THE EFFECT OF EDUCATION ON THE HEALTH OF CHILDREN UNDER-FIVE YEARS: SOME EVIDENCE FROM GHANA BY MAXWELL AGYEMANG (10363221) THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MPHIL ECONOMICS DEGREE JUNE, 2013 University of Ghana http://ugspace.ug.edu.gh ii DECLARATION This is to certify that this thesis is the result of research undertaken by MAXWELL AGYEMANG towards the award of Master of Philosophy degree in Economics in the Department of Economics, University of Ghana. I hereby declare that with exception of references made to works of other researchers, which have been duly acknowledged, this thesis is entirely my own work under the guidance of my supervisors and neither part nor whole of it has been presented for another degree elsewhere. ……………………………………….. MAXWELL AGYEMANG CANDIDATE ................................................ DATE ……………………………………. ………………………………… DR. LOUIS BOAKYE- YIADOM DR. E. NKETIAH-AMPONSAH SUPERVISOR SUPERVISOR ....................................... ...................................... DATE DATE University of Ghana http://ugspace.ug.edu.gh iii ABSTRACT The conditions of child health have improved around the globe with the passage of time. Though this improvement in children‘s health has also been witnessed in Ghana, it has been slow and unevenly distributed across the country. Ghana‘s child health indicators are still below the average conditions that prevail worldwide. The under-five mortality rate in Ghana is still higher than the average rate around the world and a relatively higher percentage of the children below age five in Ghana suffer from Acute Respiratory Infection, diarrhoea and fever than their counterparts in other parts of the world. On the average, a child in Ghana is more at risk of stunting, wasting or being malnourished than the average child worldwide. Considering the immense significance of children to the survival of our society, the development of a strong labour force and the future economic development, policies must be developed to remedy the situation. Health is multidimensional in nature, ranging from biological to social and psychological dimensions. A number of factors have been investigated to determine their effect on child health and maternal education is one of the prominent factors that have often been mentioned. However, the influence of maternal education on child health in Ghana is largely unknown and as a result, child health policies in Ghana have ignored maternal education. This study investigates the effect of maternal education on under-five mortality, prevalence of ARI, incidence of diarrhoea and occurrence of fever using logistic regression. The findings reveals that higher maternal education significantly reduces the occurrence of mortality, incidence of diarrhoea, prevalence of ARI and occurrence of fever among children below age five in Ghana. Hence, the study urges policy makers to encourage higher female education through the use of direct and indirect incentives. Education should also be made accessible to every female, whilst the disparity in economic and social conditions that prevail among households should be evened out. University of Ghana http://ugspace.ug.edu.gh iv DEDICATION I dedicate this work to the entire Agyemang family as well as friends whose tireless efforts and support have carried me through my graduate studies. University of Ghana http://ugspace.ug.edu.gh v ACKNOWLEDGEMENT I thank God Almighty for his amazing grace and blessings that have carried me safely through this programme even at the time I treaded a very precarious path. I want to also extend special appreciation to my supervisors Dr. Louis Boakye-Yiadom and Dr. Edward Nketiah-Amponsah who through their amazing support, tolerance and guidance nurtured my simple ideas into this final piece. My entire course mates especially Solomon Aboagye deserve extraordinary recognition for their uncommon input into this study. In spite of the guidance and support from my supervisors and colleagues, I assume total responsibility for errors in this study. University of Ghana http://ugspace.ug.edu.gh vi TABLE OF CONTENTS CONTENT PAGE DECLARATION .................................................................................................................. ii ABSTRACT ........................................................................................................................ iii DEDICATION ..................................................................................................................... iv ACKNOWLEDGEMENT .................................................................................................... v LIST OF TABLES ............................................................................................................... ix LIST OF FIGURES .............................................................................................................. x LIST OF ABBREVIATIONS.............................................................................................. xi CHAPTER ONE ................................................................................................................. 1 INTRODUCTION ................................................................................................................ 1 1.0 Background ............................................................................................................. 1 1.1 Statement of the Problem ........................................................................................ 4 1.2 Research Questions ................................................................................................. 7 1.3 Objective of the Study............................................................................................. 7 1.4 The Scope of the Study ........................................................................................... 8 1.5 Justification for the Study ....................................................................................... 8 1.6 Organization of the study ........................................................................................ 9 CHAPTER TWO .............................................................................................................. 10 OVERVIEW OF CHILD HEALTH AND MATERNAL EDUCATION ......................... 10 2.1 Introduction ........................................................................................................... 10 2.2 The Situation of child health and maternal education globally ................................ 10 2.3 The trend of female education in the world .............................................................. 13 2.4 Child health and maternal education in Africa ..................................................... 15 University of Ghana http://ugspace.ug.edu.gh vii 2.5 Trend of Child health and Maternal Education in Ghana ......................................... 18 2.6 Conclusion ................................................................................................................ 24 CHAPTER THREE .......................................................................................................... 27 LITERATURE REVIEW ................................................................................................... 27 3.0 Introduction ............................................................................................................... 27 3.1. Theoretical Review .................................................................................................. 28 3.1.1 Psycho-social concept of the relationship between education and health .......... 28 3.1.2 Education as a social determinant of health ....................................................... 30 3.1.3 The Grossman Model of health .......................................................................... 31 3.1.4 Mother‘s education and child health model ....................................................... 35 3. 2 Review of Empirical Literature ................................................................................ 36 3.2.1 The causal relationship between health and education ...................................... 36 3.2.2 The mechanism through which education affects health ................................... 40 3.2.3 Education and mortality ..................................................................................... 42 3.2.4 Education and diarrhoea ..................................................................................... 46 3.2.5 Education and fever ............................................................................................ 47 3.2.6 Effect of education on anthropometric measures ............................................... 48 3.3 Conclusion ................................................................................................................ 52 CHAPTER FOUR ............................................................................................................ 54 METHODOLOGY ............................................................................................................. 54 4.1 Introduction ............................................................................................................... 54 4.2 Theoretical Framework ............................................................................................. 55 4.3 The Model ................................................................................................................. 55 University of Ghana http://ugspace.ug.edu.gh viii 4.4 Empirical Estimation................................................................................................. 59 4.5 Estimation Technique ............................................................................................... 60 4.6 Definition of explanatory variables and their expected results ................................. 63 4.7 Source of Data ........................................................................................................... 69 4.8 Conclusion ................................................................................................................ 70 CHAPTER FIVE .............................................................................................................. 71 ESTIMATIONS AND DISCUSSIONS OF RESULTS ..................................................... 71 5.0 Introduction ............................................................................................................... 71 5.1 Descriptive Statistics for Regression Variables ........................................................ 71 5.2 Empirical Estimation and Discussion of Results ...................................................... 75 5.2.1 The effect of maternal education on under-five mortality ................................. 76 5.2.2 How fever among under-five children is influenced by mother‘s education ..... 80 5.2.3 Does education of mothers affect the occurrence of diarrhoea? ........................ 82 5.2.4 The effect of maternal education on the incidence of ARI ................................ 85 5.3 Conclusion ................................................................................................................ 87 CHAPTER SIX ................................................................................................................. 88 SUMMARY AND POLICY RECOMMENDATION ....................................................... 88 6.0 Summary ................................................................................................................... 88 6.1 Policy Recommendation ........................................................................................... 91 6.2 Limitations of the study ............................................................................................ 93 6.3 Conclusion ................................................................................................................ 94 REFERENCES ................................................................................................................... 95 APPENDICES .................................................................................................................. 102 APPENDIX A ................................................................................................................... 102 University of Ghana http://ugspace.ug.edu.gh ix LIST OF TABLES Table Page Table 2.1 Female literacy rate among the various regions of the world ...... 14 Table 2.2 The trend of under-five mortality rate in Sub-Saharan Africa and other regions of the world ............................................... 16 Table 2.3 How female education in Sub-Saharan Africa compares to other selected regions of the world.................................................... 18 Table 2.4 The trend of under-five mortality across the regions in Ghana ....... 22 Table 4.1 Variables and their reference categories............................................ 68 Table 5.1 Distribution of child health outcome................................................. 72 Table 5.2 Descriptive statistics of categorical regressors.................................. 73 Table 5.3 Marginal Effects of under-five mortality ......................................... 76 Table 5.4 Marginal effects of fever ................................................................... 80 Table 5.5 Marginal effects of diarrhoea ............................................................ 83 Table 5.6 Marginal Effects of ARI ................................................................... 85 Appendix A Logit Estimation of under-five mortality .......................................... 102 Appendix B Logit Estimation of occurrence of fever ........................................... 103 Appendix C Logit Estimation of occurrence of diarrhoea .................................... 104 Appendix D Logit Estimation result of Acute Respiratory Infection ................... 105 University of Ghana http://ugspace.ug.edu.gh x LIST OF FIGURES Figure Page Figure 2.1 Trend of under-five mortality in the world .................................................. 11 Figure 2.2 Trend of mortality rate among children in Ghana ........................................ 19 Figure 2.3 Trend of Under-five, ARI and diarrhoea among children in Ghana .......... 20 Figure 2.4 Rural-Urban distribution of under-five mortality in Ghana ......................... 21 Figure 2.5 Under-five mortality and female illiteracy relationship in Ghana .............. 24 Figure 3.1 Psycho-social perspective of the relationship between education and health .................................................................................. 