The bottom billion: Why are the poorest countries failing and what can be done about it



Varatharajan Durairaj1

Health Financing and Policy, Health Systems Financing, World Health Organization, 20 avenue Appia, 1211 Geneva 27, Switzerland



Author: Paul Collier
Publisher: Oxford University Press, Oxford, England; 2007
ISBN: 978-0-19-531145-7; 205 pages; £ 16. 99 (hardback)

Disadvantaged populations, such as the poor, pose a complex set of challenges to the process of economic development. While a girl child born in Japan in 2005 is expected to live for 86 years, deliver her child in a medical institution under skilled supervision and receive appropriate attention during her old age, her contemporary born in Angola, Lesotho, Sierra Leone, Swaziland, Zambia or Zimbabwe is expected to live for about 40 years, deliver her child at home without any skilled supervision and struggle to receive adequate care during old age if she survives that long. The child cannot be faulted for this diverse prospect of length and quality of life: countries that are home to such disadvantaged population groups are in extreme poverty and express their helplessness to rescue such groups. When countries are poor and small, their economies or governments are not in a position to respond effectively to diseases that predominantly affect their poor citizens. This inability to deal adequately with complex situations further impedes such countries’ growth. As a result, many low-income countries, where most of the world’s poor live, are drifting away, in developmental terms, from the rest of the world.

On the other hand, the poor living in countries that are doing well economically face a different set of problems. Such people live alongside the rich and face similar market conditions due to increased globalization and monetization of economies. Possibilities to deal with the problems of poverty exist in better-off countries, but the poor often lack access to them. In such countries, the usefulness of economic growth lies in what it does to enhance people’s health and welfare. "Growth" has no meaning if millions of the poor lack access to basic amenities, such as health care.

Whether developing or not, many low-income countries are caught in several traps which prevent them from prospering. To make things worse, the present global economy is unfavourable to the bottom billion people and the countries in which they live. Hence, it is much harder for disadvantaged countries to break out of the traps in which they find themselves. In this book, Paul Collier discusses four such traps that have previously received little attention. Interestingly, what many people would consider to be a source of prosperity – natural resources – is seen as a trap by the author. The other traps he discusses are conflict, being landlocked and surrounded by bad neighbours, and bad governance.

The author claims that low-income, slow economic growth and high dependence on primary commodity exports are the key determinants of civil war, which is likely to continue longer if a country’s income is low. Civil war also tends to reduce a country’s economic growth by about 2.3% per annum. He notes that 73% of people among the bottom billion have been affected by civil war recently, 29% live in countries where natural wealth dominates the economy, 30% live in countries that are landlocked and resource-scarce and have bad neighbours, and 76% have lived through a prolonged period of bad governance and poor economic policies.

The future progress of the bottom billion people is crucial for health and health system development. These are the people caught in the poverty/ill-health trap. Inequities in access to health care suffered by this group further disadvantage it. Conflicts, bad governance and lack of development clearly have an effect on the national health systems of the worst-affected countries. Breaking out of the traps discussed in the book is important for future health system development, and understanding these and other barriers to development is the essential first step. The book is a welcome contribution to health development literature and makes excellent reading for those who are concerned about poverty and the poor, and for those who tend to think that economic growth is the sum total of human welfare.

The book powerfully describes the increasing income divisions between sections of populations; the difficulties that development agencies face in placing materials and staff in areas with maximum needs; governments’ inabilities and failures to deal with the situation; and investment failures in poor settings. The book also serves as a timely reminder for carrying out suitable policy and development responses. The author’s rich African experience is reflected in the valuable country examples provided, while the narrative style makes the book read well. A deliberately pessimistic view of the future prospects of the bottom billion is presented, but the book does provide some suggestions that the affected countries and the Group of Eight (G8) countries could adopt to improve the status quo. The book would have benefited from use of an analytical framework to better depict the evidence presented.



1 Correspondence to Varatharajan Durairaj (e-mail:

World Health Organization Genebra - Genebra - Switzerland