Research Themes

Health

The impact of bundling health microinsurance with microcredit: Evidence from Punjab, Pakistan

Researcher: Hamna Ahmed, Sadia Hussain and Naveed Hamid (Lahore School)

A policy report that explores and analyses the main trends in utilization of the program since its inception (expected April 2018)

Researcher: Hamna Ahmed, Sadia Hussain

An academic paper that employs a Diff-in-Diff design to study the causal impact of bundling health microinsurance with microcredit on utilization of health facilities and client retention. (to be sent out to Geneva Papers on risk and insurance by June 2018).

Rainfall Shocks and child health:

Researcher: Hamna Ahmed

Rainfall Shocks and Children's Well-being in India (expected 2018)

Rainfall Shocks and Child Health in Rural Pakistan (expected 2019)

Causes and Consequences of Consanguineous Marriage in Pakistan

Researcher: Theresa Chaudhry (Lahore School of Economics) and Mushfiq Mobarak (Yale University)

Nine (out of Punjab's 35 districts) were randomly selected, comprising 70 sampling clusters. Interviews of just over 1000 households were conducted in October 2009. A total of 4643 pregnancies were reported by 391 first cousin (37.6% of the marriages) and 622 non consanguineous couples interviewed in the study.

Major objectives of the study: to more accurately measure the effects of consanguineous marriage, both negative and positive. On the negative side, the offspring of consanguineous marriages may be at greater risk of disease and infant and childhood death. The survey looks at the childhood morbidity and mortality of children born out of consanguineous and non-consanguineous marriages. On the positive side, there may be greater altruism toward the children of consanguineous unions through the extended family, because there is a greater genetic tie. In addition, given that consanguineous marriage reduces uncertainty about unobserved spousal characteristics, this may provide parents with a greater incentive to "invest" in their children, such as by educating daughters. Finally, are there other socioeconomic benefits of consanguineous marriage? Such as reducing dowry? Increasing empowerment of women? Decreasing violence toward women? The analysis will take an instrumental variables approach, to account for the possible endogeneity of cousin marriage.

Status: "Estimating the Health and Socioeconomic Effects of Cousin Marriage in South Asia," Theresa Chaudhry (Lahore School), Mushfiq Mobarak and others (Revise & Resubmit).

Birth Order, Gender, and Child Nutritional Status in Punjab

Researcher: Theresa Chaudhry (Lahore School) and Maha Khan (Lahore School; current PhD. student, The University of York)

Jayachandran and Pande (2015) have found a steep birth order gradient in height-for-age, a standard measure of long-term nutritional status, for Indian children in comparison to several African countries. On the other hand, they find that first-born sons are taller than their African equivalents, in part reflecting favoritism toward eldest sons. In replicating this exercise for data from Pakistan, we also find a steep birth order gradient.

In the next stage of the analysis, we are checking the robustness of this result through the use of mixture models and inclusion of additional sources of data.

Exposure to Fasting and Child Nutritional Status in Punjab

Researcher: Dr. Theresa Chaudhry (Lahore School) and Azka Mir (Lahore School)

Researchers are examining the intent-to-treat effect of exposure to fasting on the height-for-age and weight-for-age z-scores of children under age five, using data on children born between 1998 and 2014.

What Matters in Child Health: An Instrumental Variable Analysis

Researcher: Uzma Afzal (University of Nottingham; Lahore School of Economics - Center for Research in Economics and Business)

This paper studies factors that affect health and the nutritional status of children under the age of five. It attempts to identify the impact of socioeconomic factors such as household characteristics, parental education, community-level infrastructure and health knowledge on the health (measured by height and weight) of children. The study's theoretical framework is based on the household production model and the instrumental variable technique has been implemented for estimation. Household income, illness from diarrhea and vitamin A supplements for children are treated as endogenous variables and have been instrumented. The paper uses data from Pakistan - Multiple Indicator Cluster Survey (MICS) for 2007/08 for Punjab which is a household level dataset gathered by the Punjab Bureau of Statistics. The results suggest that maternal education, health knowledge and household characteristics are important determinants of child health, among other significant indicators. The channel through which maternal education affects child health is considered to be better nurturing and healthcare since the income effect of education is controlled by household income. Household characteristics - income, the number of household members, ownership of durables - prove to significantly affect the health of children in that household. Another important finding of this paper is that female children under five have better height and weight z-scores than their male counterparts. This finding rejects the common presumption of gender bias at the household level in South Asia in early years of life.

Published Article: Afzal, Uzma, What Matters in Child Health: An Instrumental Variable Analysis (December 23, 2013). Child Ind Res (2013) 6:673-693. Available at SSRN: https://ssrn.com/abstract=2371408

The State of Health in Pakistan: An Overview

Researcher: Uzma Afzal (Lahore School) and Anam Yusuf (Lahore School)

The Millennium Development Goals (MDGs) provide time bounded objectives to overcome extreme poverty and provide the basic human rights to health, education, and security that were pledged in the Universal Declaration of Human Rights and United Nations Millennium Declaration (Millennium Project, 2006). Two years short of the deadline in 2015, it is useful to see how Pakistan has performed in the health-related goals that were set in 2000. Health outcomes are useful in gauging a country's health performance over past decades and in conducting cross-country comparisons.

Pakistan is not on track to achieving most health-related MDGs. While there has been an improvement in the education sector, health remains on the periphery of the development landscape. With the eighth highest newborn death rate in the world ("Pakistan has the 8th highest," 2010), one in every ten children born in Pakistan during 2001-07 died before reaching the age of five years. Women have a 1 in 80 chance of dying of maternal health causes during their reproductive life (World Bank, 2010). Pakistan thus faces a daunting challenge in improving health outcomes for children and adults alike.

