rev. Bras. Epidemiol.
Ribeiro, P. de A., Ferreira, M.J. & Braga, E.
Vol. 1, Nº 3, 1998
2) Method of Determining the Cost of
the region under consideration is main-
Death
tained constant during that period of time.
As has been shown, this is not really the
A) General Considerations
case. However, this simplification is justi-
fied by estimates made with rates and co-
In the method suggested by this study,
efficients obtained in a not very strict ap-
an attempt is made to determine:
proximation.
-
average individual annual consump-
In studies of greater precision, calcula-
tion, for each age and due to prema-
tions can be made with the value of x vary-
L
ture death;
ing according to the time and does not
-
total production lost for each group
present analytical difficulties, but depends
of age, in the period between the age
only on the ability to construct sure hypoth-
at which death occurred and the
eses on the progressive evolution to be ob-
normal Lexis age, for the region un-
tained from the health rates.
der consideration;
To construct a more significant health
-
specific total annual consumption
rate, the normal Lexis age x could be com-
L
augmented at each age because of
bined with its determining frequency of
premature death;
deaths.
and finally
We could therefore adopt as the health
-
reduced total consumption, by vir-
rate for a region the product Nx .x , where
L
L
tue of premature deaths, for each
Nx is the number of deaths found on the
L
age group, in the period between the
Lexis curve for the normal age x .
L
age at which death occurred and the
A more complete interpretation of the
normal Lexis age for the region un-
nosological conditions of a region could be
der consideration.
obtained by combining the above rate with
the “Discratic Index” (35). The latter is ob-
B) Number of Premature Deaths
tained by the relation for a certain year be-
tween the infant mortality rate, per thousand
It should first be recalled that the num-
live births, and the average ages of deaths in
ber of premature death is obtained by the
the population under consideration.
Lexis curve, using values γ (Figure 5), the
This rate is rarely less than 1. Sanitary
x
ordinates of the curve of general deaths or
and health conditions of a region are con-
the difference between their values and
sidered very good when the rate is less than
those of the ordinates of the curve marking
or equal to 1.5; good when between 1.5 and
the cases taken as deaths due to natural case.
2.5; almost good, between 2.5 and 3.5; al-
The Lexis curve should be drawn on the
most bad, between 3.5 and 4.5; bad, be-
basis of survival tables calculated for the pe-
tween 4.5 and 5.5; and very bad from 5.5 up.
riod of the study in the region under con-
sideration.
C) Annual Specific Individual
In the method suggested, it is admitted
Consumption on Account of Premature
that the values of π and γ for the period of
Death
x
x
the study are maintained approximately
constant for the period ξ corresponding to
The curve representing annual specific
L
the normal Lexis age in the region under
individual consumption due to premature
consideration. When more accuracy is de-
death occurring at age x, where ordinates
sired, we can establish the law of variation
are represented by γ’’ , can not be deter-
x
of π and γ with time, in accordance with
mined with absolute accuracy owing to the
x
x
the economic development forecast for the
absolute lack of statistical data directly re-
region under consideration.
lated with this coefficient.
In the suggested method, it has also
However, rough estimates have already
been admitted that the normal Lexis age in
been considered, taking into account this
Rev. Bras. Epidemiol.
334
Economic Value of Health
Vol. 1, Nº 3, 1998
Ribeiro, P. de A., Ferreira, M.J. & Braga, E.
figure which is quite significant to the cost
are represented by tc, is obtained by calcu-
of premature death.
lating the values of the formula:
In this study it has been attempted to
Ν
.
x
drawn, in a empirical fashion, according to the
L
Y
(4) τ
xi
=
.Σ
xi
π
observation in specific population groups, a
x
100.000 x
curve to serve only to improve the suggested
i
method but for which the numerical values
where N represents the total number of
of the ordinates do not represent indices of
deaths in the population of the region un-
reasonable approximation. The need for de-
der consideration, in the period of the year
termining these coefficients for each period
for which the general curve of Lexis deaths
of time and each region, in order to obtain the
was determined.
cost of death, would not impart much value
The first factor
to the precision perchance attained for the
Y
.N
x
data presented in this study.
i
Figure 18 shows the form of the curve
100.000
for the ordinate of γ’’ , in accordance with
indicates the number of premature deaths
x
the interpretation given in this work to the
at age x in the region during the year in
i
variation of this coefficient with the age at
question. The second factor
which premature deaths occur.
xL
Σπ
D) Total Potential Production Lost
x
x
Annually on Account of Premature
i
Deaths
gives total production of each prematurely
dead individual at age x during the period
The curve representing total potential
x - x , between the age of death and the nor-
L
i
production lost annually at each age c, ow-
mal Lexis age x in the region under consi-
L
ing to premature deaths, where ordinates
deration.
