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7/21/2019 Teori Filmer

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Demand and supply interact to determine health and education outcomes

Health and education outcomes are determined by more than the availability and quality ofhealth care and schooling. Better nutrition helps children learn. Better refrigeration and

transport networks help keep medicines safe. Many factors determine outcomes on both thedemand and the supply side, linked at many levels. The demand for health and education isdetermined by individuals and households weighing the benefits and costs of their choices andthe constraints they face. The supply of services that affect health and education outcomes startswith global technological knowledge and goes all the way to whether teachers report for workand communities maintain water pumps (figure 1).

Figure 1 The determinants of demand and supply operate through many channels

Demand

Policies,

capacity,

technical

know-how,

politics

Global knowledge

National macro-,

sector-, and micro

level policies

Technical

capacity to

implement policies

Governance;

politics and

patronage;

political c apacity

and incentives to

implement policies

Health, nutrition, water

education sectors

- Service price, accessibility, and quality- Financing arrangements

Local context

- Local government and politics

- Community institutions

- Cultural norms (including exclusion:

gender, ethnic,)

- Social capital

Households and

individuals

Behaviors andactions

Health: preventive

care, care seeking for

illness, feeding

practices, sanitary

practices,

Education: enrollment

and school

participation, learning

outside of school,

Constraints

-Income

-Wealth

-Education and

knowledge

Outcomes

Child

mortality

Child

nutrition

School

completion /

Learning

achievement

Related sectors

- Availability, prices, and accessibility of:

food, energy, roads,

- Infrastructure

- Environment

Supply

Demand: individuals and households

Benefits and costsdetermine how much an individual invests in education or health. What arethe benefits? Higher levels of education and health are associated with higher productivityandhigher earnings. Investing in human capital is a way to get those returns. But the returns mightdiffer for different people, such as lower expected earnings for women or for ethnic minorities.In these cases one would expect different levels of investment: different desired levels ofschooling, for instance. A crucial element of demand is the degree to which individuals rather


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than society reap the rewards. Goods with large positive externalitiesin the extreme, publicgoodswill be demanded at less than the socially optimal level.

What are the costs? There are direct costs: user fees, transport costs, textbook fees, drug costs.Some of these can be borne by familiesthough not all families. Coping mechanisms for those

that cannot are often hard to use. For example, the lack of insurance markets can make it hard toabsorb the financial burden of sudden illness. Or the inability to borrow against future earningscan make it hard to get credit for schooling investments.

Indirect costs can also be large. For example, children often contribute to household income byworking inside or outside the home (looking after siblings, working on the family farm). Thevalue of this contribution is forgone if they spend substantial time in school.

The total cost of illness includes days of work lost recovering, seeking care, or looking after theill. Richer families can cope better with these costs, leading to a direct association betweenincome and outcomes. In addition, better health and education are often valued in themselves.

As incomes increase families demand more of them, again resulting in an association betweenincome and outcomes.

The production of health and educationdepends on the knowledge and practices of adults inhouseholds. This works through both the demand for human capital and the generation ofoutcomes. A review of four hygiene interventions in poor countries that targeted hand-washingfound 35 percent less diarrhea-related illness among children who received the interventions.1And factors in the home complement schooling: books and reading at home contribute toliteracy.

Investments in the human capital of children are sensitive to the allocation of power withinhouseholds: families in which the bargaining power of women is stronger tend to invest more inhealth and education. A study in Brazil found that demand for calories and protein was up to 10times more responsive to womens than mens income.

2 This result, strongest in societies that

proscribe womans roles, tends to affect girls more than boys.3

More generally, the roles and responsibilities of different household members can affect howinvestments are made. A woman in Egypt says: We face a calamity when my husband falls ill.Our life comes to a halt until he recovers.4 Her husbands earnings are crucial for sustaining thefamily. Since productivity is related to illness, households respond. In Bangladesh a studyfound that household members who engaged in more strenuous activities received morenutritious food.5 Daughters education might be less valuable to parents if sons look after themin old-age, so parents might be less willing to send girls to school.6

1Based on interventions in Burma, Bangladesh, India, and Indonesia (Huttley, Morris, and Pisani (1997)).2Thomas (1997).3See Quisumbing and Mallucio (2000).4World Health Organization and World Bank (2002).5Pitt, Rosenzweig, and Hassan (1990).6Reviews of the theory and empirical issues related to household decision making and demand are in Strauss andThomas (1995) and Strauss, Mwabu, and Beegle (2000).


