THE DETERMINANTS OF HEALTH AND 
NUTRITION OE OH I LDR.EN UNDER. 
FIVE IN GHANA. .
FELIX ANKOMAH ASANTE
A Thesis submitted to the Department of Agricultural Economy and 
Farm Management, Faculty of Agriculture, University of Ghana, 
Legon, in partial fulfilment of the requirements for the Degree of 
Master of Philosophy (MPhil.) Agricultural Economics
September 1994
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346398
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DECLARATION
I, Felix Ankomah Asante, author of this project report do 
hereby declare that the work presented in the thesis:
"The Determinants of Health and Nutrition of Children 
Under Five in Ghana"
was done entirely by me in the Department of Agricultural Economy 
and Farm Management, University of Ghana.
This work has never been presented in whole or in part for any 
other degree of the University or elsewhere.
This work has been submitted for examination with the approval 
as Supervisor.
Felix Ankomah Asante
Dr. W. K. Asenso-Okyere 
(Main Supervisor)
K. Y. Fosu 
(Co-Supervisor)
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DEDICATION
To my parents
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ACKNOWLEDGEMENT
I extend my sincere thanks to the Almighty God for helping me 
to complete this work successfully.
I wish to extend my thanks to my Supervisors, Dr. W. K. 
Asenso-Okyere and K. Y. Fosu, especially Dr. W. K. Asenso-Okyere 
for his guidance and valuable suggestions throughout the course of 
my work. I am also grateful to my supervisors for the encouragement 
given to me.
Sincere gratitude also goes to Messrs Peter Albersen, Maarten 
Nube and Bart Boom all of the Centre for World Food Studies of the 
Free University of Amsterdam (SOW-VU), The Netherlands, for their 
valuable contributions and comments.
My profound appreciation goes to all my friends and colleagues 
and the Household Food Security and Resilience (HFSR) Project based 
at the Institute of Statistical, Social and Economic Research 
(ISSER), University of Ghana, Legon, for their material and moral 
support throughout the study.
I thank my parents Prof. and Mrs. Asante for their continued 
interest in my education.
Finally, my thanks go to the Netherlands Ministry for 
Development Cooperation which gave a grant to the Reseau SADAOC 
under which this research was carried out.
Felix A. Asante 
September 1994
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Table of Content
Chapter Page
DECLARATION i
DEDICATION i*
ACKNOWLEDGEMENT i i i
LIST OF TABLES vii
LIST OF FIGURES viii
ABSTRACT ix
1 INTRODUCTION 1
1.1 Background 1
1.2 Problem Statement 4
1.3 Objectives of the Study 6
1.4 Relevance of the Study 6
1.5 Source of Data - The GLSS 7
1.6 Scope and Limitation of the Study 12
1.7 Organisation of the Thesis 13
2 LITERATURE REVIEW 14
2.1 Review of Studies Conducted outside Ghana 14
2.1.1 Determinants of Nutritional Status 14
2.1.1.1 The Demand for Nutrients 14
2.1.2 Determinants of Health Status 18
2.2 Review of Studies in Ghana 22
2.2.1 Health Status 22
2.2.1.1 Life Expectancy 23
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2.2.1.2 Mortality Rate 23
2.2.1.3 Access to Sanitation 24
2.2.1.4 Access to Potable Water 25
2.2.2 Nutrition Status 27
2.2.2.1 Nutritional Status of Children 28
2.2.2.2 Nutritional Status of Adults 31
3 CONCEPTUAL FRAMEWORK AND MODEL SPECIFICATION OF
THE UNDER FIVE HEALTH AND NUTRITION MODEL 3 2
3.1 Conceptual Framework 32
3.1.1 Utility Function 32
3.1.2 Nutrition and Health Production Functions 34
3.1.3 Anthropometric Indicators 37
3.1.3.1 Weight-for-Height 38
3.1.3.2 Height-for-Age 39
3.1.3.3 Weight-for-Height 39
3.1.4 Health-Nutrition Dichotomy 40
3.1.5 Nutritional Status of Children (Under
5 Years) 42
3.2 Specification of the Under Five Health
and Nutrition Model (UFHNM) 44
3.2.1 Behavioural Model 45
3.2.2 The Structural Model 4S
4 ESTIMATED RESULTS, VALIDATION AND POLICY EXPERIMENTS
OF THE UNDER FIVE HEALTH AND NUTRITION MODEL 52
4.1 Introduction 52
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4.2 Determinants of Health and Nutrition
Status 52
4.2.1 Privately Provided Inputs 52
4.2.2 Publicly Provided Inputs 60
4 . 3 Estimated Results of the Under Five Model 63
4.4 Validation of the Under Five Model 67
4.5 Policy Experiments 69
SUMMARY, CONCLUSION AND POLICY IMPLICATIONS 77
5. 1 Summary and Conclusion 77
5.2 Policy Implications 79
BIBLIOGRAPHY 84
APPENDIX
1 Health and Nutrition Related Policies and 
Programmes 92
1.1 Introduction 92
1.2 Health Policy 93
1.2 Food and Nutrition Policy 94
1-3 Primary Health Care (PHC) and Expanded
Programme on Immunisation (EPI) 96
2 Description of Variables Used in the Estimation 
and their Summary Statistics (Children 0 - 5 9
months Old) 100
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-ge
24
53
56
58
59
61
62
64
66
67
75
List of Tables
Life Expectancy at Birth
Average Calorie Intake of Children Under Five in 
Ghanaian Households, 1987/88
Mean Weight of Children Under-five Years Old by 
Age of Children, 1987/88
Distribution of Years of Education of Mothers’ 
of Children Under 5 Years in Ghana, 1987/88 
Distribution of Undernutrition among Children 
Aged 0-59 Months in Ghana, 1987/88
Distribution of Source of Drinking Water in Ghana, 
1987/88
Distribution of Source of Light in Ghana, 1987/88 
Dependent Variable: Log(Kcal)
Dependent Variable: Log(Wt)
Dependent Variable: Whzp
Response of Food Intake by Autonomous changes in 
Selected Exogenous Variables in the Under-five 
Health and Nutrition Model
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List of Figures
Figures
3 . 1 
4. 1
4 . 2
4 . 3
4 . 2
Page
The Health-Nutrition Dichotomy. A Poverty Trap 41
Simulated and Actual Values of Food Available to 
the Child (Log) versus Household Expenditures (Log) 
(Historical Simulation) 70
Simulated and Actual Values of the Weight (Log) 
versus Age of the Child (Historical Simulation) 71
Simulated and Actual Values of Food Available to 
the Child (Log) versus Household Food Expenditures 
(Log) (Ex-post Simulation) 72
Simulated and Actual Values of the Weight (Log) 
versus Age of the Child (Ex-post Simulation) 73
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ABSTRACT
This study examines the determinants of health and nutrition 
of children under five in Ghana using data on 2127 children and 
their households drawn from the Ghana Living Standards Survey in 
1987/88 (GLSS I).
The study reveals that Ghanaian children of 0 to 59 months 
obtain 82.7 percent of the recommended required daily allowance of 
calorie intake. Also the children weighed 9.9 percent higher than 
the recommended weight of 12.0 kg. It was further shown that the 
level of undernutrition of children under-five has not changed 
since 1980. About 29.5 percent of children are chronically 
undernourished, 27.2 percent are underweight and 7.1 percent are 
acutely undernourished. ,,
Empirical results show that a 10 percent increases in income 
(proxied by total expenditure), household size in adult equivalent, 
relative prices of millet, garri, cocoyam and plantain to maize 
result in an increase of 9.56 percent, 0.73 percent, 5.45 percent,
6.04 percent, 3.33 percent and 3.45 percent of food available to 
the household, respectively. Similarly, a 10 percent increase in 
the relative prices of yam, cassava and guinea corn to maize result 
in a decrease in food availability to the household by 21.29 
percent, 10.46 percent and 2.97 percent, respectively.
The study further shows that food intake of the child and the 
genetic factors of parents have important roles in the determina­
tion of the health condition of children with elasticities of 0.019
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and 0.445 respectively.
Policy experiments with household expenditure, household size 
in adult equivalent, price of cassava and price of maize showed 
that percentage changes in the mean expenditures give the greatest 
impact on the food available to the child while percentage changes 
in the mean hous.ehold size in adult equivalent give the least 
impact.
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CHAPTER ONE
INTRODUCTION
1.1 Background
Economists generally assume that changes in household incomes 
are unambiguous indicators of changes in the welfare of the 
household. However planners and government officials consider 
health and nutritional status as better indicators of social 
we 1f are.
Information on the nutritional status of a population provides 
information on the health of the economy. Moreover, insights into 
the causes of undernutrition assist planners in effectively meeting 
their social objectives.
In this respect, malnutrition as well as the policy 
instruments available to improve the nutritional status of 
populations, have distinctive features that deserve separate 
analysis (Reutlinger and Selowsky, 1978). First, nutrition is one 
of the main determinants of health. A society may generally respect 
the sovereignty of family units in respect of the allocation of 
their earnings but still take deliberate measures to affect 
allocations which ensure better nutrition for all or some members 
of the family. Second, health and nutrition interventions have an 
impact on human capital formation, with implications for the future 
earnings of individuals and the growth in Gross National Product 
(GNP). The nutritional status of an infant is the most important
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determinant of the individual’s initial physical condition, which 
in turn determines the effectiveness of further investment in human 
capital (Reut1inger and Selowsky, 1978). However, during the 
working years, malnutrition has a crucial influence on an 
individual’s level of productivity.
There is clearly a basis for concern for health and nutrition 
in Ghana. Life expectancy at birth in 1990 was only 55 years (UNDP, 
1993). This is identical to the average for all low income 
countries, excluding India and China. Infant mortality rates in 
Ghana are 83 deaths per 1,000 births (World Bank, 1993) as compared 
to 71 deaths per 1000 births average for low income economies. 
Ghana’s current infant mortality rates do not represent appreciable 
progress relative to estimates from two decades before when it was 
111 deaths per 1000 births.
The World Development Report for 1989 indicates that food 
availability per capita in Ghana in 1986 was not only one of the 
lowest in the world, but it was also appreciably lower than it was 
10 or 20 years before. Although there has been a decrease in 
mortality at all levels of the population there is a severe case of 
under-nutrition and malnutrition in Ghana. The daily calorie supply 
decreased from 87 percent of the suggested 2400 calories per day in 
1965 to 76 percent in 1985 and by 1990, had increased to 93 percent 
(UNDP, 1993). There are 27 percent of children who are 
malnourished. These statistics have a lot of consequences for human 
capacity building, productivity and poverty of individuals, 
households and communities.
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On health, between 1987 and 1990, about 76 percent of the 
Ghanaian population had access to health services (UNDP, 1993). Due 
to absence of modern facilities many people in the rural areas do 
get access to health care through herbalists and other unorthodox 
health care facilities. About 40 percent of all births are attended 
to by health personnel. Through an intensive campaign (Expanded 
Programme on Immunisation) the proportion of one-year-olds 
immunised has increased from 34 percent in 1981 to 64 percent 
between 1989 and 1991. This has drastically reduced the incidence 
of some childhood killer diseases and has therefore contributed to 
the reduction in infant mortality.
The fast growing population of the country which is estimated 
to be between 2.6 and 3.2 percent per annum, requires consistently 
higher growth in food production to reduce food insecurity. At the 
high rate of 3.2 percent per annum, food production must grow, at 
least, by 4 percent per annum to ensure adequate food supplies and 
a modest economic growth. Large families are more vulnerable not 
only to food insecurity but to the insecurity of housing, education 
for children, health and other basic needs. Haddad and Kanbur 
(1991) have observed that intrahousehold food insecurity increases 
with household size. In such large households, invariably children 
under 5 years, who are more vulnerable to infection are more food 
insecure than others.
On the policy side, the effectiveness of nutrition 
interventions depends heavily on the behaviour of households in 
relation to such policies. Households make the ultimate decision on
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production and consumption and these decisions affect nutritional 
intake which in turn affects the health of its members. It is 
therefore important that public policies are designed in the 
context of the behaviour of households.
1.2 Problem Statement
Under the Economic Recovery Programme (ERP) which was launched 
in April 1983, policies and programme were implemented by the 
Government of Ghana in an attempt to resuscitate the economy after 
a period of economic decline (see Appendix 1 for discussion on 
health and nutrition related policies and programmes for children).
Despite the economic improvements in the last decade, infant 
mortality rates remain high in Ghana; in 1991, the rate was 
estimated at 83 per 1,000 live births (World Bank, 1993), a figure 
which is much higher than in China (29), Sri Lanka (19), or Kenya 
(67) (Alderman and Garcia, 1993).
Undernutrition is a serious problem among preschoolers (0 to 
59 months) in Ghana. According to the findings of the 1988 Ghana 
Demographic and Health Survey and Africa Nutrition Chartbooks 
(1993), nearly 1 in 3 children aged 3 to 36 months are chronically 
undernourished. In order words, they are too short for their age or 
stunted.1 The proportion of children stunted is 13 times the level 
expected in a healthy, well-nourished population. About one in
1 A stunted child has a height-for-age Z-score that is below -2SD 
based on the NCHS/CDC/WHO reference population.
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three children are underweight2 for their age. Similarly, acute 
undernutrition, manifested by wasting3 which results in a child 
being too thin for his or her height, affects nearly 1 in 13 
children.
Comparing undernutrition among children aged 3 to 36 months in 
Ghana and other sub-saharan African countries between 1986 and 
1991, Ghana is in the middle range for the proportion of children 
who are stunted and third after Mali and Nigeria in terms of level 
of acute malnutrition (Africa Nutrition Chartbooks, 1993)
Undernutrition of children which also has consequences for 
their poor health is a result of both inadequate intake of food and 
poor environmental sanitation. An inadequate intake of food result 
from improper feeding practices and/or insufficient food at the 
household level. Improper feeding practices include both the 
quality and quantity of food offered to young children. Poor 
sanitation puts young children at risk of increased illness, in 
particular diarrhoeal disease, which adversely affects a child’s 
nutritional status. Both inadequate food intake and poor 
environmental sanitation reflect underlying social and economic 
condi t ions.
From the foregoing, the economic growth achieved by Ghana in 
the last decade is not easily reconciled with the health and
2 An underweight child has a weight-for-age Z-score that is below
-2 SD based on the NCHS/CDC/WHO reference population. This 
condition can result from either chronic or acute undernutrition.
3 A wasted child has a weight-for-height Z-score that is below -2
SD based on the NCHS/CDC/WHO reference population.
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nutrition status of children. Thus this study seeks to address the 
following issue: What are the determinants of health and nutrition 
of children under-five in Ghana. Knowledge of the determinants will 
be useful input into policies that seek to improve human capacity 
development which begins from infancy.
1.3 Objectives of the Study
The general objective of the study is to determine the factors 
that affect the health and nutritional status of children under 5 
years old in Ghana.
The specific objectives are:
(1) to determine the inputs (privately and publicly provided) 
which are the principal determinants of health and nutritional 
status of children under 5 years old.
(2) to determine the responsiveness of indicators of children’s 
health and nutritional status to consumption input.
1.4 Relevance of the Study
Very little or no study has been conducted in Ghana to 
determine the dual role of the determinants of health and nutrition 
of children under-five years. Most recent studies conducted either 
concentrate on the health or nutrition aspect separately. Alderman 
( 1990), in a study of the nutritional status of Ghana and its 
determinants concluded that there is a positive relationship 
between income and nutritional levels. Thus, policies that tend to 
increase the income of households tend to have an effect on the
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nutrition of Ghanaians.
Studies have rather directly or indirectly concentrated on 
poverty disparities and nutritional status in Ghana (see for 
instance Ewusi 1984; 1976; Boateng e_t al ■ , 1990; Awusabo-Asare,
1981/82; Alderman, 1990). This present study tries to fill part of 
this gap by addressing the determinants of health and nutrition of 
one important cohort of the society, the under-five years old in 
Ghana.
Children are more vulnerable to the consequences of under 
and/or malnutrition than adults. Poverty level of a household can 
therefore be easily linked to the nutrition and health status of a 
child. Also, mortality rates tend to be high for this age group 
that is, risk of preventable mortality reduces considerably after 
age five. The interconnections between the health and nutrition of 
a household is better understood by considering children in the 
early stages of their life. It is in these formative years that 
good nutrition gets translated into visible signs of health and 
ill-health on the body of the individuals and can be measured 
quantitatively (anthropometry). Such visible signs also help 
determine the health status of the individual. This and the 
vulnerability of children under five years to consequences of 
malnutrition are the motivations for basing the health and 
nutrition study on children under 5 years of age.
