Health Economics

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Health seeking behaviour in the reform process for rural households: The case of Mwea division, Kirinyaga district, Kenya
(The African Economic Research Consortium, 1999-03) Ngugi, Rose
Cost sharing resulted in a drop in the use of public health facilities in Kenya. But, these facilities continued to take a high priority among the other alternatives when sickness befell. Shifts across the facilities indicated a search for health services that yielded utility equivalent to the fee charged, while demand for services across the alternative sources reflected complementarity in consumption. Several factors influenced the observed pattern: direct and indirect costs, income base, satisfaction with services received, and demand level in the household. As rational agents, users of health care services aimed to minimize costs and maximize their satisfaction.
The determinants of health care demand in Uganda: The case study of Lira District, Northern Uganda
(AERC, 2006-05-27) Jonathan J.A.O. Odwee; Francis Nathan Okurut; Asaf Adebua
The study investigated the price and non-price factors that affect health care demand in rural Uganda using household data from Lira district in northern Uganda, which is the poorest region. The government had introduced the user-fee scheme as a strategy for supplementing government budgets to improve health care delivery systems. The results suggested that the demand for government heath care services was negatively and significantly influenced by the user-fees and drug unavailability. A simulation analysis suggested that an increase in medical charges (user-fees) leads to a fall in demand for government health facilities but increases the demand for both private health facilities and self-medication. Controlling for drugs availability, the demand for government health facilities falls when drugs are not available while demand for private health facilities rises. The policy implication is that government should be able to put resources from things like debt relief to stocking the drugs in public health facilities while the internally generated tax revenues could be utilized to provide free health services especially to the poor. In the long run, the policy option of a social health insurance scheme may be explored.
Distribution Impact of Public Spending in Cameroon: The Case of Health Care
(AERC, 2008-05-07) Bernadette Dia Kamgnia
The study assessed Cameroonians’ participation in public health care services in order to grasp the distributional effects of those services. Three specific objectives are specified: determine the extent to which public spending on health care may constitute a targeted means for poverty reduction; identify the determinants of participation in health care services in general and in public services in particular; and propose alternative health care policies compatible with the government’s concern for poverty alleviation. In a benefit incidence analysis, it is shown that the benefits acquired from using publicly funded health care services are globally progressive. Integrated health care centres are chosen because of their nearness. Households appreciate the quality of services provided at the peripheral health care centres. Private health care is chosen because of the quality of the service, and people go to traditional healers or resort to self-medication because of the low cost. The majority of the considered factors – cost, nearness, revenue, education, age, gender and illness – had the expected sign and significantly affect the choice of health care providers. But for educated individuals who are employed in the formal sector, nearness and cost are the key variables in the design of health care policies.
Social Welfare and Demand for Health Care in the Urban Areas of Côte d’Ivoire
(AERC, 2008-07-02) Arsène Kouadio; Vincent Monsan; Mamad ou Gbongue
This paper analyses the relationship between the demand for health care and that for health insurance by the population of Côte d’Ivoire. A Poisson model is used to estimate the demand for health care and a multinomial logit model for estimating the demand for insurance. The data on which the research was based were taken from a sample of 2,040 households that were interviewed as part of a survey on Recours aux soins et dépenses de santé or PSA 92 (Health care use and health expenses, or PSA 92), which was carried out in 1992 in Yopougon, a working class neighbourhood of Abidjan. The results show that the length of the illness appears to be the factor that triggers the use of modern health care. They also indicate that employment and age are important factors in making decisions about which insurance to take. Extending the data collection system to the rural population, or generalizing it to the whole population, and gaining a better definition of the variables “state of health”, “consulting a health service”, “behaviour of the insured person and of the insurance company vis-à-vis health services” should be envisaged to refine the research. All this will lead to a better grasp of the problems of moral hazard and adverse selection in Côte d’Ivoire’s health system as a result of the minimizing costs of the implementation of the expected Universal Health Insurance (AMU)
Quality and Demand for Health Care in Rural Uganda: Evidence from 2002/03 Household Survey
(AERC, 2011-01) Kaija, Darlison; Okwi, Paul Okiira
Good health, as people know from experience, is a crucial part of well-being and socioeconomic development. From an economic viewpoint, improved health contributes to growth in many ways. It reduces production losses caused by worker illness; it permits the use of natural resources that were inaccessible due to diseases; it frees resources for alternative use, other than being spent on treating illness; and it promotes child development through increased school enrolment and better learning. This report provides quantitative evidence on the importance of individual, household, and community characteristics on individual care seeking decisions during periods of illness. The report uses a “flexible” multinomial choice model to determine the key factors behind the decisions to seek a particular type of treatment using data from the 2002/03 National Household Survey for Uganda. This kind of analysis is premised on a basic theoretical framework of utility maximization and household production of health. In addition, complementary data on quality of facilities and costs were collected from sampled health facilities in the four regions (Central, Northern, Western and Eastern) of Uganda. The results show the importance of age, gender, per capita consumption (income) and number of days sick as individual determinants of health seeking behaviour. Surprisingly, education does not appear important in choice of health care in rural Uganda. The quality characteristics measured by structural indicators such as electricity and price characteristics stand out as important determinants of choice. The location also has an effect on choice of the type of health care provider. From a policy perspective, policies aimed at providing energy from gas and generators to improve quality, increasing incomes and price/cost reduction will have substantial outcomes on the demand for health care.
