Public Policy and Anthropometric Outcomes in the Côte D’Ivoire

Yale University EliScholar – A Digital Platform for Scholarly Publishing at Yale Discussion Papers Economic Growth Center 10-1-1991 Public Policy and Anthropometric Outcomes in the Côte d’Ivoire Duncan Thomas Victor Lavy John Strauss Follow this and additional works at: https://elischolar.library.yale.edu/egcenter-discussion-paper-series Recommended Citation Thomas, Duncan; Lavy, Victor; and Strauss, John, "Public Policy and Anthropometric Outcomes in the Côte d’Ivoire" (1991). Discussion Papers. 651. https://elischolar.library.yale.edu/egcenter-discussion-paper-series/651 This Discussion Paper is brought to you for free and open access by the Economic Growth Center at EliScholar – A Digital Platform for Scholarly Publishing at Yale. It has been accepted for inclusion in Discussion Papers by an authorized administrator of EliScholar – A Digital Platform for Scholarly Publishing at Yale. For more information, please contact [email protected]. ECONOMIC GROWTH CENTER YALE UNIVERSITY Box 1987, Yale Station New Haven, Connecticut 06520 CENTER DISCUSSION PAPER NO. 643 PUBLIC POLICY AND ANTHROPOMETRIC OUTCOMES IN THE c6TE d'IVOIRE Duncan Thomas Yale University Victor Lavy Hebrew University of Jerusalem John Strauss Rand Corporation October 1991 Notes: Center Discussion Papers are preliminary materials circulated to stimulate discussion and critical comments. This is a revised version of the paper originally written August 1991. We have benefitted from the comments of Martha Ainsworth and T. Paul Schultz. Rosa Balestrino, Michele Siegel and Philippe de Vreyer assisted in the preparation of this paper. Abstract Using data from the Cote d'Ivoire, we examine the impact of public policies on three anthropometric outcomes: height for age and weight for height of children as well as body mass index of adults. During the eighties, low growth rates in the Cote d'Ivoire were accompanied by an economic adjustment program which included substantial cuts in public spending together with increases in the relative price of foods. If reductions in social spending resulted in lower availability and quality of health care services, then our results suggest that child health (particularly height for age) will have been adversely affected. The provision of basic services (such as immunizations) and ensuring facilities are equipped with simple materials (such as having basic drugs in stock) will yield high social returns in terms of improved child health. Food prices have tended to rise in the Cote d'Ivoire during the eighties and we find that higher food prices have had a significantly detrimental impact on the health of Ivorian children ( as measured by weight for height) and adults (as indicated by lower body mass indices). In contrast, the effects of income on health are significant but quite small, except in the case of adult women. 1. INTRODUCTION During the 1980s there has been substantial re-alignment of public budgets in many countries, especially in Africa. Many governments have attempted to reduce budget deficits, often as part of structural adjustment or stabilization programs, with, inter alia, price policies and public expenditures on social services being subjected to particular scrutiny. Economists have traditionally been concerned with the impact of these policies on resource allocation and economic growth but have tended to pay rather less attention to their broader socio-economic ramifications. This paper examines the impact on indicators of child and adult health status of the availability and quality of health infrastructure as well as local market food prices, while also controlling for household resources. To the extent that stabilization programmes are associated with increases in food prices as well as reductions in public spending on social services -- and they often are (Jimmenez, 1987) -- the empirical results will be suggestive of how these policies are likely to affect the health of a community. The measurement of health status is far from trivial. At a conceptual level, health is multi-dimensional and context sensitive (Ware, 1989). At a practical level, clinical measurements are prohibitively expensive to be collected in large scale surveys and so researchers and policy makers have tended to rely on self-reported morbidities. It is not entirely clear, however, how to interpret self-reported perceptions of health. We examine, in this paper, anthropometric outcomes which are objectively measured and reflect the nutritional status of an individual. In a poor country, this is likely to be not unrelated to general health status. We focus on child height ( conditional on age and sex) and weight ( conditional on height) as well as adult body mass index (weight divided by the square of height). While there is