Fitsum Zewdu, Junior Research Fellow. Working Paper No 3/ 2010

Transcription

1 SOCIOECONOMIC FACTORS OF EARLY CHILDHOOD MORTALITY IN ETHIOPIA: EVIDENCE FROM DEMOGRAPHIC AND HEALTH SURVEY Ftsum Zewdu, Junor Research Fellow Workng Paper No 3/ 2010 Ethopan Economcs Assocaton / Ethopan Economcs Polcy Research Insttute (EEA/EEPRI) October, 2010 Adds Ababa 1

2 Table of Content 1 Introducton Summary of related studes Descrptve Analyss Emprcal Fndngs Concluson and Recommendaton References

3 Socoeconomc Factors of Early Chldhood Mortalty n Ethopa: Evdence from Demographc and Health Survey Ftsum Zewdu Mulugeta 1 Abstract Chldhood mortalty rates are mportant summary ndcators of socal development, qualty of lfe, overall health, maternal health and welfare. Chldhood deaths are manly caused by preventable and communcable dseases and poor coverage of health, especally n the case of underdeveloped countres. Ths mples the socoeconomc nature of the ssue besdes ts ntrnsc health nature. Ths study dentfes the socoeconomc factors causng chldhood mortalty n Ethopa based on the Ethopan Demographc and Health Survey conducted n Identfyng the mportant factors wll help n polcy formulaton and nterventon desgnng, should the country meet reducton of the nfant and chld mortalty rates to the one set by the Mllennum Development Goals. Ths study employs a probt model to dentfy these socoeconomc factors and fnds maternal educaton, maternal age at frst brth, age of the chld and sze of the household to sgnfcantly and negatvely affect chld mortalty. On the other hand, twn brths and male chldren are found to have a hgher relatve chance of dyng before seeng ther ffth brthday. Based on the fndngs, the study suggests some recommendaton for desgnng nterventon and polcy formulatons. 1 Junor Research Fellow, Ethopan Economcs Assocaton-Ethopan Economc Polcy Research Insttute (EEA/EEPRI). E-mal: ftsumz@gmal.com, Tel:

4 I. Introducton: Hgh levels of nfant and chld mortalty are among the typcal characterstcs of least developed and developng countres. Chld mortalty s one manfestaton of the poor socoeconomc condtons that a certan communty or a country n general faces. Infant and chld mortalty rate s an ndcator that s becomng more popular and s commonly quoted on the agendas of publc health and nternatonal development agences. Mutunga (2007) credts the Unted Naton s Mllennum Development Goals (MGDs) 2 for the renewed attentons to the ndcator. Infant and chld mortalty has ths socoeconomc nature as most such deaths result from darrhea, respratory nfectons, malara, measles and other mmunzable chldhood nfectons, whch are preventable and curable n hgh-ncome economes. There s a vsble correlaton between the level of development of a socety and the nfant and chld mortalty rates. For nstance, ten mllon nfants and chldren under the age of fve de each year wth large varaton n under fve mortalty rate across regons and countres; developng countres havng the hghest, accordng to Espo 2002 (as cted by Mutunga 2007). The stuaton of early chldhood mortalty n Ethopa has mproved between the years 1990 and For nstance, the under fve mortalty rate 3 declned from 210 n 1990 to 109 n 2008 (UNICWF). Despte ths drop n chldhood mortalty, the current rate s stll too hgh to be comfortable wth and turn attenton to other ssues. As mentoned above, Ethopa s performng poorly n reducng chldhood mortalty, despte the fact that most of the causes of early chldhood deaths are preventable dseases. Improvng the lvng standard and envronmental condtons could easly prevent ncdence of these dseases and sgnfcantly reduce deaths. On the other hand, a neglected envronment s a threat for health of both chldren and adults. Accordng to Iram and Butt (2008), root of nfant mortalty s n the uneven dstrbuton of resources or lack of resources. Poverty also nfluences health because t largely determnes an ndvdual s envronmental rsks, as well as access to resources to deal wth those rsks (Mutunga 2007). Households wth better ncome are able to afford better health care as well as housng and santary condtons, such as clean water and tolet facltes. The objectve of ths study s to dentfy the socoeconomc determnants of chld mortalty n Ethopa, bearng the fact that chldhood mortalty s of socoeconomc ssue n addton to ts ntrnsc health nature. Specfcally we try to dentfy how the personal characterstcs of the mother and the lvng envronment affect the chance of a chld s survval or death. Our research analyzes the data from the Ethopan Demographc and Health Survey (EDHS) to dentfy the structural relatonshp between chld mortalty and personal and household condtons that the chld lves n. Based on the dscrete nature of the dependent varable, we employed a dscrete choce model to model the problem. 2 One of the goals of the MGDs s to reduce the level of chld mortalty to two-thrds of what t was n the year 1990 by The rates of chldhood mortalty are expressed as the number of deaths before the age of fve per 1,000 lve brths. 4

