Determinants of child mortality in Angola: An econometric analysis

121 Pages·2011·1.77 MB·English

by  Ingrid Hoem Sjursen

Determinants of child mortality in Angola:
An econometric analysis

by
Ingrid Hoem Sjursen
Master thesis

Master thesis to complete the degree

Master in Economics
(Professional Studies in Economics)

University of Bergen, Department of Economics
December 2011
Acknowledgements
Acknowledgements

First and foremost, I want to thank my supervisor, Gaute Torsvik, for invaluable guidance in
the process of writing this thesis, for useful comments and advice, and for always being
available to answer my endless series of questions. I also thank my second supervisor, Arild
Aakvik, for helping me with the econometric methodology and analysis. Without the two of
you, I could never have finished this thesis.

To the Christian Michelsen Institute (CMI): thank you for accepting me as an affiliated master
student and giving me the opportunity to be a part of an inspiring research environment. In
particular, I would like to thank Ottar Mæstad and Mona Frøystad for letting me take part in
the Angola health project, for providing useful STATA tips and for taking the time to answer
my many questions. Thanks also to Magnus Hatlebakk and Ida Lindkvist for good advice and
to the rest of the health cluster for giving me the opportunity to present my project, and for
enlightening meetings. I also thank my fellow students at the CMI and at the Department of
Economics for providing good company and entertaining breaks.

Furthermore, I would like to thank mamma, Stein Jenssen and Ingeborg Forthun for useful
comments on my drafts, and to Eirik Høyer Leivestad, Ragne Rommetveit and Johannes
Oldervoll for proofreading. A special thank you goes to Kristine Husøy Onarheim for
introducing me to the topic, for enduring countless discussions and questions, and for general
support.

Finally, I would like to thank Roman Linneberg Eliassen for his patience and support, both
moral and academic.

The data used in the analysis are collected by the Christian Michelsen Institute (CMI) and
Centro de Estudos e Investigação Científica (CEIC). All interpretations and errors are my own
responsibility.

Ingrid Hoem Sjursen
Ingrid Hoem Sjursen, Bergen 30. November 2011
ii
Abstract
Abstract

Determinants of child mortality in Angola: an econometric analysis
by
Ingrid Hoem Sjursen
Master in Economics (Professional Studies in Economics)
University of Bergen, 2011
Supervisor: Gaute Torsvik
Second supervisor: Arild Aakvik

The aim of this thesis is to investigate determinants of child mortality in the regions of
Luanda and Uíge in Angola. The country has one of the highest child mortality rates in the
world. The literature on the subject has found extensive variation in causes of death between
and within countries, and knowledge on local conditions is a prerequisite for shaping sound
and efficient policies addressing the problem.

The analysis is conducted using data collected jointly by the Christian Michelsen Institute
(CMI) and Centro de Estudos e Investigação Científica (CEIC) in 2010. In the descriptive
analysis, I find large differences in infant and under-five mortality between wealth quintiles,
education levels and households belonging to different public health facilities. In the
econometric analysis, OLS, Poisson and binary logit models are estimated using both number
of infant and under-five children dead as the dependent variable. The analysis puts particular
emphasis on the effect of wealth, education, use and access to health services. While I find no
effect of wealth, education, use and access to delivery services are found to be significant
determinants of child mortality. All calculations and estimations are conducted using STATA
version 11.1.

iii
Contents

Contents

Acknowledgements .................................................................................................................... ii
Abstract ..................................................................................................................................... iii
Contents ..................................................................................................................................... iv
Tables ....................................................................................................................................... vii
Figures ....................................................................................................................................... ix
1 Introduction ............................................................................................................................. 1
2 Child health ............................................................................................................................. 4
2.1 Where do children die? ..................................................................................................... 5
2.2 Why do children die? ........................................................................................................ 6
2.3 When do children die? ...................................................................................................... 7
2.4 Regional and Country differences .................................................................................... 7
2.5 Development and trends in child mortality ...................................................................... 8
2.6 Socioeconomic determinants ............................................................................................ 9
3 The Angolan context ............................................................................................................. 11
3.1 Geography ...................................................................................................................... 12
3.2 Demography ................................................................................................................... 12
3.3 People ............................................................................................................................. 12
3.4 The Economy .................................................................................................................. 13
3.5 Health .............................................................................................................................. 15
3.6 Health system ................................................................................................................. 16
3.7 Chapter summary ............................................................................................................ 17
4 Theoretical backdrop and hypotheses ................................................................................... 18
4.1 A very brief history of mortality ..................................................................................... 18
4.2 An economic model for fertility ..................................................................................... 20
4.2.1 The model ................................................................................................................ 21
4.2.1.1 Trade-offs .......................................................................................................... 22
4.2.1.2 Income ............................................................................................................... 23
4.2.1.3 Mortality ............................................................................................................ 24
4.2.1.4 Culture and norms ............................................................................................. 24
4.3 Determinants of child mortality ...................................................................................... 25
4.3.1 Mosley and Chen’s analytical framework for the study of child survival ............... 25
4.3.2 The Huynen, Martens & Hildernik framework ........................................................ 28
4.3.2.1 Proximate determinants ..................................................................................... 29
4.3.2.2 Distal determinants ............................................................................................ 30
4.3.2.3 Contextual determinants .................................................................................... 30
4.4 Empirical work on child mortality .................................................................................. 31
4.4.1 Income/wealth .......................................................................................................... 31
4.4.2 Education ................................................................................................................. 32
4.4.3 Maternal factors ....................................................................................................... 33
4.4.4 Access to and quality of health services .................................................................. 34
iv
Contents

