Transcript Poverty and Undernutrition

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Specific topics of interest are:
◦ Infant and child mortality
◦ Adult mortality
◦ Infectious diseases
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 – new interest in Neglected Tropical Diseases
Inherited diseases
Serious injuries
Health and Pregnancy/Childbirth
Nutritional Status of both children and adults
Mental Health
 New interest in research related to child mental health
from children left behind by parents who migrate to
work (China)
1.
2.
Almost ½ of low life expectancy is due to
high infant and child mortality.
Vaccinations to children and infants can
reduce infant mortality
• UNICEF and WHO had a huge campaign in
1980's and 1990's that did this, resulting in
much lower infant and child mortality rates.
(vaccines were measles, diphtheria, pertussis,
tetanus, polio)
• 45% of deaths are due to infectious diseases or
parasites in developing countries (5% in
developed countries)
3.
Oral rehydration therapy (ORT) dramatically
reduces deaths due to infant diarrhea.
Source: 1993 World Development Report
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Difference by income:
Distribution of causes of
death
Low Income
High Income
HIV/AIDs
3%
0%
Diarrhea
18%
1%
Measles
1%
0%
Malaria
13%
0%
Pneumonia
18%
3%
Prematurity
9%
22%
Birth asphyxia
8%
7%
Neonatal sepsis
6%
2%
Congenital anomalies
2%
23%
Other
18%
32%
Injury
3%
9%
Source: 2011 World Health Report
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Differences by income
Distribution of causes of
death
Low Income
High Income
Communicable
72%
7%
Non-communicable
18%
77%
Injuries
10%
15%
Source: 1993 World Development Report
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Observation: Technological developments in health
care are increasing. However - the cost of
providing some kinds of "high-tech" health care
can be very expensive.
Observation: Continuing problem that diseases
evolve to become resistant to treatments (e.g.
tuberculosis), and new diseases emerge (e.g. AIDS)
Reasons for Government Intervention (in terms of
economic theory)
1. Distributive: i.e. basic health care is a right
2. Externalities from communicable diseases
3. Other market imperfections, e.g. lack of markets for
health insurance
4. Lack of information on the part of many households
1.
2.
3.
Provision of public health services
◦ immunization campaigns, visits by health workers to
homes and schools, construction of sewage treatment
plants, reduce pollution, public education campaigns
Pricing policies
◦ subsidization of “essential” drugs and health services,
price controls on private providers, prices of all
services offered by government health facilities,
reducing distance to health facilities, prices of goods
that effect health - alcohol and tobacco
Research on new methods to treat health
problems (research is a public good).
◦ Most research is done in developed countries.
4.
5.
Policies that promote equitable economic
growth
Increase education, especially education of
women
Percentage reduction in child mortality,
relative to mother having no schooling:
Indonesia
Kenya
Morocco
Peru
Mother
has 4-6 years
schooling
Mother
has 7+ years
schooling
-35%
-31%
-45%
-39%
-65%
-53%
-64%
-72%
Source: 1993 World Development Report
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Goal 4: Reduce child mortality
◦ Target 4.A. Reduce by two-thirds, between 1990 and 2015,
the under-five mortality rate
 4.1 Under-five mortality rate
 4.2 Infant mortality rate
 4.3 Proportion of 1 year-old children immunized against
measles
http://www.mdgmonitor.org/index.cfm
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Goal 4: Reduce child
mortality
◦ Target 4.A. Reduce by
two-thirds, between 1990
and 2015, the under-five
mortality rate
 4.1 Under-five mortality
rate
 4.2 Infant mortality rate
 4.3 Proportion of 1 yearold children immunized
against measles
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Goal 4: Reduce child
mortality
◦ Target 4.A. Reduce by
two-thirds, between 1990
and 2015, the under-five
mortality rate
 4.1 Under-five mortality
rate
 4.2 Infant mortality rate
 4.3 Proportion of 1 yearold children immunized
against measles
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Goal 4: Reduce child
mortality
◦ Target 4.A. Reduce by
two-thirds, between 1990
and 2015, the under-five
mortality rate
 4.1 Under-five mortality
rate
 4.2 Infant mortality rate
 4.3 Proportion of 1 yearold children immunized
against measles
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Goal 4: Reduce child
mortality
◦ Target 4.A. Reduce by twothirds, between 1990 and
2015, the under-five mortality
rate
 4.1 Under-five mortality rate
 4.2 Infant mortality rate
 4.3 Proportion of 1 year-old
children immunized against
measles
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Goal 4: Reduce child mortality
◦ Target 4.A. Reduce by two-thirds, between 1990 and 2015,
the under-five mortality rate
 4.1 Under-five mortality rate
 4.2 Infant mortality rate
 4.3 Proportion of 1 year-old children immunized against
measles
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Goal 5: Improve maternal health
◦ Target 5.A. Reduce by three-quarters, between 1990 and
2015, the maternal mortality ratio
◦ 5.1 Maternal mortality ratio
◦ 5.2 Proportion of births attended by skilled health personnel
◦ Target 5.B: Achieve, by 2015, universal access to
reproductive health
 5.3 Contraceptive prevalence rate
 5.4 Adolescent birth rate
 5.5 Antenatal care coverage (at least one visit and at least four
visits)
 5.6 Unmet need for family planning
http://www.mdgmonitor.org/index.cfm
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Goal 5: Improve maternal
health
◦ Target 5.A. Reduce by threequarters, between 1990 and
2015, the maternal mortality
ratio
◦ 5.1 Maternal mortality ratio
◦ 5.2 Proportion of births
attended by skilled health
personnel

