Reproductive and Overall Health Outcomes and Their Economic Consequences for

Households in Accra, Ghana

Allan Hill and Günther FinkHarvard Center for Population & Development Studies

Ernest Aryeetey and Isaac Osei-AkotoInstitute for Statistical, Social and Economic Research

Third Annual Research Conference on Population, Reproductive Health and Economic Development

Dublin, Jan 16-18, 2009

Research Questions

Broad question:

What are the economic consequences of ill health?

Original Research Questions:

a. How do spells of ill health affect household income and consumption in urban Sub-Saharan Africa?

b. How does household composition affect the coping mechanisms chosen by the household in the short run?

c. How does ill health affect household composition in the short and medium run?

Empirical challenges…

• Identifying the causal effect of ill health on economic outcomes in the presence of unobserved heterogeneity

• Distinguishing “reproductive” morbidity from general ill-health

• Measuring the indirect effects of women’s RH morbidity– Childhood illness and women’s work– Other adult illnesses in the household– “Openness” of household support (e.g. Ga non-residence of

spouses; extended family transfers; national health insurance)

• Capturing the co-incidence of a set of individually “minor” RH conditions which are nonetheless additive….

Baseline Sample

Women’s Health Study of Accra 2003:

• Representative sample of 3200 women aged 18+ from the Accra Metropolitan Area

• Over-sampling of elderly

• Stratification by social class based on census data

• Detailed home interview with focus on general and reproductive health

• Blood tests and hospital visit for a sub-sample of the women (Korle Bu Teaching Hospital)

Original Sampling Framework

SES of EASurvey Age groups

Total18-24 25-34 35-54 55+

Low class259 299 219 199 976

Low middle class207 169 203 164 743

Upper middle class189 182 187 184 742

High class189 167 176 179 711

Total844 817 785 726 3172

Findings from 2003

• Heavy burden of non-communicable diseases – strong association with age– Obesity– Cholesterol levels– Diabetes– Depression and mental illness

• Women of reproductive age in good general health– TFR=2.1– Clustering of minor reproductive health conditions (co-

morbidities c.f. Giza Study)– RH conditions additive…

Health topics covered in the home interview

Topic Questions Topic Questions General Health 11 SF36 topics Affect 2

Self-care 2 Physical activity 9 Pain and discomfort 2 Food security 3

Cognition 3 Reproductive health 4 Community interactions 2 Sexual behaviour 4

Vision 3 STIs 10 Hearing 3 Breastfeeding 3

Breathing 2 Family planning 7 Energy and sleep 2

Physical examination

– Measurement of height, weight and girth

– Measurement of visual acuity

– Measurement of blood pressure, heart rate

and temperature

– Complete physical examination: head to

toe

Self-report health changes by age

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

Age groups

%

Health Transition -somewhat+much worseGeneral Health Index<70Overall health - fair +poor

Age group

Self-reported

obesity % N

Measured with

BMI>30 % N

18-24 0.7 852 11.0 191

25-34 1.5 817 29.1 189

35-44 2.8 469 40.0 210

45-54 6.0 317 44.7 206

55-64 4.6 368 43.0 230

65 & over 6.4 359 36.4 228

All 2.8 3182 34.6 1254

Reported and measured blood pressure

0102030405060708090

18-24 25-34 35-44 45-54 55-64 65 &over

Age groups

% e

leva

ted Measured

Reported

Microeconomic Study 2008/2009

Study Design

• Sub-sample of 1000 households indexed to women interviewed both in 2003 and 2008 (in progress)

• Each households is followed over 12 weeks with at least one visit per week

• Rolling sample to guarantee regional coverage of all four socioeconomic residence types in each season

Accra Metropolitan Area- Total population estimate 1.6-2.9 Millions (about 10% of total population)

- 1741 enumeration areas (EA) in 6 sub-metros – 200 randomly selected

Rolling Sample Time Line

IV 1 round 1Week 1Week 2Week 3

October 08 December 09

IV 2 round 1IV 3 round 1

12 weeks

IV 11: round 4IV 12: round 4

IV 13: round 4Week 52

Each “cohort” consists of

- 20-25 households

- 3-5 different EAs

Background Information Collected

• Household structure and arrangements (week 1)

• Detailed schooling information for all children in the houshold (week 7)

• Detailed job information for all adult household members (week 10)

• Detailed health history of index woman and her family (WHSA II)

Main Health Information Collected

• Health Module: During each of the 12 weekly visits, a log about sickness spells in the household is kept. If any acute sickness occurred in previous 6 days, the following information is collected:uration of sickness

• Health facility name and location • Medication used• Direct cost to the household: prescriptions & doctor fees• Indirect private cost: number of hours/days not able to work• Indirect HH cost: number of hours other HH members stayed

home to take care of sick person

Additional Health Information Collected

• Daily time use and health diaries: selected household members are trained to fill out daily diaries containing:

– Principal activity for each 30 minute time block

– Overall self-health assessment each day

Daily Diary Example

Discussion Diary Data

Main benefits:

• allows to verify household response from health modules: how does daily routine change for individuals during health problems of any HH member?

• Provides interesting picture of everyday life in an modern African urban environment – how do individuals spend their time?

• Allows limited risk factor analysis: work distance, commuting and health; work/leisure balance and health

Concerns:

• Large potential error in self-reports

• Major sample selection problem: literacy!

Data Collection: Status and Projection

Currently collected Total projected

Number of Households 93 1,000

Number of Individuals 347 4,000

Number of Health Modules 213 2,130

Number of Diaries 255 5,840

More coming soon…

Thank you!