1 • 5 Source of Data - The GLSS
Data for this study was drawn from the first round of the
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Ghana Living Standards Survey (GLSS I) which was conducted by the 
Ghana Statistical Service in conjunction with the World Bank. The 
GLSS comprises a comprehensive set of data culminating from three 
rounds of surveys conducted in 1987/88, 1988/89 and 1990/91, and
designated as GLSS I, GLSS II and GLSS III, respectively.
The objective of the surveys is to provide data on a 
continuous basis to the government of Ghana for measuring the 
living standards of the population and the progress made in rasing 
them.
The GLSS is currently planned to be undertaken over a five- 
year period. This five-year time horizon will provide a set of 
panel data which can be used for policy planning, monitoring and 
evaluation in a dynamic sense so that interventions like the 
Programme of Actions to Mitigate the Social Costs of Adjustment 
(PAMSCAD) can be avoided and internalised into the overall 
development programmes. The surveys are therefore expected to lead 
to more effective formulation and implementation of policies 
designed to improve the welfare of the Ghanaian population.
The GLSS I covers a nationally representative sample of 3200 
households from 200 enumeration areas and involving 15,648 
individuals. It provides data on various aspects of the Ghanaian 
household economic and social activities and the interactions 
between these activities. Data were collected at three levels:
(i) the household level;
(ii) individual level; and 
(iii) the community level.
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A household as defined by the GLSS is a group of individuals 
who live and eat together for a period of at least three months of 
the 12 months preceeding the interview. Household data include 
income, expenditure, housing, household enterprises and assets. 
Data on individual household members cover demographic 
characteristics, education/ health, employment and time use, 
migration and anthropometrical measurements. For the local 
community, data were collected on social services availability 
(education, health), communication, transportation, food commodity 
prices, and general economic and social characteristics.
Sampling Technique
A two-stage stratified sample design was used. The aim of GLSS 
I was to arrive at a final sample of 200 interviewer workloads 
Consisting of 16 households each, giving a total sample of 3200 
households. To ensure that workloads were of equal size and that 
each household in the final sample had an equal probability of 
being selected, it was necessary to select the 200 enumeration 
areas (EAs) with probability proportional to size. The measure of 
size used for each EA was the number of households counted in the 
1984 population census, with an allowance for changes in the size 
of the selected EAs since the time of the census.
Before selecting the 200 EAs, the 12,969 EAs from the 1984 
population census was first arranged in order according to local 
councils, which were in turn ordered according to ecological zone 
(coastal/forest/savannah). Within an ecological zone, the EAs were
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further ordered according to the size of the locality; rural 
localities (those with a 1984 census population of less than 1500), 
then semi-urban localities (those with a census population of at 
least 1500 but less than 5000) and finally urban localities (those 
with a census population of at least 5000).
Finally within each group the EAs were then listed in order 
according to their EA number. This ordering provided an excellent 
geographical stratification since the first digit of each EA number 
represented the region in which the EA was located.
At the next stage of sample selection, 20 households were 
systematically selected to make up each workload. Four of these 
households (obtained by taking a 1 in 5 systematic sample from the 
20 selected households) were kept as reserves, to be used only if 
one or more of the original 16 households could not be covered in 
the survey.
Survey Organisation
The survey was carried out by ten teams. Each team included a 
supervisor, two interviewers, an anthropometrist, a data entry 
operator and a driver. Each team was assigned a landrover.
The data collection was organised in two rounds. During the 
first round, data on household composition, housing 
characteristics, education, health, economic activities, migration 
and anthropometric measurements (height and weight) of household 
members were collected. In addition the household head or the 
persons best informed about the household’s enterprises and
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expenditures was identified and interviewed. During the second 
round, the team collected data on farm economic activities, non­
farm self employment, food and non-food expenditures, fertility, 
other incomes, credit, savings, and assets. Also, another set of 
anthropometric measurements of height and weight of some selected 
household members were taken to correct errors from the first round 
of data collection.
For each household, the two rounds of interview took place at 
two weeks intervals. Before the first interview was conducted an 
appointment was sought with the respondent during an initial visit. 
At the end of the first interview the respondent was informed about 
a second visit two weeks later. To obtain a reliable recall data 
the respondent was asked to note types and levels of expenditures 
and incomes for the next two weeks for which responses will be 
sought in the second interview. During the visit, if a respondent 
was not available (travelled or died) or refused to cooperate then 
a replacement was taken from the replacement list.
Organisation of data
The questionnaires were almost entirely pre-coded; therefore, 
data in digital form were directly entered into the computer, thus 
skipping the usual coding step. Data entry operators on the team 
who were based at the regional offices of Statistical Service 
started to enter the data one week after the interview to allow for 
corrections of any omissions or errors. Data entry programmes 
specially designed for the purpose of the survey was used.
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The Questionnaires
Three types of questionnaires were used in the GLSS: (1) a
household questionnaire; (2) a community questionnaire; and (3) a 
price questionnaire.
The household questionnaire comprised 16 sections which 
allowed the collection of a total of 800 pieces of information on 
the households. The community questionnaire, used in the rural 
areas, was administered to the persons best informed about the 
community (village chief and teachers, among others). The price 
questionnaire was filled out by visiting markets and asking about 
food commodity prices. The information collected allowed price 
comparison between different parts of the country and estimation of 
the value of consumption of home produced goods.
1.6 Scope and Limitation of the Study
This study is restricted to the use of GLSS I data which was 
carried out in 1987/88. Household expenditures were used in the 
computation of food quantity. A food intake survey technique would 
have been the best in estimating the quantity of food consumed 
(Bouis e_t aJ. , 1992). Food quantity information collected from 
expenditure surveys have measurement errors which are often 
systematically correlated with income, such that the responses of 
food intakes to increase in income is seriously overstated (Bouis 
e_t aT. , 1992). This may be, firstly, because food quantities are
not measured independently of income if total expenditures are the 
proxy used for income, and secondly, because food transfers in the
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form of guest and hired worker meals are under-recorded.
1•7 Organisation of the Thesis
The thesis has five chapters. Chapter one is the Introduction. 
It consists of some background information, the problem statement, 
the objectives and relevance of the study and source of data.
Chapter two presents the literature review and it covers 
studies conducted in both Ghana and other countries. Chapter three 
outlines the conceptual framework and specification of the under 
five health and nutrition model.
Chapter four presents the estimated results, validation and 
policy experiments of the model. Chapter five contains the summary 
and policy implications of the study.
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CHAPTER TWO
LITERATURE REVIEW
2.1 Review of Studies Conducted outside Ghana
2.1.1 Determinants of Nutritional Status
The determinants of nutrient consumption can be looked at in 
two ways: the demand for nutrients and the production of nutrients 
(Behrman and Deolalikar, 1988). They hypothesise that the nutrient 
intake of an individual (demand) is presumed to be determined by 
prices, income and given endowments of the individual; while the 
production of nutrients is assumed to be determined by the food 
consumption of the individual, the education, and time of the 
household food preparer. Unobserved variables, such as metabolic 
rates, play an important role in both functions.
2.1.1.1 The Demand for Nutrients
Most studies that analyse nutrient intake do so in a demand 
framework. Two approaches are usually followed: (i) estimating food 
demand/expenditure systems and then converting the price and income 
elasticities obtained from these to nutrient elasticities using 
fixed food-nutrient conversion factor® (Strauss, 1984; Pitt, 1983 
and Pinstrup-Andersen, et al., 1975); (ii) estimating directly the 
demand for nutrients as a function of food prices, household size 
and income/expenditure (Wolfe and Behrman, 1983; Ward and Sanders, 
1980; Timmer and Alderman, 1979; Pitt and Rosenzweig, 1985).
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Most studies that analyse the relationship between the income 
elasticity of nutrient demand and the level of income have found it 
to he negative (Timmer and Alderman, 1979 and Pinstrup-Andersen et 
al., 1975). Such an inverse association between the income
elasticity of nutrients and the level of income according to 
Behrman and Deolalikar (1988), is consistent with the possibility 
that income ceases to play an important role in the marginal 
determination of nutrients at high incomes but the inverse may be 
the case at low incomes.
Behrman and Deolalikar (1987b) argue that calorie (more 
generally, nutrient) income elasticities which are derived from 
aggregate food demand equations tend to be overestimated, since 
with increasing income households switch purchases among 
disaggregated foods to higher priced, but not necessarily 
nutritionally better foods.
A common set of determinants of nutrient demand explored by 
empirical studies, is food prices. Strauss (1984) obtained negative 
food price effects on the demand for calories when he controlled 
farm profits in his sample of Sierra Leonean farm households. 
However, the majority of the food' price elasticities turned 
positive when farm profits were allowed to vary (that is, when it 
was assumed that food prices had a positive impact on farm profits 
and thereby on consumption). On the other hand, Pitt (1983) found 
that, even after controlling for income, calorie demand in 
Bangladesh had positive elasticities with respect to the prices of 
(pulses, fish, mustard oil, onions and spices) five of the nine
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foods he considered. Behrman and Deolalikar (1987c) in their study, 
also found a large number of positive food price effects on the 
unobserved nutrient consumption status of all household members, 
even after controlling for income and individual-specific fixed 
ef fects.
A survey of 15 nutrient demand studies by Alderman (1984) 
notes that own-price elasticities of food demand decline in 
absolute values with income or expenditure. Williamson-Gray (1982) 
observed a pronounced trend of a compensated own-price elasticity 
of cereals demand of -0.74 for the poor, -0.16 for the middle 
income and not significantly different from zero for the rich in 
Brazil. Few studies (Timmer and Alderman, 1979; and Williamson- 
Gray, 1982) also observed an inverse relationship between the 
absolute value of cross-price elasticities and the level of income 
or expenditure. Thus, there is compelling evidence that the poor 
are more responsive to income, own prices and cross prices than the 
rich in the demand for food. This has important distributional 
implications for food prices in poverty alleviation policies and 
programmes.
Behrman and Wolfe (1984) argue that when household size is 
entered as a determinant of nutrient demand, it is not only the 
sign but the magnitude of the household size elasticity relative to 
the household income elasticity that is important since it reflects 
the extent of returns to scale with respect to household size. In 
addition to them Wolfe and Behrman (1983); and Ward and Sanders 
(1980) obtained statistically significant negative effects of
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household size on nutrient demand. These studies are likely to be 
biased since fertility and hence household size are endogenous 
variables that are jointly determined along with nutritional status 
choices, but not treated as such in these studies. Pitt and 
Rosenzweig (1985) did not include household size as a determinant 
of per capita nutrient intake, but included household composition 
(treated as an endogenous variable), and found it to be a 
significant determinant of per capita nutrient intake. Per capita 
consumption of calories, protein, carbohydrates, and phosphorous in 
particular were all found to increase with mean household age.
With the inclusion of the education of the food preparer in 
the household nutrient demand function, Wolfe and Behrman (1983) 
and Behrman and Wolfe (1987; 1984) reported significant effects of 
women’s schooling on household nutrient composition. These studies 
revealed that Nicaraguan households in which women have more 
schooling tend to be significantly and substantially better 
nourished, ceteris paribus.
Another determinant of nutritional status which is important 
in the rural areas of Least Developed Countries (LDCs), is 
seasonality (Chambers e_t aA . , 1981). The wet season in these
countries is often the most difficult time of the year when
shortages of food are coincident with high energy demand for
agricultural activities. Food is very scarce and most expensive at 
this time of the year. Exposure to infections and diseases, like
diarrhoea, malaria, cholera and dengue fever are most common at
this period.
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Behrman and Deolalikar (1987a) incorporated seasonality in the 
determination of nutrient demand. They estimated separate nutrient 
and health demand equations for individuals for the lean and the 
surplus seasons of the year in rural south India. They obtained 
significantly negative food price elasticities of calorie and 
protein demand for the lean season, but elasticities were close to 
zero or even slightly positive in the surplus season.
2.1.2 Determinants of Health Status
Most of the demand studies on health and health-care are based 
on cross-sectional data, few of them explicitly include market 
prices as explanatory variables. Most studies include household 
characteristics, income and availability of health care, 
interpretated as the price of health care services.
Among the micro studies, Blau (1984) estimated a demand 
function for standardised height-for-age scores using 1977-78 data 
on children under five years of age in Nicaragua to determine the 
utilisation of health-care. He included the mother’s age, 
education, location (urban or rural), income and formal and 
informal sector wage rates (corrected for selection bias) as 
independent variables. Blau’s rationale for separating the two 
types of wage rates is that female informal^sector jobs in 
developing countries may be consistent with own childcare in a way 
that formal-sector jobs are not, since childcare often can be 
combined with informal-sector jobs. He found the mother’s formal- 
sector wage rate to have a significant positive effect on child
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health and the informal-sector wage not to have any significant 
effect.
Merrick (1985) used infant mortality as a proxy for health 
outcomes in his analysis of the effect of pipe borne water supply 
in Brazil on health outcomes. Mortality determination process was 
formulated in a multi-equation framework with husband's education 
influencing household income; husband's and wife's education, 
household income and community water availability influencing the 
household utilisation of pipe borne water; and husband’s and wife’s 
education, household income and pipe borne water utilisation 
affecting child mortality. He estimated the system by ordinary 
least squares (OLS) methods, arguing for recursivity among the 
three relations. He also produced reduced-form estimates for 
mortality, which were preferable to the OLS estimates. He revealed 
that while availability of pipe borne water supply had a negative 
impact on infant mortality, the effect of parental education on 
mortality was much greater. This therefore reinforces the 
importance of parental education on nutritional and health status 
of infants.
A study by Rosenzweig and Schultz (1982), on the joint 
determinants of fertility and child mortality in Colombia included 
a very comprehensive list of community level infrastructural 
variables, most of which can be interpretated as health-care price 
variables, in explaining the household demand for health outcomes. 
Among the independent variables included in their mortality 
equation were the woman’s age and schooling and the per capita
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number of hospital beds and clinics, family planning expenditures 
per capita, transportation time to the capital city, average daily 
temperature, price of food and the regional schooling variable. 
Separate equations were estimated for women residing in rural and 
urban areas.
The study concluded that, in the urban areas, child mortality 
in families with less-educated mothers is strongly affected by 
public health and family planning programmes. It was also found 
that, in the urban areas, clinics are a more cost-effective means 
of lowering child mortality than are hospitals. In the rural 
sector, there is little effect of health and family planning 
programmes on child mortality. According to Rosenzweig and Schultz, 
for urban and rural areas, maternal education had a strong negative 
effect on child mortality.
Most studies, as discussed above, neglected the fact that a 
large proportion of households are farm households in many less 
developed countries and thus the omission of farm input prices and 
farm assets from the health demand functions is a major deficiency 
in the models. Also there are very restrictive assumptions about 
product and labour markets and about the lack of links between 
health and nutrient inputs on one hand, and productivity on the 
other. Pitt and Rosenzweig (1985) and Behrman and Deolalikar 
(1987c) are two recent studies that incorporated these concerns.
Pitt and Rosenzweig (1985) using data on 2,347 farm households 
in Indonesia estimated separate health outcome demand (called 
"illness demand") functions for husbands and wives. These functions
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have as arguments, prices of thirteen consumption goods (food and 
non-foods); source of drinking water; availability of hospitals, 
family planning clinics, public lavatories; owned land; farm 
profits; and the age and education of the husband and wife. The 
authors found relatively few significant determinants of health 
using ordered probit equations. According to the authors, this 
result was attributed to the lack of precise definition of illness 
in the survey.
Using panel data on rural South India, Behrman and Deolalikar 
(1987a) estimated joint reduced-form health and nutrient 
consumption status relations. The method used allowed for differing 
price and income responses by different household members (adult 
males, adult females, male children and female children). A latent 
variable representation of unobserved health status was used,(see 
for instance Behrman and Wolfe (1987)) which had three observed 
anthropometric indicators: standardised arm circumference (age-
gender specific), triceps fatfold, and weight-for-height. It was 
revealed that three of the six prices (namely rice, milk and male 
labour) had significant positive effects on health status, even 
when income was controlled. They however found neither a 
significant income effect nor significant differences in prices or 
income responses across household members.