Goal 5: Improve maternal health
◦ Target 5.A. Reduce by three-quarters, between 1990 and
2015, the maternal mortality ratio
◦ 5.1 Maternal mortality ratio
◦ 5.2 Proportion of births attended by skilled health personnel
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Goal 5: Improve maternal
health
◦ Target 5.B: Achieve, by 2015,
universal access to
reproductive health
 5.3 Contraceptive prevalence
rate
 5.4 Adolescent birth rate
 5.5 Antenatal care coverage
(at least one visit and at least
four visits)
 5.6 Unmet need for family
planning
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Goal 5: Improve maternal
health
◦ Target 5.B: Achieve, by 2015,
universal access to reproductive
health
 5.3 Contraceptive prevalence rate
 5.4 Adolescent birth rate
 5.5 Antenatal care coverage (at
least one visit and at least four
visits)
 5.6 Unmet need for family
planning

Goal 6: Combat HIV/AIDS, malaria, and other diseases
◦ Target 6.A. Have halted by 2015 and begun to reverse the spread of
HIV/AIDS
◦ 6.1 HIV prevalence among population aged 15-24 years
◦ 6.2 Condom use at last high-risk sex
◦ 6.3 Proportion of population aged 15-24 years with comprehensive correct
knowledge of HIV/AIDS
◦ 6.4 Ratio of school attendance of orphans to school attendance of nonorphans aged 10-14 years
◦ Target 6.B Achieve, by 2010, universal access to treatment for
HIV/AIDS for all those who need it
◦ 6.5 Proportion of population with advanced HIV infection with access to
antiretroviral drugs
◦ Target 6.C. Have halted by 2015 and begun to reverse the incidence
of malaria and other major diseases
◦ 6.6 Incidence and death rates associated with malaria
◦ 6.7 Proportion of children under 5 sleeping under insecticide-treated
bednets
◦ 6.8 Proportion of children under 5 with fever who are treated with
appropriate anti-malarial drugs
◦ 6.9 Incidence, prevalence and death rates associated with tuberculosis
◦ 6.10 Proportion of tuberculosis cases detected and cured under directly
observed treatment short course
http://www.mdgmonitor.org/index.cfm
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Goal 6: Combat
HIV/AIDS, malaria, and
other diseases
◦ Target 6.1. Have halted by
2015 and begun to
reverse the spread of
HIV/AIDS
◦ 6.1 HIV prevalence among
population aged 15-24
years
◦ 6.2 Condom use at last
high-risk sex
◦ 6.3 Proportion of
population aged 15-24
years with comprehensive
correct knowledge of
HIV/AIDS
◦ 6.4 Ratio of school
attendance of orphans to
school attendance of nonorphans aged 10-14 years
http://ddp-ext.worldbank.org/ext/GMIS/home.do?siteId=2
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Goal 6: Combat HIV/AIDS, malaria, and other
diseases
◦ Target 6.1. Have halted by 2015 and begun to reverse the
spread of HIV/AIDS
◦ 6.1 HIV prevalence among population aged 15-24 years
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Goal 6: Combat
HIV/AIDS, malaria, and
other diseases
◦ Target 6.1. Have halted by
2015 and begun to
reverse the spread of
HIV/AIDS
◦ 6.1 HIV prevalence among
population aged 15-24
years
◦ 6.2 Condom use at last
high-risk sex
◦ 6.3 Proportion of
population aged 15-24
years with comprehensive
correct knowledge of
HIV/AIDS
◦ 6.4 Ratio of school
attendance of orphans to
school attendance of nonorphans aged 10-14 years
http://ddp-ext.worldbank.org/ext/GMIS/home.do?siteId=2
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Goal 6: Combat
HIV/AIDS, malaria, and
other diseases
◦ Target 6.B Achieve, by
2010, universal access to
treatment for HIV/AIDS for
all those who need it
◦ 6.5 Proportion of
population with advanced
HIV infection with access to
antiretroviral drugs
http://ddp-ext.worldbank.org/ext/GMIS/home.do?siteId=2