5 Secton II below summarzes some of the lteratures n chldhood mortalty. Then the descrptve analyss s presented n secton III. In secton IV we have the emprcal analyss and fndngs. And fnally secton V concludes and gves some recommendaton of the study. II. Summary of Related Studes: Mutunga (2007) set the theoretcal framework for analyss of chldhood mortalty as health producton functon followng Schultz (1984). Ths functon captures the structural relatonshp between health outcomes and the household s behavoral varables, such as nutrton, breastfeedng, chld spacng, etc. In the framework of health producton functon, chldhood mortalty rsks depend on both observed health nputs and unobserved bologcal endowments on fralty. Soco-economc varables such as cultural, socal, economc, communty and relgon factors are consdered to be exogenous. Bomedcal factors lke breastfeedng patterns, hygene, etc. are modeled as endogenous and as havng drect effect on health outcomes, whle that of socoeconomc ones as ndrect as they work through the bomedcal factors (Mutunga 2007) 5

6 Table 1: Summary of related emprcal studes Study Ftsum (2009), socoeconomc determnants of chldhood mortalty n rural Ethopa Data source and Model(s) ftted Ethopan Rural Household Survey (ERHS) Probt model Results Sgnfcant varables Resultng sgn Non-food per-head consumpton Household sze Safe water Educaton of household head Expected sgn Dscusson Household sze and the educaton of the household head yelded unexpected sgn. Iram and Butt (2008), socoeconomc factors of chldhood mortalty n Pakstan Pakstan Integrated Household Data (PIHD) Sequental probt model Maternal Educated Workng mother Age at marrage Chld s male Chld vaccnated Access to santaton Income ( +) Age at marrage s postve for early and late ages negatve n between. Safe water was fond to be postve and nsgnfcant. Mutunga (2007), envronmental determnants of chld mortalty n Kenya Kenyan Demographc and Health Survey (KDHS) Welbull (parametrc) and Cox (Sem-parametrc) Chld s male Chld s twn Square of maternal age Household sze Maternal age Maternal educaton Safe water Access to santaton Less pollutng fuel Income The fndng suggests that larger households have better chance of chld survval, whch s unexpected. (cont.) 6

7 Study Data source and Model(s) ftted Sgnfcant varables Results Resultng sgn Expected sgn Dscusson Ladusngh and Sngh (2006), place, communty educaton, sex and chld mortalty n north-east Inda Indan Natonal Famly Health Survey (INFHS) Multlevel logstc model Maternal educaton Educaton of communty elders Chld s male Workng mother Maternal age Have tolet Hgh standard of lvng Access to santaton s proxed by avalablty of tolet for the household. Communty elders are consdered due to ther role n makng decsons regardng communty level nfrastructures. Jacoby and Wang (2004), chld mortalty n rural Chna Chna Natonal Health Survey (CNHS) Competng rsk model Safe water Maternal Educaton Educaton stands for unversal prmary educaton for female Klaauw and Wang (2004), chld mortalty n rural Inda Indan Natonal Health Survey (INHS) Flexble duraton model Maternal educaton Indoor polluton Electrcty Santaton Incluson of electrcty s unque for ths study. Gebremaram (2001), studed darrheal (whch s major cause of morbdty and mortalty of chldren n many developng countres) morbdty among young chldren n Ertrea Ertrean Demographc and Health Survey (ErDHS) Logstc regresson Chld age Household sze Drt floor Have tolet Maternal educaton Lve n the rural The materal the floor, whch s related to nhouse santaton, s made of s unque for ths study, t s sgnfcant and postve. 7