A few studies (Bairagi, 1981; Chen et. al., 1980) have
established a link between anthropometric measures and mortality. 
These studies show that severely, mild and moderately malnourished 
children (that is, those with low and lower-than-average
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anthropometric readings) have greatly increased mortality risks 
relative to normal children. Arm circumference was found to be an 
excellent predictor of mortality.
On the link between nutrient and other health-related intakes 
and anthropometry or morbidity, Clark (1981), using data from 
Guatemala, found that the physical growth (weight gain of infants 
0-12 months) was associated significantly with the number of 
calories of atole4 consumed and length of breastfeeding.
Taylor et a 1 . , ( 1978) using the Narangwal project data, found 
that (controlling for factors such as age, gender, caste, season 
and number and composition of siblings) children in villages 
receiving nutritional care, whether alone or in combination with 
medical care, had higher weights and heights than those in control 
villages. Chernichovsky and Kielmann (1977) used two-stage least 
squares with the same data as Taylor et_ aT. to measure the impact 
of calorie intake on the weight of children aged between 6 and 36 
months. They also found a significant positive effect of calories 
on weight after controlling for age and gender.
2.2 Review of Studies in Ghana
2,2.1 Health Status
Health services are accessible to about 60 percent of the 
population (World Bank, 1989). Many people in the rural areas do
4 Atole is a high-protein-high-calorie supplementary diet.
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get access to health care through herbalists and other unorthodox 
health care sources. In 1984, the number of persons per doctor was 
14,890 and 640 per nurse. Through an intensive campaign (Extended 
Programme on Immunisation), the proportion of one-year-olds 
immunised has increased from 34 percent in 1981 to 64 percent 
between 1989 and 1991.
When human deprivation is considered, out of a population of 
15 million Ghanaians in 1990, there were about 6 million without 
access to health services, 6.5 mi 11 ion without access to safe water 
and 10.4 million without access to sanitation (UNDP, 1991).
2.2.1.1 Life Expectancy
Life expectancy at birth has increased from 47 years in 1960 
to a recent estimate of 55 years (GOG/UNICEF, 1990). Table 2.1 
gives figures by sex and total population for 1985-2000 indicating 
a projected continuous improvement in life expectancy at birth.
2.2.1.2 Mortality Rate
Mortality rate for infant and children in Ghana has been 
declining over the years (GSS, 1989b). Infant mortality rate 
estimated at around 100 deaths per 1000 in 1973-77, has declined by 
approximately 22 percent to 77 deaths per 1000 births between 1983^ - 
1987. Mortality during childhood has also declined during the
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Table 2.1 Life Expectancy at Birth
Gender 1985 1988 1990* 2000**
Male 50.3 52.0 53.0 59.0
Female 53.8 56.0 57.0 61.0
Average 52.0 54.0 55.0 . 60.0
Source: World Bank, 1988.
* Estimated 
** Projected
period under consideration. The probability of a child dying 
between birth and age 5 has dropped from 0.187 in 1973-77 to 0.155 
in 1983-88 (GSS, 1989b).
2.2,1.3 Access to Sanitation
Sanitation facilities of critical concern in the household 
environment include:
(a) excreta or human waste disposal
(b) garbage disposal; and
(c) liquid household waste and storm water disposal.
Amonoo (1988), indicated that only 50 percent of the urban and 
15 percent of the rural population have adequate sanitation 
installations. The report of GLSS I (GSS, 1989a) shows a sharp 
contrast between rural and urban areas in terms of the availability 
of human excreta disposal facilities. It reveals that urban areas 
rely on a range of toilet facilities including flush toilets while 
rural areas primarily depend upon pit latrines (improved or
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ordinary).
Using the Ghana Demographic and Health Survey (GSS, 1989b) 
carried out in 1988, undernutrition among children aged 3 to 36 
months, shows that one-quarter of households have no toilet 
facilities, over two-thirds have pit latrines and less than one in 
ten has a flush toilet. Also irrespective of the type of toilet 
about one in thirteen children are too thin.
The capability to handle household and municipal garbage in 
urban areas has deteriorated except in Accra where the Metropolitan 
Assembly has been able to improve the situation modestly with 
assistance from the Federal Republic of Germany. There is hardly 
any workable sanitation system in the rural areas. Refuse dumps are 
sited haphazardly and pose health problems to children playing in 
such environment, and this has led to quick spread of diarrhoeal 
diseases.
The disposal of liquid wastes from households in both urban 
and rural settlements poses serious problems. Open drains are 
clogged in urban areas, creating standing pools of water which are 
unsanitary and often serve as breeding spots for mosquitoes. Liquid 
waste add to the pollution of water bodies, especially in rural 
areas without any drains nor potable water supply.
2.2.1.4 Access to Potable Water
The sources of water supply for households include the 
following:
(a) pipe-borne water supply from treated water sources;
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(b) untreated pipe -borne water based on ground water sources;
(c) non pipe-borne water supply from shallow boreholes;
(d) supply from dug-we11s; and
(e) supply from ponds, springs, lakes, rivers and streams. 
According to the Ghana Water and Sewerage Corporation (GWSC,
1986) and the Ghana Population Census (1984), the situation of 
domestic and municipal water supply is as follows:
i. 93 percent of the population living in communities with more 
than 5000 inhabitants (defined as being urban) have access to 
potable water supply; communities of this size represented 30 
percent of the national population, 
ii. 70 percent of the population residing in communities with 
between 500 and 5000 have access to good drinking water mainly 
from pipe-borne supplies and boreholes fitted with hand pumps. 
These communities constituted 20 percent of the national 
population.
iii. 15 percent of the people residing in rural communities with 
population below 500 have access to potable water. They form 
about 46 percent of the population in 1984.
The quality of water available to rural households is 
unsatisfactory as most communities rely on ponds and streams as 
their sources of water supply (GSS, 1989a). About 50 percent of 
Ghanaian households obtain water from open-air sources, almost 20 
percent use a community water supply (well or borehole), and only 
33 percent have access to piped water. Similar to the type of 
toilet facility in household, irrespective of the source of water
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about one in thirteen children is too thin.
Water-borne diseases including guinea worm, bilharziasis, 
cholera, typhoid and infectious hepatitis are common in the rural 
areas and urban slums with poor sanitation. Unsafe water supply 
also contributes to diarrhoea, hookworm, yaws and scabies. 
Therefore water affects the health status which in turn affects the 
nutrition status of households.
2.2.2 Nutritional Status
In Ghana, malnutrition takes its greatest toll on young 
children and pregnant nursing mothers. The problem is a combination 
of two inter-related phenomena: protein-energy malnutrition and 
associated micronutrient deficiencies among the vulnerable groups, 
and pre-harvest hunger affecting predominantly the rural population 
(World Bank, 1989).
Although there has been a decrease in mortality at all levels 
of the population and slight improvement in daily calorie supply, 
there are still cases of under-nutrition and malnutrition in Ghana, 
especially in children. The daily calorie supply declined from 87 
percent of requirements in 1965 to 76 percent in 1985 and increased 
to 93 percent between 1988 and 1990 (UNDP, 1993). The improvements 
in the latter 1980s were due to the ERP. However, there is still an 
estimated 27 percent of children who are malnourished. This has 
substantial consequences for child health and human capacity 
development.
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2.2.2.1 Nutritional Status of Children
A study by Ewusi (1978), on nutritional status of children in 
six villages in the coastal savanna plains and in the forest zone 
in the mid-seventies summarised the incidence of malnutrition in 
the study area. Using anthropometric measurements based on changes 
in the upper arm circumference, the survey showed that for most of 
the villages, more than two-thirds of the children could be 
considered as being undernourished. He further concluded that on 
the average 70.3 percent of the children were under-nourished with
21.5 percent being seriously under-nourished.
Orraca-Tetteh and Watson (1977) in another study of the 
nutritional status of Bafi, a village in the Brong-Ahafo region in 
1976, had a result which was similar to Ewusi (1978).
A nation wide nutrition survey of 14,000 children conducted 
jointly by the Nutrition Department of the Ministry of Health and 
UNICEF in 1986 found that 58.4 percent of pre-school children fell 
below 80 percent of the U.S. National Center for Health Statistic 
(NCHS) weight-for-age standards (World Bank, 1989b). This was 
roughly twice the level obtained in the first national survey 
carried out in 1961-62. About 8 percent of children in the country 
were clinically classified as suffering from marasmus or 
kwashiorkor. Malnutrition levels were highest in the northern zone 
(64 percent) and lowest in the coastal zone (48 percent).
Alderman (1990) using the GLSS data found that 31.4 percent of 
children fell below 80 percent of the weight-for-age standard. This 
implies, then that malnutrition has declined since 1986 but remains
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above the levels reported for the early post-independence years.
Another indication of the changing pattern of malnutrition in 
the 1980s comes from data collected by the Catholic Relief Service 
for children attending maternal child health centres (CRS, 1987). 
The data shows a slightly better pattern. It indicates that, even 
in a 'good’ agricultural and nutrition year 1980, 35 percent of
children were below 80 percent weight-for-age standard; in the 
severe drought of 1983, 51 percent; and by 1986, after the recovery 
of agricultural production, about 35 percent again.
The GLSS data which is the most current national survey which 
groups the nutritional status in Ghana by age, gender and agro- 
ecologieal zone, reveals that the acute malnutrition for boys is 
appreciably higher than that for girls in the 6 - 2 4  month age 
bracket. The gap closes and reverses in the older age bracket which 
incidentally has relatively little malnutrition.
Malnutrition is observed to be severe in the savanna agro- 
ecological zone. This is consistent with earlier studies which 
reported higher levels of malnutrition in the northern regions 
(Levinson, 1988; 1961-62 and 1986 National Nutrition Surveys).
Defining chronic malnutrition as the height-for-age z score of less 
than -2.0 and acute malnutrition as the weight-for-height z score 
of less than -2.0, Greater-Accra has the lowest levels of both 
acute and chronic malnutrition. The remainder of the coastal agro- 
ecological zone has appreciably less chronic malnutrition than the 
forest or savannah regions.
The Demographic and Health Survey (GSS, 1989b) reports levels
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of malnutrition among 1,841 children between the ages of 3 - 36 
months. Chronic malnutrition constitutes 30 percent of the sample 
reported and this is comparable to the level in the GLSS data 
reported for children in the same age bracket. The survey further 
indicated high levels of malnutrition in the north, and the two 
upper regions which were comparable to the savanna zone. It was 
also found that children who recently had diarrhoea have high rates 
of malnutrition and also there was a pronounced improvement in the 
rates of malnutrition of those whose mothers have had more than a 
middle school level (10 years of schooling) of education.
According to the survey, stunting and underweight occur among 
almost one in three children aged 3 to 36 months in rural areas, 
where over two thirds of the Ghanaian population lives. Nearly one 
in three urban children are stunted and nearly one in three urban 
children is underweight.
Maternal education, related to both knowledge of good child­
care practices and household wealth, just over one-third of 
Ghanaian mothers of children aged between 3 and 36 months has never 
attended school. There are large regional variations; over 80
percent of mothers in Upper West, Upper East and Northern region 
have never been to school while between 20 and 50 percent of 
mothers in the other regions have never been to school.
Undernutrition is considerable higher among children of mothers 
with no education or only primary school education than among 
children of mothers with secondary or higher education. One in six
children of mothers with secondary or higher education is stunted,
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whereas one in three children of mothers with no education is 
stunted.
2.2.2.2 Nutritional Status of Adults
Few studies have been done on the nutritional status of adults 
in Ghana. Alderman (1990) attributed this partly to, adults being 
less vulnerable to severe consequences of under-nutrition. This is 
because nutrition status of adults especially height, to a large 
extent is determined during childhood. According to Martorell, et 
al. , (1987) the nutritional status of women as well as possible
consequences for birth outcomes and subsequent infant mortality are 
of particular concern in studying nutritional status of adults. 
Clinical signs of malnutrition for mothers have been found to be 50 
percent higher among pregnant than non-pregnant women of 
reproductive age (CRS, 1987).
Using the GLSS data, the nutritional status for adults were 
classified based on Body Mass Indices (BMI) for females (excluding 
pregnant or lactating women) for urban and rural populations 
following the classification of the Royal College of Physicians. It 
was found that generally, rural residents were thinner than their 
urban counterparts, males were leaner than females and a larger 
number of females had BMIs in the higher brackets and therefore 
indicated overweight or obesity (Alderman, 1990).
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CHAPTER THREE
CONCEPTUAL FRAMEWORK AND MODEL SPECIFICATION OF THE UNDER FIVE
HEALTH AND NUTRITION MODEL
3 .1 Conceptual Framework
3.1.1 Utility Function
A household’s decision on consumption of commodity bundles 
involves the maximisation of the utility function, U, subject to 
the income of the household. Thus, a household maximises
U = U ( Xj ) . ....... (1)
subject to the budget constraint
Y = E P. X;  ( 2)
where Xj is a vector of consumption bundles, P{ are the prices of 
the bundles and Y is the income of the consumer. Transforming 
equations (1) and (2) into the Langrangian function, V, we obtain,
V = U ( X ; ) + A ( Y  - E Pj Xj ) .... (3)
where A is the langrangian multiplier. The first order conditions
are obtained by setting the first partial derivatives of (3) equal
to zero. Thus,
dV = Uj - A P; = 0  (4)
dX;
dV = Y - p. X: = 0   (5)
dA
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The equations of (4) may also be written as
(6)
This ratio gives the rate at which satisfaction would increase if 
an additional unit of income were spent on a particular commodity. 
For example, if more satisfaction could be gained by spending an 
additional unit of currency on health, H, rather than nutrition, N, 
the consumer would not be maximising utility. Satisfaction could be 
increased by shifting some of the expenditure from H to N.
The second-order conditions as well as the first-order 
conditions must be satisfied to ensure that a maximum is actually 
reached. The second-order condition for a constrained maximum 
requires that the relevant Bordered Hessian determinant is 
positive. This is generally written as
where n is the number of commodities in utility function and i and 
j are the commodities under consideration. From equations (4) and 
(5) the following demand function is obtained.
The demand functions obtained in (8) have two important 
properties (Henderson and Quandt, 1980);
(i) the demand for any commodity is a single-valued function of 
prices,Ps, and income,Y and,
33
(7)
( - 1 ) "  IL 0
Xj = Xj ( P., Y ) (8 )
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{i i) the demand functions are homogeneous of degree zero in prices 
and income;, that is, if all prices and income change in the 
same proportion, the quantities demanded remain unchanged.
In actual fact, other characteristics of the individual and 
his environment affect the demand for the commodity and these can 
be represented by Z. Hence, the demand function is represented by:
Xj = X; (Pj, Y , Z) .............. (9)
Individuals or households make decisions on the consumption of 
health and nutrition. This depends among other factors, on the 
level of the community’s infrastructure, the prices that they face 
and the technology for producing nutrition and health.
If transfer programmes and other policies aimed at poverty 
alleviation are promoted as likely to have major nutritional 
impacts, the understanding of the interactions among the income 
transfers, the publicly provided inputs, and the household’s 
response among the poorest segments of the target population is 
needed (Schiff and Valdes, 1990c). Also the design of welfare 
policies depend on the social costs and benefits of the alternative 
public policies, where benefits relate to the response in terms of 
the production of nutrition and health.
3.1.2 Nutrition and Health Production Functions
In the production of nutrition and health, the issue of the 
complementarity of the publicly provided inputs and of those inputs 
provided by the household are crucial. Schiff and Valdes (1990a, 
1990b) disaggregated the nutrition and health status into a
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production function.
At the household level, "producing" nutrition (a nutrition 
production function) gives an indication of the nutrition status of 
the household. The nutrition status (N) is a function of (1) the 
inputs of nutrients (r) such as calories, protein, vitamins, (2) 
the input of non-nutrient food attributes (q) which affect 
nutrition, such as freshness of the foods purchased, their
cleanliness, their storability, (3) the privately provided inputs
(p) which affect nutrition, such as the time and care to prepare 
food including cleaning, cooking, boiling water and other inputs 
that ensure that the food does not get contaminated or spoiled and 
(4) the publicly provided inputs (k) which include potable water, 
sewerage, electricity, nutritional information, among many others. 
The production of nutrition (N) is also partly determined by the
individuals’ health status, as well as by age (A), sex (S) and
locality (L), either rural or urban.
