Child health on a dollar a day: some tentative cross-country comparisons

Children living on a dollar a day-the international extreme poverty line-appear to have radically different chances of dying in childhood and being malnourished, depending on the country in which they live. In Kazakhstan, a child living on a dollar a day, has only a 10% risk of being underweight, while the risk facing a child living on a dollar a day in India is nearly 60%. The Kazakh child has a risk of less than 40 per 1000 of dying before his first birthday, while a child living on a dollar a day in Niger faces a risk of nearly 160 per 1000. Countries where mortality and malnutrition risks at a dollar a day are high are not typically those where there are large gaps in child survival and in malnutrition between the poor and better-off. The two concepts of inequality and health risks at the poverty line are not only conceptually distinct-they are empirically distinct too. The large differences between countries in the risks of mortality and malnutrition in childhood beg the obvious question-what accounts for these differences? Some regression results presented in the paper suggest that these differences may be due to differences across countries in levels of per capita expenditure on the health sector. Regressions find that higher levels of per capita public spending on the health sector are associated with significantly lower levels of mortality and malnutrition amongst children living on a dollar a day.

What difference does the choice of SES make in health inequality measurement?

This note explores the implications for measuring socioeconomic inequality in health of choosing one measure of SES rather than another. Three points emerge. First, whilst similar rankings in the two the SES measures will result in similar inequalities, this is a sufficient condition not a necessary one. What matters is whether rank differences are correlated with health - if they are not, the measured degree of inequality will be the same. Second, the statistical importance of choosing one SES measure rather than another can be assessed simply by estimating an artificial regression. Third, in the 19 countries examined here, it seems for the most part to make little difference to the measured degree of socioeconomic inequalities in malnutrition among under-five children whether one measures SES by consumption or by an asset-based wealth index.

[Focusing on the subsidized health regime in Colombia]

Based on the results of the project "Evaluation of the Processes of the Subsidized health regime" in Colombia, a reflection is presented about the beneficiary selection system--Sisben as a tool to affiliate people to the subsidized health regime. The multiple interpretations which have been given to the Sisben as an instrument to focalize the health services in the poorest populations, are documented and analyzed. This has been interpreted, amongst others, as a measure of the magnitude of poverty, as an approximate indicator of resources or income, or as an evaluation of fulfillment of needs. It was found that amongst the 19 million of poor people living in Colombia in 1997, less than half of them, 8.9 million, have been included in levels 1 and 2 of Sisben, which represents an exclusion error of 53.1%. Of the 10.6 million persons classified in these levels, 1.6% are not poor, giving an inclusion error of 14.9%. The exclusion errors are much more serious than the inclusion ones, because they mean a denial of equal rights and services for all those who are in similar conditions, according to the criteria for assignation of subsidies.

Medical expenditure and rural impoverishment in China

Thanks to continued economic growth and increasing income, the overall poverty rate has been on the decline in China. However, due to escalating medical costs and lack of insurance coverage, medical spending often causes financial hardship for many rural families. Using data from the 1998 China National Health Services Survey, the impact of medical expenditure on the poverty headcount for different rural regions was estimated. Based on the reported statistics on income alone, 7.22% of the whole rural sample was below the poverty line. Out-of-pocket medical spending raised this by more than 3 percentage points. In other words, medical spending raised the number of rural households living below the poverty line by 44.3%. Medical expenditure has become an important source of transient poverty in rural China.

Factors associated with Medicaid enrollment for low-income children in the United States

This study analyzes the 1996-1997 Community Tracking Study Household Survey to identify factors associated with Medicaid enrollment for low-income children and to examine the differences between those enrolled in the Medicaid program and those who were eligible but uninsured. We estimated that 17.4% of Medicaid-eligible children were uninsured. Medicaid eligible children who were younger, African American, with single parents, with AFDC eligible parents, with no parent employed full-time were more likely to be enrolled in the Medicaid program. Children with better health status were less likely to be enrolled in Medicaid. In addition, children whose parents were uninsured were more likely not to be enrolled in Medicaid.

Relative or absolute standards for child poverty: a state-level analysis of infant and child mortality

OBJECTIVES

The purpose of the present study was to compare the associations of state-referenced and federal poverty measures with states' infant and child mortality rates.

METHODS

Compressed mortality and Current Population Survey data were used to examine relationships between mortality and (1) state-referenced poverty (percentage of children below half the state median income) and (2) percentage of children below the federal poverty line.

RESULTS

State-referenced poverty was not associated with mortality among infants or children, whereas poverty as defined by national standards was strongly related to mortality.