30 University of Ghana http://ugspace.ug.edu.gh xi LIST OF ABBREVIATIONS AIDS Acquired Immune Deficiency Syndrome ARI Acute Respiratory Infection BMI Body Mass Index CDF Cumulative Density Function DPT Diphtheria, Pertusis and Tetanus DRC Democratic Republic of Congo GCMH Ghana Commission on Macroeconomics and Health GDHS Ghana Demographic and Health Survey GHS Ghana Health Service GSGDA Ghana Shared Growth and Development Agenda GSS Ghana Statistical Service GFATM Global Fund to fight AIDS, Tuberculosis and Malaria IFLS Indonesian Family Life Survey JHS Junior High School KDHS Kenyan Demographic and Health Survey LPM Linear Probability Model MDGs Millennium Development Goals MDAs Ministries, Departments and Agencies MoH Ministry of Health University of Ghana http://ugspace.ug.edu.gh xii NUHDSS Nairobi Urban Health and Demographic Surveillance System NLSY79 National Longitudinal Survey of Youth 1979 NLSY79CY National Longitudinal Survey of Youth 1979 Children and Young Adults NHSP National Health Survey of Pakistan ORT Oral Rehydration Therapy OLS Ordinary Least Square OECD Organisation for Economic Co-operation and Development PMI President‘s Malaria Initiative RHN Regenerative Health and Nutrition RBM Roll Back Malaria SRH Self Reported Health SOWC State of the World‘s Children U5M Under-five Mortality UK United Kingdom UN United Nations UNICEF United Nations Children's Fund UNESCO United Nations Educational, Scientific and Cultural Organization US United States WHO World Health Organization University of Ghana http://ugspace.ug.edu.gh 1 CHAPTER ONE INTRODUCTION 1.0 Background Health has become paramount on the global development agenda in recent years as the international community seeks to achieve a better world with decent standard of living. This is evident in the numerous health programmes that governments and development agencies have pursued to address the health challenges like child and maternal mortality, outbreaks of epidemics, malnutrition and risky health behaviours. Counting from the Alma Ata declaration in 1978 at Kazakhstan, programmes such as Roll Back Malaria (RBM) partnership launched in 1998, the Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM) set up in 2002 and the President‘s Malaria Initiative (PMI) launched in 2005 by the United States (US) have all been pursued in an attempt to improve health around the globe. Even the Millennium Development Goals (MDGs) have largely focused on improving health (WHO, 2009). The considerable priority that has been given to health issues emanates from the immense economic benefits of good health and especially, the realization of the injurious consequence that ill health has on the poor and most vulnerable in society due to loss of income and high healthcare costs. Children especially those under five years are the most handicapped individuals in our society and hence achieving better health for children must be a social responsibility. University of Ghana http://ugspace.ug.edu.gh 2 Better child health is not only crucial for improving the health conditions of the entire society but also, it is fundamental to achieving a better world in this 21st century. Childhood is the foundation of the world‘s hope for a better future and the preservation of current human race depends on better health of the young generation. According to UNICEF (2007) ―the true measure of a nation‘s standing is how well it attends to its children - their health and safety, their material security, their education and socialization into the societies in which they are born.‖ In spite of these obvious fact, ―the childhood of many are under treat and our collective future is been compromised‖ as noted by Kofi Annan in the 2005 UNICEF report. He also noted that whilst poverty denies children their dignity, endangers their lives and limit potentials, diseases are also taking their love ones from them and killing them as well. There is no doubt that Africa is the poorest continent in the world. The high poverty in Africa has aggravated the problems of poor health among children and women on the continent and has therefore often placed the continent at the centre of many health promoting programmes. Ghana is involved in this struggle to promote good health and has implemented programmes such as free health care for pregnant women and a national health insurance scheme. The nation in 2006 also adopted and piloted the concept of Regenerative Health and Nutrition (RHN) from Dimona which is a community of African Hebrews in Israel as part of efforts to reduce the incidence of preventable diseases. Furthermore, development programmes like the Vision 2020 implemented in 1996 and Ghana Shared Growth and Development Agenda (GSGDA) of 2010 have all focused on improving health and nutrition (National Development Planning Commission, 2010). In spite of all these University of Ghana http://ugspace.ug.edu.gh 3 health programmes, the nation is still in search of solutions to the myriad of health problems especially those facing children and women. Education is one social factor that is widely known to have a large and persistent effect on the health of a population. In fact, the health of a population is the product of the interaction of their environments, psycho-social conditions, genetic inheritance and socio-economic statuses of which education is crucial. It is reported that age-adjusted mortality rate of high school dropouts between ages 25 and 64 in the US as at 1999 was twice as large as the mortality rate of those from colleges (National Vital statistics report, 2001). According to Higgins et al (2008), those with low education are more likely to die younger and are at higher risk of poor health throughout their lives. Grossman (2005) claims that "years of formal schooling completed are the most important correlate of good health". He explains that education increases one‘s efficiency to use healthcare to generate better health outcomes. Hence the more enlightened an individual is, the more likely the individual can use medical resource to stay healthy. Schultz (1999) also recognizes that there is a correlation between a parent‘s higher education and lower child mortality. A casual glance of the educational statistics and under-five mortality rate across the ten regions of Ghana provides some support for the positive correlation between improved education of parents and good child health. In 2008, the Northern Region ranked the highest with 65.7 percent of its female population being uneducated whilst the Greater Accra region was the least with 7.7 percent uneducated female population. The under-five mortality rate for the northern region and the Greater Accra region in 2008 were 137.0 and 50.0 per 1000 University of Ghana http://ugspace.ug.edu.gh 4 live births respectively (Ghana Health Service, 2009). Similarly, as the educational attainment of mothers improved from 1988 to 2008, the percentage of children who suffer from diarrhoea and ARI declined over that time period. The proportion of female adults in Ghana who had some level of education rose from 60.3% in 1988 to 71.8% in 2003 whilst the percentage of children who suffered from ARI declined from 20% to 10%. Over the same period between 1988 and 2003, the percentage of children who suffered from diarrhoea declined from 26.3 percent to 15.2 percent (GSS, 2003) 1.1 Statement of the Problem In recent times, Ghana has made some gains in improving the health conditions among children. However, the nation is far from solving these health problems which is evident in the fact that the country lag behind in terms of achieving the health objectives of the MDGs. The conditions of child health in Ghana are worse than the average conditions around the globe. The incidence of under-five mortality in the country as at 2009 was 69 per 1000 live births whilst the global average value was 60 per 1000 live births that year (WHO 2011). Furthermore, about 28.6 percent of children below five years in Ghana are estimated to be stunt whilst 20.3 percent of these children are under weight (GHS and GSS, 2009). Diseases, mainly diarrhoea and Acute Respiratory Infection (ARI) are afflicting pain and suffering on Ghanaian children on daily basis. According to the Ghana Demographic and Health Survey (GDHS) conducted in 2003, 15.2 percent of children under-five years suffered episodes of diarrhoea whilst 10 percent of the children suffered from ARI. The nation‘s poor child health problems are further characterized by a wide disparity in health status of children at varying geographical areas or economic circumstances. University of Ghana http://ugspace.ug.edu.gh 5 Remedies for these health problems cannot continue to emphasize on increasing health spending since the bulk of health expenditure in Ghana comes from the national purse and the Government of Ghana is faced with huge financial constraint. There is also the problem of inefficiency that characterizes government spending and as such the financial and social sectors of the economy must be reconciled to design a comprehensive scheme to solve the health problems. Such a scheme must be broader and multi-sectoral in nature so as to recognize and integrate the contribution of other sectors of the economy to health. Education is one sector that has been found to be a major contributor to the health of children as reported by Schultz (1993), WHO (2004), Grossman (2005) and Higgins et al (2008). Since highly educated parents are more likely to earn higher income, these parents are able to allocate more resources to the health of their children. Even when all parents are provided with equal resources for the health of their children, the highly educated ones are able to effectively use these resources to derive higher health benefits. This is because the highly educated mothers are able to access and use health knowledge much better than mothers with lesser education. For the fact that the highly educated parents are more likely to lose higher income in the event that they have to skip work to attend to a sick child, they have higher incentive to invest in the health of their children. Policy makers in some countries, upon recognizing the effect of education on health have incorporated formal education into their health policies that target children. For instance, the US has included targets for high school completion rate as part of its national health policy University of Ghana http://ugspace.ug.edu.gh 6 whilst the Government of Britain has raised the compulsory schooling age to 18 so as to reap the potential health benefit (Seager, 2009). In Ghana, the integration of education into health policy is very subtle. The national health policy by way of addressing health needs of children only emphasizes the need for a healthy environment and the maintenance of regularly mandatory exercise in schools (MoH, 2007). Consequently, the US and Britain have better educational attainment for their population as well as better health conditions for their children. Between 2000 and 2010, whilst female net primary school enrolment in Ghana was 76 percent, the US and United Kingdom (UK) boasted of 93 percent and 100 percent respectively for the same period. Under-five mortality in those two countries were far lower at 5 per 1000 live births for UK and 8 per 1000 live birth for US compared to 69 per 1000 live birth for Ghana (WHO, 2011) A possible explanation for the little premium placed on education in Ghana‘s health policies is the fact that the contribution of education to health in the country may not be known and relatively little research has been done in this area. For example, an investigation by the Ghana Commission on Macroeconomics and Health (GCMH) into cross-sectoral factors that affect health ignored education and focused on health insurance, access to water and sanitation, and human resources capacity at village level (WHO, 2004). Studies that have investigated the relationship between health and education in Ghana are scanty and have focused mainly on educational effect on health behaviours (Addai, 2000 and Tagoe and Dake, 2011). The present study explores another side of the relationship between education and health in Ghana. It focuses on the effect of mothers‘ education on the health of their children. University of Ghana http://ugspace.ug.edu.gh 7 1.2 Research Questions This study seeks to find answers to the questions on how education affects children‘s health in Ghana. In particular, it seeks to address the following questions:  What is the effect of mother‘s education on under-five mortality?  How is fever among children aged under-five years influenced by a mother‘s education?  Does the education of mothers affect the occurrence of diarrhoea?  Are children of highly educated mothers less prone to Acute Respiratory Infections (ARI) compared to those of less educated mothers? 1.3 Objective of the Study The study explores the relationship between education and health in Ghana. The overall objective of this study is to determine the contribution of education to health stock in Ghana so as to inform policy and programmes on achieving good health. In specific terms, the study will seek to find the effect of educational attainment of mothers on the following health outcomes among children under-five years in Ghana  Incidence of under-five mortality  Occurrence of diarrhoea  Incidence of fever  Presence of ARI University of Ghana http://ugspace.ug.edu.gh 8 1.4 The Scope of the Study The study attempts to find the effect of educational attainment of mothers on the health outcomes of children under-five years. The present study focuses on maternal education. According to Caldwell (1979) ―Maternal education is the single most significant determinant of the gapping differences in child mortality such that no other socio-economic determinant of child mortality has the impact of maternal education and in their totality they do not even come close to explaining the effects of maternal education.