Essentially, using the above defined notation, the nutritional 
status production function can be written as (Schiff and Valdes, 
1990c),
N = N ( r, q, p, k, H; S, A, L )  (10)
An important component of the household’s welfare is the 
health status (H) of its members. This depends in part on their 
nutritional status (N). As with nutrition at the household level, 
a health production function is a function of the nutritional
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status IN}, privately provided inputs (p), publicly provided inputs 
(k), and (m) which represent current and lagged values of 
additional inputs affecting health. The variable m consists of both 
privately provided inputs such a!3 amount and quality of child care 
and hygiene, and of publicly provided inputs such as medical 
services, information on hygiene and child care among others. The 
health production function also depends on age (A), sex (S) and 
location (rural or urban) (L) of the individual.
Mathematically, the health production function can be written
H = I ( N , p , k , m ; S , A , L ) ................(11)
The reduced-form equations for nutritional and health status 
can be derived for a farm household whose decisions on the 
consumption and production of health and nutrition are basically 
made by individuals or by the households in which they reside, 
given their assets, level of the community’s infrastructure, the 
prices that they face, and the technology for producing nutrition 
and health. In general, a household makes decision on the quantity 
of a commodity that will be purchased based on commodity prices and 
income.
Empirical estimates of health status have been obtained by 
Behrman and Deolalikar (1988) through micro studies. Their 
specification involved (i) clinical measures of bodily attributes;
(ii) anthropometric measures of height, weight, triceps skinfold 
thickness, arm circumference, among others; (iii) respondent-
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reported disease symptoms, mortality histories, and general health 
evaluation; and (iv) reports on capacity for undertaking normal 
respondent activities.
3.1.3 Anthropometric Indicators
Weight and height are the two anthropometric measurements most 
often taken in health and nutrition surveys and used in conjunction 
with each other or with age to explain health and nutrition 
conditions on individuals. These measurements, in combination with 
age, can be used to derive three indicators: weight-for-height, 
height-for-age, and weight-for-age. To obtain a particular 
indicator, a z-score is computed from the vital measurement, its 
sample mean and its standard deviation. Essentially, the z-score 
statistic is calculated as,
X - X
z = -------  , where z is the z-score, X is the measurements
a
(either the weight or height), X is the mean of the respective 
measurements of X and a is the standard deviation of X.
Each of these anthropometric indicators gives different 
information about health and nutritional status. The interpretation 
of this information is possible through comparisons with a 
reference population and usually makes use of cutoffs in order to 
imply a value judgement of acceptable or unacceptable levels.
The anthropometric measurements and their associated 
indicators have been used to measure the extent of malnutrition in 
children (under 18 years) which in turn gives an indication of the
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health status of a population.
An allied indicator, the body mass index (BMI) , which is a 
ratio of the weight in kilogrammes and the square of the height in 
meters has been used to give an idea of the nutritional and health 
status of adults (18 years and above).
3.1.3.1 Weiaht-for-height
Weight-for-height can be used as an indicator for either 
"wasting” or obesity. The individual with a weight-for-height below 
a specific cutoff may be considered wasted, or emaciated. High 
weight-for-height values can be used to denote obesity in an 
individual or a population group.
Based on the Harvard Standards, individuals with weight-for- 
height levels which are below 80 percent of the standard median are 
said to have been "wasted" and their situation reflects current 
malnutrition (United Nations, 1990). Severe wasting occurs when the 
score is 70 percent of the standard median.
One known cause of low weight-for-height levels is a food 
intake inadequate to meet the energy needs of the individual, as in 
the case of starvation or in a situation such as infection in which 
energy requirements are not met. Another cause of low level of 
weight-for-height is the inadequate uti1isat ion of available energy 
because of malabsorption of foods, fever-, or diarrhoeal diseases, 
indicating a clear link between nutrition and health.
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3.1.3.2 Height-for-age
Low height-for-age indicates "stunting". Under the Harvard 
Standards a case of stunting occurs when height-for-age is below
87.5 percent of the standard median and severe stunting is when the 
value is less than SO percent of the standard median (United 
Nat ions, 1990 ) .
While wasting can generally be attributed to inadequate food 
intake or utilisation or serious infection, the causes of stunting 
are less clear. This indicator is not as sensitive to serious 
inadequacies of food intake as is weight-for-height, and seems to 
be the last indicator to be affected, in acute starvation.
In individual cases, the arrest or slowing of linear growth, 
that is, height-for-age, has been detected following a decrease in 
weight-for-height due to limited energy availability or 
utilisation. Non-nutritional causes such as genetic effects, 
infectious diseases, and socio-economic conditions are often cited 
as causes of stunting.
3.1.3.3 Weight-for-age
Weight-f or-age has been until now the most commonly used 
anthropometric indicator; but recently a number of disadvantages of 
using only this indicator when evaluating the nutritional status of 
populations have been documented (United Nations, 1990). Weight- 
for-age gives the least clear picture of a population’s nutritional 
status, because it is a composite indicator of both weight-for- 
height and height-for-age. A short child with a normal weight-for-
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height may have a low weight-for-age, or, conversely, a tall wasted 
child may have a normal weight-for-age. In a population, weight- 
for-age would not indicate whether the malnutrition was due to 
stunting or due to wasting.
Despite these problems, this indicator is still necessary for 
comparisons with earlier surveys, as weight-for-age was the first 
anthropometric indicator in general use and it is the indicator 
used on individual "Road to Health" cards.
Of the three anthropometric indicators used, weight-for-height 
is the best indicator of current and acute malnutrition (United 
Nations, 1990). When food intake is significantly reduced, or 
infection is sufficiently serious, weight-for-height would be the 
first indicator to be affected.
3.1.4 Health-Nutrition Dichotomy
The link between poverty and one of the main root causes of 
rural poverty in Ghana is low agricultural productivity which is 
caused by inefficient input distribution, inadequate extension 
services, inefficient marketing system, lack of credit, lack of 
appropriate technology and rigid and outmoded institutions. Low 
agricultural productivity results in inadequate food supply and low 
household incomes. Since most of the people in the rural areas are 
subsistent farmers, their livelihood depends on their farms. Low 
agricultural productivity results in inadequate amounts of food and 
therefore renders the people food insecure. The health and 
nutrition status of individuals is thus affected which in turn
40
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Figure 3.1 The Health-Nutrit ion Dichotomy. The Poverty Trap.
Death
Incidence
of
disease
Poor 
health
Mai - Under­
nutr i t ion nut r i t ion -<
Low household 
income
leads to a fall or deterioration of standard of living (Figure 
3.1).
Health status has an exceptional place among the determinants 
of undernutrition. It has a direct effect on nutrient utilisation. 
Individuals suffering from poor health tend to eat less because of 
their illness and consequent loss of appetite. When an infection 
occurs to children, mothers often cease feeding the children, 
either because of simultaneous food shortages (Nabarro, 1984) or 
because of cultural believes regarding illness (Bos et al. , 1993 ). 
The ability to digest food and actually absorb nutrients into the
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blood during infection is decreased during illness, especially in 
diarrhoea (Bos et al. , 1993 ). However, during infection there is 
the need to increase nutrient utilisation to combat the infection 
and restore any damage done to body tissues.
Infectional agents which reduce the health of an individual, 
are influenced by other environmental conditions or factors. These 
include the access to clean dr inking water, type of toilet facility 
available, care of the individual, the way food is prepared and 
stored, hygiene, household size. For instance, the influence of the 
quality of sewerage on nutritional status can be explained from its 
effects on infection (Wolfe and Behrman, 1982).
3.1.5 Nutritional Status of Children (under 5 years)
The strong relationship between health and nutritional status 
has already been emphasised in earlier sections. The stock of 
health and nutrition is valued both as investment and a consumption 
commodity (Reutlinger and Selowsky, 1978; Alderman and Garcia, 
1993). The stock of health and nutrition is part of a person’s 
human capital (the productive stock embodied in human beings) and 
this appreciates at an increasing rate at the early stages of the 
life cycle and depreciates over time at an increasing rate after 
some stage of the life cycle. The stock of health and nutrition can 
be increased by investments in health and nutrition, for example, 
eating a nutritious diet, seeking medical care or keeping hygienic 
or sanitary conditions.
Bos et. aJ. ( 1993) define nutritional status as the pool of
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nutrients in the body that is or can become available to 
metabolism. During early years of life, when organs are still 
developing, low nutrient intake can impair organ growth and 
function. Martorell (1989) finds that children who grow poorly are 
likely to be severely ill when infected and more likely to die than 
children who grow well.
The nutritional status of a household depends not only on its 
nutrient intake level, but also on other privately and publicly 
provided goods and services (Schiff and Valdes, 1990c). The 
nutrient intake of the body is directly determined by the quantity 
of the food available to the individual (Bos e_t al. 1993). It is
not only how much food the individual obtains that determines the 
nutrients actually absorbed in the body, but also the quality of 
that food, for example, nutrient content, digestibility, additives 
and toxicity. This combination of quality and quantity is the 
result of external influences. An external influence occurs when 
for example, after obtaining a certain quantity of food with 
certain qualities, foodstuffs undergo changes, due to preparation 
or conservation. For instance, cooking can reduce vitamin content 
and at the same time increase digestibility. Thus, individual food 
availability, define what and how much food is at a person’s 
disposal.
Haddad and Kanbur (1991) have observed some disparities in the 
allocation of the available food to household members. Similar 
individuals are treated dissimilarly in the allocation of 
consumption within households. Thus, understanding intrahousehold
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inequality gives an idea of the food intake of an individual in a 
household.
The issue of intrahousehold inequality arose in the literature 
out of dissatisfaction with "unitary" models of the household, 
especially in explaining observed inequality in consumption and 
achievements of different household members, even after making an 
allowance for relevant differences among them (Sen, 1984). Sen 
(1984) also summarised a number of studies on outcome variables 
which argued that girls within households are discriminated against 
relative to boys. One such case is that, boys are given more food 
than girls. Some evidence of calorie intake inequality presented by 
Harriss (1986) and Haddad and Kanbur (1990) have shown that, 
standard measures of inequality in calorie adequacy would be 
understated by 30 to 40 percent if intrahousehold inequality was 
ignored.
Studies indicate that mother’s schooling may play an important 
role in determining household nutrition and health (Behrman and 
Wolfe, 1984; Heller and Drake, 1979; Rosenzweig and Schultz, 1982; 
Wolfe and Behrman, 1982; and the World Bank, 1980). This is because 
an increased level of education of women may imply knowledge of 
better nutrition and health which can be applied to the benefit of 
the whole household.
3.2 Specification of the Under-Five Health and Nutrition Model 
(UFHNM)
The under-five health and nutrition model for this study is
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based on the household as the unit of analysis. The behavioural 
model takes into consideration both publicly and privately provided 
inputs as already elucidated upon.
3.2.1 Behavioural Model
The nutritional status, proxied by food intake, of a child in 
a household depends on a number of privately and publicly provided 
goods. It also depends directly on food available to the individual 
in the household. The privately provided inputs include food 
availability, care, health condition (status), age and body weight. 
The publicly provided inputs on the other hand, include sanitation.
1. Food availability. The food available in the household (Kcal) 
is the amount of food available for all members of the household in 
kilocalories. This is obtained by converting food expenditure 
information to weight (in kg) using prices. The conversion involved 
45 food commodities whose prices were available through the Price 
and Community Survey.
Bouis et. &±. ( 1992) have pointed out that the use of food
expenditure surveys has led to severely upwardly biased estimates, 
and that food intake survey techniques give more accurate estimates 
of nutrient demand parameters. Summers (1959) has also explained 
that for econometric reasons, it is better to use income instead of 
expenditure in explaining food consumption since expenditure may be 
significantly correlated with the error term. However, Friedman 
(1957) suggests that permanent income, which may be represented 
more accurately by total expenditure, may reflect the purchasing
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power of a household better than measured current income which may­
be distorted by transitory components such as windfall income.
Food availability to the household is cast in the framework of 
a demand function and so it is assumed to depend on income, 
relative prices, the household size in adult equivalent, the 
quality of care available to the child from the household and the 
level of sanitation in the child’s immediate environment (the house 
in which the child lives). The household is assumed to have a 
definable utility function, a known income or expenditure for a set 
of prices and other characteristics of the individual and his 
environment. The apriori expectations are that households with 
higher income per capita tend to have more food available to its 
members; the prices of normal food commodities are expected to be 
inversely related to food availability. Since these foods include 
substitutes, complements and neutral commodities it may be 
difficult to apriori hypothesise the signs for the food prices in 
the equation.
The level of education of mother of child is expected to 
positively affect nutritional status. Similarly the larger the 
household size in adult equivalent, the larger the food available 
to the household (via the production function).
Households with higher food available per capita would have a 
higher nutrition status. In order to know the food intake, that is 
food available per capita (kcali), attention must be paid to intra­
household food allocation. Therefore average food availability per 
person should be corrected for age of the household member, that
46
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is, adult equivalent consumption unit, and household size in adult 
equivalent. For simplicity, it is assumed that children consume 
less food than adults.
2. Body weight. The body weight, which also measures the health 
condition of the child, is a function of food intake, the health 
status of the child, the age of the child, genetic factors of the 
parents and the gender of the individual. The amount of food 
consumed has a positive impact on body weight since excess calories 
over and above the energy requirement and other needs are converted 
into body mass. The body frame and metabolic factors of a person 
also depend upon the source of the genetic material of the person.
When the weight of a child is normal then it can be assumed 
that the child has a normal growth or an acceptable health status. 
This implies that there are no health inhibitions in the ability of 
the child to consume and convert food to nutrients for normal 
functioning of the body. Thus , the higher the weight of a child 
the higher the food intake and the better the nutritional status.
The health status, weight-for-height standardised score 
(whzp), depends on the weight and height of the child. A function 
is estimated recursively for the whzp,5 where it is assumed to 
depend upon the weight and height of the child. This is then used 
as a proxy for health status in the body weight function.
Finally, instead of estimating separate functions for the
5 The results obtained for the whzp are sufficient to use the 
estimated function as an approximation of reference curves 
(Albersen, 1993).
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rural and urban areas because of expected behavioural differences, 
a dummy variable for location was included in the food availability 
and body weight formulations.
The behavioural model can be summarised as follows:
Whzp = g ( Weight, Height)  (12)
Food availability = h (Income, Relative Prices, Care, Sanitation,
Household size in adult equivalent,
Locat ion)  (13)
Body weight = I ([(Adult equivalent consumption unit*food
available)/househo Id size in adult
equivalent],, Age, Genetic factor of parents,
Health status, Gender, Location) ........ (14)
Food intake = J ([Adult equivalent consumption unit*food
available)/househo Id size in adult
equivalent}) .... ...(15)
3.2.2 The Structural Model
In determining the structural model to be used, various forms 
of estimation procedures were employed before selecting the best 
model based on a priori expectation.
1. The specification of the under-five health and nutrition model 
in Ghana is algebraically presented in cubic formulation as 
fo1 lows:
Whzp =  (Wt -  ( a ,  + cijHt + oc2Ht2 )J /  (/3, + fyH t + j02Ht2 +
VA H t 3)  (16)
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where
Whzp is standardised weight-for-height Z-score,
Ht is height of the child in metres and
Wt is weight of the child in kilogrammes.
2. Food availability is cast in a Cobb-Douglas form (double-log).
Price of maize is used as a deflator to convert nominal prices and
total expenditures into real terms. This is because maize is one of 
the main contributors to calories in Ghana. Price of maize is used 
as a deflator to reduce inflationary tendencies in the data 
collected over a number of seasons in a period of one year.
log(Kcal) = a0 + a1 (Em) + aj(Sw) + ajlog^izeq) + a41 og(Te/Pmai ze) + 
a5log(Pcas/Pmaize) + a6 log(Pgcorn/Pmaize) + 
a7log(Pmi1/Pmaize) + a, log(Pgarri/Pmaize) + 
a9log(Pyam/Pmaize) + a10 log(Pccyam/Pmaize) +
ajjlog(Pptain/Pmaize) + aj2(Durb) + 6j ...... (17)
where
Kcal is daily household kilocalories from 45 food commodities, 
Sizeq is household size in adult equivalent,
Te is total household expenditure in cedis,
Peas is price of cassava in cedis per kilogramme,
Pmaize is price of maize in cedis per kilogramme,
Pmil is price of millet in cedis per kilogramme,
Pgarri is price of garri in cedis per kilogramme,
Pyam is price of yam in cedis per kilogramme,
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Pccyam is price of cocoyam in cedis per kilogramme,
Pptain is price of plantain in cedis per kilogramme,
Pgcorn is price of guinea corn in cedis per kilogramme,
Em is dummy for educational level of motherfEm=l for above 10 years
Sw is dummy for treated water
Durb is dummy for urban area
ej is the error term.