4.4.5 Geographic variables................................................................................................ 34
4.5 Research question and hypotheses ................................................................................. 35
4.6 Chapter summary ............................................................................................................ 36
5 Data and variables ................................................................................................................. 37
5.1 The data .......................................................................................................................... 37
5.2 Variables ......................................................................................................................... 39
5.2.1 The dependent variable; child deaths ....................................................................... 39
5.2.1.1 Limitations of the dependent variables ............................................................. 42
5.2.2 Independent variables .............................................................................................. 43
5.2.2.1 Household characteristics .................................................................................. 44
Wealth ........................................................................................................................ 44
Education ................................................................................................................... 45
Number of children .................................................................................................... 46
Maternal age .............................................................................................................. 46
Food available ............................................................................................................ 47
Use of health services: Antenatal, delivery and postpartum care .............................. 47
Breastfeeding ............................................................................................................. 47
Urban/Rural geographic position and region ............................................................. 48
Perception of quality of health facility ...................................................................... 48
5.2.2.2 Health facility characteristics ............................................................................ 48
Electricity ................................................................................................................... 49
Services available ...................................................................................................... 49
Equipment .................................................................................................................. 49
Health workforce ....................................................................................................... 50
5.2.2.3 Health worker characteristics ............................................................................ 50
Performance in patient case simulations ................................................................... 50
6 Empirical methodology ......................................................................................................... 52
6.1 The ordinary least squares method of estimation ........................................................... 52
6.1.1 Deriving the OLS-estimator ..................................................................................... 54
6.1.2 Interpretation of OLS regression coefficients .......................................................... 55
6.1.3 The OLS estimator and count variables ................................................................... 55
6.2 The Poisson model for count variables ........................................................................... 58
6.2.1 Interpretation of regression coefficients .................................................................. 60
6.3 The logit model for binary response ............................................................................... 61
6.3.1 Interpretation of logit coefficients............................................................................ 62
6.4 Clustered standard errors ................................................................................................ 62
7 Descriptive analysis ............................................................................................................... 63
7.1 Number of children born, number of under-five and infants dead and mortality rate ... 63
7.2 Summary of descriptive statistics ................................................................................... 68
8 Regression results .................................................................................................................. 69
Contents

8.1 Differences in mortality across health facilities ............................................................. 70
8.2 Wealth ............................................................................................................................. 71
8.3 Education ........................................................................................................................ 75
8.4 Other household characteristics ...................................................................................... 76
8.4.1 A note on maternal age ............................................................................................ 78
8.5 Health facility characteristics ......................................................................................... 78
8.6 Health worker characteristics ......................................................................................... 79
8.7 Separated sample between regions ................................................................................. 80
8.7.1 Household characteristics ........................................................................................ 80
8.7.1.1 Under-five dead ................................................................................................. 80
8.7.1.2 Infants dead ....................................................................................................... 81
8.7.2 Health facility characteristics ................................................................................... 82
8.7.2.1 Under-five dead ................................................................................................. 82
8.7.2.2 Infants dead ....................................................................................................... 83
8.7.3 Health worker characteristics ................................................................................... 84
8.7.4 Goodness of fit: ........................................................................................................ 84
8.8 Summary of findings ...................................................................................................... 84
9 Discussion and policy implications ....................................................................................... 86
Literature .................................................................................................................................. 89
Appendix A: Descriptive statistics ........................................................................................... 93
Appendix B: Poisson tests ........................................................................................................ 98
Appendix C: Facility dummies .............................................................................................. 100
Appendix D: Alternative wealth measures ............................................................................. 105
Tables

Tables
Table 3.1: Key indicators, Angola (2009) ................................................................................ 11
Table 3.2: Health indicators in Angola compared to regional average .................................... 16
Table 5.1: Municipalities by region ......................................................................................... 38
Table 5.2: Number of households, facilities and health workers by region ............................. 39
Table 5.3: Number and frequency of children born ................................................................. 40
Table 5.4: Number and frequency of children under-five and infants dead............................. 41
Table 5.5: Number and frequency of under-five and infant deaths with binary outcome ....... 42
Table 5.6: Education level and frequency ................................................................................ 46
Table 7.1: Total number and per household values for children born, under-five and infants
dead, and under-five and infant death rates .............................................................................. 64
Table 7.2: Number of children born, under-five and infants dead, and under-five and infant
death rates by education level .................................................................................................. 67
Table 8.1: Results from OLS, Poisson and binary logit results with under-five deaths as
dependent variable .................................................................................................................... 72
Table 8.2: Results from OLS, Poisson and Binary Logit with infant deaths as dependent
variable ..................................................................................................................................... 73