‖ The study also seeks to find the marginal effect of mother‘s education on the incidence of mortality, presence of ARI, diarrhoea and fever among children under five years. The study only focuses on quantitative measures of the relationship between educational attainment and the health of children. The qualitative measures of the effect of educational attainment on health outcomes is not considered in this work 1.5 Justification for the Study The study considers child health because of the inherent long term economic and social benefits associated with better child health outcomes. At a time when the indicators of child health in Ghana is below the world average and there are ongoing efforts to find policies that improve this situation in the country, a study of this nature is very crucial. The study looks at a health variable that is ignored in Ghanaian health policies, so the findings of this study will inform policy in this area. At a broad level, there is the belief that activities of the health and educational sectors should be efficiently coordinated since the two sectors are closely related and they also take a huge University of Ghana http://ugspace.ug.edu.gh 9 proportion of the national budget. The World Bank reported that countries spend one third of their budgets in the health and education sectors (World Development Report, 2004). In the 2012 national budget of Ghana, the health and the education sectors took 35.67 percent of the annual budgetary allocation to government Ministries, Departments and Agencies in 2012 (MDAs) (Ministry of Finance and Economic Planning, 2012). The outcome of the study will contribute to this discussion The study adds to existing literature by studying the effect of educational attainment of mothers on child health in Ghana 1.6 Organization of the study The study is made up of six (6) chapters. The second chapter presents an overview of child health and maternal education in Ghana, whilst chapter three reviews the empirical literature on the effect of education on child health. Chapter four focuses on the theoretical framework, data and statistical methodology employed for the study and chapter five presents and discusses the main findings from the study. The sixth and final chapter discusses the conclusions and policy recommendations based on the results obtained from the study. University of Ghana http://ugspace.ug.edu.gh 10 CHAPTER TWO OVERVIEW OF CHILD HEALTH AND MATERNAL EDUCATION 2.1 Introduction Education and health are two significant factors that affect human capital and the wellbeing of individuals. An assessment of the history of human society reveals a tremendous improvement in the wellbeing of man. However, many societies mainly developing ones like Ghana are confronted with the challenges of poor child health and low level of female education. There are a lot of discussions on how the education of mothers affects the health of children. This chapter presents an overview of child health and maternal education as witnessed in the world, Africa and Ghana. 2.2 The Situation of child health and maternal education globally Since the convention of the right of the child was adopted after the United Nations‘ general assembly in 1989, substantial progress has been made in improving the health conditions among children globally. The convention consolidated the gains from the Alma Ata conference in 1978 and formed a key building block for the MDGs which were functioned to achieve better health conditions among children. Currently, health conditions among children are better than they were two decades ago. The number of children who die before their fifth birthday globally has declined from 12 million in 1990 to an estimated figure of 6.9 million in 2011. This represents a 41 percent decline of global under-five mortality rate from 87 deaths per 1,000 live births in 1990 to 51 in 2011 (You, New and Wardlaw, 2012) University of Ghana http://ugspace.ug.edu.gh 11 Source: UNICEF 2012 Figure 2.1 Trend of Under-Five Mortality rate in the World The diagram above shows the declining global trend of under-five mortality in the last two decades after the adoption of the convention of the right of the child. Aside the declining under-five mortality rate observed around the globe, the disease burden and epidemics that beleaguered children have also declined over the years. Improved vaccines together with increased immunization have reduced the recorded cases of diseases. UNICEF in its 2012 report of the State of the World‘s Children (SOWC) estimated that about 2.5 million under-five deaths are averted annually through immunization against Diphtheria, Pertussis and Tetanus (DPT) and measles. Indeed some progress has been made in improving the health of children globally but it is still insufficient. According to UNICEF (2012), on average 19,000 children below five years die daily whereas a total of 6.9 million of them die annually around the world. A lot of these children also suffer from several diseases mainly respiratory infections, diarrhoea and malaria. University of Ghana http://ugspace.ug.edu.gh 12 Currently, respiratory diseases predominantly pneumonia is the world‘s leading cause of death in children under age five. It is estimated that two million children die yearly from pneumonia worldwide. This means that more children die from pneumonia than AIDS, malaria and measles combined (UNICEF, 2010). The second most dangerous disease that torments children worldwide is diarrhoea. In 2010, approximately four billion global cases of diarrhoea were reported among children below five years and it is believed that the disease led to more than 1.5 million under-five mortality (representing 17 percent of the global cases). Malaria and malnutrition also greatly affect children worldwide. WHO in 2006 estimated malaria cases to be around 250 million worldwide of which one million death cases were reported. This translates into a child dying of malaria every 30 seconds. In a WHO, World Bank and UNICEF joint report prepared by De Onis et al (2012), 165 million children under-five years were estimated to be stunted in 2011 whilst 16 percent of them were underweight in that year. The problem of malnutrition and hunger among children persist in many regions of the world. In addition to this, 270 million children live in what amounts to a health care desert – lacking access to even the most basic healthcare provisions (UNICEF, 2004). It is regrettable when one considers the fact that a lot of children suffer and die from diseases that are easily preventable such as pneumonia, diarrhoea and malaria. The progress in improving child health is further undermined and derailed by unequal health conditions experienced by children in different regions of the world. The rich economies of developed countries experience greater and rapid improvement in child health than the struggling economies of developing countries. UNICEF in its 2012 report – levels University of Ghana http://ugspace.ug.edu.gh 13 and trends in child mortality – asserts that the fraction of under-five mortality that occurs in Africa and Asia is not only large but also growing. For instance, in 1990 the possibility of a child below five years dying in Sub-Sahara Africa was 12.1 times higher than in developed countries, however this probability has risen to 16.5 times that of developed economies in 2011. Furthermore, of the 24 countries that still had under-five mortality rate above 100 per 1000 live births in 2011, none is a developed country. According to UNICEF (2004), many children in developing countries succumb to respiratory, diarrhoea and early childhood ailments which are virtually nonexistent in developed countries. The health disadvantages that confront children in developing countries are staggeringly higher than their counterparts born in developed countries. 2.3 The trend of female education in the world There exist a symmetrical relationship between the global trends of child health and that of female education. Just as progress has been made in improving child health, the recent trends in female education provide some optimism (UNICEF, 2006). There has been increased participation by females at various levels of education. The last three decades have witnessed increase in female enrolment at college level by sevenfold (World Bank, 2011). Many countries have achieved gender parity at primary school level and even the World Bank estimates that 53 percent of primary school pupils around the world are females. Though this is a significant improvement in female education, gender disparity in education has not been totally eradicated. In many countries especially developing countries, girls are confronted with schooling disadvantages. The female-male enrolment ratio falls University of Ghana http://ugspace.ug.edu.gh 14 dramatically as one continues the gender enrolment comparison up the educational ladder. Given this continuous decline in female-male ratio up the educational ladder, and the fact that the general enrolment is lower in developing countries than in developed countries, it is not surprising that disparity in female literacy is observed across the various regions of the world. Table 2.1 shows female literacy rate for various regions of the world. Table 2.1 Female Literacy Rate among the Various Regions of the World Region Adult literacy rate (%) Number of adults unable to read and write (in thousands) Total Female Total Female Female % Developed 99.0 98.9 8,358 4,921 58.9 Commonwealth of independent states 99.5 99.4 1,061 750 70.7 North Africa 67.3 58.1 36,290 23,408 64.5 Sub Sahara Africa 62.5 53.6 175,871 110,123 62.6 Latin America and the Caribbean 91.0 90.3 36,065 20,111 55.8 Eastern Asia 93.8 90.7 70,233 51,577 73.4 Southern Asia 61.9 50.9 412,432 261,764 63.5 South-Eastern Asia 91.9 89.5 32,782 21,685 66.1 Western Asia 84.5 76.9 21,332 15,271 71.6 Oceania 66.4 62.6 1,750 967 55.3 World 83.4 78.9 796,165 510,577 64.1 Source: UNESCO Institute for Statistics The developed and rich regions host the highest female literacy whilst the poorer regions have lesser percentage of their female population being literate. This is because the richer regions have more resource and are able to invest more in education. Differences in cultural and social factors have also contributed to the disparity in female literacy among the regions. University of Ghana http://ugspace.ug.edu.gh 15 2.4 Child health and maternal education in Africa When one compares the past to present times, it will be observed that health conditions of children in Africa have improved. Children born in Africa now have higher chance of surviving than those born just a decade ago. Despite the fact that better health conditions have been achieved among children in Africa, the progress that has been made is the least in any part of the world. The region lags behind the rest of the world as it continues to be the region with the highest under-five mortality, high disease burden among children and the worse growth and development of children. According to Kinney et al (2009), although the population of Africa is just about 11 percent of the world‘s population, the region accounts for 50 percent of all the under-five mortality that occur across the globe. The assertion by Kinney et al (2009) re-echoes Anyanwu and Erhijakpor (2007) assertion that out of the total of 10 million cases of under-five mortality that occurred globally in 2006, nearly five million of those cases representing 50 percent occurred in Africa. The region is also currently witnessing a situation in which every 1 in 9 children born in the region dies before age five. This is more than 16 folds of the average of 1 in every 152 birth for developed regions and far more than 1 in 16 for Southern Asia (UNICEF, 2012). When the trend of under-five mortality in sub-Sahara Africa is compared to other regions in the world, it comes off worse. In 2011, under-five mortality for Sub- Sahara Africa stood high at 109 per every 1000 births relative to the world‘s average of 51 per 1000 births. The improvement in under-five mortality has been slower in Sub-Sahara Africa than the other parts of the world and as a result, it has widened the under-five University of Ghana http://ugspace.ug.edu.gh 16 mortality rate between the region and the rest of the world. Table 2.2 below shows how Sub- Sahara compared to some selected MDG regions through time. Table 2.2 The Trend of Under-five Mortality Rate in Sub-Sahara Africa and Other Regions of the World Region 1990 1995 2000 2005 2010 2011 Developed regions 15 11 10 8 7 7 Developing Regions 97 91 90 69 57 32 North Africa 77 59 45 34 26 25 Sub-Sahara Africa 178 170 154 133 112 109 Latin America and the Caribbean 52 43 34 26 22 19 Eastern Asia 48 45 35 24 16 15 Southern Asia 116 102 88 74 63 61 World 87 82 73 63 53 51 Source: UNICEF, 2012 The region‘s worse child health is not limited to unfavourable under-five mortality alone but also disproportionately high disease burden. As indicated earlier, Sub-Sahara Africa inhabits only 11 out of every 100 people in the world, yet approximately 90 percent of all malaria deaths including those among children under age five occur in the region (UNICEF, 2010). Similarly, 37.5 percent of all cases of measles and 32.2 percent of all neonatal tetanus cases were recorded in Africa in 2009 (WHO, 2011). The region together with Asia accounts for the vast majority of deaths due to pneumonia and diarrhoea. Out of 2197000 cases of University of Ghana http://ugspace.ug.edu.gh 17 pneumonia and diarrhoea that resulted in under-five mortality in 2010, 1078000 representing 49 present, occurred in sub-Sahara Africa (UNICEF, 2012). Furthermore, children in Africa are more likely to be either stunted or underweight. The 2011 world health report estimates that 30 million out of 115 million children under five years (representing 26 percent) who are under-weight lives in Africa. The region is greatly lagging behind the rest of the world in terms of improving the horrific health conditions that stare children in the face. The trend of female education in Sub-Sahara Africa also mimics the progress in child health in the region. With the passage of time, female education has improved and more women in the region can read and write now than it was twenty years ago. In the 2011 World Health Statistics, adult literacy in the region is reported to have increased from 51 percent for the period of 1990-1999 to 63 percent in 2000-2008. According to Burris and Duncan (2009), the number of school-aged children who were not in school between 2002 and 2006 decreased by 18 million (representing 19 percent) from 115 million to 93 million. This fact is re-echoed by World Bank report which asserted that the number of out-of-school girls in Sub-Sahara Africa has decreased from 25 million in 1999 to 17 million in 2008. Female to male primary completion ratio between 1990 and 2008 increased from 0.78 to 0.91 for Africa (World Bank, 2011). Indeed there has been progress in female education in Africa but it has been the slowest in the world and it is very unevenly distributed. In most of sub-Saharan Africa (excluding Southern Africa), women‘s literacy rates ranged from about 50–60 percent between 1990 and 2007. This is much lower when compared to the increase from 76 to 84 percent of University of Ghana http://ugspace.ug.edu.gh 18 literacy rate among women in Europe (Kinney et al, 2009). Table 2.3 shows how Sub- Sahara Africa compares to other parts of the world in terms of gross percentage of females who completed secondary education. Table 2.3 How Female