[Em=0 otherwise 
Sw=l for treated water
i
Sw=0 otherwise
Durb=l for urban area , and
purb=0 for rural area
3. The body weight equation is in a mixed log form and it is 
specified as follows:
log(Wt) = b0 + bjlog( [Scale*Kcal ]/sizeq) + b2 (Hm) + b3(Whzp) +
b,(Months)+ b5(Dsex) + b6(Durb) +  (18)
where
Wt is the weight of the child (kg),
Scale is adult equivalent consumption unit,
Kcal is daily household kilocalories from 45 food commodities, 
Sizeq is household size in adult equivalent,
Hm is height of mother of child (in metres),
Whzp is standardised weight-for-height Z-score,
Months is the age of the child (in months),
Dsex is dummy for gender of child lDsex=l for female
!Dsex=0 otherwise
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Durb is dummy for urban area *Durb —1 for urban area , and
Durb=0 for rural area
e2 is the error term.
4. The individual daily calorie intake is obtained from the 
household food availability using a conversion factor. The 
conversion is done as
Kcali = (Scale x Kcal)/Sizeq  (19)
where
Kcali is individual daily calorie intake estimate in kilocalories, 
and Scale, Kcal and Sizeq have the same notation as in equation 18, 
above.
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CHAPTER FOUR
ESTIMATED RESULTS, VALIDATION AND POLICY EXPERIMENTS OF THE UNDER 
FIVE HEALTH AND NUTRITION MODEL
4.1 Introduct ion
This section is in three parts. The first part discusses the 
results from frequency computations, and bi-variate relationships 
through cross tabulations and the estimation of the econometric 
model presented in chapter three. The validation of the model then 
follows in the second part. Results and discussions of policy 
experiments of the under five model are summarised in the last 
part. The analysis is based on a sample size of 2,127 children of 
below five years of age drawn from the GLSS I data set.
4.2 Determinants of Health and Nutritional Status
4.2.1 Privately Provided Inputs
Some of the important privately provided inputs that determine 
the health and nutritional status of children of 0 to 59 months old 
are food intake, care, weight and the anthropometric indicators. 
Comparison of these inputs will be by locality (rural and urban); 
agroecological (coastal,, forest and savannah and zone); north and 
south to bring out the distribution of these important variables in 
Ghana.
The distribution of food intake (kcali), by children of 
various age groups is presented in table 4.1. When compared with 
Required Dietary Allowance (RDA), it is found that on the average
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Table 4.1 Average Calorie Intake of Children Under Five in
Ghanaian Households, 1987/88
Average calorie intake
Infants Children
0-6 months 7-12 months
r ....
13-36 months 37-59 months
means std. dev. mean std.dev. means std. dev. means std. dev.
*RDA 702 - 972 - 1300 - 1800 -
Ghana 479 787 947 942 1138 1159 1397 1306
Locality
Rural 522 914 975 1030 1206 1265 1445 1402
Urban 379 318 880 685 987 862 1275 1016
Region
Ashant i 287 376 738 525 793 464 1042 727
Brong-
Ahafo 410 560 894 817 1058 910 1209 1065
Central 410 396 772 655 870 734 1312 984
Eastern 569 1221 1015 1381 1305 1736 1615 1723
Greater-
Accra 545 364 1004 609 1041 631 14 66 1111
Northern 448 570 1891 1447 1839 1710 2013 1896
Upper East 864 1198 1174 1090 1407 1692 2400 2064
Upper West 819 1613 1147 1185 1927 1629 1804 1706
Volta 434 464 717 588 992 925 1242 1122
Western 270 248 845 721 1086 848 1140 838
Zone
North 724 1257 1426 1276 1763 1686 2045 1885
South 429 643 853 833 1016 980 1290 1151
Agroecologv
Coastal 445 390 962 1069 968 S33 1359 1071
Forest 421 809 771 614 994 977 1165 1097
Savannah 592 1017 1265 1183 1562 1573 1825 1723
Source: Computed from Ghana Living Standards Survey, 1987/88 data of the 
Statistical Service, Ghana.
* RDA, 1974. Recommended Dietary Allowances. National Academy of Science, eight 
edition. Food and Nutrition.
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Ghanaian children of 0 - 59 months old receive 82.7 percent of the 
required dietary allowance, although there are wide geographical 
di f f erences .
Food intake in the rural areas turns out to be higher than 
that for the urban areas for all age groups under 5 years. This 
finding is at variance with the notion that there is more poverty 
in the rural areas than in the urban areas as reported by Boateng 
et al. ( 1990). However, Minhas (1991) obtained similar results as 
the present study when he compared the average intake of calories 
of rural and urban people in India.
With reference to the ten political administrative regions of 
Ghana, the Upper East and Upper West regions have a higher consump­
tion of calories as compared to the other regions. Western region 
has the lowest calorie intake for children of under five years old.
Dividing Ghana into two zones, the North and South, the North 
which comprises the Northern, Upper East and Upper West regions has 
a higher caloric intake than the South in all the age 
categories of children under five years old. Just like the rural- 
urban comparisons, the food intake results do not corroborate 
poverty studies which have concluded that the North is poorer than 
the South. These differences in caloric intake are possible since 
lower prices in the rural areas and in the North may imply higher 
estimates of quantity of food intake via expenditure data than in 
the urban areas and in the South where food prices are generally 
higher.
Comaparing the average caloric food intake across the
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agroecological zones, the savannah has the highest food intake 
estimate followed by the coastal and then the forest zones with 
1490 kcal/child/day, 1046 kcal/child/day and 961 kca1/chi 1 d/day,
respect ively.
Table 4.2 shows the mean weight distribution of children 
under-five years old by age in Ghana, by rural/urban, region, 
north/south and agroecological zone. The mean weight of children 
under five years old is 13.19 kg which is higher when compared with 
the recommended average weight of 12.00 kg for a child under 5 
years (RDA, 1974). This represents about 9.92 percent difference
over the recommended mean weight of children. The mean weight of 
children in the rural and urban areas are 13.18 kg and 13.22 kg, 
implying that children in urban areas are a little heavier than 
those in the rural areas.
In the ten political regions, Brong-Ahafo, Eastern, Northern 
and Upper East regions have mean weight of a little above 14.00 kg. 
The region with the lowest mean weight is the Volta region followed 
by the Central region with 11.88 kg and 11.95 kg respectively.
Dividing Ghana into two, the north and south, the mean weights 
are 13.66 for the north and 13.11 kg for the south. Comparing the 
mean weight and the average food intake of a child 0 to 59 months 
old, the weight value follows the same pattern as the food intake 
with children in the north being heavier then those in the south.
In terms of agroecology, children in the savannah zone have 
the highest mean weight followed by the coastal and forest zones
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Table 4.2 Mean Weight of Children Under-Five Years Old
by Age of Children, 1987/88
Age Group (months)
1-12 13-24 25-36 37-48 49-59 Comb ined
Ghana 10.37 12. 67 13.30 15.41 15.57 13.19
Localitv
Rural
Urban
10.53
10.03
12.91
12.11
13 . 25 
13 . 40
15 .40 
15.43
14 . 93 
17.34
13.18 
13 .22
Region
Ashant i 
Brong-Ahafo 
Cent ral 
Eastern 
Greater-Accra 
Northern 
Upper East 
Upper West 
Volta 
Western
10 . 00 
11.36 
7.61 
12 . 95 
9 . 62 
10 .82 
13.16 
8 . 60 
8. 10 
11 . 26
12. 38 
14.79 
11 .09 
13.61 
11.23 
15.94 
15 . 60 
10.91 
10.03 
12.02
13 . 67 
14.37 
13.11
12.50
13.51 
13.13 
16.15 
13 . 77 
12.05 
12. 98
15.31 
17.05 
13.70
16.31 
14. 88
14 . 45 
14.74
15 . 25 
15.19 
15.77
14 . 40
15.16 
16. 30
17.17 
16.73 
16. 64 
14 . 20 
14.71 
14 . 54 
15.41
12.74 
14.41 
11 .95 
14. 18 
12.77 
14.09 
14 . 85 
12.01 
11 .88 
13.43
Zone
North
South
10 . 89 
10 . 28
14. 56 
12. 27
13.93
13.19
14 . 79 
15.52
15 .92 
15.53
13.66
13.11
Agroecologv
Coastal
Forest
Savannah
10.46 
9 . 53 
11 . 67
11 . 62 
12 . 26 
14 . 43
13.31 
13.19 
13 . 45
15.30 
14.97 
16. 18
16.74 
14.37 
16 . 49
13.21
12.60
14.14
Source: Computed from Ghana Living Standards Survey, 1987/8S data 
of the Statistical Service, Ghana.
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with 14.14 kg, 13.21 kg and 12.60 kg, respectively.
Years of formal education of mother of children under 5 years 
old, which is used as a variable to explain the care given to a 
child shows that about 52.7 percent of the children under 5 years 
have mothers who have no formal education (table 4.3). About 32.4 
percent of the mothers had 7 to 10 years of formal education that 
is, up to middle school education, and 12.0 percent of them had 1 
to 6 years of formal education, that is primary school education. 
Only 0.2 percent of the mothers had been able to attain 18 to 25 
years of education, which is equivalent to tertiary or university 
education. About 78 percent of the mothers in the rural areas had 
never been to school as compared with about 22 percent in the urban 
areas.
The distribution of undernutrition among children, 0-59 months 
reveals that 29.50 percent of children are chronically under­
nourished, that is, they are too short for their age or stunted 
(height-for^age z-score that is below -2 standard deviation of the 
reference population). This shows that about 1 in 3 children aged 
0-59 months are chronically undernourished (table 4.4). About 27.20 
percent of children in Ghana are underweight (weight-for-age 
z-score that is below -2 standard deviation of the reference 
population). This implies that about 1 in 3 children in Ghana are 
underwe ight.
Acute undernutrition, which is manifested by wasting (weight- 
for-height z-score that is below -2 standard deviation of the 
reference population) is about 7.10 percent of children in Ghana
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Table 4.3 Distribution of Years of Formal Education of Mothers’ 
of children Under 5 Years in Ghana, 1987/88 
(in percentages).
Years of Education
0 1-6 7-10 11-17 18-25
Ghana 52.70 11.99 32. 36 2 .76 0. 19
Locality
Rural 77 . 69 
(58.51)
70.55
(12.09)
61.51
(28.45)
22.54 
( 0.89)
20 . 00 
( 0.06)
Urban 22.31
(39.15)
29.45
(11.76)
38 . 49 
(41 .47)
77 . 46 
( 7.11)
80 . 00 
( 0.52)
Aaroeco1oev
Coastal 25 . 70 
(44.74)
32.04 
(12.69)
35.13
(37.56)
50.70 
( 4.62)
60 . 00 
( 0.38)
Forest 36.52
(44.05)
53 . 72 
(14.74)
52.40
(38.81)
35 . 21 
( 2.22)
40.00 
( 0.18)
Savannah 37.78
(76.45)
14. 24 
( 6.56)
12.47
(15.50)
14 . 08 
( 1-49)
0.00 
( 0.00)
Source: Computed from Ghana Living Standards Survey, 1987/88 data 
of the Statistical Service, Ghana.
Figures in parenthesis give the contribution of mothers’ years of 
formal education.
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Table 4.4 Distribution of Undernutrition among Children Aged 0-59 
Months in Ghana, 1987/88 (in percentages)
Chronically 
undernour i shed
Underwe ight Acute 
undernutr it ion
Ghana 29.50 27.20 7.10
Localitv
Rural 80.22 78. 57 76. 96
Urban 19.78 21.43 23.04
Region
Ashant i 16.18 17.41 20. 10
Brong-Ahafo 13.97 13.54 9.31
Central 10. 10 9.97 7.31
Eastern 11.76 10 . 42 11 .35
Greater-Accra 7.61 6.85 9.31
Northern 7.61 8.48 10.78
Upper East 3.73 3.27 4.41
Upper West 6.82 7 . 29 7.84
Volta 9.82 9.82 9.31
Western 12.31 12.95 10.29
Zone
North 18 . 26 19.05 23 .04
South 81. 74 80 . 95 76.96
Aeroecoloav
Coastal 24.07 23 . 96 24.51
Forest 47 . 16 47 .32 42. 16
Savannah 28.77 28.72 33 . 33
Source: Computed from Ghana Living Standards Survey, 1987/88 data 
of the Statistical Service, Ghana.
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aged 0-59 months. Thus, approximately 1 in 13 Ghanaian children are 
wasted. The distribution of undernutrition is thus consistent with 
results obtained from the Demographic and Health Survey carried out 
in 1987.
The rural areas turn out to be more undernourished (high 
percentages of chronically undernourished, underweight and acute 
undernutrition) than the urban areas (table 4.4). This confirms 
earlier findings (Boat eng jet ad. , 1990) that poverty in Ghana is a 
rural phenomenon. The Southern part of Ghana have more children 
undernourished than the Northern part. This is not consistent with 
other revelations that levels of poverty are higher in the North 
than in the South. Undernutrition of all forms is severe in the 
forest area followed by the savanna and coastal areas.
4.2.2 Publicly Provided Inputs
Sources of drinking water and light are some of the important 
publicly provided inputs which affect the health and nutritional 
status of children especially those under 5 years of age.
When the source of drinking water is disaggregated into 
untreated and treated water, about 75.62 percent of the children 
are raised in households with untreated source of drinking water 
(table 4.5). This has a serious repercussion on the health and 
nutritional status of the children, who tend to be vulnerable to 
all types of diseases especially, in these formative years of their 
1ives.
Only 24.4 percent of the children under 5 lived in households
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Tab l e  4 5 Distribution of Source of Drinking Water in Ghana,
1987/88
Source of drinking water
Untreated Treated
Ghana 75.62 24.38
Localitv
Rural 86.35 18.22
(93.63) ( 6.37)
Urban 13.64 81.78
(34.10) (65.90)
Agroecologv
Coastal 19.77 65.06
(48.51) (51.49)
Forest 48.57 26.96
(84.82) (15.18)
Savannah 31.67 7.98
(92.48) ( 7.52)
Source: Computed from Ghana Living Standards Survey, 1987/88 data 
of the Statistical Service, Ghana.
Figures in parenthesis give the contribution of source of drinking 
water in Ghana.
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which has treated drinking water. Of this group, 81.8 percent of 
them were in the urban areas. The coastal areas are better 
endowed with potable drinking water, with 65 percent of children 
having access to treated drinking water as compared with 27 percent 
in the forest zone and 8 percent in the savanna zone (table 4.5).
In Ghana, 79.36 percent of the children under 5 years of age 
live in households without electricity. Most of these households 
are in the rural areas. About half of the sample which had 
electricity were in the coastal areas and about 44 percent were in 
the forest zone. Availability of electricity was negligible in the 
savanna zone (table 4.6).
Table 4.6. Distribution of Source of Light in Ghana, 1987/88
Source of light
No electricity Electricity
Ghana 79.36 20.64
Local itv 
Rural 83.66 16.19
(95.21) ( 4.79)
Urban 16 . 34 83 .81
(42.84) (57. 16)
Asroecolosv
Coastal 25 . 68 50 . 53
(66.15) (33 .85)
Forest 43 . 08 44 . 13
(78.97) (21 .03)
Savannah 31 .24 5 . 34
(95.74) ( 4.26)
Source: Computed from Ghana Living Standards Survey, 1987/88 data 
of the Statistical Service, Ghana.
Figures in parenthesis give the contribution of source of light in 
Ghana.
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4.3 Estimated Rasalts of the Under Five Model
Using the Statistical Analysis System (SAS) a non-linear 
ordinary least squares (NOLS) estimation procedure was used in the 
estimation of the system of equations presented in chapter three 
for the Under-Five Health Nutrition Model (UFHNM) . Appendix 2 gives 
a description of the selected variables along with their means and 
standard deviations. The estimated equations are presented in 
tables 4.7 and 4.8. The standardised weight-for-height Z-scores 
equation estimated earlier on is also presented in table 4.9.