Pakistan is going through an epidemiological transition where it faces the double burden of communicable diseases combined with maternal and perinatal conditions, and chronic, noninfectious diseases. The landscape of public health service delivery presents an uneven distribution of resources between rural and urban areas. The rural poor are at a clear disadvantage in terms of primary and tertiary health services. They also fail to benefit fully from public programs such as the immunization of children. Following the 18th Amendment to the Constitution, the health sector has been devolved to the provinces, but the distribution of responsibilities and sources of revenue generation between the tiers remains unclear.

Given the current situation, there is much that needs to be done, possibly in every domain of the health sector. Women and children still have the most to lose. There is a dire need for aggressive intervention to strengthen the network of health services, expand the outreach of health programs, and introduce technologies to better monitor and strengthen the health programs in place.

It is imperative for the government to tackle the country's abysmal child and maternal health indicators. Maternal mortality needs to be addressed carefully by increasing the number of skilled health service providers such as female doctors and LHWs in rural areas. These workers should also focus on disseminating awareness of family planning services and supplies.

There is evidence that, apart from low nutritional intake, communicable diseases are also largely responsible for malnutrition in children. In addition to programs such as the EPI, preventive information on healthy practices such as washing hands, treating drinking water, and sanitation should be systematically disseminated. It is estimated that 4 billion cases of diarrhea each year, mostly in developing countries, cause at least 1.8 million deaths, of which 90 percent are children under the age of five (United Nations Children's Fund, 2008). About 88 percent of these deaths are attributable to unsafe water supply, inadequate sanitation, and poor hygiene (WHO, 2005).

In this regard, the private sector and NGOs could play a crucial role in spreading awareness among schools, colleges, and universities. In 2009, the private multinational Procter & Gamble Pakistan and the NGO Save the Children came together to build 100 sanitation facilities in 100 days across Karachi, Lahore, and Quetta. They targeted 40,000 school-age children in their health and hygiene awareness campaign. Such measures could help reduce the burden of communicable disease to a large extent.

However, this does not shed the public sector's responsibility, which has the most to contribute in terms of improving the country's water and sanitation sector. Public-private partnerships need to be encouraged in tackling health issues.

Addressing the issue of no communicable diseases is equally important for the adult population. Given the loss of healthy life years caused by these diseases, the government needs to incorporate programs at the BHU level to effectively prevent the spread of such diseases. Moreover, in order to accurately determine and analyze the burden of disease, a cause-of-death system that collects detailed information on disease prevalence and mortality should be put in place (Hyder & Morrow, 2000). The healthcare system must cater to the twin burden of communicable and noncommunicable diseases simultaneously, which again necessitates public-private support in health financing.

This leads us to the issue of health expenditure in Pakistan. With one of the lowest public expenditure shares on health, the government needs to make an effort to mobilize more resources. While out-of-pocket expenditure on free health services is growing enormously, approximately 4 percent of the population falls into poverty due to health shocks each year. This risk is even higher in rural areas-the highest being in KP-and increases with household size and lower income levels (World Bank, 2010).

Improved monitoring and evaluation is also necessary not only to improve the performance of the health sector but also to enhance existing programs and reforms. Some instruments, such as the Health Monitoring Information System developed by the government in 1992 with the help of USAID, are in place, but the public health surveillance system in Pakistan is still fragmented and has been unable to generate the data required to make informed public health decisions.3 Callen, Gulzar, Hasanain, and Khan (2013) draw on the admirable example of an intervention conducted at the BHU level to monitor public worker absenteeism. They use smartphone technology designed to increase inspections at rural clinics, which proved practical for their purposes. Such studies can be useful in developing effective means of monitoring and evaluating the health system.

Social protection in the form of health insurance could also play a critical role in protecting against health shocks, although the idea has limited scope in Pakistan. In KP, bilateral agencies have promoted social health insurance with support from the religious community, capitalizing on its nonprofit solidarity characteristics. This has served as a call to policymakers for future action. The federal and Punjab governments have also assessed the prospect of health insurance but no plans have been implemented. Needless to say, there is minimal linkage between Pakistan's social protection strategy and the health sector (Nishtar, 2010). In its budget for 2009/10, the government announced that the Benazir Income Support Program would cover health insurance, implying that it was a program only for the ultra-poor (World Bank, 2011). Most evaluations of the program are, however, cautiously optimistic.

We can analyze alternative means of health financing by looking at the health sector across the border in India. The Rajiv Aarogyasri Health Insurance Scheme is an example of one such successful program implemented in Andhra Pradesh. It has successfully covered 87 percent of families living below the poverty line, even though it only covers medical conditions that pertain to catastrophic illnesses (Yellaiah, 2013). The scheme has also substantially reduced out-of-pocket expenditure per capita in the state. On the downside, disease prevention is relegated to the background under such publicly funded insurance schemes, while hospitalization is seen to be a one-off solution to ill health (Karan & Selvaraj, 2012). Despite the pros and cons of such state-funded localized health insurance schemes, an ideal policy would target universal health coverage, providing a push from primary healthcare-level upward.

Following the promulgation of the 18th Amendment to the Constitution, provincial and local governments in Pakistan are constrained by a lack of expertise in formulating pertinent health policies and inadequate institutional capacity to carry out reforms. What the country needs at this point is a focused multi-pronged approach that will improve the provision of primary and tertiary healthcare by building on existing infrastructure and expanding services into areas with limited outreach. With more funds allocated to health, a system of monitoring should be in place to ensure that public resources are properly utilized. Once a universal health policy is formulated, the private sector can better identify its role in complementing that of the state in health service provision.

Published Article: The Lahore Journal of Economics, Volume18: SE (September 2013): pp. 233-247.

RESEARCH