Economic Value of Health
335
Rev. Bras. Epidemiol.
Ribeiro, P. de A., Ferreira, M.J. & Braga, E.
Vol. 1, Nº 3, 1998
Figure 19 shows the form of this curve
of the curve of ordinates in Figure 18, and
of ordinate t , drawn on the basis of values
the value of N as approximately 700.000.
x
taken for curve of Figure 5 and those of the
curve of ordinate p in Figure 1, and the
F) Total Potential Consumption
x
value of N as approximately 700.000.
Reduced Annually on Account of
Premature Deaths
E) Specific Total Annual Consumption
Increased on Account of Premature
The curve representing total potential
Death
consumption reduced annually at each age
x, by virtue of premature deaths where or-
The curve representing specific total
dinates are represented by l , is obtained by
x
annual consumption augmented at
calculating the values given in the formula:
each age, by virtue of premature deaths,
where ordinates are represented by e , is ob-
x
Ν
.
x
tained by calculating the values given in for-
L
Y
(6) λ
xi
=
.Σ
x i
γ
mula:
x
000
.
100
xi
Y .N
(5)
xi
.γ "
ε =
x i
xi
000
.
100
the elements thereof have been described
above.
the elements used have been described
Figure 21 shows the form of this curve
above.
of ordinates l , draw on the basis of values
x
Figure 20 shows the forms of this curve
given to the curve of Figure 5 and those of
of ordinates e , drawn on the basis of val-
the curve of ordinates in Figure 2, and the
x
ues given to the curve of Figure 5 and those
value of N as approximately 700.000.
Rev. Bras. Epidemiol.
336
Economic Value of Health
Vol. 1, Nº 3, 1998
Ribeiro, P. de A., Ferreira, M.J. & Braga, E.
Economic Value of Health
337
Rev. Bras. Epidemiol.
Ribeiro, P. de A., Ferreira, M.J. & Braga, E.
Vol. 1, Nº 3, 1998
CHAPTER IV
1π =π ×F (x)
x
x
1
CONCLUSIONS
(7) 1γ =γ ×F (x)
x
x
2
1x =x ×F (x)
L
L
3
1) The Value of Health and Some
where F (x), F (x) and F (x), are formulas
1
2
3
Representative Rates
which provide the coefficients relating to
time for calculation of the variation of the
A) General Considerations
value of π , γ and x , in the future periods.
x
x
L
As a primary approximation, we may
From this study we may deduce general
use F (x), F (x) and F (x), expressions of the
1
2
3
formula for the economic value of health
form:
either by grouping separately the figures
due to morbidity and mortality, or group-
(8) F(x) = [1+r (x-x )]
i
ing then in such a manner as to obtain sepa-
rately the influence of those two fundamen-
The values of rates r, is fixed in each pe-
tal factors on the total reduction of produc-
riod for each region; and x, varying from x ,i
tion and on the total increase of consump-
- lower limit of the summations of the re-
tion.
spective formulas, corresponding to using
We can also examine the value corre-
the values of p , g and x , for the year being
x
x
L
sponding to the year when the study was
studied, - to x , upper limit in the summa-
n
made as well the potential value, taking into
tions of the respective formula.
account lost future production and econo-
mized future consumption by virtue of the
B) Balance of Potential Values of
premature deaths occurring during the year
Production and Consumption of a
being studied.
Population
Also, as has been described, these cal-
culations of potential values may be carried
From the above explanations, it is clear
on with greater precision by fixing for πχ,
that the following formula can express the
γχ, χ , a law of growth as time goes on. For
balance of the potential value of production
L
this purpose it is sufficient to substitute
and consumption of a population composed
those values in the formula presented by the
of ages shown by the curve of p - Figure 3.
x
following:
where S , represents the balance of the po-
p
i =ω
x
i=
x
m
m
(9)
=
{
S
Σ p .
