Good Health and Well-Being

Living Edition
| Editors: Walter Leal Filho, Tony Wall, Anabela Marisa Azul, Luciana Brandli, Pinar Gökcin Özuyar

Gross Domestic Product and Health

  • Rosa Maria FernandezEmail author
Living reference work entry


Health is defined as “a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity” (WHO 1978). In this regard, well-being is understood “as how people feel and how they function, both on a personal and social level, and how they evaluate their lives as a whole” (New Economics Foundation 2012). This means that health is not only one of the factors contributing to individual well-being, but it also plays a role on how we all contribute as part of a society. If an individual is healthy as opposed to suffering from ill-health, they can work (economic function) and be more productive, which ultimately means increased capability to contribute to economic activities. This will make their individual income grow (they receive a salary for their work), but it will also make the global economy grow, raising countries’ GDP levels.

The Relationship Between Health, Development, and Economic Growth


Traditionally, GDP (Gross Domestic Product) has been used, albeit incorrectly, as a measure of economic welfare. In reality it is only a measure of national output or income (Sloman et al. 2018), i.e., an indicator of how many goods and services are produced and exchanged in a country, as a proxy of growth (the more a country produces, the more it grows economically). In fact, in order to measure income correctly the indicator should be the Gross National Income (GNI), which includes GDP plus the “net receipts from abroad of wages and salaries and of property income, plus net taxes and subsidies receivable from abroad” (OECD 2018). Other indicators, such as the Human Development Index (HDI), would be more appropriate measures of welfare or well-being (UNDP n.d.). The purpose of this piece of work is not to delve into the limitations that the use of GDP has as indicator of well-being (Frajman-Ivkovic 2016). Notwithstanding those limitations, the focus will be given to explain the relationship between investments in health and progress in development and growth. This will be done through the analysis of existing literature from health and economics disciplines, as well as the works (studies and reports) of international organizations. The contribution of this piece to the existing body of work will be the compilation of empirical evidence used as basis for policy recommendations. Development will be understood as “the process of improving the quality of human lives and capabilities by raising people’s levels of living, self-esteem, and freedom” (Todaro and Smith 2015). The role of health will be twofold, as it can be analyzed both as an input contributing to development and as an output of the development process (Todaro and Smith 2015). On one side, healthier population is more productive, can get greater gains from education, take advantage of and contribute to innovation, and as such obtain higher income and contribute to economic growth. At the same time, higher income will increase the consumption of education and health, and higher demands will contribute to increase the quality of both elements (Lopez-Casasnovas et al. 2005). This view is related to the consideration of health as part of human capital, as it will be explored in section “Health as Part of Human Capital.” For developing countries, a low-level equilibrium trap becomes apparent, with evidence pointing at a relationship between low life expectancy (as indicator of poor health) and low rates of economic growth (Mayer-Foulkes 2005). Experts have defined improvements in the health of humans as “the most important measure of economic and social progress” (Deaton 2013 as cited in Thirlwall and Pacheco-Lopez 2017), but the following sections will look at it in conjunction with other factors, particularly education, as proof that health-related issues cannot be considered in isolation, since they affect and are affected by many other variables of human life.

Health-related issues have recently been given an eminent economic approach in international forums. It thus makes sense, within this context, to describe health as one of the components of human capital, defined as “the knowledge, skills, competencies and attributes embodied in individuals that facilitate the creation of personal, social and economic well-being” (Keeley 2007). This approach is consistent with the measurement of the benefits of health expenditure in terms of return on investment (Brousselle et al. 2016). It follows then that international institutions have been promoting investments in health programs in order to improve countries’ economic performance (World Bank 1993; World Health Organization [WHO], 1996, 2001; OECD 2010a), particularly in developing countries. For developed countries, the focus has been on improving the efficiency of the expenditure already made, in trying to prevent excessive health expenditure by countries with tightened budgets (OECD 2010b), particularly after the last economic crisis (2008).

The main indicator used as measure of health in a country is life expectancy at birth. However, life expectancy is affected by many factors and it is also linked to the level of income and equality of countries (Deaton 2003). Health status indicators look at general country specific conditions that consider the access to health services (antenatal care coverage, births attended by skilled health personnel, immunization coverage among 1-year-olds, etc.) and also lifestyle (prevalence of tobacco use in adolescents and adults, adults who are obese, etc.). Indicators are usually classified in five groups: mortality, morbidity, health services coverage, risk factors, and health systems (WHO 2006).