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Demand: links between sectors at individual and household levels

Health and nutritional status directly affects a childs probability of school enrollment andcapacity to learn and succeed in school. Malnutrition among children was associated withsignificant delays in school enrollment in Ghana.7 Improving child health and nutrition at the

pre-primary level has long-term impacts on development. A study in the Philippines found that aone-standard-deviation increase in early-age child health increased subsequent test scores byabout a third of a standard deviation.

8

Improving the health and nutritional status of students positively affects school enrollment andattendance. A longitudinal study in Pakistan found that a one-third of a standard deviationincrease in child height increased school enrollment by 19 percentage points for girls and 4percentage points for boys.9 An evaluation of school-based mass treatment for deworming inrural Kenya found that student absenteeism fell by a quarterbut test scores did not appear to beaffected.10 Improving nutrition is not as simple as supplementary feeding at school: householdscan reallocate resources with the effect of sharing that food. A study in the Philippines found

no such sharing in general, but for a school snack program there was sharing in poorerfamilies.11

Parents educationhas intergenerational effects on the health, nutritional status, and schooling oftheir children. Adult female education is one of the most robust correlates of child mortality incross-national studies, even controlling for national income. Similarly, mothers education is astrong determinant of lower mortality at the household level, though the relationship weakenswhen other household and community socioeconomic characteristics are controlled for.

12 A

large part of this effect might not be general education but specific health knowledge, perhapsacquired using literacy and numeracy skills learned in school, as a study in Morocco found.13The effects can also be interspatial: a study in Peru found that the education of a mothersneighbors significantly increases the nutritional status of her children.14 Parents education issimilarly associated with the schooling of their children, though the magnitude of the effectandthe relative roles of mothers and fathers educationvary substantially across countries.

15

Access toand use ofsafe water, as well as adequate sanitation, have direct effects on healthstatus. Hand-washing is a powerful health practice, but it requires sufficient quantities of water.An eight-country study found that going from no improved water to optimal water wasassociated with a 6 percentage point reduction in the prevalence of diarrhea in children underthree years old (from a base of 25 percent) in households without sanitation. Nutritional status

7

Glewwe and Jacoby (1995).8Glewwe and King (2001).9Alderman and others (2001).10Miguel and Kremer (2001).11Jacoby (2002).12Desai and Alva (1998); Bonilla-Chacin and Hammer (2000).13Glewwe (1999).14Alderman, Hentschel, and Sabates (2001).15For examples in Conakry, Guinea, see Glick and Sahn (2000); in rural China see Brown and Park, forthcoming.;for a multi-country comparison see Filmer (2000).


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was likewise associated with access to improved water.16

But not all studies find strongassociations between water source and better health.17

The water source is only part of the story: in Bangladesh water accessed through tubewellsanimproved source is frequently contaminated with arsenic. One study found that arsenic

levels higher than the World Health Organizations maximum acceptable level are associatedwith twice the level of diarrhea in children under 6. Extremely high levels of arsenic areassociated with shorter stature among adolescents.

18

The same eight-country study mentioned above found that going to optimal sanitation fromnone was associated with a 10 percentage point drop in recent diarrhea in households with noimproved water source.19 As in education, there are spillover effects: sanitation practices at thecommunity level impact everyones health.20 In Peru the sanitation investments of a familysneighbors were associated with better nutritional status for that households children.

21

The use of safe energy sourcesaffects both health and education. Indoor air pollutionfrom

using dirty cooking and heating fuelshurts child health. One review of studies found that theprobability of respiratory illness, or even death, was between two and five times higher in houseswhere exposure to indoor air pollution was high.22 A study in Guatemala found birthweights 65grams lower among newborns of women who used wood as a domestic cooking fuel.