1
[ + r (
π
ω
γ
1 x −
−
+
−
i
x )]
{
Σ
Σ p .
1
[
r2(x
i
x )]
Σ
p
x
x i
x i
x
i=0
ι=0
x
x
i
i
tential values of production and consump-
C) Total Influence of Morbidity on the
tion; x , represents each group of age under
Economic Value of Heath
i
consideration; x , represents the average
m
life for each age under consideration, taken
The formula for calculation of the total
on a hypothetical table fixed in each region
influence of morbidity on the economic
for this purpose; and r and r , the rates of
value of health, in accordance with this
1
2
growth of p and g in the course of time.
study, may be expressed in the following
x
x
The remainder represent values already
manner:
described.
i ϖ
=
i ω
=
i
Z
=
x
Z
Z
i
x
x
(10)
=
[(
.
V
Σ
p .
) + (
i .
π
ω
p .
i
γ = Σ
p π +γ
= Σ σ +ϕ
m
x i
' )]
[(
.
)(
x i
' )]
(
)
x
x i
x i
x
x
x
i
i
i
i
x i
i=0
300
300
i=0
300
i=0
Rev. Bras. Epidemiol.
338
Economic Value of Health
Vol. 1, Nº 3, 1998
Ribeiro, P. de A., Ferreira, M.J. & Braga, E.
where V represents the value of the total
D) Total Influence of Mortality on the
m
influence of morbidity on the economic
Economic Value of Health
value of health. The remainder have the
values described above.
The formula for calculation of the total
influence of mortality on the economic
value of health, in accordance with this
study, may be expressed by the following
formula:
i =ω
.
i =ω
N
.
i =ω
N
.N
Y x
Y
Y
i
=
.
xi
xi
V α Σ
π + Σ
"
γ − Σ
γ =
d
i =0 100.
xi
000
i =0 100.
xi
000
i =0 100.
xi
000
(11)
i =ω
.
i =ω
N
=
Y
(
xi
)(
Σ
π + 'γ' − γ ) = (
Σ τ + ε − λ )
i =0
100.
x
x
x
x
x
i
x
i
i
i
i
i
000
i =0
i =ω
.N
x
ω
N
ω
N
x
L
i =
.
i =
.
1
1
L
Y
Y
Y
x
1
1
=
i
x
x
.
V
π
γ
γ
d p
Σ
Σ
+
x
Σ i
" −
i
.
x
Σ
Σ
=
i =
x
0
000
.
100
i = 0
000
.
100
i
i = 0
000
.
100
x
x
i
i
(12)
1
1
i =ω
.N
xi
xL
i =ω
=
Y x
(
i
)(
1
+
π γ − γx = ( + − )
Σ
Σ
ε
x
"x Σ
Σ Τxi
x
x
i
Λ
i =
i
0
000
.
100
i
i = 0
x
x
i
í
where Vda represents the value for the year
E) Total Production Lost by Virtue of
under study, for the total influence of mor-
Morbidity and Mortality
tality; Vdr represents the potential value of
the total influence of mortality; Tci the po-
Taking into consideration the formula
tential value of production lost through pre-
already established, we may express by the
mature deaths occurring at age ci; and Dci
following formula the values of total pro-
the potential value of consumption reduced
duction lost by virtue of morbidity and mor-
owing to premature deaths at age ci.
tality.
The remainder have the values
descrived above.
i=ω Z
i
x
=ω Y N
.
i
x
=ω
i
i
(13) P =
α
Σ
.p
.π
+ Σ
π = Σ (σ + τ )
x
x
x
x
x
300
i
i
i
i
000
.
100
i=0
i=0
i=0
1
i=ω
i=ω
.N x
ω
L
i=
(14)
=
Z
Y
x
x
i .
.
i
1
+
π
πx = ( + )
P
p
σ
p
Σ
x
x
x
x
i
Σ
Σ
Σ
i
Τ
i=
i
0 300
i
i=0
000
.
100
i=0
xi
where P , represents the value, during the
the potential value of production lost for the
a
year under study, of total production lost by
same reasons; and the remainder have the
virtue of mobility and mortality; P , represents
same values as described previously.
p
Economic Value of Health
339
Rev. Bras. Epidemiol.