The following sections will look at health as a whole, as well as its relationships with economic performance. The main purpose is to understand the limitations of the current approaches used to measure so-called successful health outcomes.

Health as Part of Human Capital

Economic literature recognizes that health can have a positive impact on economic growth if it is considered part of human capital. This idea would be linked to the theories of economic growth defending that capital accumulation enhances growth, and improving the health status of the population would have a positive contribution toward economic growth, insofar population would become more productive (Hartwig 2010).

The consideration of health as capital allows for the analysis of the costs and benefits of investments in health, which should lead to increases in both the quantity and quality of human capital. Health benefits will be measured through indicators of employment and leisure, while costs will be looked at in terms of treatment costs and productivity loses as a result of health impairment (Gardner and Gardner 2012). Through this lens, investment in health appears to be a decision linked to the preferences of companies (employers/producers) and households (employees/consumers). However, the provision of healthcare often requires some form of government intervention, due to externalities linked to the public interest and the existence of market failures associated to asymmetric information and uncertainty (Bloom and Canning 2003).

Other authors make a slight distinction, and though they look at health as capital, they take it separately from human capital, associating the latter to knowledge and skills related assets (Arrow et al. 2014). However, they recognize the value of health capital through three different angles: the contribution to direct well-being, the contribution to productivity, and the contribution to longevity (Arrow et al. 2014). Interestingly, they assume that as provider of health services directly to an individual (through the possibility to greater enjoyment of current consumption and longer life), health would not be included in the measurement of GDP. Its contribution to productivity would be indirect, and as such more difficult to measure, which does not mean that it has no value (Arrow et al. 2014). In addition to this assessment, it is worth considering that the provision of health services requires doctors, nurses, and other specialists, which means that the health sector is per se an employer, and as such, a contributor to the generation of income (Buckley 2017), both for the individuals employed, and for the wider economy, through their tax payments.

In sum, health may not be traditionally included as part of a production function, though it could, but that does not mean that it has no value, nor that its contribution to productivity can be ignored. It is perfectly acceptable to consider it as capital, and as part of the capital stock it makes sense to invest in it. The problem comes, as for many other aspects, with the limited resources available to invest, and the need to prioritize which areas of health will receive said resources. For many (Lee et al. 2007), the focus should be given to the area of primary healthcare, as a key contributor to both human capital and social capital, which is an aspect not previously covered.

Individuals are part of a broader social fabric. Subsequently the well-being of other members of the social fabric can affect individuals’ decisions and behaviors. It is for this reason that in some instances the minimum unit of analysis for societal related issues would be the household or family (Gardner and Gardner 2012). Social capital, defined as “social resources which can facilitate positive outcomes with respect to a broad range of phenomena” (McPherson et al. 2013), can then be approached from three perspectives: individual social capital (Eriksson 2011), family social capital, and community social capital (McPherson et al. 2013). Some studies have looked at the relationship between health and social capital from the opposite perspective, i.e., analyzing the effects that social capital may have on health (Rocco and Suhrcke 2012) and reaching the conclusion that interventions should give priority to individual social capital. The effect would be twofold: they would directly improve individuals’ health and they would contribute to improve community social capital.

Whatever the approach taken, the conclusions seem to be clear: A healthy individual is a happier individual and can influence positively those around him/her. This can be translated into better quality of life out of work, as the individual will be able to enjoy leisure time, but also into higher productivity at work, as the individual would not be distracted or impaired by ill-health conditions or effects. As a result of better focus, the quality of production can improve, and the income generated from it will increase. So health as human capital is important not only for the individual but for the society as a whole. In this respect, individuals will be born with certain health attributes, but over lifetime these can be negatively affected by disease, accidents, age, or environmental conditions, among other factors. Interventions to prevent the worsening of health conditions would need to be taken at individual level (with healthy habits) but also at collective level (with healthy living and working environments). These interventions should be seen as investments, and the same view would be applicable to the provision of healthcare, as an investment to minimize the costs and negative effects of ill-health. Among these interventions, one could query which would be the role of health insurance provision. Academic literature seems to agree on the conclusion that health insurance markets are affected by adverse selection (Handel 2013; Boone 2015). This means that high-risk consumers – those with worse health conditions – would purchase insurance paying a premium based on low-risk groups, and even if the cost is subsidized, there is no guarantee that everybody would enroll in an insurance program (Wang et al. 2006). This poses questions about health insurance being publicly covered or privately offered, with subsequent added cost for the individual or employers. Universal basic health insurance covered by governments is said to correct the problem of adverse selection to some extent, but it would not cover issues related to moral hazard (Boone 2015). Additionally, one could argue that for developing countries, where incomes are low, the affordability of private insurance is limited, so the role of public health insurance systems is key.