CONCLUSIONS

Infant and child mortality is more closely tied to families' capacity for meeting basic needs than to relative position within a state's economic hierarchy.

Participation in a public insurance program: subsidies, crowd-out, and adverse selection

This paper examines how varying the level of subsidies affects participation in a public insurance program, crowd-out of private insurance, and adverse selection. We study the experience in Washington's Basic Health program in 1997. Findings show that adverse selection is not a problem in voluntary public programs. Increasing subsidies have only modest effects on participation in subsidized programs, though the gains are not at the expense of the private market. Overall participation in the subsidized plan is also modest, even though participants benefit from it. The challenge to policymakers is to find program design characteristics, beyond subsidies, that attract the uninsured.

A note on the use of a single inequality index in testing the effect of income distribution on mortality

A new literature has recently emerged which suggests that among the developed economies, at least in terms of health status, the distribution of income may be more important than its absolute level. In this literature, the effect of income inequality, in particular, relative inequality on health status is tested by examining the relationship between aggregate mortality and a single measure of inequality (such as the Atkinson Index). In this paper we look at whether a single measure of income inequality, even augmented by a measure of representative income can at the aggregate level, distinguish between the effects of relative as opposed to absolute income. An alternative approach that uses disaggregated income to distinguish between the effects of changes in relative and absolute income levels is applied to data from the 1990 US Census and mortality figures from the National Centre for Health Statistics. Our results indicate that the rate of mortality is sensitive to absolute, but not relative poverty and therefore suggest that to improve the health of the poor the focus must be on raising their absolute standard of living. The results also indicate that government supported programs may have important health enhancing effects and may therefore represent a key policy tool to improve the health of those at the bottom of the income distribution.

Impact of improvement of water supply on household economy in a squatter area of Manila

To estimate the impact of the improvement of water supply. a comparative study on water collection and household expenditure on water was conducted between a former squatter community with an improved water supply (Leveriza: LE) and a typical squatter community with public water faucets (Maestranza: MA) in Manila, the Philippines. Data were collected from 201 structured household interviews and a focus group discussion among housewives in each community. To measure the time spent collecting water, observations of private and public water faucets were conducted. The residents in LE enjoyed significantly larger quantities of water from private water connections than in MA, where only three public water faucets were available as a water source. Conversely, the unit price of water in LE was much lower than in MA. In LE, 72.1% of the households started working for more income using time saved through the improvement of water supply and the proportion of the households under the poverty threshold was reduced from 55.6% to 29.9%. In MA, 68.6% of the households expressed their willingness to work for more income when time spent collecting water was saved. It would be possible for MA to reduce the proportion of the households under the poverty threshold through the improvement of the water supply. The results of the study indicated that the improvement of water supply would possibly encourage urban slum residents to increase their household incomes through reallocating time saved to income-generating activities. The underserved residents spent more money for less water compared to those with access to private water connections. In MA, it took 3-4 h, on average, to complete one water collecting task, even though the nearest public water faucet was within 100 m of any housing unit. This suggests that the definition of accessibility to safe water be reconsidered when discussing the urban poor.

Millions of mothers lack health insurance coverage in the United States. Most uninsured mothers lack access both to employer-based coverage and to publicly subsidized health insurance

Some 5.9 million American mothers caring for young or school-aged children lack health insurance. Although nearly nine in ten uninsured mothers are members of working families, most lack access to affordable coverage through their job or a spouse's job. Most are ineligible for publicly subsidized coverage unless their incomes are far below the poverty line. The millions of uninsured mothers are at high risk of going without needed preventive and primary care. If they become seriously ill, their families can face the prospect of a financial crisis. The nation has made significant progress in extending health care coverage to children in low-income families through Medicaid and the State Children's Health Insurance Program (SCHIP), but no comparable effort has been made to insure the mothers of these children. A few states have started to address the problem by transforming their SCHIPs into family-based programs that also cover low-income parents. Bipartisan legislation under consideration, known as FamilyCare, would encourage this trend by providing more federal funding to states that could be used to extend health insurance to the parents of children already covered by publicly funded programs.

America's affordable housing crisis: a contract unfulfilled

For many poor Americans, having a decent home and suitable living environment remains a dream. This lack of adequate housing is not only a burden for many of the poor, but it is harmful to the larger society as well, because of the adverse effects of inadequate housing on public health. Not only is the failure to provide adequate housing shortsighted from a policy perspective, but it is also a failure to live up to societal obligations. There is a societal obligation to meet the housing needs of everyone, including the most disadvantaged. Housing assistance must become a federally-funded entitlement.