Ribeiro, P. de A., Ferreira, M.J. & Braga, E.
Vol. 1, Nº 3, 1998
F) Total Consumption Augmented
Because of Morbidity and Mortality
Taking into consideration the formula
already established, we may express by the
following formula the values of total con-
sumption augmented because of morbid-
ity and mortality.
i ω
=
i ω
=
.
i ω
N
=
.N
i
Z
Y
Y
=
x
x
x
i
(15)
=
.
C
Σ
p .
i
i
+
−
=
+
−
Σ
Σ
=
Σ
α
γ
ω
'
.γ "
γ
(ϕ
)
x
x
x
x
x
ε x
x
i
λ i
i=0 300
i
i
i=0 100.000
i
i=0 100.000
i
i=0
i
x
i=ω
i=ω
.N
i=ω
.
1
L
N
i=ω
1
(16)
=
Z
Y
Y
x
x
x
i .
C
p γ
γ
γ
ϕ ε
p
Σ
' +
i
.
x
x
Σ
" −
i
.
=
(
+
−
)
x
Σ
Σ x Σ
x
x
x
i
Λ
i=
i
0 300
i
i
i=0
000
.
100
i
i=0
000
.
100
i=0
i
xi
where C , represents the value for the year
2) Organization of Health Systems
a
under study of total consumption aug-
Based on the Value of Health
mented because of morbidity and mortal-
ity; C , represents the potential value of con-
Recognition of the Rights of Man to en-
p
sumption augmented for the same reasons;
joy a state of health such as that defined by
and the remainder have the same values as
the WHO suffers no restriction and has al-
those described previously.
ready attained written approval in Interna-
tional Agreements and in the Constitutions
G) Representative Rates
of many countries.
This study has emphasized the binomial
In addition to the rough values of for-
Production-Well Being and has permitted
mula 10, 11 and 12, or to the sum of these
taking up the problem of health from a ma-
three values, rates may be determined for
terial and concrete point of view. In the
the economic value of health. In this study,
planning, hierarchical arrangement, and
the following are suggested:
structure of health services, the governing
powers should face this problem, not from
the angle of mere application of budgetary
V
+
m
Vdα
allocations, but as the investment of capi-
(17) ρ
=
α
S
tal in a safe and profitable field.
p
The extreme diversity of the political
and
and economic structure of the various
countries creates the corresponding need
Vdp
ρ
=
for adapting to each case the conclusions
dp
S
which may be drawn from the special angle
p
proposed by this study. The main prin-
which may be obtained by dividing the val-
ciples, however, will always be valid, what-
ues given in formula 10 and 11, and those
ever the result of concret application. The
of the formula 12, respectively, by the val-
disorganization and poor results generally
ues given in formula 1 and 9.
the case with national public health orga-
Rev. Bras. Epidemiol.
340
Economic Value of Health
Vol. 1, Nº 3, 1998
Ribeiro, P. de A., Ferreira, M.J. & Braga, E.
nizations are mainly due to a lack of recog-
mechanical agents, because he has the
nition of the economic value of health.
unappreciable value of being an instrument
In analyzing the present organization of
which observes itself and corrects itself, a
the various national public health systems
motor which stops of its own accord, which
we gain the first impression that in the di-
moves by its own intelligence and which
versity of those systems little can be found
perfects itself greatly by thinking and not
to permit of generalizations.
less by work”.
However, in the first place, there is the
After admitting and recognizing the eco-
prime objective common to all systems: the
nomic value of health, national govern-
well being of the population. This objective
ments could then give due priority to the
gives all systems a multitude of points of
problems involved, outline the fields of
contact since, in planning, the objective
responsability, avoiding duplication of ef-
determines the processes and techniques
fort among the various sectors of its politi-
applicable in the proposed organization.
cal structure, and above all, combining the
The scope of that objective permits the
various fields of public power which, by
innumerable special agencies engaged in its
definition, aim at favoring the well-being of
realization. Its magnitude causes men to
man.
demand always more than those agencies
C E.A. Winslow (37), in his noteworthy
can usefully produce.
study on “The Cost of Disease and the Price
“The desire to attain a legitimate pur-
of Health”, quotes Farnsworth, whose con-
pose is of itself unlimited, but the desire for
cepts present the above perfectly: “The
a means to this purpose will always be pro-
complete success of any public health pro-
portional thereto. Hence, a doctor will never
gram is subordinated to the parallel and
be too desirous of curing his patient, al-
coordinated study of the social, educa-
though he may not give the greatest pos-
tional, and economic problems in the re-
sible amount of drugs, but only the amount
gion under consideration. Better health is a
necessary for cure”.
necessary corollary of better education and
The purpose is desirable of itself, and
higher economic and social level. The ef-
however more the thing is desired of itself,
forts of all interested agencies in the region
more so is it taken as the purpose.
should be joined in a common program”.
