Germano Mwabu

Quality of Medical Care and Choice of Medical Treatment in Kenya An Empirical Analysis

Underutilization of medical facilities in African countries is widely believed to be a result of consumer disappointments with quality of care. This paper uses data from a randomized household survey, enriched with exogenous information on health facility attributes, to examine more deeply the quality factor in health care demand in rural Kenya. We find that broad availability of drugs in a medical facility is positively related to medical care use. Contrary to intuitive expectations, lack of prescription drugs is also positively related to medical care demand, while lack of aspirin reduces demand. We explain this counter-intuitive result by noting that any measure of availability of a consumable input is evidence of both demand and supply. Demand may be positively correlated with lack of drugs, for example, precisely because there is excess demand for available supplies. The results indicate the importance of selecting truly exogenous indicators of service quality for demand analysis. We also find that health care demand decreases with user fees and with greater distance to the provider, but increases with income. Gender is not a significant determinant of the choice of medical care in this dataset-whether considered separately or interacted with service variables.

Labor Unions and the Distribution of Wages and Employment in South Africa

Few countries have higher wage inequality than South Africa, where wages of African and white workers differ by a factor of five. Using survey data collected in 1993, the authors analyze the complex effect of unions on this wage gap. Among male African workers in the bottom decile of the wage distribution, union membership was associated with wages that were 145% higher than those of comparable nonunion workers, and among those in the top decile the differential was 19%. Regression estimates also indicate that returns to observed productive characteristics of workers, such as education and experience, were larger for nonunion than union workers. If the large union relative wage effect were cut in half, the authors estimate that employment of African youth, age 16–29, would increase by two percentage points, and their labor force participation rate would also increase substantially.

The Effect of Agricultural Extension on Farm Yields in Kenya

The paper examines effects of agricultural extension on crop yields in Kenya controlling for other determinants of yields, notably the schooling of farmers and agro-ecological characteristics of arable land. The data we use were collected by the Government of Kenya in 1982 and 1990, but the estimation results reported in the paper are based primarily on the 1982 data set. The sample used for estimation contains information about crop production, agricultural extension workers (exogenously supplied to farms), educational attainment of farmers, usage of farm inputs, among others. A quantile regression technique was used to investigate productivity effects of agricultural extension and other farm inputs over the entire conditional distribution of farm yield residuals. We find that productivity effect of agricultural extension is highest at the extreme ends of distribution of yield residuals. Complementarity of unobserved farmer ability with extension service at higher yield residuals and the diminishing returns to the extension input, which are uncompensated for by ability at the lower tail of the distribution, are hypothesized to account for this U-shaped pattern of the productivity effect of extension across yield quantiles. This finding suggests that for a given level of extension input, unobserved factors such as farm management abilities affect crop yields differently. Effects of schooling on farm yields are positive but statistically insignificant. Other determinants of farm yields that we analyze include labour input, farmer experience, agro-ecological characteristics of farms, fallow acreage, and types of crops grown.

Wage Premiums for Education and Location of South African Workers, by Gender and Race

This paper focuses on wage premiums associated with educational investments and on how wages vary by region and within race and sex subsamples through the use of data from the 1993 Project for Statistics on Living Standards and Development in South Africa. Analysis of the given data revealed that although the quality of education for Africans in South Africa was lower than that for Whites the percentage wage gains associated with additional years of primary secondary and higher education were significantly higher for Africans than for Whites. These rates increased at higher levels of education for both race groups. The lower quantity of education received by Africans compared to Whites is a simple explanation for the wage structure presented in this paper. Meanwhile the other two racial groups Colored (mixed races) and Indians occupy intermediate positions between Whites and Africans in terms of both the quantity of education received and wage returns to those levels of education.