Methodologic implications of allocating multiple-race data to single-race categories

OBJECTIVE

To illustrate methods for comparing race data collected under the 1977 Federal Office of Management and Budget (OMB) directive, known as OMB-15, with race data collected under the revised 1997 OMB standard.

DATA SOURCES/STUDY SETTING

Secondary data from the 1993-95 National Health Interview Surveys. Multiple-race responses, available on in-house files, were analyzed.

STUDY DESIGN

Race-specific estimates of employer-sponsored health insurance were calculated using proposed allocation methods from the OMB. Estimates were calculated overall and for three population subgroups: children, those in households below poverty, and Hispanics.

PRINCIPAL FINDINGS

Although race distributions varied between the different methods, estimates of employer-sponsored health insurance were similar. Health insurance estimates for the American Indian/Alaska Native group varied the most.

CONCLUSIONS

Employer-sponsored health insurance estimates for American Indian/Alaska Natives from data collected under the 1977 OMB directive will not be comparable with estimates from data collected under the 1997 standard. The selection of a method to distribute to the race categories used prior to the 1997 revision will likely have little impact on estimates of employer-sponsored health insurance for other groups. Additional research is needed to determine the effects of these methods for other health service measures.

Childhood poverty, early motherhood and adult social exclusion

Childhood poverty and early parenthood are both high on the current political agenda. The key new issue that this research addresses is the relative importance of childhood poverty and of early motherhood as correlates of outcomes later in life. How far are the 'effects' of early motherhood on later outcomes due to childhood precursors, especially experience of childhood poverty? Subsidiary questions relate to the magnitude of these associations, the particular levels of childhood poverty that prove most critical, and whether, as often assumed, only teenage mothers are subsequently disadvantaged, or are those who have their first birth in their early twenties similarly disadvantaged? The source of data for this study is the National Child Development Study. We examine outcomes at age 33 for several domains of adult social exclusion: welfare, socio-economic, physical health, emotional well-being and demographic behaviour. We control for a wide range of childhood factors: poverty; social class of origin and of father; mother's and father's school leaving age; family structure; housing tenure; mother's and father's interest in education; personality attributes; performance on educational tests; and contact with the police by age 16. There are clear associations for the adult outcomes with age at first birth, even after controlling for childhood poverty and the other childhood background factors. Moreover, we demonstrate that the widest gulf in adult outcomes occurs for those who enter motherhood early (before age 23), though further reinforced by teenage motherhood for most adult outcomes. We also show that any experience of childhood poverty is clearly associated with adverse outcomes in adulthood, with reinforcement for higher levels of childhood poverty for a few outcomes.

Do area-based markers of poverty accurately measure personal poverty?

Area-based markers of deprivation (e.g., postal codes) are commonly used to identify groups of people with low socioeconomic status (SES); the validity of this approach, however, remains unknown. In this study, we determined the accuracy of using income quintile groups calculated on the basis of the median family income of each forward sortation area (1996 Canadian census) to identify those living in poverty (i.e., annual family income of < $12,620). The sensitivity and specificity of using the lowest income quintile to capture those in poverty were 26% and 83%, respectively (likelihood ratio (LR) of 1.49; 99% CI, 1.49 to 1.50). Among those in non-metropolitan and metropolitan areas, the LRs were 1.26 (99% CI, 1.26 to 1.27) and 2.01 (99% CI, 2.01 to 2.02), respectively. The use of postal codes as the only marker to identify people with low SES may result in substantial misclassification of personal poverty, particularly in non-metropolitan areas.

[Family socioeconomic deprivation and vulnerability in the pediatric emergency room: evaluation and management]

OBJECTIVE

The aim of this study was to evaluate the importance of socioeconomic deprivation and other forms of vulnerability in families attending the pediatric emergency unit (PEU). It was based on a five-level classification of family types and an analysis of responses provided by the French healthcare system.

METHOD

The prospective study involved 150 families admitted to the PEU on the basis of open-response interviews that analyzed demographic and socio-economic characteristics, motivations for consultation, the child's quality of life, family problems experienced by the parents, and their support network.

RESULTS

Five categories of families were defined as follows: complete destitution necessitating immediate social measures (0.7%); acknowledged and well-managed economic deprivation (13.3%), unacknowledged and/or complex economic deprivation with a significant deterioration in the quality of life (22.2%), familial psychological vulnerability without economic deprivation (30.4%), and families without any apparent problems (33.7%). Consultation at the PEU appears to be a multifactorial phenomenon motivated by socioeconomic, psychological and cultural factors. This phenomenon is connected with the present-day imbalance in the healthcare system, which does not adequately respond to the needs of vulnerable families.