1. Food availability. The food availability equation in double-log 
form had an R2 of 0.649 and an F-value of 307.26, signifying a good 
fit. All the price ratios were significant at least at the 0.05 
level, except the ratio of guinea corn price to the price of maize 
which was significant at the 0.1 level. Whereas price ratios of 
cassava, guinea corn and yam to maize had negative signs, those of 
millet, garri, cocoyam and plantain to maize had positive signs 
(table 4.7). The positive signs between these food commodities and 
food availability imply that when the relative prices increase, 
households may substitute for cheaper calorie sources of food.
Level of education of mother (Em), which was used as a proxy 
for care of the child entered as a dummy variable. It was found 
that even though this is significant at less than 0.1 percent 
level, more than 10 years of education had a negative relationship 
with food available to the household. A plausible explanation for 
this negative result is that with education, mothers are able to
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Table 4.7 Dependent Variable: Log(Kcal)
Variable Coefficient t-value Probability Elasticity
Constant -0.0699 -0.21 0.8345 -
Log(Te/Pmaize) 0.9555*** 47.81 0.0000 0.9555
Em -0.1138* -1.83 0.0668 -
Sw -0.1888*** -5.35 0.0001 -
Log(sizeq) 0.0733*** 2.91 0.0036 0.0733
Log(Pcas/Pmaize) -1.0459*** -5.42 0.0001 -1.0459
Log(Pgcorn/Pmai ze) -0.2970* -1.74 0.0825 -0.2970
Log(Pm i1/Pmai ze) 0.5445** 2.20 0.0281 0.5445
Log(Pgarr i/Pma i z e) 0.6043*** 2.64 0.0084 0.6043
Log(Pyam/Pmai z e) -2.1290*** -4.79 0.0001 -2.1290
Log(Pccyam/Pmai ze) 0.3329** 2.05 0.0404 0.3329
Log(Pptain/Pmaize) 0.3454** 1.89 0.0595 0.3454
Durb -0.1594*** -5.09 0.0001 _
Sample size = 2000 *** Significant at < 0.01 percent level
F-value = 307.26 ** Significant at < 0.05 percent level
R = 0.649 * Significant at < 0.1 percent level
Adjusted R = 0.646
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substitute less expensive but nutritious diets for more expensive 
ones.
Source of drinking water, dummy for treated water (Sw), has a 
negative and significant impact on food available in the household. 
This implies that treated water has negative influence on the food 
available in the household and to the child.
The household size in adult equivalent (Sizeq) which is 
significant at less than 5 percent level, has a positive relation­
ship. A 10 percent change in the household size leads to a less 
than the proportionate change in food available to the household 
(0.7 percent).
2. Weight of the child. In table 4.8, all the explanatory variables 
are significant at less than 5 percent except location (durb). The 
weight of the child under-five years old, which also determines the 
health condition of the child, is influenced by the food intake of 
the child ([scale x kcal}/sizeq). When the food intake increases by 
10 percent the weight increases by only 0.19 percent. Thus, when 
the nutrient level of the food intake of the child increases, the 
weight of the child improves by increase in the weight ceteris 
par ibus.
Standardised weight-for-height z-score (whzp), which is 
recursively determined has a positive sign in the weight equation. 
This means that there is a direct relationship between weight of a 
child and his/her weight-for-height anthropometric score. A healthy 
child has a normal increase in weight as he/she grows and the
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height increases.
The genetic factors of the parents, proxied by the height of 
the mother of child (mht) and the age of child (months) both play 
important roles in the weight of the child and thus the health 
condition of the child. Both of them positively affect the weight 
of the child (elasticities of 0.445 and 0.405 for mother’s height 
and age of child in months, respectively). Thus, although food 
intake and environmental factors affect the weight of the child, 
genetic factors also have significant influence on it.
Table 4.8 Dependent Variable: Log(Wt)
Variable Coefficient t-value Probability Elasticity
Constant 1.4198*** 8.02 0.0001 -
Log([Scale*Kcal]/ 
Sizeq) 0.0195** 2.05 0.0406 0.0195
Mht 0.2825*** 2.67 0.0076 0.4452
Whzp 0.0448*** 13.66 0.0001 -0.0143
Months 0.0145*** 30.01 0.0001 0.4053
Dsex -0.0359** -2.41 0.0162 -
Durb -0.0002 -0.01 0.9885 -
Sample size = 2000 *** Significant at < 0.01 percent level
F-value = 201.89 ** Significant at < 0.05 percent level
R2 = 0.378
Adjusted R = 0.376
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3. Standardised weight-for-height z-score (whzp). Results in table 4.9 was 
estimated using a quadratic specification for the reference height in metres and 
a polynomial of degree three for the standard deviation. It shows that all 
parameters are significant and the R2 shows a very good fit. Albersen, 1993 thus 
concluded that the results could be used in an estimated function as an 
approximation of the reference wieght-for-height z-score.
Table 4.9 Dependent variable: Whzp4
Variable Coefficient t-value
“o -3.8806** -7.25
al 9.8633** 7.36
*2 10.2190** 12.95
-6.5529** -8.83
25.7169** 9.75
h -30.5348** -10.03
Pi 12.8457** 11.21
Sample size = 2927 ** Significant at < 0.05 percent level
R2 = 0.9725
4.4 Validation of the Under-Five Model
To be able to generate confidence required in the model 
specified and estimated it is necessary to validate it. Johnson and 
Rausser (1977) define validation as the process of evaluating the
6 Adapted form Albersen, 1993.
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ability of a model to duplicate the characteristics of the system 
required to fulfill the modeling objectives.
A model can be validated by using some of the data used in 
estimating it to see how the model reproduces the data (historical 
simulation). An ex-post simulation can be carried out using a sub­
set (historical) of the data that was not used for the estimation. 
When future values of the exogenous variables are available an ex- 
ante
simulation can be carried out. The problem with ex-ante simulation 
is that the exogenous variables have to be predicted before the 
simulation can be carried out.
For historical and ex-post simulations the model can be 
examined to find out how well it reproduces the data (through plots 
of the actual and predicted/simulated values or by calculating 
errors of prediction) and how well it performs at turning points.
Data splitting and simulation is an ex-post simulation 
exercise and it involves setting aside some of the data and using 
it to investigate the model and its predictive ability. This 
technique was used in validating the estimated under-five health 
and nutrition model.
The data set for estimating the model of the under-five health 
and nutrition model was split into two parts using random 
selection. Thus the estimation was carried out using 2000 
observations and the remaining 127 was used for ex-post validation 
of the mode 1 .
Figures 4.1 and 4.2 show the simulated and actual values of
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the food available to the child (kcal) and weight of the child 
(wt). It can be seen from the plots of the ex-post simulations that 
the model tracks quite well (figures 4.3 and 4.4) with most of the 
values of the endogeneous variables (Log kcal and Log wt) correctly 
predicted.
In quantitative terms, the predictive ability of the model can 
be measured by computing the mean squared error of the predictions. 
The mean squared error (MSE) of the predictions is given by:
£  (Yj -  Yj )2
MSE = --------------
n
where Yj is the value of the response variable, Y; is the predicted 
value for the ith case (child), and n is the number of cases in the 
validation set. Low MSE denotes a reliable predictive model. 
Comparing the MSEs estimated for the food available and weight 
equations (0.223 and 0.110, respectively) using historical data 
(historical simulation) and that obtained for the ex-post 
simulation of the model (0.319 and 0.109, respectively) the 
differences in the MSEs are negligible. Thus, the models have good 
predictive power outside the data used for estimation.
4.5 Policy Experiments
In a dynamic world static models are of little use. Due to the 
uncertainty that surrounds policy instruments and other exogenous 
variables it is necessary to subject a model to some changes and 
determine the resilience of the endogeneous variables. It should be
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(Historical Simulation)
Figure 4.1 Simulated and Actual Values of Food Available to the Child (Log)
versus Household Expenditures (Log)
10
Log 
(Kcal) A
5 --
A A
A AAAAAAAAAAAAAAAAPAAAP 
AAAAAAAAAAAAAAAAAAPAAAPPAP A 
AAAAAAAAAAAAAAAAAAAAAAAAAAAAA AA A 
P A PAAAAAAAAAAAAAAAAAAAAAAAAAAA A A 
AAAAAAAAAAAAAAAAAAAA AAA A A
\ A AAAA A A 
A
10 11 12 13 14
Log(HHEXPENS)
Predicted = ’P’.
Actual = ’A’ (also when actual=predicted). 
NOTE: 3839 obs hidden.
P
AA A
A
-I— '------------- r
15 16
70
cn 
Cu
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Figure 4.2 Simulate# and Actual Values of the Weight (Log) versus Age of
the Child (Months) (Historical Simulation)
6 4-
A A
A
AAA A A AA A A
A A A A
A A A A
A A A A AA AA AAAAAAAAAA
AAA AAA A A A A A A  A
A A A A  AA A A  AA A A  
AA A A AA A
Log(Wt) AA A AA A AAA
A P A AA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA
PAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA 
AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAA AAAA AAAA AAA A 
AAAAAAAAA A A A A A  A A A A A A  A A 
AAAAA A AA A A
A
10 20 30 40 50
age of children under 5 (months)
60
Predicted = ’P’.
Actual = ’A’ (also when actual-predicted). 
NOTE: 3732 obs hidden.
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(Ex-post Simulation)
Figure 4.3 Simulated and Actual Values of Food Available to the Child (Log)
versus Household Expenditures (Log)
12  4-
10
Log(KCAL)
P
A
A
A A 
AAA A 
A A P P 
A A APPAAAPA 
A APA PAA PAPAA 
AA AAPP APAAPPAAPAA 
PPAAA AAAPAPAAA AAA 
PPPA PA A A A 
A P P A A A A 
AA A
AAA P 
PP
A PP PA
P
A
11 12 13
Log(HHEXPENS)
14 15
Predicted = ’P’.
Actual = ’A’ (also when actual-predicted).
NOTE: 146 obs hidden.
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Figure 4.4 simulated and Actual Values of the Weight of the Child (Log) versus
Age of Child (months) (Ex-post Simulation)
4 --
3 -
Log(wr)
A
PP AAP P 
PPAAAA AAAA 
P A A A  
AA
P A A 
P AAPA 
AA A
P A
-A— ~  AA" A
A P AAAA AAAAAA AA 
PP AAAAAAAPA AAA AAA 
AA A A
A AA A
AAPAPA 
AA A PPPA A ” 
A AA 
A
10 20 30 40 50
age of children under 5 (MONTHS)
60
Predicted = ’P’.
Actual = ’A’ (also when actual=predicted). 
NOTE: 143 obs hidden.
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possible to assess the effect on the system of a shock or 
disturbance through autonomous changes in the policy or exogenous 
variables. Policy experiments or sensitivity analyses have proved 
useful in examining these effects (Okyere, 1982).
In order to carry out the policy experiments, a base solution 
of the model was obtained by simulating it at the mean values of 
the exogenous variables. The exogenous variables that seemed to 
have the greatest impact on the model performance were identified 
and the value for each of these exogenous variable was changed 
within a reasonable range to observe its effect on the model 
outcome.
Policy experiments were conducted using four exogenous 
variables. Each experiment consisted of four parts. The mean value 
of the exogenous variable was increased by ten percent and twenty 
percent and then decreased by ten percent and twenty percent. 
Exogenous variables used were price of maize (Pmaize), Price of 
cassava (Peas), household expenditure (hhexpens) and household size 
in adult equivalent (Sizeq). Results of the experiments are 
reported in table 4.10.
Changes in household size produced the least sensitive 
responses in these policy experiments. The most sensitive results 
were obtained for household expenditure. A ten percent increase and 
twenty percent increase in the household expenditure results in 
66.23 percent and 71.91 percent of the recommended required daily 
allowance {RDA) of food intake for a child, respectively. 
Similarly, a ten percent and twenty percent decrease in household
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Table 4.10 Response to food intake by autonomous changes in 
selected exogenous variables in the Under-five 
Health and Nutrition Model
Individual 
food intake* 
(Kilocalor ies]
10%
increase
)
20%
increase
10%
decrease
20%
decrease
Percentage 
needed to 
meet RDA
Household Expenditure
720.29
(60.35)
790.43
(66.23)
858.84 
(71.96)
652.40
(54.66)
583.23 
(48.87 ) 42.18
Household Size in Adult Equivalent
720.29 
(60.35)
727.48 
(60.95)
734.85 
(61 .57)
713.13
(59.75)
706.03 
(59.16) 464
Price of Cassava
720.29
(60.35)
651 . 75 
(54.61)
595.66 
(49.91)
804.05 
(67 .37)
906.57 
(75.96) -37 . 92
Price of Mai ze
720.29
(60.35)
772.52
(64.73)
820.29 
(68.73)
671.60 
(56.27)
619.97 
(51. 95) 34. 51
* This was obtained by converting the food available to the child 
in the household obtained in the base solution of the model to 
individual food intake in kilocalories. Base solution is obtained 
by simulating the model at the mean values of the exogenous 
variables.
Figures in parenthesis are percentage of recommended required 
dai ly al lowance for a child 0 to 59 months ( 1194 kca 1/ch i 1 d/day) .
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expenditure results in a 54.66 percent and 48.87 percent of the 
recommended RDA to the child in the household. For the child to 
meet the recommended RDA, then average household expenditure will 
have to increase by 42.18 percent (table 4.10).
A ten and twenty percent increase in the mean price of cassava 
results in a reduction of food availability from 60.35 percent of 
requirements for the base solution to 54.61 percent of require­
ments. When the mean price was increased by 20 percent, the food 
available to a child in the household fell to 49.91 percent of the 
RDA.
However, a ten percent and twenty percent increases in the 
mean values of the price of maize led to a percentage increase in 
the RDA available in the households (64.73 percent and 68.73 
percent, respectively). Similarly, cassava and maize decreases 
induced opposing changes in the proportion of RDA available in the 
households (see table 4.10).
The average price of cassava will have to decrease by 37.92 
percent so as to meet the recommended RDA for a child 0 to 59 
months whereas the mean price of maize will have to be increased by 
34.51 percent so as to move children aged 0 to 59 months to the 
recommended RDA.
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CHAPTER FIVE
SUMMARY, CONCLUSION AND POLICY IMPLICATIONS
5.1 Summary and Conclusion
To date most health and nutrition studies undertaken in Ghana 
have focused on either nutrition and calorie consumption aspects or 
health and illness aspects of nutrition without linking nutrition 
and health simultaneously. To bridge the gap this study has tried 
to find out the factors (publicly and privately) which are the 
principal determinants of health and nutrition of children under- 
five in a simultaneous context.
The study used econometric modelling technique to specify and 
estimate the determinants of the health and nutrition status of 
children under-five years in Ghana. The estimation was based on a 
sample of 2,127 children between the ages of 0 and 59 months from 
the first round (1987/88) of the Ghana Living Standards Survey 
conducted by the Statistical Service of Ghana with World Bank 
ass istance.
Results presented in chapter four reveal that over three- 
quarters of Ghanaian children of 0 - 59 months are raised in
households which do not have access to treated water and about the 
same proportion also do not have electricity supply in their homes. 
Low levels of undernutrition and educational achievements of mother 
of child were all biased towards the rural areas with majority of 
children in rural areas being disadvantaged in this respect.
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Contrary to popular belief, results obtained for calorie 
availability was higher with rural children than their urban 
counterparts. This seemingly surprising result may stem from the 
fact that food prices are lower in the rural areas than in the 
urban areas. Thus computation of calorie availability to a child in 
a household using the expenditure approach is likely to have higher 
quantity of food availability in the rural than urban areas,
although actual intake may indicate different relativities. On the 
average, Ghanaian children aged 0 to 59 months obtain 82.7 percent 
of the required dietary allowance, which is lower than the 93 
percent for all Ghanaians between 1988 and 1990 reported by the 
UNDP (1993). Undernutrition at all levels (chronically 
undernourished, underweight and acute undernutrition) is still 
severe for children under-5 years old.
In an attempt to characterise the nutrition and health of 
children under five years in the GLSS data (first round), an
econometric model was specified and estimated. Results indicated a
positive relationship between food available to the child in a
household and the level of income (total expenditure of the 
household). Dummies for treated source of drinking water and level 
of education of mother above 10 years were found to have a negative 
relationship with food available to the child in the household. 