Education in Sub-Sahara Africa Compares to Other Selected Regions Region Gross Percentage of females with Secondary education Percentage of males with Secondary education Africa 38 44 Sub-Sahara Africa 30 37 Asia 58 63 Latin America and Caribbean 94 88 World 65 55 Source: SOWC, 2011 2.5 Trend of Child health and Maternal Education in Ghana The health conditions including child health have significantly improved in Ghana. Saleh (2012) opines this fact by asserting that Ghana‘s achievements in improving health are admirable when compared to other sub-Saharan countries but lags behind when compared to the global average conditions. The tendency of children dying or falling sick in Ghana are to a larger degree better now than they were in past. University of Ghana http://ugspace.ug.edu.gh 19 From the time of Ghana‘s independence to 1988 when the first Demographic and Health Survey was conducted in the country, the country‘s under-five mortality rate fell progressively. The next twenty years that followed also witnessed a decline in the rate from 155 per 1000 live births in 1988 to 108 per every 1000 live births in 1998. The phenomenon however picked up slightly to 111 in 2003 (Johnson, Ruststein and Govindasamy, 2005) but has since fallen to 78 per 1000 live births (UNICEF, 2012). The diagram below shows the trends of under-five mortality, neonatal mortality and child mortality in Ghana as measured by the last five demographic health surveys. Sources: GDHS 1988, 1993, 1998, 2003, 2008 Figure 2.2 Trend of Mortality Rate among Children in Ghana This has translated into a decline in the risk of a child born in the country dying before his fifth birthday. Hill (1993) reports that the probability of a child under-five years to die in Ghana was 0.371 in 1936. This fell to 0.164 in 1980, 0.111 in 2003 and 0.080 in 2008 as per the Ghana Demographic and Health Surveys in 2003 and 2008. University of Ghana http://ugspace.ug.edu.gh 20 There has also been consistent improvement in reducing disease burden faced by children born in Ghana and today they are faced with lesser risk of falling sick than it was in the past. The percentage of children who suffer from diarrhoea and ARI in recent times has been declining consistently over time. Whereas approximately 26 out of every 100 children below the age of five stood the risk of being infected with diarrhoea in 1988, the risk faced by children in the same age category fell to 15 out 100 in 2003. In terms of ARI, twenty percent of children were reported to have shown the symptoms of ARI in 1988. This fraction has subsequently fallen and ranges between 10 to14 percent in 2008 (GDHS 2008). The trends of the proportion of children who were reported to be ill from ARI and diarrhoea between 1988 and 1993 is shown in the graph below. Source: GDHS 1988, 1993, 1998 and 2003 Figure 2.3 Trend of Prevalence of ARI and Diarrhoea among Children in Ghana Despite the fact that some progress has been made in reducing under-five mortality and the incidence of diseases among children in the country, the improvement has been slow. The nation‘s under-five mortality rate of 78 per 1000 children is still above the global average of University of Ghana http://ugspace.ug.edu.gh 21 51 (UNICEF, 2012). Furthermore, the nation is characterized by a wide variance in the incidence of diseases among rural and urban dwellers in the country. The rate is higher in the rural area of the country than in the urban settlements. . Source: GDHS 2008 Figure 2.4 The Urban - Rural Distribution of Under-Five Mortality in Ghana The pie chart shows the fraction of under-five mortality that occurred in the urban and rural areas respectively in 2008. Under-five mortality is higher in rural Ghana where 55 percent of the phenomenon occurred. Furthermore, a gapping disparity in child health is also witnessed across the ten regions of Ghana. The Greater Accra and other regions in the south and middle belt of the country have favourable child health conditions than the three regions in the northern part of the country. This difference in child health observed across the regions in the country is epitomised by the pattern of under-five mortality within these regions. This disparity in child health among the regions can largely be explained by the difference in the economic conditions prevailing in these regions. The regions in the south and middle belts are richer than the regions in the northern regions in Ghana. Table 2.4 shows the trend of under-five mortality among the regions over the last 2 decades. University of Ghana http://ugspace.ug.edu.gh 22 Table 2.4 The Trend of Under-Five Mortality Across the Regions in Ghana UNDER FIVE MORTALITY BY REGIONS OF RESIDENCY Region 1988 1993 1998 2003 2008 Upper West 221.8 187.7 155.6 208 142 Northern 221.8 237 171.3 154 137 Central 208.2 128 142.1 90 108 Eastern 138.1 93.2 89.1 95 81 Ashanti 144.2 97.6 78.2 116 80 Upper East 221.8 180.1 155.3 79 78 Brong Ahafo 122.6 94.6 128.7 91 76 Western 151.2 131.8 109.7 109 65 Volta 132.7 116.4 98 113 50 Greater Accra 103.8 100.2 62 75 50 National 155 119 108 111 80 Source: GDHS 1988, 1993, 1998, 2003 and 2008 The Greater Accra region has consistently had lower rate of under-five mortality whilst the Upper West and the Northern region have experienced high rate of under-five mortality. Possible explanation to this phenomenon is the fact the Greater Accra Region has more healthcare facilities and more health workers per square area, richer population and more educated people. The percentage of literate female population is higher in the Greater Accra Region. University of Ghana http://ugspace.ug.edu.gh 23 Female education in Ghana has improved albeit slow progress in recent years. The literacy rate among women in the country has increased whereas the discriminatory barriers that hindered the girl child from going to school have greatly been eliminated. The proportion of females without any formal education has declined from the national average of 39.7 in 1988 to 21.2 in 2008. In spite of the reduction in the percentage of females without education, the urban female population in Ghana tends to be more educated than their rural counterparts. It was estimated in 2008 that one out of every ten females in the urban areas of Ghana was without formal education. However, this fraction of females in rural areas of Ghana who have never had formal education is three times that of the urban centres. The ten regions also show varied percentage of females without education. Greater Accra has the lowest level of female illiteracy with a percentage of 7.7 whilst 65.7 percent of females in northern region have never had formal education (GHS, 2010). The trends of child health and female illiteracy have both fallen over time and are more favourable in urban areas than in rural areas. A casual glance of the distribution of female illiteracy and under-five mortality rate across the ten regions of Ghana show a positive correlation between them. This is depicted in the following scatter diagram which is constructed from the data obtained from the 2008 GDHS. University of Ghana http://ugspace.ug.edu.gh 24 Figure 2.5 Under-Five Mortality and Female Illiteracy Relationship in Ghana In 2008, the northern region was ranked the highest with 65.7 percent of its female population being uneducated whilst the Greater Accra region had the least uneducated female population of 7.7 percent. The under five – mortality rate for the northern region and the Greater Accra region in 2008 was 137.0 and 50.0 respectively (Ghana Health Service, 2009). Education and health are seemingly positively correlated in the country. 2.6 Conclusion The global trend of child health has generally improved as under-five mortality and the prevalence of diseases that beleaguer children are declining with the passage of time. Children born in today‘s world are at less risk of dying or falling sick than it was in the time past. Despite the improvement in child health, many children are still vulnerable and susceptible to dying or falling sick. The progress in bettering the health conditions of children has been characterized by severe disparity of health among the various regions of University of Ghana http://ugspace.ug.edu.gh 25 the world. The richer countries have made rapid progress whilst developing countries stagger in their pursuit of good health for their children. Sub-Sahara Africa remains the worse place in the world for a child to be born. Children in this region face a high risk of dying or suffering from the pain of avoidable diseases. Every 1 out of 10 children born in Sub-Sahara Africa die before he or she attains five years. The region also accounts for high proportion of pneumonia, diarrhoea and malaria cases reported among children. Again, most children in the region are either under weight or stunted as a result of malnutrition. Clearly, one cannot be excited about the progress that has been extremely slow. Whilst children in the region are challenged in terms of health conditions, the female population in region also has the highest proportion being illiterate. The barriers to girl child education persist and the region lags behind the rest of the world in terms of female education. Effective policies ought to be designed to hasten the process of attaining good health conditions for children in the region as well as achieving desirable level of literacy among women in the region. The case of child health and female education in Ghana reminisce that of Sub-Sahara Africa. Though the country compares favourably to the average conditions in Sub-Sahara Africa, it falls short when compared to the rest of the world. A child below five years in Ghana stands a 7.6 percent risk of dying whilst the average global risk of such a child dying is about 5 percent. Children in Ghana are more prone to suffering diarrhoea, pneumonia and malaria than the average global case. Interestingly, the health risk varies for children across the country. Children who are fortunate to be born and live in urban areas have higher University of Ghana http://ugspace.ug.edu.gh 26 possibility of surviving beyond age five and living healthier lives than those born in rural areas of Ghana. Across the regions, those children living in the northern regions of Ghana are greatly disadvantaged in terms of health. Education of women in the country also follows a similar pattern and an attempt to relate child health problems and female illiteracy among the ten regions of the country reveals a positive correlation. Given that the health of the children of any nation is a significant determinant of the future wealth of that nation, improving the health of the children should be given an utmost priority. However, policy makers ought to find out how to promote child health. Can better child health be advanced in Ghana by increasing maternal education? An enquiry to ascertain a precise answer to this question is worth it. The next chapter reviews various relevant literatures on the effect of maternal education on child health. University of Ghana http://ugspace.ug.edu.gh 27 CHAPTER THREE LITERATURE REVIEW 3.0 Introduction This chapter presents a broad review of the literature on the effects of education on the health of children under-five years. The study commences with a review of the relationship between education and health. Emphasis is placed on the effects of mother‘s education on the health status of children later on. Contrary to what seems to be the case, there is no absolute consensus among researchers regarding the exact effects of education on the health status of people. This disagreement among researchers is more pronounced when the discussion is centred on the effects of mother‘s education on the health status of her children. In fact, a number of arguments have been raised regarding the relationship between education and health, the effects of education on health status of people and more importantly, on the effects of parent‘s (or mother‘s) education on the health status of their children. Empirical studies have been conducted to support either side of the argument. This section will look at the empirical studies conducted on the theme. But prior to this, the current study presents the theoretical perspective underpinning the research. University of Ghana http://ugspace.ug.edu.gh 28 3.1. Theoretical Review 3.1.1 Psycho-social concept of the relationship between education and health A number of theories have being espoused in an attempt to explain the relationship between education and health in general. Feinstein et al (2006) developed a conceptual framework depicting the education and health relationship that considers key aspects of psycho-social development, health behaviours, social context and qualification. The model was base on Bronfenbrenner‘s ecological perspective (Bronfenbrenner, 1979; 1986). Founded of the idea that an individual exist in several spheres of life and interacting contexts of which each of them have implications for his health, this model highlights the channels through which health is affected by education. Health as considered in the model is not merely the absence of disease but rather ―state of complete physical and social well-being‖ as defined by the WHO constitution (WHO, 1946). This conceptualisation of health relies on psychological measures of health based on self-report rather than absence of morbidity. As such, one‘s health depends on his or her self concept or personality. Among other things like competencies, capabilities and identity capital, the self consist of belief, valuation of the future and resilience. These components of the self – belief, valuation of the future and resilience – influence one‘s health. However, one‘s concept of him or herself however does not exist in isolation but in a social context in which the individual experiences dynamic interaction with others in terms on social relation. The social context varies from a small immediate group such as family to a larger distant group like a nation. University of Ghana http://ugspace.ug.edu.gh 29 The model explains that education influences the individual‘s personality or his or her self concept as well as the context in which the individual find him or herself. For instance a more educated individual is more likely to believe in him or herself, behave well, have an optimistic view of the future and related better to others than a less educated person. This implies that education affects one‘s self concept and then conveys the effect of education onto how the individual behaves. In terms of context, a highly educated society will have improved sanitation, better social order and better economic system than less educated society. The model explains that the impact of education on the self and the context affect the health of the individual directly or indirectly. Education improves one‘s belief in himself and value of the future which boost his state of mind and thus his health. Also the improved self concept improves his health behaviour in terms of low alcohol consumption, lower tendency to smoke and engage in safe sex. Furthermore, such individual will make better health investment in terms of usage of health service. In the broader term of context, education improves the social relation which in turns improves the health of the individual. For instance improved education improves the sanitation of the society which then positively affects the health of the individual. This psycho-social relationship between education and health is depicted in the diagram below. University of Ghana http://ugspace.ug.edu.gh 30 Source: Feinstein et al (2006) Figure 3.1 A Diagram Showing the Psycho-Social Perspective of How Education Affect Health In brief, the theoretical framework shows that education affects the personality as well as the context in which the individual relates with others. The individual‘s personality (including state of mind) and the context have implications on the person‘s health. Also, what the individual thinks of himself and his relationship with others influence his behaviour in the form of lifestyle and service use which affects his health. 