A Comparative Analysis of the Determinants of Seeking Prenatal Health Care in Urban and Rural Areas of Togo
(AERC, 2013-07) Johnson, Ablamba; Issifou, Alima; Homevoh, Etsri
A country may have invested significantly in essential health facilities in order to supply goods and services related to reproductive health, but still see the demand for prenatal health care influenced by equally important economic and social factors. The aim of the present study was to identify the economic and social factors that would determine the probability of a pregnant woman choosing one type of prenatal health care over another and to specifically measure the effects of the variables of living standards on seeking this care. The study used a multinomial logit model to analyze data collected during the 2006 Multiple Indicators Cluster Survey (MICS-3) survey. From the main results, the following observations could be made: (i) pregnant women without formal education went for prenatal consultations less frequently than those with formal education; (ii) the higher the wealth index was for the household in which the pregnant woman lived, the more likely that she would seek prenatal care from trained medical staff; (iii) the pregnant woman’s level of formal education, her age, the size of the household she lived in, the household’s wealth index, the number of children below five years living in the household, the cost of prenatal consultations at public health facilities, and the quality of care these offered, were all found to have a statistically significant effect on the pregnant woman’s choice to seek prenatal care from a modern health facility or not.
Determinants of Neonatal and Under-five Mortality in Kenya: Do Antenatal and Skilled Delivery Care Services Matter?
(AERC, 2017-09) Machio, Phyllis Mumia
Declines in neonatal and under-five mortality in Kenya were much slower than what was required to meet the Millennium Development Goal (MDG) on childhood mortality. Therefore, while Tanzania and Uganda met and surpassed their MDG targets, Kenya did not. Effort is now directed at ending all preventable deaths among neonates and under-fives, as envisaged in the Sustainable Development Goals (SDGs). Most childhood mortality can be prevented by ensuring that women have access to quality care during conception, pregnancy, intra-partum and in the post-natal period. This study investigated the effects of antenatal and skilled delivery care services on neonatal and under-five mortality in Kenya using pooled Kenya demographic and health survey data for 1998, 2003, 2008/2009 and 2014. Two-stage residual inclusion estimation procedure and the control function approach were used to test and control for potential endogeneity of antenatal and skilled delivery care and for potential unobserved heterogeneity. The study unveiled presence of both endogeneity and unobserved heterogeneity and found that failure to control these would have biased downwards the effects of antenatal and skilled delivery care services on childhood mortality. Findings indicated that adequate use of antenatal care services reduced risk of neonatal and under-five mortality by 2.4 and 4.2 percentage points respectively. Similarly, use of skilled delivery care services was associated with reduced risk of neonatal and under-five mortality by 0.3 and 1.8 percentage points respectively. Increasing coverage of women using adequate antenatal care services and skilled delivery care services can reduce the risk of neonatal and under-five mortality in Kenya. Policies that promote use of these services such as promoting women education and reducing average distances to health facilities should be promoted.
Analysis of the Technical Efficiency of Public Hospitals in Togo: A non-Parametric Approach
(AERC, 2018-01-02) Atake, Esso-Hanam
Most health facilities in Togo are poorly equipped. Consequently, the rate of post-natal consultation remains low and varies between 9.5% and 39.4%. Barely half of all deliveries (47.1%) take place in health facilities. In this study, we analysed technical efficiency scores of 139 Togolese public hospitals over the period 2008–2010, and then identified the determinants of this efficiency. Double bootstrap data envelopment analysis was used to draw consistent inferences. We first estimated bootstrapped efficiency scores. Then, bootstrapped truncated regression was used to identify the determinants of public hospitals efficiency. The results indicate that, on average, small-sized hospitals (periphery care units) investigated, had the highest efficiency scores. The University Teaching Hospitals and regional hospitals which have significant material, human and financial resources were associated with lower efficiency. The most significant and robust factors of technical efficiency are per capita income, competition, hospital’s balance, types of contract, and medical density. We found that income constraint and accessibility to health facilities are obstacles to efficiency. According to our results, we can infer that non-competitive public provision of health services is likely to be inefficient. Another important practical implication is that Togo must vigorously promote reform of the management system in public hospitals which regards corporate quality governance as the core. We hypothesize that if subsidies are allocated according to performance, they can positively affect efficiency. Policy makers should consider tying grant revenues to performance indicators.