This departure from prior expectations may be due to the 
possibility of educated women substituting more nutritious but less 
expensive food commodities in the household food basket. The 
negative relationship between treated drinking water and the food
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available may be due to the low availability of treated water in 
rural areas when at the same time food availability is greater 
there than the urban areas as a result of lower rural prices as 
previously conjectured. As expected the weight of a child, which 
also measures the health condition, has a positive relation with 
the food available to the child.
There were indications that a price increase for a number of 
food commodities relative to the price of maize would lead to an 
increase in food available in kilocalories to the household. This 
is the case for millet, garri, cocoyam and plantain. These are 
relatively expensive sources of food energy. Hence, when these 
relative prices increase, households may substitute for cheaper 
calorie sources of food. The resulting income effect may lead to a 
net increase of calories.
5.2 Policy Implications
In assessing the relative merits of various public policies to 
deal with malnutrition among the poor, a better understanding of 
the household behaviour is the starting point (see chapter three). 
It is in this context that public policies must be designed, that 
is, they must take into account the fact that households make the 
ultimate decisions concerning the family’s expenditure on nutrition 
and health.
One of the main causes of death among children under 0-59 
months is malaria (ISSER/SOW, 1993). This is conditioned mainly by 
the absence or availability of basic facilities of treated water
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supply and basic child care services. Bivariate relationships 
confirmed the importance of the publicly provided input, drinking 
water, in the health and nutritional status of children. Castaneda 
(1989) also found this relationship using data from Chile. It was 
found that the most important variable explaining the remarkable 
reduction of infant mortality in Chile from 107 per 1,000 in 1965 
to 19.4 per 1,000 in 1986 was the increase in the urban coverage of 
potable water and sewerage. Thus, the government will have to 
increase the provision of good drinking water and other publicly 
provided inputs to have a lasting impact on health and nutrition.
As already postulated, educated mothers may use their 
knowledge to substitute cheaper but higher quality food for more 
expensive ones. This is in line with the expectation that education 
plays an important role in the process of raising nutrition. Not 
only can it raise the quality of food intake but it can also reduce 
household expenditure on food. One might also expect the nutrition- 
related and health-related child care to improve with the level of 
the mother’s education. Garcia and Pinstrup-Anderson (1987), in 
their study on the Phillipines found that the mother’s education 
directly affects the food consumption and nutritional status of 
pre-schoolers in a strong way. The improvements in the education of 
women is likely to bring dramatic improvements in the long-term 
nutrition of children.
The level of nutrition, measured by the use of anthropometric 
indicators (weight-for-height, weight-for-age and height-for-age) 
of children 0 - 5 9  months old have to be improved. On the average
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29.5 percent, 27.20 percent and 7.10 percent of children are 
chronically undernourished, underweight and acutely undernourished, 
respectively. A national nutrition strategy and related programmes 
(including a surveillance system) must be put in place in order to 
address the serious nutritional deficiencies which have been 
identified. Also the food security objectives of the Ministry of 
Food and Agriculture’s, Medium Term Agriculture Programme (MTADP) 
have to be translated into concrete programmes which will address 
existing problems in credit availability, input pricing and 
distribution and marketing which will help improve the food supply 
situation at levels which would be affordable to many people.
Also policies designed to raise nutrient content of some food 
ingredients, such as food fortification progammes, can lead to an 
increase in the level of nutrition of children.
It was shown that households with children do decrease 
(increase) their food availability as the relative price of cassava 
to maize increases (decreases). Cassava is a good source of energy 
and so shifting from it to another food commodity which is cheaper 
may not necessary be cost effective since the cost per unit of 
kilocalories for the substitute may be higher than that of cassava. 
Increases in the relative prices are likely to lead to a reduction 
of food available to the household. While there is little 
likelihood that the government can directly influence the price of 
cassava through market stabilisation or price subsidies, programmes 
that reduce the cost of transport, or the amount of spoilage, will 
have significant effect on the food available to the child.
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Simulation of total expenditure in the under-five health and 
nutrition model, indicates that 10 percent increase (decrease) in 
income results in a 9.55 percent increase (decrease) in food 
available to the child. Some of this increase may be allocated to 
quality improvements instead of just quantitative increase in food. 
According to Schiff and Valdes (1990a), as income increases, a 
larger proportion of food expenditures is spent on non-nutrient 
food attributes such as diversity of products consumed, freshness, 
taste, convenience foods which save time in their preparation and 
others. Similar results were found in low-income households in 
Pakistan by McCarthy (1977), who found that as income rises, 
increase in food expenditures are allocated mostly to quality 
rather than quantity of food. Thus, raising income may have little 
to do with caloric increases although in general, nutrition may 
rise through qualitative adjustments in the food provided.
Therefore, programmes that tend to increase the incomes of 
poor households have a good chance in improving the nutrition of 
members of these households since there will be both qualitative 
and quantitative response in food availability.
The positive relationship between household size in adult 
equivalent and food availability gives an indication that large 
household sizes are preferable to smaller ones. This is at variance 
with family planning teaching which advocates for reduction in 
family sizes. However, if it is considered that many rural 
households are both producers and consumers of food, then an 
increase in the farm family size may not be harmful in the
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production process. Whatever the situation is, the optimum rural 
household size is the one that can produce enough food for the 
household with some marketable surplus to earn cash income to cater 
for some other needs. In this case, the size of the household 
labour force vis-a-vis the dependents is very important in 
considering the food security needs of the household.
Finally, priority should be placed on closing the gap between 
rural and urban areas in the availabi1ity of social infrastructure, 
such as water and sanitation facilities, through low-cost and 
technologically appropriate interventions. This will include the 
local manufacture and maintenance of basic equipment such as 
handpumps for rural water supply.
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BIBLIOGRAPHY
Albersen, P. 1993- On the estimation of standardised weight for
hejght‘scores . Centre for World Food Studies, Free University 
of Amsterdam, The Netherlands. Unpublished.
Alderman, H. and Garcia, M. 1993. "Poverty, household food
security, and nutrition in rural Pakistan". International Food 
Policy Research Institute, Research Report 96. Washington D.C.
Alderman, H. and Higgins, P. 1992. Food and Nutritional Adequacy in 
Ghana. Cornell Food and Nutrition Policy Program. Working 
Paper 27. U.S.A.
Alderman, H. and Shively, J. 1991. Prices and markets in Ghana.
Food security study paper No. 1. Washington D.C.: Cornell Food 
and Nutrition Policy Programme.
Alderman, H. 1991. Incomes and food security in Ghana. Food
security study paper No. 2. Washington D.C.: Cornell Food and 
Nutrition Policy Programme.
1990. Nutritional status in Ghana and its determinants. 
Social dimensions of adjustment in sub-Saharan Africa. Working 
Paper No. 3. World Bank, Washington, D.C..
1984. The effects of income and food price changes on the 
acquisition of food by low-income households. International 
Food Policy Research Institute, Washington, D.C.. Mimeo.
Amonoo, E. 1988. Small communities appropriate water and sanitation 
programme: Lawra, Techiman, Winneba. Tarkwa and Ketu
districts. Accra: Peace Corps.
ANC, 1993. Nutrition of infants and young children in Ghana.
Findings from the 1988 Ghana demographic and health survey. 
Africa Nutrition Chartbooks (ANC). Macro International Inc. 
Maryland, U.S.A.
Asante, E. 0., Asuming-Brempong, S. and Bruce, P. A. 1989. Ghana: 
Grain marketing study. Prepared for the Medium Term 
Agricultural Development Programme (MTADP). Ministry of Food 
and Agriculture/The World Bank.
Awusabo-Asare, K. 1981/82. "Towards an integrated programme for 
rural development in Ghana". Ghana Journal of Sociology. Vol. 
14, 2.
Bairagi, R. 1981. "On validity of some anthropometric indicators as 
predictors of mortality". American Journal of Clinical
University of Ghana                              http://ugspace.ug.edu.gh
Nn t rit i on. Vol. 34.
Behrman, J.R. and Deo 1alikar,A .B . 19S8. "Health and nutrition". In 
Handbook of Development Economics. Vol. 1. Edited by H. 
Chenery and T.N. Srinivasan. Elsevier Science Publishers.
Behrman, J.R. and Deo 1 a 1ikar,A .B . 1987a. "Seasonal demands for
nutrient intakes and health status in rural South India", in: 
Causes and Implications of Seasonal Variability in Household 
Food Security. edited by D.E. Sahn.Washington, D.C.:
International Food Policy Research Institute.
1987b. "Will developing country nutrition improve with 
income?". A case for rural South India. Journal of Political 
Economy. Vol. 95.
---. 1987c. Determinants of health and nutritional status
of individual family members in rural India: A latent variable 
approach. University of Pennsylvania. Mimeo.
Behrman, J.R. and Wolfe, B.L. 1984. "More evidence on nutrition
demand: Income seems overrated and women's schooling
underemphasised". Journal of Development Economics. Vol. 14.
Behrman, J.R. and Wolfe, B.L. 1987. "How does mother's schooling 
affect the family's health, nutrition, medical care usage and 
household sanitation?". Journal of Econometrics.
Benneh, G., Nabila, J.N. and B. Gyepi-Garbarh. 1989. Twenty Years 
of Population Policy in Ghana. Population Impact Project 
(PIP/Ghana).
Blau, D.M. 1984. "A model of child nutrition, fertility and women's 
time allocation: The case of Nicaragua". In: Research in
Population Economics. Edited by T.P. Schultz and K.I. Wolpine. 
Greenwich, C.T: JAI Press.
Boateng, E.O., Ewusi, K. , Kanbur, R. , Mckay, A. 1990. A poverty
profile for Ghana, 1987-88. Social dimensions of adjustment 
in sub-Saharan Africa. Working Paper No. 5. World Bank, 
Washington, D .C ..
Bos, E., Adolfse, L. and Heerink, N. 1993. Undernutrition: a
constant threat. Wageningen Economic Papers 1993-2. Faculty 
of Economics. Wageningen Agricultural University. The 
Nether 1ands .
Bouis, H., Haddad, L. and Kennedy, E. 1992. Does it matter how we 
survey demand for food ? Evidence from Kenya and the 
Phi 1ippines. Food Policy. International Food Policy Research 
Institute. Washington D.C.
S5
University of Ghana                              http://ugspace.ug.edu.gh
Brown, C.K. 1984. Social structure and poverty in selected rural 
communitj_es in Ghana. ISSER Technical Publication Series, No. 
54. University of Ghana, Legon.
Castaneda, T. 1989. Innovative social policies for reducing
poverty; Chile in the 1980s. The World Bank, the J. Hopkins 
University Press.
Chambers, R., Longhurst, R. and Pacey, A. eds. 1981. Seasonality
dimensions to rural poverty. London: Frances Pinter.
Chen, L.C., Chowdhury, A.K.M. and Huffman, S.L. 1980.
"Anthropometric assessment of energy-protein malnutrition and 
subsequence risk of mortality among preschoo1-aged children". 
American Journal of Clinical Nutrition. Vol. 33.
Chernichovsky, D. and Kielmann, A.A. 1977. "Correlates of preschool 
child growth in rural Punjab". In: A.A. Kielmann et al., eds.. 
The Narangwal Nutrition Study. Mimeo.
Clark, C.A.M. 1981. Demographic and socioeconomic correlates of
infant growth in Guatemala. Rand Corporation Report. No. N- 
17 02-AID/RF.
CRS. 1987. Growth survei1 lance system. Annual Report 1986. Catholic 
Relief Service. Accra. Mimeo.
Dutta-Roy, D.K. and Mabey, S.J. 1968. Household budget survey in 
Ghana. Technical publication No. 2. Institute of Statistical 
Social and Economic Research. University of Ghana, Legon.
Ewusi, K. 1984. The dimensions and characteristics of rural poverty 
in Ghana. ISSER Technical Publication No. 43, University of 
Ghana, Legon.
1978. Planning for neglected rural poor. Accra.
1976. "Disparities in levels of regional development in 
Ghana". Social Indicators. Vol. 3.
FAO. 1992. Food and nutrition: creating a well-fed world. Food and 
Agriculture Organisation, Rome.
Friedman, M. 1957. A theory of the consumption function. Princeton, 
NJ: Princeton University Press.
Garcia, M. and Alderman, H. 1989. "Patterns and determinants of
malnutrition in children in Pakistan: impact of community
health". The Pakistan Development Review. Vol. 28, No. 4.
Garcia, M. and Pinstrup-Andersen, P. 1987. The pilot food price
subsidy scheme in the Philippines: its impact on income, food
86
University of Ghana                              http://ugspace.ug.edu.gh
consumption, and nutritional status. IFPRI Research Report, 
No. 61.
Ghana statistical Service(GSS) . 1989a. Ghana Living Standards_____
Survey(QT.SS) ■ First Year Report. Sept. 1987-Aug. 1988. Accra.
Ghana statistical Service(GSS). 1989b. Ghana demographic and health 
Sn rve.v (GHDS ) 198 S . Accra.
1984. Population census of Ghana.
Government of Ghana(GOG). 1987. Programme of Action to Mitigate the 
Social Cost of Adjustment. Government of Ghana.
GOG/UNICEF. 1990. Children and women of Ghana: A situation
analysis. Republic of Ghana and The United Nations Children’s 
Fund.
Haddad, L. and Kanbur, R. 1991. Intrahousehold inequality and the 
theory of targeting. Policy, Research, and External Affairs. 
The World Bank. WPS 789.
Haddad, L. and Kanbur, R. 1990. "How serious is the neglect of 
intrahousehold inequality?" Economic Journal.
Haggblade, S., Hagell, P. and Brown, J. 1989. "Farm-non-farm
linkage in rural sub-saharan Africa". World Development. Vol. 
17 .
Harriss, B. 1986. "The intrafamily distribution of hunger in South 
Asia". In The political economy of hunger. Vol. I: Entitlement 
and we 11-being, ed. J. Dreze and A. K. Sen. Oxford University 
Press.
Henderson, J.M. and Quandt, R.E. 1980. Microeconomic theory, A 
mathematical approach. McGraw-Hill Book Company.
Heller, P. S. and Drake. 1979. "Malnutrition: child morbidity and 
the family decision process". Journal of Development 
Economics, Vol. 6.
Horton, S. 1984. Birth order and chi Id nutritional status: evidence 
on the intrahousehold allocation of resources in the 
Phi 1jppines. University of Toronto.
ISSER/SOW, 1993. Background to food security in Ghana. Institute of 
Statistical, Social and Economic Research, University of 
Ghana, Legon and the Centre for World Food Studies of the Free 
University, Amsterdam. Working Paper No. WP-93-HFSR-1.
Johnson, S.R. and Rausser, G.C. 1977. System analysis and
simulation: A survey of applications in agricultural and
87
University of Ghana                              http://ugspace.ug.edu.gh
resource economics. In A Survey of Agricultural Economics.
Literature. Volume 2 . Edited by Judge et al . University of 
Minnesota Press.
Kanbur, S.M.R. 1987. "Measurement of alleviation of poverty: With 
an application of the impact of macroeconomic adjustment". IMF 
staff Papers 34, No. 1.
Levinson, F.J. 1988. Combating malnutrition in Ghana. Mimeo.
Martorell, Reynaldo and Gonzalez-Cossio, T. 1987. Maternal
nutrition and birth weigh. Yearbook of Physical Anthropology, 
30.
Merrick, T.W. 1985. "The effect of piped water on early childhood 
mortality in urban Brazil, 1970 to 1976". Demography. Vol. 22.
McCarthy, D. 1977- "Food consumption, income distribution and 
quality effects". Food Policy. Vol. 2, No.l.
Minhas, B.S. 1991. "On estimating the inadequacy of energy intakes: 
revealed food consumption behaviour versus nutritional norms 
(nutritional status of India people in 1983)". Journal of 
Development Studies. Vol. 28, No. 1.
MOA. 1991. Agriculture in Ghana. Facts and Figures. Issued by
Pol icy Planning, Monitoring and Evaluation Divis ion. Ministry 
of Agriculture.
Nabarro, D. 1984. "Social, economic, health and environmental
determinants of nutritional status".. Food and Nutrition 
Bu11et in. Vol. 6, No. 1.
Ofosu-Amaah, S. 1975. "Health problems in relation to food and
nutrition in Ghana". Economic and Social Affairs. Vol. 1. No.
1.
Okyere, W.A. 1993. "Integration of poverty programmes into overall 
development strategies with special reference to Ghana’s 
PAMSCAD". In Strategy for.Poverty Reduction, ed. C. Easter. 