Determinants of health insurance ownership among South African women

BackgroundStudies conducted in developed countries using economic models show that individual- and household- level variables are important determinants of health insurance ownership. There is however a dearth of such studies in sub-Saharan Africa. The objective of this study was to examine the relationship between health insurance ownership and the demographic, economic and educational characteristics of South African women.MethodsThe analysis was based on data from a cross-sectional national household sample derived from the South African Health Inequalities Survey (SANHIS). The study subjects consisted of 3,489 women, aged between 16 and 64 years. It was a non-interventional, qualitative response econometric study. The outcome measure was the probability of a respondents ownership of a health insurance policy.ResultsThe χ2 test for goodness of fit indicated satisfactory prediction of the estimated logit model. The coefficients of the covariates for area of residence, income, education, environment rating, age, smoking and marital status were positive, and all statistically significant at p ≤ 0.05. Women who had standard 10 education and above (secondary), high incomes and lived in affluent provinces and permanent accommodations, had a higher likelihood of being insured.ConclusionPoverty reduction programmes aimed at increasing womens incomes in poor provinces; improving living environment (e.g. potable water supplies, sanitation, electricity and housing) for women in urban informal settlements; enhancing womens access to education; reducing unemployment among women; and increasing effective coverage of family planning services, will empower South African women to reach a higher standard of living and in doing so increase their economic access to health insurance policies and the associated health services.

Scaling Up What Works: Experimental Evidence on External Validity in Kenyan Education

The recent wave of randomized trials in development economics has provoked criticisms regarding external validity. We investigate two concerns – heterogeneity across beneficiaries and implementers – in a randomized trial of contract teachers in Kenyan schools. The intervention, previously shown to raise test scores in NGO-led trials in Western Kenya and parts of India, was replicated across all Kenyan provinces by an NGO and the government. Strong effects of short-term contracts produced in controlled experimental settings are lost in weak public institutions: NGO implementation produces a positive effect on test scores across diverse contexts, while government implementation yields zero effect. The data suggests that the stark contrast in success between the government and NGO arm can be traced back to implementation constraints and political economy forces put in motion as the program went to scale.

Health Economics for Low-Income Countries

Good health is a determinant of economic growth and a component of well-being. This paper discusses and synthesizes economic models of individual and household behavior, showing how they may be used to illuminate health policy making in low-income countries. The models could help address questions such as: How can the health of the poor be improved, and what are the economic consequences of better health? What policies would improve intra-household distribution of health outcomes? An extensive literature on health human capital and household models, and on related field experiments is reviewed in an attempt to answer these questions. It is found that there are large returns to health improvements in low-income countries. Moreover, health improvements in poor nations can be achieved through implementation of simple interventions such as dietary supplements, control of parasitic diseases, and pro-poor social expenditures. The paper concludes with a discussion of these policy options.

Health care financing in Kenya: a simulation of welfare effects of user fees.

This paper examines the efficiency and equity effects of introducing user fees in public health facilities in Kenya. These effects are studied with the aid of a simulation technique. It is found that through their favourable effects on quality of medical services, the user fees in public clinics would yield welfare gains. However, these gains might involve unacceptable equity trade-offs. Thus, in general, the net welfare effects of user charges on medical services is ambiguous. More specifically, if the user fees were imposed across the board in government health facilities, the equity trade-offs would be large, and for that reason, the user fees would be socially and politically unacceptable. But, if the user charges are restricted to government hospitals, the attendant equity problem would not be too difficult to manage.

Health care reform in Kenya: a review of the process

The paper looks at the process of health care reform in Kenya during the past 30 years, with a focus on implementation strategies. The data are from official documents of the government. The main finding is that development plans served as the medium through which the government announced its intentions as well as its decisions to implement reforms. A decision to implement a reform was normally accompanied by an implementation budget, whereas an announcement of an intention typically lacked such support. Some of the reforms were implemented speedily and firmly, whereas others suffered delays and reversals. Reforms were implemented with speed and firmness when research provided clear guidance on key policy issues or when political will and skill existed. Donor influence on the timing of reforms might have been excessive. Policy lessons from the process are indicated.

Predicting Household Poverty: A Methodological Note with a Kenyan Example

Household surveys provide data that is used for identifying and measuring the poverty status of households and individuals. However, carrying out such surveys is expensive, especially in poor developing countries. Thus it is important to make maximum use of the available survey data in developing countries, especially in sub-Saharan Africa, where such data are expensive to collect and analyse. This paper develops a simple method for using poverty indices derived from survey data for a given year, to predict poverty rates for subsequent periods without having to conduct a new household survey. We illustrate the workings of the method with data from Kenyan household surveys for 1994 and 1997.