Demand For Improved Water Quality: An Analysis of Averting Actions by Cameroonian Households
(African Economic Research consortium, 2018-01-04) Armand, Totouom Fotue Luc; Tagne, Sostaine Romuald Foueka; Poufoun, Jonas Ngouhouo
This study aims to investigate the demand for improved water quality in Cameroon by analysing the determinants of household averting actions to cope with unsafe drinking water. The study is based on primary data collected in 2013 from a sample of 789 households in the cities of Douala and Yaoundé, Cameroon. The econometric approach used in the study is the same as that of McConnell and Rosado (2000). The main findings of the estimated model are: the decision to adjust water quality decreases when income decreases, when there are no children under five in the household, and when the quality of the water consumed is not a concern. Also, the probability of adopting a given avoidance measure decreases with its cost of adoption and increases with its level of efficiency (measured by people’s favourable opinion on the quality of water after adjustment). Implications for public policies are discussed in the paper.
Corruption and Users in Douala-Cameroon Public Hospitals: An Evaluation of Determinants
(African Economic Research consortium, 2018-01-30) Bayemi, Oscar
This paper examines the factors that determine an individual's exposure to corruption in public hospitals in Douala, Cameroon. A survey of 407 users who attended these hospitals revealed corruption to be prevalent in services that are offered in sections such as reception, hospitalization and the drugstore. Estimates obtained through odds ratios reveal that in general, the determinants of a user’s exposure to corruption vary from one hospital to another and even from one service to another. For example, in the hospitalization service of the General hospital, these determinants are: Income above 250,000 FCFA, gender (male), educational level below university, and age over 40 years. On the contrary, in the hospitalization service of the Bonassama hospital, it is an income below 250,000 FCFA, woman, educational level below university, and age below 40 years. However, the educational level below university appears as a common determinant of corruption in all services and almost all hospitals. This allowed us to propose a typology of hospitals based on the factors behind this phenomenon.
Socio-economic Status and Health Expenditure of Households in Benin
(African Economic Research consortium, 2018-03-30) Hilaire, Houeninvo Gbodja
This paper studies the determinants of household health expenditure. It focuses on catastrophic health expenditure using the recent year 2009 household survey for Benin, and uses the Heckman approach to control for potential selectivity bias. We find that household income, level of education and household size have positive and significant effects on the magnitude of health expenditure. Furthermore, health care is a necessary good for households in Benin. Households comprising both children and elderly persons, the size of the household and living in a rural area are major risk factors for catastrophic health expenditure. In addition, catastrophic health expenditure has a significant and negative effect on the budget allocated to education and food. These results have some policy implications in terms of ensuring better access to health care. For instance, as health care is a necessary good in Benin, the Ministry of Health could subsidize public health facilities to enable access for the poor.
Health Aid and Child Mortality in Developing Countries: Accounting for Transmission Mechanisms
(African Economic Research consortium, 2018-08-30) Mallaye, Douzounet; . Yogo, Thierry U
Using a sample of 94 developing countries over the period 1990-2011, this paper examines both the direct and indirect effect of health aid on child mortality. We test for this relationship using a dynamic panel data model. The results reveal that health aid decreases infant mortality in developing countries. More specifically, a 1% increase in health aid per capita leads to a 0.047% decrease in child mortality over five years. This effect operates mainly through the improvement of primary education completion rate of female and governance. However, the magnitude of the effects is too small if developing countries would like to achieve Millenium Development Goals (MDGs through) additional health aid. The policy implications of the paper are further discussed.
Determinants of Child Malnutrition in Mauritania
(African Economic Research consortium, 2020-01-04) Ly, Yahya Abou
The empirical context of this research is in an environment where malnutrition is a real public health concern. The objective of this study was to identify the determinants of the nutritional state of children under the age of five years in Mauritania. Using data obtained from multiple indicators cluster surveys (MICS) in Mauritania in 2007 and 2015, we undertook fixed-effects clusters techniques to control for unobserved heterogeneity. The empirical results demonstrate that the age and sex of a child, level of education of the mother, the standards of living of the household, the area of residence, the availability and use of health care services and access to drinking water are all important factors for the good health of children in Mauritania. These findings suggests improvements in nutritional health, for example, by education of girls until completion of secondary school; an improvement in the conditions of households that are headed by women and an expansion in the coverage rate of multi-purpose health centres.