3.1.2 Education as a social determinant of health Related to the psycho-social concept of education and health is a social determinant theory espoused by Higins et al (2008). In this concept, education is identified to be an important social determinant of health. The benefit of education exceeds economic gains to include better health outcome. People‘s participation in the educational process improves their involvement in social engagements and hence produces a vital channel for achieving a safer, HEALTH BEHAVIOUR: LIFESTYLES AND SERVICE USE CONTEXTS SELF EDUCATION University of Ghana http://ugspace.ug.edu.gh 31 cohesive and healthier society. On the micro level, the individual experience and the social skill produced by education help the person to be able to better access information and service and use them to improve his or her health as well as the family‘s health. To depict the entire interdependence of health and education, the theory adds the economic influence of education on health. Education and health are explained to be influenced by a number of mediating factors which are classified as either social or economic factors and are not specific to health or educational policies. 3.1.3 The Grossman Model of health The Grossman‘s model of ―demand for health‖ (Grossman, 1972) also provides a theoretical basis for the association between health and education. The model on demand for health provides the conceptual framework for analyzing the interaction of socioeconomic factors that influence the demand for and production of health. According to the model, health can be considered as a commodity and hence demand for health can be viewed as demand for a commodity ‗health‘ whilst in a similar manner, health can be viewed as a product that is produced from factor inputs. The theory explains that utility is derived from good health as much as satisfaction is derived from other consumption goods. Good health is therefore desirable and the more of it that an individual gets, the higher the welfare of the person. Hence an individual‘s utility function depends on his or her health stock and all other goods consumed. Thus, U = ƒ (Ht, Zt) t = 0, 1,...,n 3.1 University of Ghana http://ugspace.ug.edu.gh 32 Where U is the individual‘s level of utility, Ht is health stock at time t and Zt is index for all goods in time t. The indifference curve which shows health and consumable goods choices that gives the same level of utility, exhibits all the characteristics of a normal indifference curve. It exhibits diminishing marginal utility or benefit which means that additional units of successive ―health goods‖ yields lesser utility to the consumer. Hence, the consumer will give up a smaller amount of ―consumable goods‖ for every extra unit of ―health good‖ if his utility is to remain the same. Given that he enjoys the same ―consumable goods‖, an increase in ―health good‖ moves the consumer to a higher indifference curve and raises the welfare of the individual. Consequently individuals prefer more of better health to less of it. The individual can increase his health stock by investing in his health in the form of usage of health services, exercises and better dieting. However, the individual‘s health stock also depreciates with time and the relationship between the individual‘s present and future health stock is expressed as; Ht+1 – Ht = It –δHt 3.2 Where It is health investment at time t (present period), δ is depreciation in health stock, Ht is health stock at time t (present period) and Ht+1 is health stock at future time. Furthermore, a person‘s ability to obtain more utility is constrained by the prices of health goods, prices of consumer goods and his limited income which depends on his labour hours and the wage rate paid to the person. Hence, the individual maximises his utility subject to the constraint: University of Ghana http://ugspace.ug.edu.gh 33 wTw = (Income) = PMM + PZZ 3.3 Where W is wage rate, TW is labour hours, PM is price of health inputs, M is quantity of health input, Pz is price index of all goods and Z is quantity index of all consumer goods. The Grossman model also indicates that the consumer goods and health goods in the individual‘s utility functions are produced. Hence, individuals produce their health status by combining health inputs such as food, environment, medical care, exercise, water, heat among others. This relation uses the economics concept of production function which expresses the relationship between health input and health outcome. The model expresses individual production functions for health stock (health investment) and consumer goods as; It = ƒ(Mt, THt, E) 3.4 Zt = ƒ(Xt, Tt, E) 3.5 Where M is medical care use, THt is time spent seeking health, E is education, X is vector for factors of production and Tt is time for producing consumer goods. The production function gives the relationship between the stock of health one can achieve with combinations of health inputs for a given state of technology and education over a given period of time. Therefore improvement in the state of technology increases the efficiency in producing health output from a given amount of health inputs thereby producing more health. Similarly, better educated individuals are in a better position to understand and implement information about their health. Therefore the ability to turn health inputs to desired health outcomes depends on the state of the quality and amount of education. Higher education leads to higher health outcome from a given set of health inputs University of Ghana http://ugspace.ug.edu.gh 34 which implies that greater education leads to greater efficiency. Since this study focuses on the influence of education on child health, emphasis will be on this production concept of health. The theory recognizes the income constraint of the individual which limits his or her ability to consume as well as produce as much health goods as he or she may desire. The individual has limited income and time whilst health inputs are also obtained at a price. Consequently, the individual can consume quantities of health goods and consumer goods that are permissible by his income and time. In a similar way, since health depends on health inputs which are obtained at a price, the consumer can produce limited health given his income and time. In terms of time, all persons have equal time period to distribute among the labour hours, leisure period, investment in health and time spent on sick bed. Thus, T0 = 365 = TI + TW + TL + TS 3.6 Where T0 is the total number of days available to everyone in a year, TI is time invested in health, TL is time for leisure, TW is time for work and TS is time spent on sick bed Hence total time available to an individual less leisure is; T0 - TL = 365 = TI + TW + TS 3.7 In its entirety, the Grossman model posits that a person demands ―health good‖ for the intrinsic value that it possess for improving welfare whilst the health stock of the individual is a product of health inputs and the production of the health stock depends on the quality and volume of education. However, the quantity of health that the individual can consume and produce is limited by the individual‘s income, time and the prices of health inputs. University of Ghana http://ugspace.ug.edu.gh 35 3.1.4 Mother’s education and child health model McCray and Royer (2006) in their inquiry into the effect of female education on fertility and infant health built a model reminiscent of the Grossman model that relates mother‘s education and child health. The model expresses infant health to be dependent on maternal choice variables (such as smoking while pregnant) and maternal endowments like the genetic constituents of the mother. The maternal endowments are fixed but the maternal choice depends on the educational level of the mother which affects her use of health inputs. Education affects the fertility rate of women and their child investment choices through their involvement in the labour market and life choices. Whereas education is a vehicle through which the earnings of women are increased, it also serves to increase the knowledge women have on healthy pregnancy behaviours, use of medical inputs, preventive and curative care and contraceptive use. Thus, the demand for health inputs is influenced by resources, endowments, and the demand for schooling where resources refers to non-schooling factors that affect a mother‘s choice of health inputs such as income. The model recognizes child health as a product of genetic factors, economic factors, health input and social factors like mother‘s education. It highlights the potential for heterogeneous education effects as there are several mechanisms by which education could potentially improve infant health University of Ghana http://ugspace.ug.edu.gh 36 3. 2 Review of Empirical Literature This section presents a review of empirical works on the relationship between health and education, and this is achieved under four specific groups. The review of the empirical works begins by considering the causal relationship between health and education and the mechanisms through which each of them affects the other. These discussions help to explore the general relationship between health and education. Building on the relationship between the two social factors, the effect of education on mortality with emphasis on how maternal education affects child health is also discussed next, followed by how health affects morbidity among children. The final categorization of the review of empirical literature is a consideration of studies that focus on the influence of education on anthropometric characteristics. 3.2.1 The causal relationship between health and education The controversies over the relationship between education and health even commence at the fundamental question of the causal relationship between education and health. There is no agreement on the causal relationship between health and education. Some researchers argue that better health leads to better educational outcome whilst there are others who harbour the opposite view that higher education leads to better health. Some researchers also maintain that the causal relationship between education and health is difficult to determine because both education and health are influenced by other factors in similar ways. The first view of education being dependent on health is supported by the work of Miguel and Kremer (2004) which investigated the effect of a mass treatment of deworming in University of Ghana http://ugspace.ug.edu.gh 37 Kenyan schools. Though their work could not show that the treatment lead to a change in school performance, it indicated an increase in school participation by 25 percent. Contrary to the view that education depends on health, some studies argue that education has a causal effect on health. Fayissa, Danyal and Butler (2011) used the National Longitudinal Survey of Youth 1979 (NLSY79) panel data set from 1979-2006 for a cross-section of 12,686 individuals to investigate the effect of educational attainment on the health status of an individual as measured by ―the inability to work for health reasons.