Goal 6: Combat
HIV/AIDS, malaria, and
other diseases
◦ Target 6.B Achieve, by
2010, universal access to
treatment for HIV/AIDS for
all those who need it
◦ 6.5 Proportion of
population with advanced
HIV infection with access to
antiretroviral drugs
http://ddp-ext.worldbank.org/ext/GMIS/home.do?siteId=2

Goal 6: Combat HIV/AIDS, malaria, and other
diseases
◦ Target 6.C. Have halted by 2015 and begun to reverse the
incidence of malaria and other major diseases
◦ 6.6 Incidence and death rates associated with malaria
◦ 6.7 Proportion of children under 5 sleeping under insecticidetreated bednets
◦ 6.8 Proportion of children under 5 with fever who are treated with
appropriate anti-malarial drugs
◦ 6.9 Incidence, prevalence and death rates associated with
tuberculosis
◦ 6.10 Proportion of tuberculosis cases detected and cured under
directly observed treatment short course
http://ddp-ext.worldbank.org/ext/GMIS/home.do?siteId=2
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http://ddp-ext.worldbank.org/ext/GMIS/home.do?siteId=2

Goal 6: Combat
HIV/AIDS, malaria, and
other diseases
◦ Target 6.C. Have halted by
2015 and begun to reverse
the incidence of malaria and
other major diseases
◦ 6.9 Incidence, prevalence and
death rates associated with
tuberculosis
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Goal 7: Ensure environmental sustainability
◦ Target 7.C. Halve, by 2015, the proportion of people
without sustainable access to safe drinking water and basic
sanitation
 7.8 Proportion of population using an improved drinking water source
 7.9 Proportion of population using an improved sanitation facility
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Goal 7: Ensure
environmental
sustainability
◦ Target 7.C. Halve, by 2015,
the proportion of people
without sustainable access to
safe drinking water and basic
sanitation
 7.8 Proportion of population using
an improved drinking water
source
 7.9 Proportion of population using
an improved sanitation facility
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Goal 7: Ensure environmental sustainability
◦ Target 7.C. Halve, by 2015, the proportion of people
without sustainable access to safe drinking water and basic
sanitation
 7.8 Proportion of population using an improved drinking water source
 7.9 Proportion of population using an improved sanitation facility
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Goal 7: Ensure environmental sustainability
◦ Target 7.C. Halve, by 2015, the proportion of people
without sustainable access to safe drinking water and basic
sanitation
 7.8 Proportion of population using an improved drinking water source
 7.9 Proportion of population using an improved sanitation facility

Child health-education linkages (2 studies)
1. Martorell, Habricht and Rivera (1995) INCAP nutritional
project in Guatemala.
◦ Basics: randomly chosen 4 villages were randomly assigned
into 2 groups
 Group 1 (2 villages): children and expecting moms got a high
energy/high-protein drink called "Atole“
 children received a low energy/low protein drink called "Fresco".
◦ Results: After a decade of following the children
 children in Atole villages showed height/weight gains, greater
work capacity (especially among boys) and gains in some
cognitive measures that are likely to be linked to school
performance
 this was one of the most convincing studies to date that
childhood nutrition and health affect subsequent life outcomes.