Birth Order and Demand for Immunization for Children under the Age of Five in Cameroon
(AERC, 2020-01-07) Rodrigue, Nda’chi Deffo; Vincent de Paul, Negou Kamga
Despite free basic vaccines administered by the Expanded Programme on Immunization (EPI), there is still a fairly high death rate of children aged 0-5 worldwide due to vaccine-preventable diseases. Sub-Saharan Africa is the most affected region due to low levels of vaccination. This study analyses the effect of birth order on the immunization status of children in Cameroon, considering the contribution of cultural, economic and community factors. To do this, it uses data from the Demographic and Health Surveys of 1991, 1998, 2004 and 2011 produced by the National Institute of Statistics with the support of UNFPA, UNICEF, the World Bank and USAID. The EPI module was administered to 3,350, 2,317, 8,125 and 25,524 children under five in 1991, 1998, 2004 and 2011, respectively. The multinomial probit model makes it possible to find that birth order has a negative and highly significant effect on the full and timely immunization of children under five and the impact increases with birth order. Moreover, the impact of birth order increases after adjusting for cultural factors. This increase indicates that, beyond the effect of birth order, cultural factors are at the root of prejudices leading to the abandonment of children. Considering children under two years of age, and vaccines taken during the first four months, the corresponding birth order effect points to the benefits of routine immunization and response campaigns in promoting immunization of children under five.
Analysis of Health Care Utilization in Côte d'Ivoire
(AERC, 2020-04-27) Cisse, Alimatou
Health constitutes a sufficiently solid entrance to reduce poverty and promote economic growth. Yet, in most African countries and particularly in Côte d’Ivoire, the populations’ state of health has seen a real deterioration over the last decade. This study seeks to explain this decline by determining the explanatory factors of recourse to health care providers. To this end, the multinomial logit model is used. The theoretical basis for this analysis is the maximization of a utility function to produce health. The data to test the study’s hypotheses came from the survey of the National Institute of Statistics, entitled Social Dimension of Structural Adjustment, carried out in April 1993. The results show that the education level of the household head, the household’s income, the price of medication, and the time to reach the health care provider (as a proxy for the distance to a health care provider) determine the choice for a specific health care provider. The level of education and the income positively influence this choice, while the cost of medication and the time to provider (time to reach the health provider) negatively influence the choice of health care provider.
Role of Maternal Education and Prenatal Care on Child Health in Cameroon
(AERC, 2020-07-27) Josiane, Saleu Feumeni
Child health is considered a key indicator of economic development and quality of life in developing countries. In this context, this study attempts to empirically analyse the role of maternal education and prenatal care on child heath at birth in Cameroon using the databases of the Demographic and Health Surveys of Cameroon of 2004 and 2011 (EDSC) collected by the National Institute of Statistics of Cameroon. We follow a two-step estimation procedure. In the first step, a probit for participation and a multinomial probit for prenatal provider choice, and a negative binomial model of the number of prenatal visits by mothers were estimated. In the second step, a structural birth weight equation correcting for sample selection and prenatal healthcare provider choice biases was estimated. The results of the estimates show that the mother's level of education, the choice of different health professionals and the number of prenatal visits play an important role in the health of the child. In particular, the probability of consulting doctor increases with maternal education and consulting a doctor correlates positively with birth weight
Household Economic Wellbeing and Child Health in the Democratic Republic of Congo
(African Economic Research consortium, 2020-12-03) Kasiwa, Janvier Mwisha-
Health is both a direct component of human well-being and a form of human capital that increases an individual’s capabilities and opportunities to generate income, and reduces vulnerability. It is argued that these two views are complementary and both can be used to justify increased investment in health in developing countries. Therefore, investment in child health constitutes a potential mechanism to end the intergenerational transmission of poverty. This paper examines the empirical impact of household economic well-being on child health, and the gender differences in effects using the Democratic Republic of the Congo (DR Congo, or DRC) Demographic and Health Survey conducted in 2014. A series of econometric tools are used; the control function approach appears to be the most appropriate strategy as it simultaneously removes structural parameters from endogeneity, the sample selection and heterogeneity of the unobservable variables. Results suggest a significant positive effect of household economic well-being on child health. However, the magnitude of the effect varies by gender of household head; children from households headed by males appear healthier compared to those from female-headed households. In the context of DR Congo, female-headed households often have a single parent, therefore, the economic well-being effect on child health in the male sub-sample can be considered to include the unobserved contribution of women. These results have implications for public interventions that enable women to participate in paid labour market activities as a means of improving household economic well-being, which in turn could improve child health.
