Child health in rural Colombia: determinants and policy interventions
Introduction
Malnutrition is a very serious problem in developing countries. According to De Onis et al. (2000) about one third of less than five years old children are stunted. There is evidence that inadequate nutrition in childhood affects long-term physical development (Martorell and Habicht, 1986, Barker, 1990), as well as the development of cognitive skills (Brown and Pollitt, 1996, Balazs et al., 1986) and educational attainment (Behrman, 1996, Strauss and Thomas, 1995), affecting productivity later in life (Dasgupta 1993, Strauss and Thomas, 1998, Schultz, 1999). The aim of this study is to explore the main determinants of child health in Colombia, where the positive influence of health on wages has also been documented (Ribero, 1999).
We focus on the influence of household consumption and public infrastructure on child health. This would inform policy makers when setting priorities among different interventions. It is important to understand whether different policies are substitutes or complements. We will give some examples in order to motivate out work. Poverty and low education could cause bottlenecks, not allowing other public policies to influence child health. If this is the case, an effective policy aimed at improving child health might need to be complemented with different interventions. Moreover, policy interventions do not necessarily have a homogenous impact across the population. Some, maybe the lowest educated, might not benefit from certain programs. To uncover these types of interactions would help a better targeting of programs that aim at improving child health. Finally, it is also worth considering that different policies manifest their effect over different horizons. If one finds that mother's education is crucial for children health and possibly for the effectiveness of other interventions, such as those aimed at developing health infrastructure, one could not hope to have results in the very short run. However, such results would constitute a further reason and justification for education interventions. On the contrary, if one were to find that health and other basic infrastructure was important per se and for the whole poor population, then one might want to concentrate resources there and hope for results even in the short run. These considerations should be important in any cost–benefit analysis.
Malnutrition and child health are generally related to household's resources, and to household consumption in particular. More affluent households can provide their children with more and better nutrients. Medicines and visits to doctors might not be affordable for the poorest. While this might seem an obvious point, its quantification remains important in order to understand how different policies will help child health as well as to study the relative merit of some policy instruments (for instance, cash transfers) relative to others.1 For instance, Thomas et al. (1996) find that the magnitude of the income effects are small in the Cote de Ivoire but the provision of basic services and ensuring facilities are equipped have high social returns in terms of improved child health.
In this paper we are also interested in how public infrastructure influences child health. Access to sanitary and health care infrastructure is another likely determinant of child health. There is evidence that increasing the provision of basic health services (birth services, availability of drugs, immunizations) improves child health considerably (Thomas et al., 1996; Lavy et al., 1996). Wolfe and Behrman (1982) find evidence that access to refrigeration and good quality sewage systems positively influence child health. There is also evidence that child height is positively affected by access to infrastructure such as sewage, piped water and sanitation (Lavy et al., 1996, Thomas and Strauss, 1992, Jalan and Ravallion, 2003).
It is of particular interest to determine how education interacts with other factors and policies in explaining child health. While Jalan and Ravallion (2003) find that child health from poorest and lowest educated households in India do not significantly improve by having piped water at home, this is not the case for children from more educated households. Wolfe and Behrman (1982) find that child health and nutrition are positively associated with schooling, except in low-income rural areas. These findings suggest the existence of bottlenecks: low education does not allow other interventions to improve health care (as in Jalan and Ravallion, 2003) or poverty does not allow education to improve child health (as in Wolfe and Behrman, 1982).
Section snippets
The endogeneity of consumption
We use a regression framework in order to estimate the relation between child health and its determinants: consumption, background variables including household education and community level variables. Child health will be measured using four anthropometric indicators.
We take into account that behavioral responses can cause a negative correlation between Household Consumption and the regression error term. Parents might increase household consumption in response to a negative shock in child
The sample
The data set used for this paper comes from the baseline data of the evaluation of Familias en Acción, a program implemented by the Colombian government to foster human capital accumulation among poor children living in small municipalities. The program, modeled after the Mexican PROGRESA, provides monetary transfers to mothers in beneficiary families, conditional on having completed some requirements: (a) children under seven should be taken to development check-ups, and (b) children between 7
The data
Household and individual variables were collected using an extensive household survey that includes information on household structure, household consumption, expenditure, income, health indicators and educational attendance.7 The survey was conducted between June and October of 2002. In this subsection, we describe the main variables used in
Results
First, we estimate the first stage regressions, that is, the regression of log consumption over the instruments and other covariates (Table 3). This regression has an R-Square of 0.15 or 0.16 depending on whether municipality wages or household assets are used as instruments. If no instruments were used, the regression would have a R-Square of 0.13. The F-test for the joint significance of the instruments gives a P-value smaller than 0.001, for any of the set of instruments used.
Table 4, Table 5
Conclusion
This paper has analyzed the determinants of child health in a sample of poor children living in small Colombian municipalities. We have found that both household variables and public infrastructure variables are important determinants of child health. Among household variables, we have found that household consumption is an important determinant of both long-term health (height-for-age, leg length) and medium-term health (weight-for-age). This has important consequences for policy. Lack of
Acknowledgements
We would like to thank the participants in the IADB project on Child Health, Poverty and the Role of Social Policies for the comments received in the meetings held in Puebla and Washington. In particular, we would like to thank Jere Behrman, Sebastian Galiani, Ernesto Schargrodsy, and Emmanuel Skoufias for discussing our paper and provide us with useful comments. We have received very useful comments from the Editor of the journal and an anonymous referee. We would also like to thank Marisol
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