Bearing this in mind, investment in health is seen as investment into one key component of capital stock, but as the following sections will show, it cannot be considered as unique contributor to well-being or growth. What is more, the aspects that require more attention will differ in developed and developing countries, so it is no surprise that experts are still debating the role of health, described as an “asset” (capital), in development and growth.

Health and Education

Previous sections have hinted the multifaceted characteristics of health, with the necessary inference that health-related interventions would affect and be affected by other aspects of people’s life. It is quite possible that one of the closest relationships in this regard occurs between health and education. Both, and even to a greater extent education, are considered the main components of human capital (Bloom and Canning 2003; Keeley 2007; Bedir 2016, among others).

The relationship between health and education is clear. On the one hand, health improves educational outcomes, since healthy children will have higher attendance school rates and improved cognitive functioning (Thirlwall and Pacheco-Lopez 2017). The same can be applied to education for adults, when they attend further or higher education. Talking in “capital” terms, greater health capital may improve the return to investments in education (Todaro and Smith 2015), for the aforementioned reasons, but also because someone healthy will live a longer life, and that means that potentially they can receive more education and get better jobs with higher salaries for a longer period of time. Additionally, better health during working life may lower the rate of depreciation of education capital, so people can reap the benefits of education and skills for longer (Galama and van Kippersluis 2015).

On the other hand, “greater education capital may improve the return to investments in health” (Todaro and Smith 2015). It can be argued that health professionals would need to receive training and specialized education to be able to work as such in the first place. At a more basic level, and particularly in developing countries but also in developed ones, public health programs rely on basic skills usually learnt at school, such as personal hygiene and sanitation. In this regard, one of the key elements for sustainable development is the provision of education to girls and women, so that they can increase their autonomy (and get jobs) and feel empowered to decide about their fertility, get the right information about pregnancies and their health-related issues, and, as a consequence of this, see an improvement in their health later in life (Langer et al. 2015). This realization has identified the need to increase the levels of “health literacy,” particularly in developing countries (Kickbusch 2001).

The mutual benefits that health and education achieve together have led many to consider that both should be taken as joint investments for development (Sen in Misra 2013; Todaro and Smith 2015). However, with limited resources, it may happen that some countries give priority to health over education or vice versa, hindering the possibilities of success of a joint approach. Recent evidence (Madsen 2012) suggests that health has a significant positive influence in the quantity and quality of schooling, innovations, and growth, at least in OECD (Organisation for Economic Cooperation and Development) countries. From this, it could be inferred that health is a prerequisite to receive sufficient amounts of education that would lead to growth. But in the same way, it could be argued that educated people are required to educate in “health,” so the debate is still open for those who would like to prioritize one over the other. Such debate should be left aside, bearing in mind that both health and education are joint components of human capital. In that sense, the study of the variables that have an impact on economic growth include both elements (Dreher 2006; Hartwig 2012), or focuses on one of the elements acknowledging the interaction between both of them (Teixeira and Queiros 2016). This means that both should be given equal level of priority.

Health and Development

The definition of development given in the introduction has a natural consequence that development involves all human choices and is not based just on income but on human centrality, sustainability, and empowerment (WHO 1996). Within this context, health is considered as a prerequisite of development, given that better health reduces premature mortality, increases life expectancy, and as explained in previous sections, this increases the potential for socioeconomic development (WHO 1996).

The opposite is also true. With higher income and better living conditions, i.e., with higher levels of socioeconomic development, there are positive impacts in health, as countries will progressively develop their health systems’ infrastructure and can benefit from technological innovations (Deaton 2003). This can be considered a virtuous circle.