8 Several socoeconomc factors have been found to be assocated wth nfant and chld mortalty n the developng countres. However, the relatve mportance of these socoeconomc factors vares from socety to socety based on ther level of development (Iram and Butt 2008). Many emprcal studes also show that health outcome s a result of dfferent socoeconomc nputs. The results of the studes revewed above confrm ths clam. Besdes confrmng ths argument, the studes also dentfy the drecton of nfluence of these socoeconomc factors. The emprcal lteratures show that socoeconomc and envronmental condtons are very mportant n explanng nfant and chld mortalty n many developng countres. Almost n cases, the role of mother s educaton s mportant. Some of the studes argue that maternal educaton can affect chld mortalty n two ways. The frst way s that educated mothers are more health conscous and they take a better care of ther chldren, whle the second channel s that educaton delays the age that the woman gves her frst brth. The other mportant attrbutes of a household wth respect to chldhood mortalty are santaton (represented by avalablty of tolet), access to safe drnkng water, economc status of the household (ncome) and locaton of the household (urban versus rural). The gender of the chld was also consdered to be mportant factor of chld mortalty n some of the studes despte contradctng results. III. Descrptve Analyss: Accordng to CSA (2005) the Ethopa Demographc and Health Survey (EDHS) was conducted under the auspces of the Mnstry of Health and mplemented by Central Statstcal Agency (CSA). The frst ever Demographc and Health Survey (DHS) n Ethopa was conducted n The prmary objectve of the 2005 EDHS was to provde up-to-date nformaton for polcy makers, planners, researchers and programme managers, whch would allow gudance n the plannng, mplementaton, montorng and evaluaton of populaton and health programmes n the country. The nformaton obtaned from the EDHS, n conjuncton wth statstcal nformaton obtaned from the Welfare Montorng Survey (WMS) and Household Income, Consumpton and Expendture Survey (HICES), wll provde crtcal nformaton for the montorng and evaluaton of the country s Plan for Accelerated and Sustaned Development to End Poverty (PASDEP), the varous sector development polces and programmes, and assst n the montorng of the progress towards meetng the Mllennum Development Goals (MDGs). The 2005 EDHS nformaton on the populaton and health stuaton, coverng topcs on famly plannng, fertlty levels and determnants, fertlty preferences, nfant, chld, adult and maternal mortalty, maternal and chld health, nutrton, malara, women s empowerment, and knowledge of HIV/AIDS (bd). The target populaton for ths study s chldren below fve years of age and ther mothers. The study subjects consdered for ths study are women n the reproductve age (between 15 and 49 years). The average age of these women s 32 years. The sample was drawn from nne regonal states and two cty-admnstratons n a natonally representatve way. Among these sample unts, 87 percent are from rural areas whle the remanng 13 percent are from urban. When we look at the educatonal status, the majorty (around 81 percent) have no educaton. Fourteen percent attended prmary educaton, 5 percent attended secondary and only less than one percent attended hgher educaton. The stuaton of access to safe water s much better than that of educaton. Ffty-nne percent reported to have access to safe water whle the remanng 41 8

9 percent does not. On the contrary, majorty of the respondents do not have any form of tolet whle the remanng mnorty, the 34 percent, has some sort of tolet faclty. Table 2: Samplng dstrbuton by regon Regon Freq. Percent Tgray 1, Afar Amhara 2, Oromya 2, Somal Benshangul-Gumz 1, SNNP 2, Gambela Harar Adds Ababa Dre Dawa Total 14, Source: Own computaton usng EDHS-2005 data Avalablty of electrcty concentrates around urban areas. From our respondents, only thrteen percent have electrcty. When consderng the man materals from whch the floor materals of the houses s made, 91 percent of the houses have drt floor where the remanng 9 percent are made from ether wood planks, parquet, vnyl, cement or carpet. Table 3: Percentage of households havng access to electrcty by type of place of resdence Type of place of resdence Percentage of households havng access to electrcty Urban 78 Rural 3 Total sample 13 Source: Own computaton usng EDHS-2005 data A typcal household has around sx whle the smallest stand at one and the maxmum at nneteen. Eghty-three percent of these households have male heads. On the average, women gve ther brth at around ther 18 th brthday, but the mnmum age of gvng frst brth s reported to be 9 years whle the maxmum s 40 years. For ths study we elmnated those who reported to have gven ther frst brths at ages below 12. The chldren of nterest are composed of almost smlar proporton n terms of gender, wth 53 and 47 percent for male and female chldren respectvely. On the other hand, only 3 percent of them are twns. The varables consdered n the econometrc model are summarzed n table 4. The dependent varable s defned to be one f a chld des before the age of fve and zero f the chld s below fve and stll alve at the tme of the survey. By ths defnton, we elmnated those who lved to see ther ffth brthday. 9