CONCLUSION

This survey contributes to the current reflection on the integration of psychosocial factors in child healthcare at both the hospital and local community level. The method described herein has determined the factors of vulnerability and the risks of economic deprivation. It can contribute to the development of improved communication and cooperation between practitioners, the hospital and local social workers.

Estimating wealth effects without expenditure data--or tears: an application to educational enrollments in states of India

Using data from India, we estimate the relationship between household wealth and children's school enrollment. We proxy wealth by constructing a linear index from asset ownership indicators, using principal-components analysis to derive weights. In Indian data this index is robust to the assets included, and produces internally coherent results. State-level results correspond well to independent data on per capita output and poverty. To validate the method and to show that the asset index predicts enrollments as accurately as expenditures, or more so, we use data sets from Indonesia, Pakistan, and Nepal that contain information on both expenditures and assets. The results show large, variable wealth gaps in children's enrollment across Indian states. On average a "rich" child is 31 percentage points more likely to be enrolled than a "poor" child, but this gap varies from only 4.6 percentage points in Kerala to 38.2 in Uttar Pradesh and 42.6 in Bihar.

Health care access and use among low-income children: who fares best?

In this paper we assess how access to care and use of services among low-income children vary by insurance status. Although 40 percent of low-income children rely on private health insurance, little is known about how this coverage compares with Medicaid coverage in meeting their health care needs. We find that Medicaid and privately insured low-income children appear to have fairly comparable access but that Medicaid-covered children are more likely to receive services and to have more visits when they receive care. Expanding public coverage may not be sufficient to ensure that all low-income children have access to comprehensive and high-quality care. It may require improvements in preventive and dental care for children with private coverage, an area in which states have limited influence.

Risk factors for late or no prenatal care following Medicaid expansions in California

OBJECTIVES

To describe the characteristics and risk factors of women with only third-trimester (late) or no prenatal care.

METHODS

A statewide postpartum survey was conducted that included 6364 low-income women delivering in California hospitals in 1994 and 1995.

RESULTS

The following factors appeared most important, considering both prevalence and association with late or no care: poverty, being uninsured, multiparity, being unmarried, and unplanned pregnancy. Forty-two percent of women with no care were uninsured, and uninsured women were at dramatically increased risk of no care. Over 40% of uninsured women with no care had applied for Medi-Cal prenatally but did not receive it. Risks did not vary by ethnicity except that African American women were at lower risk of late care than women of European background. Child care problems were not significantly associated with either late or no care, and transportation problems (not asked of women with no care) were not significantly related to late care.

CONCLUSIONS

Lack of insurance appeared to be a significant barrier for the 40% of women with no care who unsuccessfully applied for Medi-Cal prenatally, indicating a need to address barriers to Medi-Cal enrollment. However, lack of financial access is unlikely to completely explain the dramatic risks associated with being uninsured. In addition to eliminating barriers to prenatal coverage, policies to reduce late/no care should focus on pre-pregnancy factors (e.g., planned pregnancy and poverty reduction) rather than on logistical barriers during pregnancy.

Assessing SCHIP effects using household survey data: promises and pitfalls

OBJECTIVES

To describe how household surveys can be used to assess the effects of the new State Children's Health insurance Program (SCHIP) , review methodologic issues associated with household survey data, and propose solutions for dealing with these issues.

PRINCIPAL FINDINGS

To estimate the effect of SCHIP, analysis must explicitly recognize and control for the fact that other factors that could affect the outcomes of interest besides the new program will change over the analysis period. In assessing SCHIP's effect, SCHIP-eligible children must be identified using a detailed simulation model. Analyses that use either a simple eligibility model or only examine children with incomes between 100 and 200 percent of poverty will not accurately identify SCHIP-eligible children. Under these circumstances estimates of the effect of SCHIP will be biased downward. In addition analyses must rely on the same survey in the pre- and post- SCHIP periods to obtain reliable estimates. Moreover, the survey must attempt to obtain data on separate SCHIP programs, and analysts must consider the implications of the possible increasing underreporting of public health insurance coverage. Finally, analysts should be cautious about evaluating SCHIP's success before the program is mature.

CONCLUSION

While evaluating SCHIP using household surveys has some challenges, if conducted carefully such analyses will provide important in formation on the effect of the SCHIP program that can not be obtained elsewhere.