Food Production and Rural Development Division, Commonwealth 
Secretariat.
Okyere, W.A., Asante, F.A., Gyekye, L.O. 1992. Case studies on 
rural poverty alleviation in the commonwealth: Ghana. Food
Production and Rural Development Division, commonwealth 
Secretariat. London.
Okyere, W.A., Atsu, S.Y. and Obeng, Irene S. 1993. Communal
property resources: policies and prospects. Discussion Paper 
No. 27. Institute of Statistical, Social and Economic 
Research, University of Ghana.
88
University of Ghana                              http://ugspace.ug.edu.gh
Okyere W.A. 1982. "A quarterly econometric model of U.S. beef
sector". A Ph.D thesis submitted to faculty of the Graduate 
School, University of Missouri-Co 1umbia, U.S.A.
Orraca-Tetteh, R. and Watson, J.D. 1977. Report of the re­
assessment of the nutritional status of the population of 
Ba.fi. Department of Nutrition and Food Science. University of 
Ghana, Legon.
Pinstrup-Andersen, P., Ruiz de deLondono, N. and Hoover, E. 1975. 
"The impact of increasing food supply on human nutrition: 
Implications for commodity priorities in agricultural research 
and policy". American Journal of Agricultural Economics. Vol. 
58.
Pitt, M.M. 1983. "Food preferences and nutrition in rural
Bangladesh". Review of Economics and Statistics. Vol. 65.
Pitt, M.M. and Rosenzweig, M.R. 1985. "Health and nutrient
consumption across and within farm households". Review of 
Economics and Statistics. Vol. 67.
Reutlinger, S. and Selowsky, M. 1978. "Malnutrition and poverty. 
Magnitude and policy options". World Bank Staff Occasional 
Paper. No.28. The John Hopkins University Press, Baltimore.
RDA. 1974. Recommended dietary allowance. National Academy of 
Sciences, eight edition. Food and Nutrition Board. U.S.A.
Rosenzweig, M.R. and Schultz, T.P. 1983. "Estimating a household 
production function: Heterogeneity, the demand for health
inputs and their effects on birth weight". Journal of 
Political Economy. Vol. 91.
Rosenzweig, M.R. and Schultz, T.P. 1982. Child mortality and
fertility in Colombia: Individual and community efforts’,
health policy and education, 2. Amsterdam: Elsevier scientific 
publishing co..
Sen, A. K. 1984. "Family and food: sex bias in poverty". In
Resources, value, and development. Ed. A. K, Sen, Oxford: 
Blackwel1.
Schiff, M., Valdes, A. 1990a. "Nutrition: Alternative definitions 
and policy implications". Economic Development and Culture 
Change. Vo 1. 38.
1990b. "Poverty, food intake, and malnutrition: 
Implications for food security in developing countries". 
American Journal of Agricultural Economics. Vol. 72, No.5.
89
University of Ghana                              http://ugspace.ug.edu.gh
1990 c ■ The link between poverty and malnutrition. A
household theoretical approach. Policy, Research and External 
Affairs. WPS 536. The World Bank. Washington, D.C. .
Schnepf, R. D. 1991. Understanding the health and nutritional
status of the children of Rwanda. Cornell Food and Nutrition 
Policy Programme. Monograph 13.
Senauer, B. , Garcia, M. 1991. "Determinants of the nutritional and 
health status of preschool children: An analysis with
longitudinal data". Economic Development and Cultural Change. 
Vol. 39, No.2.
Strauss, J. 1990. "Households, communities and preschool children’s 
nutrition outcomes. Evidence from rural Cote d ’Ivoire”. 
Economic Development and Cultural Change. Vol. 38, No.2.
Strauss, J. 1984. "Joint determination of food consumption and
production in rural Sierra Leone: Estimates of a household- 
firm model". Journal of Development Economics, vol. 14.
Taylor, C. , et al. . 1978. "The Narangwal experiment on interaction 
of nutrition and infections: Project design and effects upon 
growth". Indian Journal of Medical Research. Vol. 68.
Timmer, C.P. and Alderman, H. 1979. "Estimating consumption
parameters for food policy analysis". American Journal. of 
Agricultural Economics. Vol. 61.
Tripp, R. 1981. "Farmers and traders: some economic determinants of 
nutritional status in northern Ghana". Journal of Tropical 
Pediatrics. Vol. 27.
UNDP. 1991. Human development report 1991. United Nations 
Development Programme.
UNDP, 1993. Human development report 19.93. United nations 
Development Programme.
United Nations. 1990. Assessing the nutritional status of young
children. National household survey. Capability Program. 
United Nations.
Vogel, R.J. 1988. Cost recovery in the health care sector. Selected 
country studies in West Africa. WorId Bank Technical Paper No. 
82. The World Bank, Washington, D.C..
Von Braun, J. and Pandya-Lorch, R. 1990. Employment and income
sources of the rural poor: micro level information for the 
design of policy priorities. Washington, D.C.: International 
Food Policy Research Institute.
90
University of Ghana                              http://ugspace.ug.edu.gh
Waddington, C. and K. A. Enyimayew. 1989. "A price to pay: the
impact of user charges in Ashanti-Akim district, Ghana". 
International Journal of Health Planning and Management, Vol. 
4~.
Ward, j.o. and Sanders, J.H. 1980. "Nutritional determinants and 
migration in the Brazilian northeast: A case study of rural 
and urban areas". Economic Development and Cultural Change. 
Vol. 29.
WHO. 19S3. Measuring change in nutritional status. World Health 
Organisation, Geneva.
Williamson-Gray, C. 1982. Food consumption parameters for Brazil 
and their application to food policy. International Food 
Policy Research Institute, Washington, D.C..
Wolfe, B.L. and Behrman, J.R. 1983. "Is income overrated in
determining adequate nutrition". Economic Development and 
Cultural Change. Vol. 31.
Wolfe, B. L. and Behrman, J. R. 1982. "Determinants of child
mortality, health, and nutrition in a developing country". 
Journal of Development Economics. Vol. 11.
World Bank. 1993. World development report, 1993. Oxford University 
Press.
World Bank. 1989. World development report. 1989. Oxford University 
Press.
World Bank. 1989. Ghana: Population, health and nutrition. Sector 
review. Report No. 7597-GH. The World Bank.
World Bank. 1988. World development report, 1988. Washington: World 
Bank. Oxford University Press.
World Bank. 1980. World development report. 1980. Washington: World 
Bank. Oxford University Press.
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APPENDIX 1
HEALTH-RELATED POLICIES AND PROGRAMMES TO ALLEVIATE POVERTY
1.1 Introduction
Health and nutrition interventions have an impact on human 
capital formation, through their impact on schooling and labour 
productivity and have implications for the future earnings of 
individual and the growth in Gross National Product (Reutlinger and 
Selowsky, 1978). Specific investment policies in nutrition and 
health increase the endowment of human capital of the poor by 
increasing their earning capacity. Such programmes do not 
necessarily imply a trade-off between economic growth and poverty 
alleviat ion.
The decisions on health and nutrition are basically made by 
individuals and households in which they live, given their income, 
the price structure they face, and the level of services and 
infrastructure in the community, and the nutrition and health 
production technology. It is in this context that public policies 
and programmes must be enacted and designed, with the full 
cognisance of the households which will make the ultimate decisions 
concerning the family’s expenditures on nutrition and health. It is 
therefore important to devise prudent policies to promote reduction 
of poverty and improve upon the living standards of the people.
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1.2 Health Policy
The health policy of Ghana revolves around a Primary Health 
Care (PHC) programme and an Expanded Programme on Immunisation 
(EPI) to accelerate the expansion of out-reach services and 
strengthen immunisation activities for children and pregnant women. 
Six problems have been identified as priority areas to form the 
basis of maternal and child health policy. They are:
(a) diarrhoeal disease control;
(b) immunisation of children against vaccine - preventable 
diseases;
(c) control of malaria;
(d) maternal and prenatal mortality;
(e) malnutrition; and
(f) uncontrolled spacing and a high number of pregnancies 
resulting in a high birth rate.
As a policy of cost sharing the government introduced a user- 
fee scheme under the Hospital Fees Regulations (1985). Under the 
scheme there is a full cost recovery for drugs, but user fees are 
differentiated by type of user, type of procedure and type of 
faci1ity.
The health services of Ghana have been plagued with many 
problems with funding and management being the major ones. 
Inadequate budgetary allocations have rendered the PHC programme 
ineffective. In real terms the Ministry of Health (MOH) budget 
declined by 27 percent per capita in the first two years after the 
introduction of economic reforms (Okyere et. aj.. , 1992). Health
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expenditure has generally been less than 3 percent of 1987 GDP -
Increased proportions of the inadequate budget have been 
allocated to strengthen the predominantly urban-based, curative 
health care system where only 30 percent of the population live. 
Whereas the PHC programme normally receives about 20 percent of the 
MOH budgetary allocation, in 1987 the urban-based health care 
system was allocated 59 percent of the MOH budget (Okyere, 1991) - 
This is inconsistent with the policy objectives of expanding 
coverage of PHC, particularly to the under served rural areas.
1.3 Food and Nutrition Policy
The major thrust of Ghana’s food policy is to provide enough 
food to the people of Ghana at affordable prices. If this can be 
achieved then there will be a reduction in food insecurity. 
However, the dilemma in the policy is that as food prices decrease 
there will be a concomitant reduction in food production as farmers 
will not be motivated enough to increase production when profits 
decrease. Therefore a cheap food policy must be accompanied by 
cost-saving and productivity-enhancing technology if it should 
succeed. Nevertheless, observation of seasonal and annual food 
prices in Ghana indicates that there are wide swings in the data 
and also there are regional differences which imply that Ghana is 
far from implementing a successful cheap food policy.
The provision of enough food can be done through domestic 
sources and/or foreign sources. The food policy of Ghana allows 
individuals and firms to bring in food imports to augment domestic
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supplies. Under this policy, large amounts of rice and maize are 
imported into the country. The government also imports occasionally 
to forestall any anticipated food shortage and these commercial 
imports are solid at market prices.
Another dimension of the food policy of Ghana is to stabilise 
prices over the whole season through a storage programme. In this 
respect the Ghana Food Distribution Corporation has expanded its 
storage programme to about 70,000 tonnes to hold both the strategic 
reserves and farmers7 grains. However, the cost of the programme 
can be reduced if farmers are encouraged to store some of their 
produce through the use of narrow cribs either on the farm or in 
the village.
In order that prices do not fall extremely low during seasons 
when there is a surge in production, there are provision for 
exports under Ghana’s food policy. However, to control the 
situation, especially in normal and bad years, an exporter needs 
the permission of the Ministry of Food and Agriculture before food 
can be exported.
Ghana’s nutrition strategy has combined encouragement of 
agricultural production with Ministry of Health programmes 
addressing malnutrition. The latter range from monitoring to 
facilities for treating acute malnutrition cases. The nutrition 
policy cover both preventive and curative aspects. The most 
important component quantitatively is supplementary feeding.
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1.4 Primary Health Care (PHC) and Expanded Programme on 
Immunisation (EPI)
Due to the problem of reaching rural areas and neglected urban 
communities with modern health care, the government is pursuing PHC 
initiatives in the hope of providing basic health care to the 
disadvantaged population in their communities. The PHC has eight 
components: maternal child health/family planning (MCH/FP), health 
education, immunisation, control of locally endemic diseases, 
environmental sanitation, nutrition and food supplementation, 
treatment for minor ailments and supply of essential drugs.
Special training for Traditional Birth Attendants (TBAs) and 
"Wansams" (specialists in circumcision) has also been in progress. 
With the TBAs, the special training is an extended programme 
involving pre and post-natal care, health education, oral 
rehydration therapy and some other aspects of child health and 
family planning.
Even though the MOH is the pivot around which are PHC-related. 
Prominent among the government institutions are the Ministry of 
Local Government, Social Welfare and Employment, Food and 
Agriculture, Works and Housing and Education, the Ghana Water and 
Sewerage Corporation (GWSC), and the Ghana National Family Planning 
Programme. The NGOs include the Christian Health Association of 
Ghana (CHAG), World Vision International, the Catholic Secretariat 
and the Red Cross.
Despite attempts to improve PHC there are persistent problems 
in its implementation. These can be classified as follows:
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(a) inadequate communication;
(b) poor organisation and delivery at peripheral levels;
(c) improper referrals;
(d) paucity of data to serve as the basis for further planning;
(e) lack of logistical support;
(f) insufficient funding;
(g) scarcity of necessary equipment and supplies; and
(h) staff unavailability.
Even though official policy is PHC-based, rural health 
coverage still remains below 50 percent with only 10 percent of 
smaller communities benefiting from the services of trained health 
workers.
The Expanded Programme on Immunisation was launched in 1978 
with the objective of fully immunising 80 percent of children aged 
0-23 months by 1983. In 1988, the target group was modified to 
differentiate between children aged 0-11 months and 12-23 months.
Prior to 1985, the programme experienced a variety of 
difficulties due to managerial problems and insufficient supplies 
and equipment. In 1985, the MOH took the decision to reactivate the 
programme with the objective of strengthening static immunisation 
activities and accelerating expansion of outreach services.
EPI operations were intensified in 1988 with the adoption of 
a revised schedule for immunisation, regionalised/decentralised 
strategy formulation and implementation and reaffirmation of the 
objective of 80 percent coverage. As a result, routine immunisation 
services were considerably extended and mass campaigns (up to three
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times a year in each of the ten regions) reinforced.
Assessment of achievements to date indicates that the quality 
°f immunisation services has improved significantly. The strategy 
adopted have proven that 90 percent of the nation’s children can be 
reached by vaccinations during a twelve month period. Estimated 
coverage prior to the reactivation of the programme in 1985 was as 
follows: BCG, 19.8 percent; DPT, 3-10 percent; OPV, 3-7.4 percent; 
and Measles, 12.6 percent. National EPI coverage data indicate a 
significant improvement in programme performance since 1988, as 
shown in Table 1.
In spite of the success of the programme in reaching the 
country’s children and women and thereby spearheading the 
enhancement of PHC, achievement in terms of third dose vaccinations 
is still low: only 50.7 percent of DPT-3 and 51.2 percent of OPV-3, 
indicating a drop out rate of about 40 percent. This clearly 
suggests the need for regularising outreach services to reduce the 
drop out rate between campaigns. Such a development would not only 
ensure full immunisation of 80 percent of infants every year, but 
more importantly, contribute to the establishment of an effective 
PHC.
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Tab l e  1. National EPI Coverage, Children 0-11 Months
1985-89 (Percentages)
Vaccine 1985 1988 Dec. 1989
BCG 19.8 56.0 100 . 3
DPT 3 10 . 0 32.0 50.7
0PV3 7.4 32.0 51.2
Measles 12.6 45.0 65.3
Source: MOH, 1989. Epidemiology Division
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Description of Variables used and their Summary Statistics
(children of 0 - 59 months old)
Appendix 2
Variable Description Mean Standard deviation
whzp Standardised weight-for-height score -0.32 2.28
Wt Weight of child (kg) 11.87 7.60
Ht Height of child (m) 0.84 0.18
kcali Individual daily food intake 
(kilocalories) 1046.46 868.45
Sizeq Household size in adult equivalent 4.96 2.64
Scale Adult equivalent consumption unit 0.42 0.12
Mht Height of mother (m) 1.58 0.07
Em Dummy for level of education of 
mother (above middle(l) below(O) 0.03 0.18
kcal Total daily calories available 
to child (kilocalories) 11647 11068
Ac Age of child (months) 27.96 16.52
Pmaize Price of maize (cedis/kg) 80.38 22.99
Peas Price of cassava (cedis/kg) 33.12 9.92
Pmil Price of millet (cedis/kg) 97.58 21.33
Pgar Price of garri (cedis/kg) 121.16 18.22
Pyam Price of yam (cedis/kg) 87.39 34.79
Pccyam Price of cocoyam (cedis/kg) 89.03 73.58
Pptain Price of plantain (cedis/kg) 129.65 156.83
Pgcorn Price of guinea corn (cedis/kg) 93.16 24.35
Te Total household expenditure (cedis) 403381 341995
Sw Dummy for treated water 0.24 0.43
Dsex Dummy for gender (male=0, female=l) 0.50 0.50
Durb Dummy for urban area 0.30 0.46
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