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SAGA Research Proposal:

1.2.2 Health and Nutrition

Levels of health, measured for example by life expectancy and child survival rates, are lower in Africa than in other regions of the developing world, even controlling for differences in per capita incomes (Schultz 1999). These gaps existed before the effects of the HIV/AIDS pandemic began to be felt, and they will obviously worsen because of it. Similarly, the share of pre-school age children suffering from malnutrition remains extremely high in Africa relative to southeast Asia and Latin America, though not South Asia (Sahn and Stifel, forthcoming).

At the same time, recent research on the returns to investments in human resources finds that improvements in the health and nutrition contribute to increased productivity and higher incomes. This has been confirmed for Africa, for men and women and for the wage and non-wage sectors (Glick and Sahn 1997; Schultz and Tansel 1997; Strauss 1986). The implication is that Africa's low level of health, like its low levels of schooling, acts a major constraint on growth, and that improvements in health and nutrition will have large economic payoffs.

The benefits of investments in health and in education are mutually reinforcing, providing another example of interactions between our potential research topics. Compelling evidence has been compiled that cognitive development in children is enhanced by better nutrition, in terms of protein-energy status and intake of micronutrients such as iron (Pollitt 1993, 1997) and iodine (Oldham et al. 1998). Consequently, healthier children do better in school, showing less grade repetition, less delayed enrolment, and better test scores (Glewwe and Jacoby 1994; Behrman 1996) However, much of this literature has not dealt with the important feedback effects arising from the joint determination of nutritional status and schooling outcomes (Behrman and Lavy 1994). Therefore the strength of the links remains unclear and are an important topic for further investigation, especially in the African context.

Another important example of interactions is the strong positive impact of mothers’ education on children’s health and nutrition outcomes, and on the use of key inputs to health such as medical care, even when controlling for the level of household income (Sahn, Younger, and Genicot 2000; Strauss and Thomas 1995). This is not because health or childcare practices are taught in school, but rather that educated mothers are better able to acquire and process information about providing for the health and nutritional needs of the their children (Thomas, Strauss, and Henriques 1991; Glewwe 1999). These examples of positive education-health interactions imply that the benefits from improving access to education and health, particularly in a dynamic sense, are likely to be greater than the short-term and one-dimensional returns we measure using traditional rate of return calculations.

Research in recent years for Africa has begun to analyze the individual, household, and community determinants of health and nutrition, especially of children, but important gaps remain. We require a better understanding of demand behavior: why do the poor not make greater use of health services, even public services that are free or heavily subsidized? Distance or availability is one reason, but not the only one. Simply making health care, or specific treatment programs, locally available will not insure uptake and a successful course of treatment — "availability" does not mean "access" in the broader sense of the term. Low quality reduces the attractiveness of health services even where they are close at hand (Sahn, Younger, and Genicot 2000; Castro-Leal et. al. 1999). In addition, education, income, social attitudes, and the possibility of learning from others (or more broadly, social capital) are each also likely to be important.

The importance of understanding individual health behavior seems most obvious for the HIV/AIDS pandemic. Public efforts to prevent the spread of HIV will fail unless they incorporate such information. Research in the U.S. (Ahituv, Hotz and Philipson 1996) indicates that condom use among young adults responds strongly to the local prevalence of HIV/AIDS. In Africa, behavior can change as well. For example, HIV prevalence among young people and pregnant women has declined in Uganda (Ainsworth and Teokul 2000). Research is needed on how individuals' behavior will respond to public information campaigns promoting awareness of HIV transmission and safe sex practices, and especially, how individuals in targeted, high-risk populations respond.

Another key area where we need to learn more is the dynamics of health and nutrition, and their interactions with poverty and vulnerability - how individuals and families respond to health shocks such as illness or shortages of calories. For young children, there is some resilience to isolated health shocks. If a period of inadequate caloric intake or a bout of infectious illness is not prolonged, children can catch up in their growth. However, repeated health shocks in young children (those under 3 years) can have irreversible effects on growth, leading to chronic malnutrition or stunting that persists to adulthood (WHO 1995). This in turn has negative implications for future adult productivity and incomes. What this suggests is that vulnerability to illness and food insecurity have potentially strong intergenerational impacts on poverty. In this and other ways our suggested research topics of vulnerability and health are tightly linked.

The effects on families of health shocks to adults are potentially permanent and devastating as well. For Africa, Schultz and Tansel (1997) show that morbidity reduces labor earnings in Ghana and Côte d’Ivoire. What is not yet understood are the longer-term effects of illness at the household level. Like a crop failure, a temporarily disabling bout of illness for an income-earner in a family near the poverty line could push that family below the line, and through distress sales of assets result in permanent impoverishment. Evidence from several cross-section surveys in Africa indicates that households do sell assets when hit by a major illness (Evans 1989; Chambers 1982). With panel data sets becoming available for many African countries we can begin to address the dynamic implications of this coping response to illness.

Among illnesses with potentially devastating consequences for households (and macroeconomies) in Africa, HIV/AIDS obviously looms large. Because there is no recovery from the disease, we might expect that the chances that a household can recover economically from having a prime-age adult fall ill with HIV/AIDS are poor. But the very limited evidence emerging from Africa provides a mixed picture (Over et al, forthcoming; Ainsworth and Semali 1999). A longitudinal study of the Kagera region in Tanzania found that consumption per person of basic needs first fell but then recovered after a breadwinner died of AIDS. The recovery in basic needs consumption was funded in part by sacrificing other consumption (and presumably also investment), in part by selling assets, and in part through increased private transfers. However, a great deal more research is needed on the household-level impacts of HIV/AIDS, and on public policies to offset these impacts. As the prevalence of HIV/AIDS increases within a village or wider area, social networks that provide transfers to smooth consumption may cease to function well or at all as the health shocks become less individual and more covarying within the area. Even temporary shortfalls in consumption related to AIDS deaths may lead to irreversible effects on the health of young children along the lines noted above. Beyond the primary concern with avoiding catastrophic reductions in consumption, the implications for rural development and poverty reduction of illness and death from AIDS among working age adults are almost certainly very significant, but have yet to be assessed at the micro level.

On the supply side, health delivery systems in Africa are under-funded and suffer from well known misallocations. Primary care, preventative services, and rural areas receive too little funding relative to tertiary services and urban areas. In many countries in Africa decentralization of the health sector has been implemented, or is planning to be implemented, as a way to redirect resources to rural areas and primary care, where the returns are highest. (We discuss decentralization further in section 1.2.4.1). Increasing the role of the private sector in health service delivery is another potential route to improving quality and utilization rates of health care services. While relatively undeveloped in Africa — accounting for about 30 percent of all care (Castro-Leal et al. 1999) — the private sector is thought to provide better quality services. To some extent, of course, this is consistent with higher costs charged to consumers. However, through contracting with the public sector, private providers (and concomitant incentives for quality) can be use to provide subsidized care that reaches the poor. There is a great deal of scope for research and policy on health care strategies that link public and private sectors.

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