‖ Employing a wide variety of models including the fixed-effects model, random-effects model, between-effects, and the Arellano- Bond dynamic models to control for unobserved heterogeneity, educational attainment is found to have a statistically significant and positive effect on the quality of an individual‘s health status (Fayissa, Danyal and Butler, 2011). On the other hand, Silles (2009), using school reform as an instrumental variable, employed regression discontinuity and found that additional years of schooling reduce the long term effect of education on self-reported illness in the United Kingdom. A study by Oreopolus (2003) on the effect of increasing the number of years of compulsory schooling years on health in England and Ireland supports the causal effect of education on health. Similar studies by Arendt (2005) and Spasojevic (2003) in Demark and Sweden respectively yield similar results. University of Ghana http://ugspace.ug.edu.gh 38 An enquiry by Curie and Moretti (2002) into the openness of college education to women and its effect on educational attainment and child mortality reveals a causal relation between mothers‘ education and child health. They found that mothers with education have healthier children and hence concluded that the health of a child depends significantly on maternal education. The third perspective about the causal relationship between health and education argues that both health and education depend on other socioeconomic factors which in turn cause them to move in the same direction. Proponents of this view argue that because of the presence of these other mediating factors, the difference in health status among groups of people with different educational attainment cannot be solely attributed to education. Clark and Royer (2010) in an attempt to estimate the health effects of education exploit two changes to British compulsory schooling laws that generated sharp differences in educational attainment among individuals born just months apart. Using regression discontinuity methods, they confirm that the cohorts just affected by these changes completed significantly more education than slightly older cohorts subject to the old laws. However, the study finds little evidence that this additional education improved health outcomes or changed health behaviours. As a consequence, the authors concluded that it is very hard and inappropriate to attribute these findings to the content of the additional education. Differently put, the study results suggest a caution in respect of health interventions that focused on increasing educational attainment, a target of recent health policy efforts. University of Ghana http://ugspace.ug.edu.gh 39 Cultler et al (2006) also argue that since the number of people who could not participate in schooling because of poor health has reduced with time, the gradient of education should diminish. Yet, the gradient of education is increasing and it suggests that changes in health are not entirely explained by changes in education. Unobservable variables such as family background, genetic characteristics and work environment all influence health status as well as education. Lillard, Simon and Ueyama (2006) used an IV approach to examine the causal effect of mother‘s high school education on child health using the 1979-2002 waves of the National Longitudinal Survey of Youth 1979 (NLSY79) and the 1990-2002 waves of the National Longitudinal Survey of Youth 1979 Child and Young Adult (NLSY79CY). Instrumenting education with a rich set of education policy variables, it was found out that a mother who completes high school is more likely to report that her child was ill enough to need a doctor. Across samples of mothers who dropped out of high school and those who completed high school, the study finds no difference in the date of their children‘s last routine health check up, percentiles for weight-for-age, height-for-age, Body Mass Index (BMI)-for-age, or in the probability of children at risk of overweight and of being overweight. Examining the possible mechanisms, the authors found that mother‘s high school education increases mother‘s age at child‘s birth, health insurance coverage and child care use indicating a suggestive evidence of a much more complex set of behaviours that are causally related to education (child care use, health insurance status, fertility decisions) and that likely affect child health. In this regard, the authors were quick to caution that much more work needs to be done before one can strongly conclude that child health does or does not systematically vary with differences in maternal education. University of Ghana http://ugspace.ug.edu.gh 40 3.2.2 The mechanism through which education affects health Related to the contrasting views of the causal relationship between education and health is the discussion on the channels through which education affects health. A number of studies try to explain how higher educational attainment affects health outcome and vice versa as observed in health – education relationship in general as well as from mothers to their children. Altindag, Cannonier and Mocan (2010) conducted an investigation of the allocative efficiency hypothesis by analyzing whether education improves health knowledge using data from the 1997 and 2002 waves of the NLSY97. The survey design allows us to observe the increase in health knowledge of young adults after their level of schooling is increased by differential and plausibly exogenous amounts (Altindag, Cannonier and Mocan, 2010). Using nine different questions measuring health knowledge, the study finds weak evidence that an increase in education generates an improvement in health knowledge for those who ultimately attend college. For those with high school as the terminal degree, no relationship is found between education and health knowledge. As a result, of these findings the authors concluded that the allocative efficiency hypothesis may not be the primary reason for why schooling impacts health outcomes and that further investigations are needed to handle these contrasting results. In a study that aimed at exploring whether there is any relation in education, gender, and health for Pakistan, Asghar, Attique and Urooj (2009) using data collected by Pakistan and Medical Research Council under National Health Survey of Pakistan (NHSP 1990-1994) employed both exploratory data analysis and ordinal logistic regression. The authors find evidence that individuals with higher education level tend to have better health status than University of Ghana http://ugspace.ug.edu.gh 41 persons with lower level of education. There is also evidence of gender being an important determinant of health in Pakistan. Thus, Asghar, Attique and Urooj (2009) asserted that education affects health not because of the knowledge and practices one can learn at school, but rather it shapes an individual‘s life and can alter the characteristics of an individual to be healthier. After controlling for employment, individual characteristics, socio-economic status, they still found education to be a significant determinant of the Self Reported Health (SRH). However, the group with less than primary education is barely significant whilst the other groups of educational level are highly significant. Angeles, Guilkey and Mroz (2003) explain that education could serve as a proxy for such unobservable determinants as ability, motivation and parental background, as these factors are the most likely important determinants of a woman‘s educational attainment. The authors posit that, the above reasoning is true owing to the fact that the estimated impact of education on fertility most likely includes the impacts of these unobserved factors as well as the true education effect. Using the 1993 Indonesian Family Life Survey (IFLS), Guilkey and Mroz (2003) compare the estimated impacts of education on fertility from a simple model that assumes the exogeneity of education on one hand and an unobserved factor model that allows for endogeneity of schooling on the other. The findings provide key evidence that the importance of female education as a means of reducing fertility is unambiguously positive. However, the researchers cautioned that using empirical model that does not control for endogeneity would overstate the results for Indonesia due to the phenomenon of self-selection of a woman‘s educational status (Angeles, Guilkey & Mroz, 2003). University of Ghana http://ugspace.ug.edu.gh 42 Caldwell (1994), in explaining how greater maternal education evolves into better child health indicated that educated mothers are more likely to take their children to a health centre for preventive and curative care. Furthermore, the study argues that educated mothers want to take control of things and feel more responsible to ensuring good health for their children. These actions which seem more deliberate, Caldwell (1994) argues that they are rather internalized and form part of the subconscious of educated mothers as they journey through the formal education process. The uneducated mothers on the other hand tend not to understand the formal health institutions and modern science medicine and hence patronize less of it. 3.2.3 Education and mortality One dominant measure of health outcome is the population‘s mortality rate. Several studies have been undertaken to understand and measure how educational attainment affects the possibility of an individual dying. Whilst some of these studies have been conducted across different countries, others have focused on the households within a particular country or society. Abuqamar, Coomans and Louckx (2011) examined the impact of parental education on infant mortality in Gaza. To achieve their objective, the researchers conducted face to face interviews with 550 mothers of infants of whom 275 of them had their babies living and the other 275 agonizing from the tragedy infant mortality. The authors employed logit analyses to identify the relationship between health behavioural factors and infant mortality. The result of a binary logistic regression showed that the families with lower educational level had a much higher risk of infant mortality. There was a positive statistical association University of Ghana http://ugspace.ug.edu.gh 43 between parental education and survival of infants. These findings underscore the importance of explicit attention to health education. Osei-Kwakye et al (2010) use case control study to examine the determinants of under-five mortality among mothers in the Builsa district in the Upper East Region of Ghana. The Upper East Region has experienced significant decline in under-five mortality than any other region in the country and the researchers sought to find out factors that have contributed to this success. The researchers by matching 60 mothers with a control group of 120 mothers on the basis of age, sex and place of residence, gathered data to estimate the determinants of under-five mortality in the district. They found education not to be a significant determinant of under-five mortality in the district but rather, they found that children who have never had vitamin A supplement were 10 times more likely to die, whilst children born to mothers who have previously experienced child death were 8 times more likely to die too. Hence, they argued that health personnel should pay more attention to mothers who have experienced child death before. Though their work is a pioneering study in Ghana, it is limited to a small district in the Upper East Region and cannot be used to generalize for the entire country. The study conducted by Kan (2010), was primarily motivated by his conviction that although a negative relationship between schooling and health has been observed by social scientists, these associations may not necessarily represent a causal effect due to the presence of omitted variables or reverse causality from health to education. Taking advantage of a compulsory education reform in Taiwan, Kan (2010) attempted to identify the impact of education on health, as measured by mortality using data from the 2000 Population Census and the 1999–2008 death records of Taiwan, where there was an University of Ghana http://ugspace.ug.edu.gh 44 extension of compulsory education from six to nine years. The results of the study suggest that education does have an impact on mortality for men, but not for women. Also, Mondal, Hossain and Ali (2009) studied the influencing factors on infant and child mortality of suburban and rural areas of Rajshahi District, Bangladesh. A multivariate technique is employed to investigate the effects of those variables (i.e. socioeconomic and demographic) on infant and child mortality using primary data. The study results reveal that several socioeconomic, demographic and health-related variables affect infant and child mortality. Multivariate analysis results indicate that the most significant predictors of neonatal, post-neonatal, and child mortality levels are immunization, ever breastfeeding, mother‘s age at birth and birth interval. Parents‘ education, toilet facilities and treatment places are significant predictors during neonatal and childhood period while father‘s occupation is significant at post-neonatal periods. Specifically, risk of neonatal mortality is 31.4% lower among the women having primary education and 52.3% lower among the women having secondary and higher education than those having no education. It is observed that the risk of child mortality is 32.0% lower among households having hygienic toilet facilities than those who do not have such facilities. Similarly, risk of child mortality decreased with increased female education and wider access to safe treatment places. So, attention should be given to female education and expansion of public health system for reducing the risk of infant and child mortality. Through an analytical cross-sectional design through secondary data analysis of the 2003 Kenyan Demographic and Health Survey (KDHS) dataset for children, Mustafa (2008) fitted series of logistic regression models to select the significant factors affecting infant mortality both in urban and rural areas. The study reported breastfeeding, ethnicity and sex of the University of Ghana http://ugspace.ug.edu.gh 45 child as the significant determinants of infant mortality in the urban areas while birth order and intervals were the significant determinants of infant mortality in the rural areas. The study recommended that the focus of interventions in child health should be on the social and economic empowerment of women via education and employment while breastfeeding promotion should be encouraged (Mustafa, 2008). In the words of the author, ―policies and efforts have to be put to improve women education and occupation environment‖ (Mustafa, 2008). Employing a panel regression on data from Demographic and Health Surveys for 22 developing countries, Desai and Alva (1998) also examine the effect of maternal education on three markers of child health: infant mortality, children‘s height-for-age, and immunization status. In contrast to other studies, this study argues that although there is a strong correlation between maternal education and markers of child health, a causal relationship is far from established. Specifically, introducing controls for husband‘s education and access to piped water and toilet attenuate the impact of maternal education on infant mortality and children‘s height-for-age. This effect is further reduced by controlling for area of residence as maternal education continues to have a statistically significant impact on infant mortality and height-forage in only a handful of countries. However, maternal education remains statistically significant for children‘s immunization status in about one-half of the countries even after individual-level and community-level controls are introduced. University of Ghana http://ugspace.ug.edu.gh 46 3.2.4 Education and diarrhoea To assess the association between maternal illiteracy and frequency of childhood diarrhoea, Shukr, Ali, Khanum and Mehmood (2009) conducted a cross sectional study using data on 200 mothers of children between 1-2 years of age. One hundred children belonged to breastfed group and 100 to bottle-fed group. All mothers lived in houses with piped water supply, filtered drinking water in immediate neighbourhood and latrines inside the house. Husbands‘ educational status varied between matriculate to intermediate and earning between Pak Rs 7000-9000/month. The incidence of diarrhoea was analyzed for both groups of children after stratifying mothers‘ education into 4 categories nil to class 3, class 4 to 9, metric and intermediate to graduate. Results obtained indicate that, for the breast-fed group the frequency of diarrhoea annually varied from 0.41 for highly educated mothers (intermediate to graduate) to 2.182 for uneducated mothers (p=0.001). As a consequence, the authors concluded that