23 Coping

with the cold, in cold climates, affects health and imposes substantial direct and indirect costs onhouseholds.24 Education is affected as well: schools have to close when there is not enough heat,and it is hard to imagine that working on schoolwork at home is an option when indoortemperatures are below freezing.

Supply: global developments

At any given income, health and education outcomes have been improving (figure 2). Thedifference between 1990 and 2000, continuing a trend that goes back several decades, isinterpreted as advances in technologiesand leaps in knowledge about health and hygiene.

25

Predicted levels of child mortality declined more at higher incomes, although some debate thisfinding.26 The changes are large, even among poorer countries. At a national income of $600

16The model includes indicators of household assets, number of siblings, characteristics of parents (includingeducation), as well as child age and country dummy variables. The countries are Burundi, Ghana, Guatemala,Morocco, Sri Lanka, Togo, and Uganda (Esrey (1996)).17Alderman, Hentschel, and Sabates (2001); Lee, Rosenzweig, and Pitt (1997).18Hallman, background note for the WDR 2004.19The model includes indicators of household assets, number of siblings, characteristics of parents (including

education), as well as child age and country dummy variables. The countries are Burundi, Ghana, Guatemala,Morocco, Sri Lanka, Togo, and Uganda (Esrey (1996)).20Hughes, Lvovsky, and Dunleavy (2000).21Alderman, Hentschel, and Sabates (2001).22Bruce, Perez-Padilla, and Albalak (2000); also see discussion in Hughes, Lvovsky, and Dunleavy (2000).23After taking into account confounding socio-economic factors although the authors admit that this is perhapsimperfect (Boy, Bruce, and Delgado (2002)).24World Bank (2002).25Preston (1980).26Hill and Pebley (1989).


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per capita, the predicted child mortality fell from 100 per 1,000 births to 80a full 20 percentreductionbetween 1990 and 2000. If this association were sustained, major headway would bemade toward the Millennium Development Goal through these changes alone. Majorbreakthroughs in immunizations for malariaor even HIVcould have a huge impact onmortality at any given level of income.

Recent years have seen major developments in global fundingfor health and educationexpenditures. Debt relief through the Heavily Indebted Poor Countries initiative is tied toincreases in expenditures on these sectors. New assistance, delivered through multisectoralproducts, such as Poverty Reduction Support Credits, requires explicit strategies for humandevelopment investments. Global funds for health and the Fast-Track Initiative for educationare international pledges to support initiatives in the sectors.27 Easing financial constraints goeshand-in-hand with using resources effectively to support services that work for poor people.

Figure 2 Mortality at a given level of national income has been declining

Changes over time in the association between GDP per capita and child mortality

1

2

3

4

5

6

4 5 6 7 8 9 10 11

GDP per capita (1995 US$ log)

Under-5mortality(per1000log)

1990

2000

Sources: GDP per capita data from World Development Indicators database. Under-5 Mortality from Unicef(2002).Note: Lines show outcome as predicted by a non-linear function of GDP per capita.

Supply: national resources`

National incomeis strongly associated with child mortality and primary school completion.Income and health and education outcomes build off of each other. More income leads to betterhuman development outcomes, and better health and education can lead to increased productivityand better incomes. Studies that have tried to disentangle these relationships typically findincome to be a robust and strong determinant of outcomes.

27See Chapter 11.


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National endowments are also a strong determinant. Geography and climate sometimes make ittougher to overcome health problems. For example, areas conducive to mosquito survival havegreat difficulty in combating malariaand widely dispersed populations are difficult to servethrough traditional school systems.

The performance of public expenditurein producing outcomes varies substantially acrosscountries. There are large differences in achievements at similar levels of expenditure andsimilar achievements with very large differences in expendituresconditional on income.Spending more through the public sector is not always associated with improved outcomes. Thisis not to say that spending cannot be helpfulbut the way resources are used is crucial to theireffectiveness.

Supply: political, economic, and policy context

Governanceaffects the efficiency of expenditures: in corrupt settings money that is ostensiblyearmarked for improving human development outcomes is diverted. Staffs ostensibly delivering

services do not. But the effects of poor governance can be deeper. Famines are caused as muchby human factors as by nature.28

And the repercussions run across national borders. Forexample, a drought combined with misguided policies and bad governance in Zimbabwe resultedin a regional food shortage.