Child health-education linkages (2 studies)
2. Miguel and Kremer (2004) “Worms and Schooling in Rural
Kenya
◦ Evaluated the Primary School Deworming Project (PSDP) in Busia,
Kenya on education
◦ Basics: 75 schools with 32,565 primary students (7-17 years old)
 90% of students were infected with helminths
 Schools were randomly divided into 3 groups of 25 school
Group 1
Group 2
1998
treatment
1999
treatment
treatment
2000
treatment
treatment
2001
treatment
treatment
Group 3
treatment
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Child health-education linkages (2 studies)
2. Miguel and Kremer (2004) “Worms and Schooling in Rural
Kenya
◦ Results:
◦ treatment schools received ⇓in helminth infections, ⇓ in kids
reporting being sick, ⇑ in HAZ scores, ⇓ in anemia.
◦ ⇓ in absenteeism and increase in school participation among
youngest primary school children (grade 4 and below).
◦ deworming ⇓ worm burden and ⇑ school participation among
untreated children in the treatment schools and among children in
neighboring primary schools
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Child health-education linkages (2 studies)
2. Miguel and Kremer (2004) “Worms and Schooling in Rural
Kenya
◦ Points
 failure to take into account these externalities into account
would lead one to substantially underestimate the cost
effectiveness of deworming
 As a result of this study: most LDCs can receive donations of
deworming medications for all (cost os $.02/pill 1-2x per year).
◦ However: limited results on deworming effects on
academic/cognitive test scores
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Parent health-education linkages (4 studies)
1. Case, Paxson and Ableidinger (2002): 10 SSA
countries between 1992-2000 to estimate the
impact of parent death on school enrollment.
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
Find that orphans are less likely to be enrolled in school
than non-orphans.
Orphans are more likely to stay with distant relatives
who may have less genetic incentives to care for these
children
2. Gertler, Levine and Ames (2004): use panel data
in Indonesia in the 1990s.

Find that parent death during past 12 months leads to a
doubling of probability that child drops out of school
that year.
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Parent health-education linkages (4 studies)
3. Ainsworth, Beegle and Koda (2002): Study
children in northwestern Tanzania
Find that school enrollment is unaffected by parent
death for non-poor households, whereas for poor
households they find that enrollment is delayed for
younger children and unaffected by older children.
Why mixed results?? 2 theories
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when the local orphan rates surpass a critical level, the
insurance networks breakdown.
it is possible that HIV/AIDs victims were somewhat better
off (income wise) because they worked as: truckers,
soldiers, teachers and prostitutes - relatively affluent jobs.
Thus negative effects of death may be obscured...
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Parent health-education linkages (4 studies)
4.
Evans and Miguel (2003): Kenya deworming dataset, look only at
kids whose parents were alive in 1998 and compare those
children whose parents died during 1998-2002 with those that
did not die.
Findings:
◦
parent death has a large effect on school participation rate, it does not
matter which parent dies
◦
Participation rates drop sharply the year of the death and continue to
fall for up to 3 years.
◦
the magnitude of the effect is smaller than the magnitude of eliminating
one worm infection a year
◦
the effect of parent death is similar to the estimated impact of several
measures of poverty (households without latrines/toilets have similar
participation rates)
◦
children from poorest households have greatest reduction in
participation rates
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Why is there little demand for health care among
the poor? Visit: Udaipur District in western India
◦ Rural, very poor village:
40% below the official poverty line
 46% males illiterate & 11% females illiterate
 21% have electricity
◦ Health status: most had very low BMI
 80% were anemic
 work functioning was poor (>30% could not walk 5k, draw water or
work in the fields.)
◦ People seemed worried about their health
 See doctor about 0.5 visits per month per adult
 7% of personal consumption expenditures is on heath 60% of visits are
to private doctor
 20% to public (government) doctor
 20% to bhopas (traditional healer)
 Poorest 1/3 most likely to see bhopa and richest 1/3 most likely to
see private doctor.
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Why don’t they see public doctors?
◦ Public (gov) doctors are closest to village, more qualified to
treat and cheaper. Why little demand?
◦ Supply side problems
 the public facility is closed more than 1/2 of the time during
regular hours and nurses don't show up to work
◦ Demand side problems:
 private doctors pander to what people want (medicine, shot or a
drip).
 Public doctors are said to provide less treatment and less
injectables
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Why don’t the poor see public doctors?
◦ When do the poor see doctors?
 fever, diarrhea, vomiting, upper abdominal pain (acute conditions that
are likely to be self-limiting)
◦ When do they not seek treatment?
*
 weakness, backache, pain during urination, hearing loss, chest pain,
memory loss, weight loss (these are chronic conditions that are often
life-threatening)
◦ When do they see a bhopa?
 chronic, potentially life-threatening conditions.
 Why? Perhaps because the Bhopa provides some emotional support and
comfort whenthey don't expect to get well.
◦ Point:
 The poor may spend money on the wrong conditions.
 The poor get treatment, but incorrectly (lots of injections, antibiotics
and steroids).
 Since health care providers really might not have resources help the
chronic conditions, the poor seek providers to get comfort about doing
some thing about acute conditions.
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1.
Policy Research Question: What do we gain from supply side
intervention (will demand follow?) Or what do we gain from
demand side intervention?
Two studies:
Problem of non- attendance of government nurses. There
was no incentive to come to work because no one monitors
them. Organization (Seva Mandir) proposed to monitor.
Intervention: a program to required monitoring of nurse attendance at
public health facilities (treatment facilities).
◦
Result: In the first 6 months, the results showed that the program was
initially quite effective; the rate of presence increased from 25% to 40%.
Result: Monitoring had no effect on demand for services