However, it has become apparent that just raising levels of income is not enough (Todaro and Smith 2015), and while there is a vicious circle between poverty and ill-health, inequalities in access to health (both between rich and poor countries and rich and poor people within a country) are the main issue that needs to be addressed (Deaton 2013). In fact, good health could be “thought of as a goal in its own right independently of its relationship with income” (Bloom and Canning 2008). Conversely, it could also be true that higher levels of income in a country do not involve increasing expenditure levels in health, as other policy areas may be given higher priority. Developing countries have progressively increased the amount of resources dedicated to healthcare (IHME 2011), but many are still to reach the targets committed through the Abuja Declaration (Piabuo and Tieguhong 2017). Increase in the funding has not translated as expected in improvements on the quality of the healthcare provided, with reasons more connected to governance than to funding as explanations for the failures (Makuta and O’Hare 2015). Improved quality of governance, reduction of corruption, and improvements in transparency and accountability (Hewlett Foundation 2010) become paramount to overcome the barriers for improved health outcomes in developing countries.

Another way of looking at health, from a theoretical point of view, is considering healthcare as one of the inputs for the production of health, which will become the output (Grossman 1999). This opens the debate for those who wonder to which extent health investments should be provided by employers (Gardner and Gardner 2012), but this approach would somehow contradict the view that health would not be part of the production function and as such, not part of GDP, due to its “indirect” contribution to productivity and growth, as explained in previous sections. Health would have its own market, with corresponding supply and demand functions, and with government intervention to correct the existence of market failures (Bhattacharya et al. 2014), so in essence, it could be analyzed almost like any commodity.

The majority of the literature focuses however in the relationship between health and development from a more holistic point of view, given the prominence that health has achieved in public debates for a variety of reasons. It is generally accepted that better nourished workers would be more productive, so improved health through a higher calorie intake has been promoted as a factor that contributes to economic development (Strauss and Thomas 1998). A healthy workforce is also a factor for the attraction of foreign direct investment [FDI] (Alsan et al. 2006), the same way that lack of FDI can be explained by insufficient provision of public goods, specifically low human capital accumulation in terms of both health and education (Azemar and Desbordes 2009). In poor countries with population struggling to find food, policies that help increase the calorie intake would make sense, but when the public domain echoes the news about obesity epidemics in both developed and developing countries (Prentice 2006; Bleich et al. 2008; Caballero 2007), it becomes apparent that the problem is not so simple to solve.

One of the main issues for health interventions in developing countries, however, is the fact that relatively low cost measures have been increasing survival rates, which is positive, but if a fertility transition is not happening at the same time, population growth may create high pressures in the already limited amount of resources available, outweighing the gains from health (Bloom and Canning 2008). This is another example of the complexity that health policies and health interventions in developing countries carry. Acknowledging the role of health as a tool for growth, it has also been suggested that in terms of priority, widespread diseases with low mortality rate but with great impact on productivity could be moved to the top of the list (Bloom and Canning 2008). This step would make sense if there is a need to justify the investment in health as a way to reach better economic growth.

In developed countries, the main worry seems to be in the growing levels of government expenditure in healthcare (Gruber 2016), and while international institutions keep calling for more investments in health in developing countries (WHO 2001), the trend for developed countries is to try and contain public spending on healthcare (OECD 2010b). This is the result of a perception that expenditure in health has been outpacing economic growth (Smith et al. 2009), so many are questioning to which extent investment in health is worth the effort, in the high proportion of public budget that is reaching in many developed countries.

Health and GDP

Part of the debate around the contribution of health to economic growth (measured by the growth in GDP) comes from the use of the return on investment (ROI) in healthcare as an indicator of “value for money.” There are examples of this use by private companies (Stepanek et al. 2017), but it is particularly frequent to see its use by academics (Luce et al. 2006) and after the last economic crisis, by public institutions and policymakers (NICE 2011). The widespread use of ROI has already led to the identification of its limitations, given the fact that it mostly assesses the effectiveness of individual health interventions, instead of looking at packages of interventions, which most countries undergo (Pokhrel 2015).