Is there an underclass in Britain?

This paper sets out to define the underclass and then test the predictions of three competing theories in the underclass debate. Using the National Child Development Study for the analysis it is found that an 'underclass' suffering from a lack of qualifications, low cognitive ability and chronic joblessness exists. The validity of making a distinction between the working class and an 'underclass' has often been questioned both because of the dubious history of such a distinction and because it is not believed that such a distinction is empirically true. The results in this paper contradict this assertion by finding the underclass to be distinctive from the working class in terms of patterns of family formation, work commitment and political allegiance. The distinct attitudes of the underclass, when coupled with evidence of inter- and intra-generational stability of membership, provide early evidence that a new social class, the underclass, may now exist in Britain.

Utilization of health care services among subgroups of urban homeless and housed poor

The objective of this study was to describe health services utilization by homeless and housed poor adults stratified by six-month primary sheltering arrangements. The primary method used in this study was a cross-sectional survey of 373 homeless adults. Interviews at twenty-four community-based sites (in Allegheny County, Pennsylvania) assessed demographic and clinical characteristics, reasons for homelessness, functional status and social support networks, and health services utilization during the previous six months. Multivariate logistic regression analysis identified factors independently associated with health services utilization. Subjects were classified as unsheltered, emergency-sheltered, bridge-housed, doubled-up, and housed-poor. The median age of the subjects was 38.4 years; 78.6 percent were African American and 69.9 percent had health insurance. Overall, 62.7 percent reported health services use in the past six months, with significantly more use among emergency-sheltered and bridge-housed subjects than among unsheltered subjects. The study concludes that health services use among the homeless is substantial and is independently associated with sheltering arrangement, comorbid illness, race, health insurance, and social support.

Methodology for determining whether an increase in a state's child poverty rate is the result of the TANF program--Administration for Children and Families, HHS. Proposed rule

The Administration for Children and Families is proposing a methodology to determine the child poverty rate in each State. If a State experiences an increase in its child poverty rate of 5 percent or more as a result of its Temporary Assistance for Needy Families (TANF) program, the State must submit and implement a corrective action plan. This requirement is a part of the new welfare reform block grant program enacted in 1996.

Office of the Secretary Assistant Secretary for Planning and Evaluation notice inviting applications for new award for fiscal year 1998--HHS. Announcement of the availability of funds and request for applications from states to determine the status of Temporary Assistance to Needy Families (TANF) recipients after they leave the TANF caseload, eligible families who are diverted before being enrolled, or eligible families who fail to enroll

The Office of the Assistant Secretary for Planning and Evaluation (ASPE), with support from the U.S. Department of Labor and the Economic Research Service of the U.S. Department of Agriculture, announces the availability of funds and invites applications for research into the status of individuals and families who leave the TANF program, who apply for cash welfare but are never enrolled because of non-financial eligibility requirements or diversion programs, and/or who appear to be eligible but are not enrolled (hereafter jointly referred to as welfare leavers). Approximately eight to ten States or counties will receive funding that will enable them to track and monitor how individuals and their families do in the first year after they leave welfare and provide a foundation for longer follow-up. States may choose any method for such tracking, including the linking of administrative data, surveys or other methods as appropriate. We are particularly interested in learning about individuals' ability to obtain employment and the support provided by their earnings, public programs besides TANF, and other sources. The funds could support a newly designed project or could be used to add new data sources and analyses to an existing project. In addition, ASPE announces the availability of supplementary funding from the Office of Policy Development and Research (PD&R) of the U.S. Department of Housing and Urban Development (HUD) to track the consequences of welfare reform for low-income families with children who receive housing assistance. These funds will only be available to ASPE Grantees.

User fees, self-selection and the poor in Bangladesh

The widespread uncontrolled introduction of user fees in any developing country is likely to have a disastrous impact on poorer patients. Furthermore, traditional targeting schemes aimed at their exemption are often expensive, difficult to administer and ineffective at reaching those in greatest need. This research study examines how user fees can raise revenue and target poorer patients, under the right market conditions, without resorting to costly targeting schemes. The authors draw their findings from case studies of cost recovery in the health and population sectors in Bangladesh. The mechanism suggested in the paper is to use self-selection. It is argued that under certain market conditions poorer patients will choose the health-care option that is appropriate to their means. They will thus identify themselves as poor without having to be selected or tested by an independent authority. This self-selection allows the relevant authorities to cross-subsidize their market choice by over-charging the non-poor in other segments of the market.