Perhaps change is slow
◦
Result: program failed after 6 months (system did not work well
because nurses protested... other internal problems).
◦
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2.
Policy Research Question: What do we gain from supply side
intervention (will demand follow?) Or what do we gain from
demand side intervention?
Two studies:
Problem of lack of child immunizations. A baseline study
revealed only 2.63% of children between ages 1-5 were fully
immunized. Also 57.7% never received any vaccines.
◦
◦
Intervention: To increase parent demand for vaccines, a
program gave 1 kg of dal (dried lentils, peas or beans) for each
immunization and set of plates for completing immunization.
Result: It worked, affecting demand was easier in this case and
might provide a basis for affecting supply.
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We question again: Why is there a low demand for health? In
particular, a low demand for preventative health care?
There exist technologies that are known to be effective and
cheap ways to promote good health
◦ Bed nets for malaria, immunization, breast feeding, ORS (oral rehydration
salts), bleach for water
◦ Further studies have shown that a child not exposed to malaria in
Childhood would have an income 50% higher for all their life-time than a
child exposed to malaria

Investments in malaria control measures seem highly cost
effective
◦ Why are the poor not spending on preventative health care?

Why are the poor not spending on preventative health care?
◦ Is it that people really don't care about their health care?
 They do care, recall in the Udaipur survey they spent 7% per
month on health care.
 Most of this was spent to cure (not to prevent)
◦ Is it that governments are to blame?
 To some degree yes.
 Nurses are often absent
 Governments doctors and nurses do not treat patient very
well: 3 minutes, 3 questions, 3 medicines!
 When services are good, people do not always get them: for
example in the immunization camps, only 12% of people got
all the shots: there is something about demand, not only
about supply!
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2 Problems with demand for preventative care
1. It is difficult for the poor to know what works
 For example: many diseases are ‘self-limiting’. They get better on their own after
being worst.
 Thus if you believe you need a shot (and can get a doctor to give you one) and you
eventually get better. Tendency to attribute the health to a shot, when really it
would have gotten better on its own.
 Tendency to overmedicate! But that is not what really works!
2. Benefits are in the future and the cost is now.
 With Preventative care, you are taking action (vaccines) to prevent
something from happening….a long time after the fact. For many
drawing the link is difficult.
 Human tend to put too much weight on the present, relative to the
entire future. Parents may intend every month that they will get the
immunization next month…. But something else comes up, and they
don't end up doing it.

1.
2.
3.
Policy: Large benefits from making things
easy/automatic for people:
Free Chlorine dispenser right where you collect your water
Small incentives for immunization/compulsory immunization
if you can pull it off
In many cases, the superficial cost benefit analysis gives you
the wrong answer.
◦ Charging a small amount may be counter-productive
◦ Giving people small incentives may save you money
4.
The role of learning and trust is key
◦ Because preventive care is hard to teach, need to maintain trust:
important for governments to chose their battles.