10 The explanatory varables are of three type, the frst one beng maternal characterstcs such as the educatonal attanment of the mother, her age when gvng her frst brth and the square of the maternal age at frst brth (Iram and Butt, 2008; Mutunga,2007; Ladusngh and Sngh, 2006; Jacoby and Wang, 2004; Klaauw and Wang, 2004 and Gebremaram 2001). In order to control for the chld related bologcal characterstcs, we ncluded a second group varables, namely whether or not the chld s a twn, the age of the chld and chld gender. (Iram and Butt, 2008; Mutunga, 2007; Ladusngh and Sngh, 2006 and Gebremaram 2001). Fnally, the thrd group of varables whose mpact on the chances of chld mortalty are analyzed are those of the household characterstcs. These household characterstcs are type of place of resdence (rural versus urban), number of famly members (.e. the household sze), the household s access to tolet, safe water and electrcty, the type of materal from whch the floor of the house s made of as well as the nature of the cookng fuel used by the household. These varables are selected based on the fndng of the studes Ftsum, 2009; Iram and Butt, 2008; Mutunga, 2007; Ladusngh and Sngh, 2006; Jacoby and Wang, 2004; Klaauw and Wang, 2004 and Gebremaram Table 4: Descrptve statstcs of the selected varables Varable Mean Std. Dev. Dependent varable Chld mortalty (1=chld s dead before age fve, 0= chld survved ffth brthday) Explanatory Varables Maternal characterstcs Educaton level s prmary (1=yes, 0=no) Educaton level s secondary (1=yes, 0=no) Educaton level s hgher (1=yes, 0=no) Age at frst brth Square of Age at frst brth Chld characterstcs Chld s twn (1=yes, 0=no) Age of the chld Chld s male (1=yes, 0=no) Household characterstcs Type of resdence (1=rural, 0=urban) Household sze Have access to safe water (1=yes, 0=no) Have tolet faclty (1=yes, 0=no) Have electrcty (1=yes, 0=no) The floor materal s drt (1=yes, 0=no) Uses cookng fuel that s pollutng (1=yes, 0=no) Source: Own computaton usng EDHS-2005 data Unlke the other studes, we dd not drectly nclude varables that ndcate the ncome level or the lvng standard of the household. Ths s nspte of the fact that the EDHS has a wealth ndex. 10