the frequency of diarrhoea was more in less educated mothers. This suggests that one of the interventions aiming to reduce diarrhoea should be to improve maternal education status. Sastry and Burgard (2008) examine changes in diarrhoea prevalence and treatment in Brazil between 1986 and 1996. Over the ten-year period, there was a small decline in diarrhoea prevalence but treatment with Oral Rehydration Therapy (ORT) increased greatly. According to Sastry and Burgard (2008), the decline in diarrhoea prevalence was largely due to changes in the effects of several key covariates, such as breastfeeding, with only a modest role played by socioeconomic change, infrastructure improvements and other behavioural factors. Also, ORT treatment of diarrhoea was essentially unrelated to child and family characteristics, suggesting that the large increase was due to the success of public health University of Ghana http://ugspace.ug.edu.gh 47 efforts to promote its use widely. In conclusion, the authors consider the results of the study to suggest that the most effective policies for reducing diarrhoea prevalence are likely to further increase education and the promotion of breastfeeding. Mensah et al (1998) conducted a study into the risk factors associated with the incidence and persistence of diarrhoea in the slums of Accra. The researchers selected 95 children at birth and followed up on them until they were 2 years to gather data on the incidence of diarrhoea among the children. Data collected also included socioeconomic factors such as mothers‘ education and sanitation. The study found that more but brief episodes of diarrhoea occurred at the early stage of life whilst long lasting diarrhoea occurs later in the lives of the children. Most episode of diarrhoea occurred after the rains in June and August. Mothers‘ lack of education, unemployment among mothers and presence of pets at home were found to significantly increase the risk of the child to suffering from diarrhoea. Also lack of education and presence of pets were found to be the major cause of persistent diarrhoea among children in the slums of Accra. The study by Mensah et al (1998) is however limited to the urban slums of Accra and does not hold for the entire nation‘s situation. 3.2.5 Education and fever In a study aimed at assessing mothers‘ education (measured by knowledge and ability to recognize fever in their child, as well as management instituted at home) Oshikoya and Senbanjo (2008) sampled 144 mothers whose children were less than 12 years old and had fever. The findings from data obtained through interviewed with a structured questionnaire give evidence to the hypothesis that mother‘s education is a strong and enduring determinant of child‘s health status measured in this study which is the incidence of fever among children University of Ghana http://ugspace.ug.edu.gh 48 Thuilliez (2010) investigates how schooling affects occurrence of fever. The study utilizes cross-sectional regression model to estimates the effect of school performances (which uses class repetition as a proxy) on the prevalence of fever in Mali. Data from the demographic and health surveys conducted in 2001 and 2006 is grouped by the researcher to provide the needed clusters for the cross-sectional analysis. The result reveals an association between low school performance (in the form of frequent repetition) and high prevalence of fever. In an inquiry to uncover the sources district spatial variations of childhood diarrhoea and fever morbidity in Malawi, Kandala et al (2006) use individual data of children from the Malawi Demographic health survey conducted in 2000. The authors modelled the spatial effect through Bayesian approach and employed geo-additive probit model to control for the spatial dependence. Children living in cities whose parents had relatively higher education were found to be less affected by fever. Maternal education attainment was found to be a highly significant socio-economic determinant of the occurrence of both fever and diarrhoea. 3.2.6 Effect of education on anthropometric measures Abuya, Ciera and Kimani-Murage (2012) conducted a study on 5156 children aged 0–42 months using the Nairobi Urban Health and Demographic Surveillance System (NUHDSS). Employing a binomial and multiple logistic regressions to estimate the effect of education on health, maternal education was revealed as a strong predictor of child stunting with some minimal attenuation of the association by other factors. The other factors including child birth weight and gender, marital status of mother, equal power of mother over the household, pregnancy intentions, health seeking behaviour of mother and social economic University of Ghana http://ugspace.ug.edu.gh 49 status of the household are also independently significantly associated with stunting. The study concluded that mothers‘ education persists as a strong predictor of child‘s nutrition even after controlling for other factors. Also, Aslam and Kingdon (2012) investigated the relationship between parental schooling on the one hand, and child health outcomes (height and weight) and parental health-seeking behaviour (immunization status of children), on the other. While establishing a correlational link between parental schooling and child health is relatively straightforward, the authors reveal that confirming a causal relationship is more complex. Using unique data from Pakistan, the following ‗pathways‘ are investigated: educated parents‘ greater household income, exposure to media, literacy, labour market participation, health knowledge and the extent of maternal empowerment within the home. The findings are that while father's education is positively associated with the 'one-off' immunization decision, mother's education is more critically associated with longer term health outcomes in OLS equations. Also, Instrumental variable (IV) estimates suggest that father's health knowledge is most positively associated with immunization decisions while mother's health knowledge and her empowerment within the home are the channels through which her education positively impacts her child's height and weight respectively. Emina, Kandala, Inungu and Yazoume (2011) similarly, examine the association between maternal education and child nutritional status in the Democratic Republic of Congo using data from the 2001 Democratic Republic of Congo (DRC)-Multiple Indicators Cluster Survey. Analyzing data based on chi-square tests and logit generalized estimating equations, the results showed that maternal education is associated with a lower prevalence of simultaneous multiple-malnutrition. In contrast, the prevalence of single malnutrition University of Ghana http://ugspace.ug.edu.gh 50 indicators ―stunting only‖ or ―wasting only‖ is higher among children whose mothers have secondary education or higher. However, depending on the indicator, the association disappears or appears only after controlling for the province of residence and as a consequence, the authors were quick to warn that future studies on the determinants of children‘s nutritional status should be based on a clearly defined nutritional indicator. In addition, only national policies integrating education, access to food and use of health service are pivotal to improve child health and nutrition. Further, Cutler and Lleras-Muney (2010) using a variety of data sets from two countries, examine possible explanations for the relationship between education and health behaviours, known as the education gradient. Their results show that income, health insurance, and family background can account for about 30 percent of the gradient. Knowledge and measures of cognitive ability explain an additional 30 percent. Social networks account for another 10 percent. The researchers argue that their proxies for discounting, risk aversion, or the value of future do not account for any of the education gradient, and neither do personality factors such as a sense of control of oneself or over one‘s life. Thus, in a nutshell, the authors generally agree to the assertion that, education affects health outcome strongly and positively, although different components of education influence health at varying degrees. A study by Oyekale and Oyekale (2009) which sought to analyze the effect of mothers‘ educational levels on child malnutrition used data from the 2000 End-Decade Multiple Indicator Cluster Survey by the UNICEF for Gambia and Niger. Analyzing data with the Foster-Greer Thorbeck approach and Probit regression, they obtained results to the effect that stunting, wasting and underweight are higher in Niger rural and urban areas, while the University of Ghana http://ugspace.ug.edu.gh 51 severity and depth of stunting, wasting and underweight are higher among children whose mothers had no secondary education for all the countries. The Probit analysis reveals that attainment of secondary education by the mothers, alongside other variables such as urbanization, presence of pipe water, presence of mother and father at home, polio vaccination, breast feeding and access to radio and television significantly reduce the probability of stunting, wasting and underweight. Infection with diarrhoea, fever and age at first polio vaccine were found to significantly increase stunting, wasting and underweight. In this regard, the authors highly recommended that to reduce malnutrition and achieve the MDGs in Gambia and Niger, institutional arrangements for catering for secondary education of girls and ensuring consistency in child health programs must be strengthened, among others. Medrano, Rodriguez and Villa (2008) used the 1993 South Africa Integrated Household Survey to study the effect that mother‘s education through the knowledge channel has on children‘s health using height for age Z-scores as health measure. Under a two-stage least square methodology the authors find that an increase in 4 years on mother‘s education (approximately 1 standard deviation) will lead to an increase of 0.6 standard deviations on her child‘s height for age Z-score. They also find evidence to support the hypothesis that mother‘s education is more important for children older than 24 months of age. De Walque (2007) tests the hypothesis that education improves health and increases people‘s life expectancy by analyzing the effect of education on smoking behaviours. To account for the endogeneity of smoking, the study develops an instrumental variable approach which relies on the fact that during the Vietnam War, college attendance provided a strategy to avoid the draft. The results indicate that education does affect smoking University of Ghana http://ugspace.ug.edu.gh 52 decisions. Specifically, educated individuals are less likely to smoke, and even among those who have smoked before, the educated ones are more likely to have stopped. In a study, Abuya, Kimani, and Onsomu (2012) sought to determine the effect of maternal education on child health in Kenya, as measured by complete immunization and nutritional status using the Kenya Demographic Health Survey (KDHS, 2003). After controlling for confounding variables, children born to mothers with primary education were 2.17 times more likely to be fully immunized compared to those whose mothers lacked any formal education, (p<0.001). For nutrition, unadjusted results reveal that children born to mothers with primary education were at 94% lower odds of having stunted growth compared to mothers with no primary education, (p<0.01). Overall, maternal education though was a significant determinant of complete child immunization; it was not significant predictor of nutritional status. Despite these mixed results, the authors admitted that policy implications for child health in Kenya should focus on increasing health knowledge among women for better child health outcomes (Abuya, Kimani, and Onsomu, 2003) 3.3 Conclusion Some conceptual frameworks have been developed to examine the relationship between health and education. Feinstein et al (2006) uses a psycho-social perspective where education is considered to influence the individual‘s self concept which in turn influences the health behaviour and health choice of the individual. Higins et al (2008) develop a similar concept that focuses more on social settings. In this model, education is argued to influence individual‘s social participation which in turn influences health in several University of Ghana http://ugspace.ug.edu.gh 53 directions. Also, Grossman‘s model of health demand greatly explains the relationship between health and education. Because health has utility and also affects the individual‘s ability to be productive, individuals produce as well as invest in their health. As part of a broad model of health, Grossman argued that individuals produce their health using health inputs, exercise, nutrition etc. However, the individual‘s ability to produce health depends on technology and education. Hence, in a state when everything is unchanged, higher education will lead to healthier individuals. The chapter also reviewed empirical studies on health and education and explored how these studies validate or nullify the theories and proposed relationship between health and education. Categorising the reviewed literature under the themes; general relationship between health and education, effect of education on mortality, how education affect morbidity and effect of education on anthropometric characteristics, a consistent pattern is evident. Though, there are divergent opinions over the causal relationship between health and education many researchers believe that both health and education are affected by social, economic and psychological factors. Hence in addition to each variable affecting the other, there are other transmission mechanisms. The literature reviewed reveals that, using dynamic regression model or bivariate model mostly logistic model, education significantly affect morbidity, mortality, health behaviour and anthropometric characteristics either directly or indirectly. Maternal education is found to significant affect mortality, morbidity and anthropometric measures among children. The next chapter discusses the methodology employed for the study. University of Ghana http://ugspace.ug.edu.gh 54 CHAPTER FOUR METHODOLOGY 4.1 Introduction This chapter details the methodology used for this study. The theoretical concepts underpinning the research, the econometric estimation technique and the data set used for this enquiry are also discussed in this chapter. Several studies have investigated the effect of education on health by finding out how structural changes in a country‘s educational system have affected the health of a group of persons belonging to each educational system (Clark and