Managing public expenditurescan be a critical link in ensuring that allocated expenditures getput to uses that improve outcomes. Cash budgeting in Zambia led to unpredictable socialservice spending and deep cuts in spending on rural infrastructure.

29

Conflictleaves long-lived scars on health and education. Children in wartorn countries are hardto find, hard to get into school, and hard to keep in school. During Sierra Leones recent civilwar, tens of thousands of children attended primary school but hundreds of thousands did not.30Wars, including civil wars, lead to lost generations of undernourished and undereducatedchildren. These deficiencies are difficultif not impossibleto make up for. Out of school fora long time, it is hard to return. And bad health and poor nutrition at an early age affects childrenthroughout their lives.

Periods of national economic and social crisiscan result in bad health and education outcomes.This is clear in Russias recent history: adult mortality has increased dramatically over the past10 years. Sustained economic depression can severely compromise childrens health, withcascading effects on subsequent development and learning. The evidence of shorter termeconomic crises is more mixed. In middle-income environments school enrollments mightincrease as the opportunity cost of time of young people falls.31 Even in Indonesia, a relativelypoor country, the deep economic and social crisis of the late 1990s had smaller impacts onoutcomes than initially feared. This was partly because broad social safety nets were rapidly putin place.

28For discussions see Sen (1981) and Ravallion (1996).29Dinh, Adugna, and Myers (2002).30Sommers (2002).31Schady (2002).


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Supply: the local context of government and communities

Decentralizationcan be a powerful tool for moving decisionmaking closer to those affected by it.Doing so can strengthen the links and accountability between policymakers and citizenslocalgovernments are potentially more accountable to local demands. It can also strengthen them

between policymakers and providerslocal governments are potentially more able to monitorproviders. But local governments should not be romanticized. Like national governments theyare vulnerable to captureand this might be easier for local elites on a local scale.

32

Community-level institutions, shaped by cultural norms and practices, can facilitate or hinder anenvironment for improving in outcomes. A review of safe-water projects in Central Java,Indonesia, associates success with greater social capital.33 In Rajasthan, India, manifestations ofmutually beneficial collective action were associated with watershed conservation anddevelopment activities more generally.

34 A broader review of the literature suggests that

participatory approaches to implementing projects are more successful in communities with lesseconomic inequality and less social and ethnic heterogeneity.35

Supply: services and their financing

Services themselves are important. Inaccessible or poor quality services raise the effective priceof health care and schooling, which results in higher mortality and lower educationalachievement. Bad quality schools deter enrollment and reduce attainment and achievement,especially among children of poor families. Health clinics where the technical skills of staff areso bad as to be dangerous will lead to higher mortality. Lack of water will significantly hurtchild health.

Financing arrangements matter. Absorbing the burden of unpredictable large expendituresthrough health insurance can reduce impoverishment, which in turn will affect outcomes.Financing primary schooling might seem relatively minor: direct costs are typically small. Evenso, a lack of access to credit has been found to be associated with lower school enrollment.

36

Borrowing to pay the direct costs of primary school is almost unheard of, but there could besecond-round effects if the lack of access to credit means that families need children to engage inhome production.

Supply: services working together to produce outcomes

Links among servicesare critical. Vaccines can become less effective, ineffective, or evendangerous if they get too hot, freeze, or are exposed to light. The ability to transport and storevaccines properly thus determines the success of immunization campaigns. In cold climatesschools and health facilities often need to close because of the lack of heating, and dependableenergy sources can directly affect health and education outcomes. The accessibility of services

32Bardhan and Mookherjee (2002).33Isham and Kahkonen (2002).34Krishna and Uphoff (2002).35Mansuri and Rao (2003).36For example see Jacoby (1994) and Rose (2000).


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can be a deterrent to their use: roads and adequate transport contribute to the total cost of using aservice. Since the expected return to education determines the benefits of schooling, labormarkets that are not fundamentally distorted (for example, through discriminatory practicestoward marginalized groups) can contribute to higher education achievement.


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References

The word processed describes informally reproduced works that may not be commonly availablethrough libraries.

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