Breastfeeding and Child Health in Uganda
(African Economic Research consortium, 2020-12-10) Bbaale, Edward
The study set out to estimate the effect of breastfeeding on child mortality and stunting. We used nationally representative Uganda Demographic and Health Survey (UDHS) of 2011 merged with the community section of the Uganda National Household Survey (UNHS) of 2012/13 to include community variables, such as distance to the health facility, that are potential instrumental variables. We used various techniques: ordinary least squares (OLS), Instrumental Variables (IV) approach and control function during the analysis. We found that breastfeeding reduced child mortality but was weakly associated with child stunting. Just as previous literature documents, the OLS estimate of the coefficient on breastfeeding was biased downwards compared to the IV and control function estimates. Health knowledge was important in influencing child mortality. Government efforts towards sensitizing citizens about the importance of breastfeeding should be strengthened. Additionally, government needs to prioritize dissemination of health knowledge to women of reproductive age who are no longer in school. Furthermore, school curricula should be improved to include communication of health knowledge to students during early education to mitigate poor child health outcomes for future generations.
Effects of Maternal Immunization on Birth Weight in Rural Cameroon
(African Economic Research consortium, 2021-01-20) Tambi, Mbu Daniel
This study investigated the effects of tetanus immunization on birth weight in rural Cameroon. Specifically, the study sought to: examine the determinants of mother’s immunization in Cameroon; assess the impact of mother tetanus immunization on child health production; examine how birth weight production function can be estimated by area of residence and household income; and propose policy implications on the basis of the findings. To tackle these objectives, the study used the ordinary least square (OLS) model. Empirical results were based on pooled data from the 2004 and 2011 demographic and health surveys (DHS) collected by the government’s statistics office. The results showed that maternal immunization during pregnancy was associated positively with birth weight, overall in rural and urban areas, and among poor and non-poor households. Other variables that were significantly associated with birth weight in rural Cameroon were: mother’s education in years of schooling, mother’s age, father’s age, first twin birth, male child birth, nonpoor, interaction of mother’s and father’s education and urban household residence. These results have implications for addressing child health concerns in the ongoing process of growth, employment and poverty reduction in terms of improving access to antenatal care and family planning in rural Cameroon.
Inequality of Health Opportunity Among Children Aged under 5 Years in Togo
(African Economic Research consortium, 2021-01-20) Sanoussi, Yacobou
The literature on public health shows that health status of children and their nutritional status influence their health and well-being in adulthood. Therefore, policies to improve the health status of a population must consider children’s health and take into account all the elements that can influence child health status. The inequality of opportunity (lack) and efforts (behaviour in relation to health) towards improvement of the health status and mortality of individuals raises the issue of unequal distribution of health in a given population. However, this subject is relatively less discussed in the literature on public health in developing countries, including Togo. By focusing on health inequalities of opportunity, we analyze their evolution and contribution to children's health (as measured by the standardized height) in Togo using data from Demographic and Health Survey (DHS) 1998 and 2013. The objective of this study is to measure and compare the importance of the contribution of inequality of opportunity (from differences in life circumstances) to total health inequality of children under 5 years. Because children are not accountable for any part of their health outcomes by age five, total inequality is decomposed into a part due to inequality of opportunity (observed variables) and another part due to other unobserved factors (inequality within opportunities) after controlling for the inequality from random variations in the health status of children or genetic variations from a reference population (healthy population). The methodological approach is based on decomposable general entropy measures such as the Theil-T index to measure total inequality after dealing with natural variation in the height of children. This inequality is decomposed into within- opportunities inequality and the between-opportunity (inequality of opportunity) by using a non-parametric approach after building the opportunity groups with the selected circumstances variables. The results show that the total health inequality experienced a decline between 1998 and 2013 from 0.65 to 0.26 in 15 years. This decrease is also observed for the inequality of opportunity and in within opportunity. The contribution from inequality of opportunity (inter-group inequality of opportunity) has increased over the period 1998-2013. It increased from 0.14 to 0.18, respectively, in 1998 and 2013. These relatively low levels of inequality of opportunity are interpreted as an estimate of the lower bound of the set of variables in circumstances that may influence the children's health. In view of the results, the increase in the level of inequality of health opportunities comes more from the increase in the contribution of the unfavourable opportunities group.

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