11 We choose to exclude ths ndex snce we already have ncluded some of the components of the ndex as they are, such as tolet faclty, access to safe water, type of materals that the resdental house s made of, etc. so that our model wll not suffer from multcollnearty. IV. Emprcal Fndngs:. Model Specfcaton The dependent varable n ths study s whether an under fve chld s alve or not. In ths case death before the age of fve s reported as one and zero otherwse, hence, the dependent varable s a dchotomous varable wth outcomes 0 and 1. We therefore, employed the probt model recognzng the dscrete choce nature of the response varable. Let the observed outcome be * y. Accordng to Verbeek (2002), the underlyng latent varable y, whch s the unobserved threshold level that marks between a certan chld s survval or not of the ffth brthday, s a functon of observed personal and socoeconomc factors, say x, and unobserved characterstcs, say, for ndvdual. Ths can be expressed n equaton form as: y * x ', ~ NID(0,1 ) If ths threshold level s set to zero, wthout loss of generalty, then the probt model can be fully descrbed as: y * x ', ~ NID(0,1 ) y 1 0 f f y * y * 0 0 A probt model wth robust standard errors and clustered by regon s estmated by employng the method of the maxmum lkelhood estmaton technque. We clustered the regresson by regon to account for some smlartes wthn each regon followng Cameron and Trved (2010). The results of ths estmaton are reported n the followng secton.. Dscusson of Results Followng the estmaton of the probt model for under-fve mortalty usng maternal characterstcs, chldren characterstcs as well as the stuaton of the household that the chldren lve n, the results reported by table 5 are found. In-lne wth most studes n the area (see for nstance Iram and Butt, 2008; Mutunga, 2007; Ladusngh and Sngh, 2006; Jacoby and Wang, 2004; Klaauw and Wang, 2004 and Gebremaram, 2001) maternal educaton s an mportant factor affectng chldhood mortalty. Maternal educaton s a sgnfcant factor that affects chldhood mortalty negatvely. The margnal effect of maternal educaton on the probablty of a chld s survval ncreases wth the level of educaton, as educaton level advances from prmary to secondary and to hgher educaton. Maternal educaton s mportant n reducng chldhood mortalty snce better educated mothers can gve a better care to ther chldren as well as earn better ncome to satsfy the chldren s 11

12 nutrton, santary and medcal needs. The other channel n whch educaton can affect chldhood mortalty and fertlty s that grls attendng school wll delay marrage and early pregnancy. The above argument s also confrmed by one of our fndngs that the maternal age at frst brth has sgnfcant and negatve mpact on chldhood mortalty. Ths means that the older the women are when gvng ther frst brth, the hgher the chances are for the chldren to survve ther ffth brthday. Ths also confrms the fndng of Mutunga, (2007) and Ladusngh and Sngh (2006). Table 5: Estmaton results of the probt model Varable Coeffcents Margnal effects Constant term (0.3751)*** Prmary educaton (0.0609)*** (0.0183)*** Secondary educaton (0.0760)*** (0.0178) *** Hgher educaton (0.0847)*** (0.0151) *** Maternal age at frst brth (0.0280)*** (0.0109) *** Square of Maternal age at frst brth (0.0006)*** (0.0003) *** Chld s twn (0.1006)*** (0.0367) *** Chld age (0.0140)*** (0.0048) *** Chld s male (0.0246)*** (0.0092) *** Lve n rural (0.0807) (0.0311) Household sze (0.0075)*** (0.0029) *** Access to safe water (0.0380) (0.0142) Has tolet (0.0389)* (0.0147)* Has Electrcty (0.0554) (0.0211) Drt floor (0.0786) Pollutng cookng fuel (0.1075) Number of observatons Correctly classfed 71.67% Source: Own computaton usng EDHS-2005 data 12 (0.0299) (0.0403) Notes: Standard errors n parenthess. Coeffcents are sgnfcant at *10 percent, ** 5 percent and *** 1 percent.

13 The square of the maternal age at frst brth s sgnfcant and postve. Ths ndcates that very early and very delayed frst brths contrbute sgnfcantly to the ncreased chances of under fve mortalty. The bologcal controls for the chld specfc characterstc are also found to be sgnfcant. The results suggest that twns and male chldren have hgher chance of mortalty before reachng fve as compared to sngle brths and female chldren respectvely. On the other hand, the probablty of dyng before the age of fve declnes as the chldren grow older as ndcated by the negatve coeffcent of the varable chld age. The fndng that male chldren are bologcally more dsadvantaged than female chldren s n-lne wth the fndngs of Mutunga, (2007) and Ladusngh and Sngh (2006); whle t contradcts that of Iram and Butt (2008). Mutunga, (2007) also found ths hgher probabltes of death of twns than sngle brths. The age of the chld s also found to be negatvely related wth chldhood darrheal morbdty study of Gebremaram (2001). In lne wth Ftsum (2009) and Mutunga (2007), the sze of a household s sgnfcantly and negatvely related to chldhood mortalty, meanng that chldren n larger households have a better chance of survvng to see ther ffth brthday. Ths fndng s explaned by Ftsum (2009) as the possblty of mproved chld care from the members of the extended famly members of larger households. The argument also suggests the possblty that larger households could be the wealther ones. 13