Nevertheless, the use of ROI seems to be justified by the diverging results that recent studies have obtained about the contribution of health investment to economic development and growth. Some authors have found a two-way relationship between health and income in developing countries, coming to the conclusion that the growth in healthcare expenditure has a positive influence on GDP, and that economic growth increases healthcare expenditure, though with caveats for specific countries (Bedir 2016). Other authors have focused the analysis on individual countries, finding, for instance, that health as a component of human capital formation is important for the economic growth of Nigeria (Dauda 2011). For the US, a historical analysis concluded that the value of improved health in 2000 compared to 1980 significantly outweighed the additional expenditures on healthcare of the period (Luce et al. 2006).

In an analysis of African countries, it was found that for Botswana, Rwanda, Zambia, Madagascar, and Togo, one unit change in health expenditure can potentially increase GDP per capita by 0.30 units, while for the Economic Community of Central African States (CEMAC), the increase would be of 0.38 units (Piabuo and Tieguhong 2017), concluding that health expenditure has a positive effect on economic growth. However, in an analysis for OECD countries, the conclusion was that health capital formation does not tend to foster long-term economic growth (Hartwig 2010). These differing findings have made some experts to conclude that the “effects of health improvements on income per capita are substantially lower than those often quoted by policymakers, and may not emerge at all for three decades or more after the initial improvement in health” (Ashraf et al. 2009), leading them to conclude that the justification for investments in health in developing countries should be made on humanitarian rather than economic grounds.

Without agreeing with such statement, it becomes apparent that in the majority of cases the evidence support that health investments in developing countries would produce higher returns than those in developed countries, among other reasons, because there are health-related issues usually endemic of less developed areas, which are inherently connected to the improvement of economic conditions (WHO 2002). In this regard, there is no reason why this fact cannot be taken into consideration for the rearrangement of policies and the adaptation to the needs of countries in different stages of the development process.

It is equally important to acknowledge that one of the reasons for the increase in health expenditure in developed countries is related to the use of innovative technologies, which by definition will be more expensive (Smith et al. 2009). At this point, it would not be possible to assess if the gains achieved in health due to the use of these technologies would outweigh their cost in the long term, thus the conclusions reached so far for some developed countries may well need to be reassessed in the future. At the same time, it is important to bear in mind that such technologies could be shared and transmitted to less developed countries, reducing their need to increase massively their expenditure, for instance, in research and development. This could contribute to shorten the gap between developed and developing countries on this area, but it would require political will.


Latest figures (OECD 2015) indicate that the expenditure in health has continued increasing in OECD countries in line with economic growth, which means that, in general, health expenditure as a share of GDP has been kept stable in recent years, perhaps with the exception of the USA. This trend is, on one side, an indication that investments on health are still considered a priority for most governments, in terms of individual well-being and contribution to productivity. On the other side, it seems that the fears created by the last economic crisis, when health spending outpaced the rest of the economy (OECD 2015) have started to subside.

There seems to be a general recognition that health is an important contributor to economic development and growth, but with unequal results depending on the stage of development of each country. Health cannot be considered in isolation, and health interventions will be usually connected to and affected by interventions in other policy areas, particularly education. One of the biggest issues identified for the maximization of positive effects of health investment is the unequal distribution of the interventions, both between rich and poor countries and between richer and poorer segments of the population within the same country. It has become apparent that there are parts of the population that are still left out of reach and cannot enjoy the benefits of better access to health services and better information on health-related issues. For developing countries, the weakest groups are children and particularly women; so in order to reverse the situation, it is imperative that the gender gap in the access to health is broken, so it is no coincidence that many of the interventions of health programs are designed for this group of the population in particular. This approach is also connected to another of the SDGs: Goal 5 – Achieve gender equality and empower all women and girls (UN 2015).

Whether health is considered in economics terms as part of human capital or not, the reality is that it is an indispensable part of the development process, both a prerequisite and an outcome of development, and as such, directly or indirectly, in bigger or smaller proportion, it contributes to economic growth, so it cannot be viewed in isolation nor perceived as a burden, but a valuable investment for the future. This should be regardless of any country’s current level of development.



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Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of Social and Political ScienceEconomics Programmes, University of ChesterChesterUK

Section editors and affiliations

  • Meherun Ahmed
    • 1
  1. 1.Asian University for WomenChittagongBangladesh