The forming of a population of healthy
This necessity to coordinate the various
men is the greatest ideal of a nation, both
activities in attaining a common purpose
from the moral and social meaning and be-
involves the national character of the prob-
cause of the economic value it represents.
lem of health. This does not mean that the
Jules Amar (36), in his book on the
task should be executed by agencies of the
“Physiological Organization of Work”,
central power. This subject, well known by
points out the value of man in the economy
students of sanitary administration, does not
of a country and quotes the words with
belong within the natural limits of this study,
which Charles Duplin initiated one of his
but requires reference at the moment. The
admirable courses in the Conservatory of
almost infinite variety of the types of organi-
Arts and Crafts in Paris:
zation of public health work is a conse-
“We have concerned ourselves greatly
quence of the respective disordered growth,
with the perfection on machines, of instru-
of interference’s a political nature, of tech-
ments and of the material tools used by the
nical deficiencies, and many other factors
worker in the mechanical arts. We have con-
causing disturbance of the solid basis of
cerned ourselves very little in perfecting the
man’s recuperation for productivity and
worker himself. However, even though he
consequent realization of his own well-be-
were considered as merely an instrument,
ing, that of his family and of the state.
a tool, a motor, he should be given first place
The primary objective is common to all
among all the instruments, among all the
public health systems, and they all have
Economic Value of Health
341
Rev. Bras. Epidemiol.
Ribeiro, P. de A., Ferreira, M.J. & Braga, E.
Vol. 1, Nº 3, 1998
common basic elements and principles of
medicine, also do not present great differ-
structure.
ences, when adapted to the conditions of
The basis elements have already been
each region.
pointed out in this study, when examina-
The apparent diversity of public health
tion was made of the various influences of
systems of the various nations results pre-
morbidity and of mortality on questions
cisely from the identical form of interpret-
connected with production and consump-
ing these basic elements applied to the great
tion.
variety of health conditions, of social con-
The principles determining a good pub-
ditions, of cultural levels and of economic
lic health system are those universally
levels occurring in the regions of the world,
adopted in the technique of planning. Al-
determining forms of articulation and of
though these principles are recent they
coordination applicable to each region.
have provided such good results to the or-
Where differences exists which do not
ganization of the modern world, that they
result from the above factors, these should
are being adopted in all fields of activity of
be mainly considered as poor application
all civilized nations.
of the technique of planning, poor organi-
The meaning of planning is so ample
zation of the fields of activities for establish-
that it is difficult to define this technique
ment of the scale of priorities, defective
which “is the group of principles orienting
limitation of powers in the distribution of
and disciplining the activities of human
responsability to the various administrative
work; of rules for most advantage use of the
units of the the country, and finally, insuffi-
capital and of the human labor expended;
ciency of resources in face of the needs of
and of the rules for application of these gen-
the region.
eral principles and regulations, and for con-
In concluding this study dealing with the
trol of results obtained” (38).
economic value of health and demonstrat-
The structures of public health systems,
ing the possibility of establishing highly
planned according to this principle, must
objective criteria for fixing national health
have points in common in the purposes of
plans according to the scale of activities to
their agencies and their constitution.
be developed in each region, we wish to
In the first place, the basic elements of
point out, once again, that there is no doubt
all systems are: personnel (public health
that public funds find no better reproduc-
workers, doctors, sanitary engineers,
tive application than when used to improve
nurses, etc.) and public health units (health
the health and education rates of the
centers, dispensaries, hospital, etc.). They
people.
present little difference from the various
The economy of a nation is measured
present systems of public health.
by the degree of development of its techni-
The forms and processes of work, both
cal labor organization and by the indices of
of preventive medicine and of curative
health and instruction of its people.
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