14 V. Concluson and Recommendaton: Based on the fndngs of our analyss we conclude that sendng grls to school wll mprove the stuaton of chldhood mortalty. The government and ts development partners should exert ther at most effort to ensure unversal access to educaton as well as to moblze the socety to send ther chldren, especally grls to school. Programs desgned to tackle ths problem should also have nformaton, educaton and communcaton sub-programs targeted at creatng awareness about the problems of early marrage and early pregnancy. Ths approach could be ntegrated wth motvatng parents to send ther grls to school, as schoolng contrbutes to delayng marrage and pregnancy. Due to the vulnerablty of twns and male chldren, extra attenton must be gven whle carng to chldren. More obvously, younger chldren also need more attenton and care than older ones. The reducng effect of household sze, as explaned n the prevous secton, could be due to the care extended to the chld by the grandparents or bgger brothers and ssters. Ths suggests that extra care for chldren s benefcal for ther survval. In general we suggest that nterventons desgned to reduce nfant and chld mortalty should pay attenton to these socoeconomc factors of chldhood mortalty along wth the preventve and curatve healthcare nterventons. The natonally representatve data gves us a general pcture, but nterventons should consder the peculartes of each socety and vllages whle desgnng and mplementng nterventons, hence, there s a need to conduct specfc studes for specfc area of nterventon. 14

15 References: Cameron, A. C, and Trved, P. K. (2010) Mcroeconometrcs Usng Stata, Stata Press, College Staton, Texas CSA (2000) Ethopa Demographc and Health Survey 2000 Central Statstcal Authorty, ORC Macro Calverton CSA (2005) Ethopa Demographc and Health Survey 2005 Central Statstcal Authorty, ORC Macro Calverton EEA, (1999/2000) Annual Report on the Ethopan Economy Ethopan Economc Assocaton. Vol I, ed. Befkadu Degfe and Berhanu Nega Espo, M. (2002) Infant Mortalty and ts Underlyng Determnants n Rural Malaw, Dssertaton, Unversty of Tamper Medcal School. Flmer, D. and Prtchett, L. (1999) The Effect of Household Wealth on Educatonal Attanment: Evdence from 35 Countres. Populaton and Development Revew 25(1): Ftsum Z. M. (2009), Socoeconomc Determnants of Infant and Chld Mortalty n Rural Ethopa, Proceedng of the 7 th Internatonal Conference on Ethopan Economy, ed Getnet Alemu, May 2010 (2): Gebremaram, W. (2001) Darrheal Morbdty among Young Chldren n Ertrea: Envronmental and Socoeconomc Determnants, Journal of Health Populaton Nutrton 19(2): Iram, U. and Butt, M. S. (2008) Socoeconomc Determnants of Chld Mortalty n Pakstan: Evdence from Sequental Probt Model, Internatonal Journal of Socal Economcs, Vol. 35 No. 1/2, 2008 Jacoby, H. and Wang, L. (2004) Envronmental Determnants of Chld Mortalty n Rural Chna: A Competng Rsks Approach, World Bank Polcy Research Workng Paper 3241, March 2004 Klaauw, B and Wang, L (2004) Chld Mortalty n Rural Inda, World Bank Ladusngh, L. and Sngh, C. H. (2006) Place, Communty Educaton, Gender and Chld Mortalty n North-East Inda, Populaton, Space and Place 12, Mutunga, C. J. (2007) Envronmental Determnants of Chld Mortalty n Kenya, World Insttute for Development Economcs Research, Unted Natons Unversty, Research Paper No. 2007/83. Pass, C. Lowes, B. Daves, L (2005) Collns Dctonary of Economcs, 4th ed. Prtchett, L. and Summers, L. H. (1996), Wealther s Healther Journal of Human Resources 31(4): Schultz, T. (1984) Studyng the Impact of Household Economc and Communty Varables on Chld Mortalty, Populaton and Development Revew, 10: UNICEF: - Accessed on Aprl, 2010 Verbeek, M. (2002) A Gude to Modern Econometrcs, John Wley & Sons Ltd. Wang, L. (2002) Determnants of Chld Mortalty n Low-Income Countres: Emprcal Fndngs from Demographc and Health Surveys, World Bank 15

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