scope for some adaption of the body to nutritional stress (Srinivasan, 1981; Sukhatme, 1982) a large literature suggests that child height for age is a good indicator of longer run child nutritional status. The evidence indicates that well-nourished children of diverse ethnic backgrounds from around the world follow remarkably similar growth curves (Habicht et al., 1974; Martorell and Habicht, 1986). Whereas height for age reflects the cumulation of past outcomes, weight for height is thought to be a good shorter run measure of health status (Falkner and Tanner, 1986). The household level determinants of these outcomes have been documented in many studies and it has often been demonstrated that parental education, especially maternal education, together with household 1 resources tend to be positively associated with both outcomes; see Behrman (1990) for an excellent review of the literature. Rather less is known about the impact of community characteristics on child health. Several studies indicate the availability of infrastructure -- in particular modern water or sewerage systems -- tends to be positively associated with child health.1 The evidence on the impact of the availability of health facilities is more ambiguous and there is very little known about the returns (to health) of raising the quality of health services.2 The effect of prices on child health are perhaps even less well understood.3 Outside the biomedical literature, adult health has received little attention (Mueller, 1986) and so there is scant evidence on its socio-economic determinants, especially in developing countries (Feachem, Graham and Timaeus, 1989; Birdsall, 1990). A small number of papers have examined the determinants of self-reported 4 indicators of general ill-health (Wolfe and Behrman, 1984; Pitt and Rosenzweig, 1985; Behrman and Wolfe, 1989) specific illnesses, such as malaria, (Castro and Mokate, 1988; Fernandez and Sawyer, 1988) or problems with activities of daily living (Strauss Gertler and Ashley, 1991). Alderman (1989) has studied the impact of education, expenditure and parity on the BMI of adult women in Ghana. Although little is known about the socioeconomic correlates of adult body mass index, there is evidence that, within certain ranges, adult BMI is significantly associated with higher risk of mortality.5 Lean body mass index, which is related to BMI, is positively associated with the maximum rate of oxygen intake (Spurr, 1983) 1 See Horton (1986), Behrman and Wolfe (1987), Barrera (1990), Strauss (1990), Thomas, Strauss and Henriques (1990) and Thomas and Strauss (1991). 2 Strauss (1990) finds the presence of a traditional healer in rural C6te d'Ivoire reduces child height as does the absence of drugs and congestion problems in the nearest health facility. Barrera (1990) reports an inverse relation between distance to a clinic and child height in the Philippines. Thomas and Strauss (1991) find that, in Brazil, child height is inversely related to the number of nurses and beds in the community. Rosenzweig and Schultz (1982) indicate that fertility and child mortality are invariant to health facilities in rural Colombia but tend to be lower with more clinics, and possibly hospitals, in the urban areas. 3 Changes in child weight for height are negatively correlated with changes in rice prices in Bangladesh (Foster, 1990). Higher sugar and dairy prices are associated with lower height for age in Brazil (Thomas and Strauss, 1991). Behrman and Deolalikar (1989) find that in India the prices of sorghum, pulses and rice are positively associated with child weight for height in the lean season and have no impact in the surplus season; price effects on nutrient intakes are also significant but in the opposite direction. The reasons for these possibly contradictory results are not entirely clear. 4 The interpretation of some of these results is not unambiguous since it is not entirely clear what is being reported (Behrman, 1990). 5 Dangerous ranges for European populations appear to be under 20 and over 30; see studies by Keys (1980) and Waaler (1984); Payne (1985) provides a good summary. 2 which is, in turn, related to maximum work capacity and thus, potentially, to labor productivity. Several studies have indeed demonstrated a positive correlation between adult BMI and labor productivity or wages. Many of the earlier studies in this literature, however, failed to take account of the fact that weight for height or body mass index is likely to vary in the shorter run and respond to changes in energy inputs and outputs (see Strauss, 1986, for a review and discussion); interpretation of these studies is not unambiguous since reverse causality remains a possibility. More recent work has addressed the issue of endogeneity and indicate

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