Table A.1: Name, description, number of observations, mean, standard deviation, min and
max values for all variables in the analysis .............................................................................. 93
Table A.2: Per household values of number of children born, under-five dead, infants dead,
under-five mortality rate and infant mortality rate .................................................................. 95
Table A.3: Facility dummies, names and region ...................................................................... 96
Table B.1: Regression results from negative binomial regression ........................................... 98
Table B.2: Goodness of fit test for Poisson models ................................................................. 99
Table C.1: OLS, Poisson and binary logit regression with under-five deaths as dependent
variable and facility dummies ................................................................................................ 100
Table C.2: Regression results for OLS, Poisson and binary logit with infant deaths as
dependent variable and facility dummies ............................................................................... 102
Table D.1: OLS, Poisson and binary logit regressions with under-five deaths as dependent
variable and wealth quintiles .................................................................................................. 105
Table D.2: OLS, Poisson and binary logit regression results with number of infant deaths as
dependent variable and quintile dummies .............................................................................. 106
vii
Tables
Table D.3: OLS, Poisson and binary logit results for under-five deaths in Luanda with Luanda
wealth index ........................................................................................................................... 108
Table D.4: OLS, Poisson and Binary logit results for Luanda with infant deaths as dependent
variable and Luanda wealth index .......................................................................................... 109
Table D.5: OLS, Poisson and binary logit for Uíge sample with number of under-five deaths
as dependent variable and Uíge wealth index ........................................................................ 110
Table D.6: OLS, Poisson and binary logit for Uíge with infant deaths as dependent variable
and Uíge wealth index ............................................................................................................ 111
Figures
Figures

Figure 2.1: Definitions, important health indicators (World Health Organization, 2010b) ....... 4
Figure 2.2: World map with territory size proportional to the countries fraction of world total
child deaths. ................................................................................................................................ 5
Figure 2.3: Distribution of child deaths by cause (Black et al., 2008) ....................................... 6
Figure 2.4: Worldwide neonatal, late neonatal, postneonatal and childhood mortality, 1990-
2011 (Lozano et al., 2011) ......................................................................................................... 8
Figure 3.1: Organizational structure, health service system in Angola (Connor, 2010) .......... 16
Figure 4.1: Proximate determinants and the ways they work on health................................... 26
Figure 4.2: Health determinants: different hierarchical levels of causality (Huynen et al.,
2005a) ....................................................................................................................................... 28
Figure 4.3: Multi-nature and multi-level framework for population health (Huynen et al.,
2005a) ....................................................................................................................................... 29
Figure 5.1: Angola and its regions ........................................................................................... 37
Figure 6.1: Distribution of number of under-five children dead and normal distribution ....... 56
Figure 6.2: Distribution of infants dead and normal distribution ............................................. 57
Figure 7.1: Per household death rates by wealth quintile ....................................................... 65

ix
Introduction
1 Introduction

Improving the health of women and children contributes extensively to economic
development, which in turn contributes to better conditions for women and children
Jens Stoltenberg1

The right to health is a fundamental part of the Human Rights declaration of 1948 (United
Nations High Commissioner for Human Rights, 2008). Striving for improvements in health is
therefore a moral obligation for policy-makers around the world, at the international as well as
the national and local level. In addition to being a goal in itself, researchers and the
international community are starting to recognize that health plays an important role in other
aspects of development. This represents a shift in development strategy; earlier, health has
been viewed as an end of development, but now the general tenet is that that improvement of
health standards is a means to achieve other aspects of development.

Millions of people die every year from diseases that could have been easily prevented and
treated. The world is in the possession of the medical knowledge and the resources to reduce
mortality, and improve on the quality of life of the world population. Failing to do so would
be an unacceptable moral failure of the international community and mean opportunities lost
for economic and social development. However, health is not only affected by direct
biological factors, but is influenced by the economic, the social, the cultural and the
institutional environment. More research is needed to acquire knowledge and understanding
about how these factors influence health in local settings.

Premature deaths are unequally distributed worldwide, and life expectancy at birth depends
heavily on which continent, country and social class one is born into. While a child born in
Japan can expect to live as long as 83 years, the life expectancy is just the half of this (44
years) in Afghanistan, the country with the lowest life expectancy in the world (World Bank,

1 The Global Campaign for the Health Millenium Development Goals 2011. Innovating for Every Woman,
Every Child. Thematic Report. Oslo.

1