Royer, (2010) and Silles (2009)). These studies often used standard regression discontinuity framework to capture the effect of the educational structure change. Other studies which have engaged in a cross country comparison to examine the effect of education on health regularly use instrumental variables (Arendt (2008) and Oreopoulos (2006)). The binary models are relatively popular when the study utilizes micro level data to investigate the relationship between education and health within a particular nation. These models have the advantage of providing the relative effect of education and other socioeconomic factors on health. Because this study seeks to determine the relative effect of education on selected child health indicators in Ghana and rely solely on micro level data for the analysis, the logistic regression model provides a better estimation method to achieve these objectives. University of Ghana http://ugspace.ug.edu.gh 55 4.2 Theoretical Framework 4.2.1 The Relationship between Health and Education Many conceptual frameworks have been developed to explain the relationship between health and education. These include those which viewed the effect of education on health from a psychological perspective where education influences the self-concept of the individual and his or her social participation which in turn affects the health status of the individual. Related to this psychological perspective are other frameworks that emphasize the effect of education as a social factor that influences health. Models by McCray and Royer (2006), Higins et al (2008) and Brunello et al (2011) are popular models that examine the relationship between health and education with emphasis on the social determinants of health. All these psychological and socioeconomic models are grounded on the classical work of Grossman (1972) which created the theoretical framework of human capital model for the demand for health where health is demanded as well as produced. Though the model developed by McCray and Royer (2006) is specific for child health and mother‘s education, it is characterised by complexities and it is more suitable for panel studies. Due to its simplicity, the model developed by Brunello et al (2011) is adopted and modified for this study. 4.3 The Model Based on the Grossman (1972) health demand theory, Brunello‘s model posits that the stock of health capital enters the utility function as a consumption good because better health increases utility. In other words, households obtain utility from better health (H) of children, consumption goods (C) and risky health behaviours (B) of parents. Thus, utility is denoted University of Ghana http://ugspace.ug.edu.gh 56 as U(C, H, B) and it is concave in its arguments. The marginal utility of health is characterised by diminishing marginal utility and the marginal utility of consumption (UC) and marginal utility of risky health behaviours (UB) vary with health. The utility of the household is depicted as U = U (C, H, B) (1) In addition to healthy children generating utility for the household, children‘s health is also a human capital. It determines the amount of time and resource that the household can devote to other markets. In an event a child falls sick, the household will have to devote its scarce time and resources to care for the child. The health of the child depreciates over time, and this requires the household to invest in the child‘s health using health inputs such as medical care, diet, and vaccination. The relationship between the health inputs and health outcome of the child is shown by the production function of child health. As illustrated by Grossman in his model, whereas medical inputs (M), diet, exercise and other health behaviours affects health, education (E) acts as a catalyst that positively influence the stock of individual health (H). In the case of child health, the health stock of the child can be improved with the use of medication, proper nutrition, use of health equipment and other behavioural characteristics of parents whereas the education of the parent increases the efficiency of health production. For instance, educated parents will be able to properly administer medicine to children than less-educated parents. Lleras-Muney (2005) and Currie and Moretti (2003) all provide evidence that education affects health. In addition to generating good child health using medical inputs (M) and education (E), the health stock of children (H) also depends on the behaviour of their parents (B) as well as University of Ghana http://ugspace.ug.edu.gh 57 unobservable traits of the household (such as genetic features, environment, and occupation of key members of the household) which is denoted by µ. This relationship between health stock of children, medical input, education and the other unobservable factors is expressed by the relation: H = F (M, E, B, ) (2a) From the above relationship a linear specification of the health production function of children can be expressed as; (2b) Rationally, households seek to increase their utility from consumption, subject to their child health production function and to their budget constraint. The budget constraint of individuals in this case is given as; (3) where Y is income of the household, which depends on education and a vector of observable controls Z, P1 and P2 are the vector of prices for medical input (M) and consumption goods (C) as well as the price of risky health behaviour (B) which is normalized to 1. If an internal solution exists, the necessary conditions for a maximum are UC – P1 = 0 OR UC = 𝜆P1 (4) UB – UH – 𝜆P2 = 0 OR UB – UH = 𝜆P2 (5) where 𝜆 is the Lagrange multiplier. University of Ghana http://ugspace.ug.edu.gh 58 The concavity of the utility function implies UHH < 0. Since the marginal utility of consumption increase with improved health conditions of the child and the marginal utility of risky behaviours of the parent rises with higher health of the child, UCH > 0 and UBH > 0. By totally differentiating (3) and (4) and using (1) we find that higher education reduces health damaging behaviours of parents if the following condition holds; |UHE|> β (6) Households with better education usually earn higher income per a given period of time and have higher expectations for the future than less-educated households. As such, the higher- educated households‘ value of time is higher and hence, they are expected to suffer a greater loss of satisfaction if they have to take time off to take care of a sick child. Conversely, they should derive a higher utility from better health stock of a child. This is because the resources and the time that they are able to conserve from parenting a healthy child give them a higher utility. Due to this, it is logical to assume that the marginal utility of good child health increases with an increase in education (E). In other words, UHE 0 The optimal consumption plan for the household in implicit form is given by C = C (E, P1, P2, , Z) (7) B = B (E, P1, P2, , Z) (8) Using (8) in (1) and in the utility function yields the "reduced form" health equation for the household H = H (E, P1, P2, , Z) (9) University of Ghana http://ugspace.ug.edu.gh 59 and the indirect utility function V = V(E,P1,P2, ,Z). The marginal effect of education on health in (9) is the "education gradient" (HEG). Assuming that the cost of education Γ(E,W), where W is a vector of cost of education shifters, is convex in the years of education, optimal education is given by VE (E, P1, P2, , Z) = ΓE(E,W) (10) 4.4 Empirical Estimation From the discussions so far, the health of a child depends on a number of socio-economic factors as well as the health behaviours of the parent. The relationship between the health stock of the child and education as well as behaviours of the mother is estimated using the regression model: Where Hi is a measure of child i's health, Ei is the educational level of child i's mother, Xi is a vector of or the socio-economic characteristics that includes geographical area of residence of child i‘s mother, Bi is a vector of health behaviours of child i's mother, C is a constant term and ε is the error term. (Culter and Lleras-Muney, 2006) In specific terms, child health will be estimated as U5M = C + + + + + + + + + Fe = C + + + + + + + + + ARI = C + + + + + + + + + Dir = C + + + + + + + + + University of Ghana http://ugspace.ug.edu.gh 60 Where the health outcome of children is measured independently as under-five mortality (U5M), fever (Fe), diarrhoea (Dir) and presence of ARI (ARI). Each of these health outcomes is estimated as depending on mother‘s educational level, mother‘s health behaviours and household socio-economic characteristics which are: Ei: Maternal educational level Mi: the income/wealth of the household Ri: area of residence of household Wi: presence of treated water Vi: vaccination of the child Gi: gender of the child Zi is region of residence Ai: antenatal visit : the error term α1, α2, α3, α4, α5, α6, α7 and are parameters which measures the relative effect of the explanatory variables on each of the individual health outcomes of children. 4.5 Estimation Technique Studies where the unknown variable or the regressand is qualitative and dichotomous or binary variable, the binary models of Linear Probability Model (LPM), logit or probit are employed. The LPM which allows for the use of Ordinary Least Square to estimate the parameters is plagued with a number of challenges. It is characterized by hetroscedasticity, non-normality of the disturbance term, low R2 and non-fulfilment of 0 restriction of binary models. Though these challenges can be surmounted with a number of University of Ghana http://ugspace.ug.edu.gh 61 remedies, the LPM assumes that the marginal or incremental effect of the explanatory variables remain constant throughout (Gujarati, 2004). This makes the LPM an unattractive binary model of estimation, though it is the simplest one. The logit and probit models overcome the problems that the LPM poses. When using micro level data, the standard OLS estimation is not feasible for both the logit and probit. The maximum likelihood method is used to estimate the parameters. To assess the association between the health outcomes among children and the educational level of their mothers, the study like many other health economics studies that employ micro level data, uses the logit model. The logistic regression predicts the probability of an event occurring (Green, 2003). This statistical model provides a good description of the relationship between the probability of a response which has two outcomes and the variable or variables that influence(s) this outcome. The logit (natural logs) regression expresses the odds of the unknown binomial variable as linearly dependent on the explanatory variable and this linear relationship is derived from the logistic Cumulative Density Function (CDF). Given that the probability density function (𝜆) of the logit distribution is (l) = - chi2 0.000 Pseudo R-square 0.427 Source: Author‘s Construct from GDHS, 2008. *, **, *** imply significance of 10%, 5% and 1% respectively University of Ghana http://ugspace.ug.edu.gh 103 APPENDIX B Logit Estimation Results of the Occurrence of Fever Variable Coefficient Std. Err Z-Stats Mother’s Education Primary Educ. of mother -0.119* 0.061 -1.942 Secondary Educ of mother -0.881*** 0.242 -3.631 Higher Educ of mother -0.512** 0.177 -2.888 Gender of child Male 0.021 0.311 0.066 Region of residence Upper east region 0.067 0.044 1.523 Northern region 0.457 0.821 0.557 Brong-Ahafo region -0.112*** 0.034 3.294 Eastern region -0.048* 0.025 1.921 Western region -0.126*** 0.030 -4.142 Ashanti region -0.109** 0.049 2.213 Greater Accra -0.787*** 0.251 -3.142 Central region 0.099** 0.049 2.020 Volta region -0.009 0.007 -1.286 Area of Residence Urban Location -0.128* 0.065 -1.955 Wealth Quintile Middle Wealth quintile -0.237** 0.107 -2.218 Richest wealth quintile -0.802* 0.408 -1.966 Attend Ante-natal -0.074*** 0.011 -6.969 HH has bednet -.815*** 0.181 -4.477 HH has treated water2 -0.486*** 0.168 -2.899 Immunization -1.004** 0.192 -5.218 Constant 4.882*** 0.424 11.53 LR Chi2 (11) 89.78 Prob.>chi2 0.0073 Pseudo R-square 0.331 Source: Author‘s Construct from GDHS, 2008. *, **, *** imply significance of 10%, 5% and 1% respectively University of Ghana http://ugspace.ug.edu.gh 104 APPENDIX C Logit Estimation Results of the Occurrence of Diarrhoea Variable Coefficient Std. Err Z- Stats Mother’s Education Primary Education of mother -0.177*** 0.059 -2.959 Secondary Education of mother -0.441*** 0.101 -4.363 Higher Education of mother -0.940** 0.466 -2.019 Gender of child Male -0.054*** 0.015 -3.694 Region of residence Upper east region 0.023 0.014 1.655 Northern region 0.244 0.199 1.224 Brong-Ahafo region -0.181*** -0.037 -4.891 Eastern region -0.085** 0.039 -2.128 Western region 0.087 0.926 0.094 Ashanti region -0.631** 0.299 -2.104 Greater Accra -0.743*** 0.113 -6.551 Central region 0.008 0.007 1.094 Volta region -0.012 0.007 -1.547 Area of Residence Urban Location -0.157*** 0.053 -2.987 Wealth quintile Middle Wealth quintile -0.497*** 0.121 -4.121 Richest wealth quintile -1.008*** 0.206 -4.887 Attend Ante-natal -0.816** 0.133 -6.125 HH has bednet 0.089 0.079 -1.125 HH has treated water2 -0.341* 0.171 -1.996 Immunization -0.067** 0.028 -2.418 Cons 3.090*** 0.434 7.112 LR CHI2 (11) 112.21 Prob.>chi2 0.0000 Pseudo R-square 0.439 Source: Author‘s Construct from GDHS, 2008. *, **, *** imply significance of 10%, 5% and 1% respectively University of Ghana http://ugspace.ug.edu.gh 105 APPENDIX D Logit Estimation Result of Acute Respiratory Infection (ARI) Variable Coefficient Std. Err Z–Stats Mother’s Education Primary Education of mother -0.042** 0.020 -2.101 Secondary Education of mother -0.280** 0.105 -2.667 Higher Education -1.501* 0.793 -1.893 Gender of child Male -0.029 0.018 -1.654 Region of residence Upper east region 0.045 0.037 1.225 Northern region 0.112 0.061 1.858 Brong-Ahafo region -0.009 0.034 -0.262 Eastern region -0.723* 0.343 -2.108 Western region 0.244*** 0.043 5.671 Ashanti region -0.211*** 0.026 -8.240 Greater Accra -0.108*** 0.048 2.241 Central region 0.082 0.138 0.594 Volta region -0.092 0.049 1.842 Area of Residency Urban Location -0.070** 0.013 -5.228 Wealth Middle Wealth quintile -0.033** 0.015 -2.251 Richest wealth quintile -0.917** 0.282 -3.254 Attend Ante-natal -0.052* 0.026 -1.965 Household has bednet -0.044 0.036 -1.239 Household has treated water2 -0.275* 0.144 -1.916 Immunization -0.613** 0.289 -2.114 Constant 0.080*** 0.011 7.258 LR Chi2 (11) 74.67 Prob.>chi2 0.0000 Pseudo R-square 0.358 Source: Author‘s Computation from the 2008 GDHS *, **, *** imply significance of 10%, 5% and 1% respectively University of Ghana http://ugspace.ug.edu.gh