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Health, Nutrition, Education and Equity

Health, Nutrition, Education and Equity. Jere R. Behrman University of Pennsylvania World Bank Conference "Equity, Development and Policy: Evidence , New Ideas & Future Directions" 10 June 2011. This paper reviews selected relatively recent evidence on:

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Health, Nutrition, Education and Equity

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  1. Health, Nutrition, Education and Equity JereR. Behrman University of Pennsylvania World Bank Conference "Equity, Development and Policy: Evidence, New Ideas & Future Directions" 10 June 2011

  2. This paper reviews selected relatively recent evidence on: • Short-run policy impacts on human capital investments • Longer-run impacts of human capital investments and some benefit/cost ratios • Impact of targeted policies on inequality and on poverty

  3. 1. Short-run policy impacts on human capital investments

  4. 1. Short-run policy impacts on human capital investments 1A. Early Childhood Development (ECD) Programs 1B. Food for Education (FFE) Programs 1C. Conditional Cash Transfers (CCTs) 1D. Performance Incentives and Vouchers 1E. Conclusions

  5. 1A. Early Childhood Development (ECD) Programs ECD has multiple interacting components: Cognitive-language skills, Interpersonal skills, Social-emotional skills and Physical development (nutrition, sensory-motor) Large numbers of children in developing world, estimated 200+ million, fail to reach their development potential -- four major risks: stunting, iron deficiency, iodine deficiency, and lack of cognitive and social-emotional stimulation* *Grantham-McGregor, SM., YB Cheung, S Cueto, P Glewwe, LM Richter, BJ Strupp, 2007, “Over Two Hundred Million Children Fail to Reach Their Developmental Potential in the First Five Years in Developing Countries,” Lancet 369 (January): 60–70.

  6. Mean Z-scores for height-for-age relative to the new WHO standards for Peru, 2000 Age (months) Z

  7. ECD Enrollment Rates for 3 & 4 y Olds by Income Quintile (Engle et al 2011 Lancet)

  8. No. of Mothers’ Activities in Last 3 Days that Support Child Learning by Income Quintile (Engle et al 2011 Lancet)

  9. Evidence on impacts of ECD programs What interventions have worked at scale to reduce the loss of developmental potential from the four major risks: stunting, iron deficiency, iodine deficiency, and lack of cognitive and social-emotional stimulation? • Engle, Patrice L., Maureen M. Black, Jere R. Behrman, Meena Cabral de Mello, Paul J. Gertler, Lydia Kapiriri, Reynaldo Martorell, Mary Eming Young, International Child Development Steering Committee, 2007, “Strategies to Avoid the Loss of Potential Among 240 Million Children in the Developing World,” Lancet 369 (January), 229-242.

  10. Effects of interventions on cognitive and social-emotional development

  11. Effects of combined improved nutrition and environment and age Adapted from Winick M, Meyer K, Harris R. Malnutrition and environmental enrichment and early adoption. Science 1975: 190: 1173-75 and Lien N, Meyer K, Winick M. Early malnutrition and “late” adoption: a study of their effects on the development of Korean orphans adopted into American families. Am J Clin Nutr 1977: 30: 1734–39.

  12. Philippines ECD Program Effects: Age and duration (marginal PSM)Armecin, G, JR Behrman, P Duazo, S Ghuman, S Gultiano, EM King, N Lee, and The Office of Population Studies, University of San Carlos ECD Team, 2006. “Early Childhood Development through Integrated Programs: Evidence from the Philippines,”, 2006.

  13. Characteristics of Successful Program According to Engle et al(2007) • Comprehensive • Target disadvantaged children • Begin with younger children • Sufficient intensity and duration • Quality • Training of staff, • Initiative and exploration in learning environment, • Partnership with families • Blend traditional child rearing with evidence-based approaches

  14. 1B. Food for Education Programs (FFE)* • FFE programs aim to increase enrolment, attendance and performance in school. • School feeding programs (SFP) –subsidy to school attendance and increase in real income for family. • Take home rations (THR)-can be resold unlike SFP programs. • Long history of FFE programs, e.g. World Food Program operating for > 45 years. *For more details, see Behrman, JR, SW Parker, & PE Todd (BPT), 2011, “Incentives for Students and Parents”, in P Glewwe, ed. Education Policy in Developing Countries: What Do We Know, and What Should We Do to Understand What We Don’t Know? (in preparation)

  15. Large Scale FFE Programs • Global Food for Education pilot: USDA donated surplus U.S. agricultural commodities for use in school feeding and pre-school nutrition programs in 4000 schools in 38 developing countries between 2001 and 2003. • World Food Program: operated by United Nations, 22.6 million beneficiaries in school feeding programs in 2008.

  16. FFE Program Evaluations • Large number of studies but few rigorous evaluations of Global Food for Education and World Food Program interventions. • BPT focus on recent individual level school feeding projects with rigorous evaluations (mostly randomized). • Bangladesh (5 studies), Burkino Faso (2) and Uganda (2), Jamaica (1) and Peru (1).

  17. FFE Programs: Conclusions • Generally positive impacts of FFE programs on enrollment and attendance. • More limited results on performance in school including repetition rates and achievement tests. • Few estimates of real resource costs and relationship to benefits.

  18. 1C. Conditional Cash Transfers (CCTs) • Monetary transfers to poor families conditional on human capital investment, principally regular school attendance of children in beneficiary families. • Over 30 countries in 5 continents with CCTs, around half with rigorous evaluations. • Rigorous randomized large-scale evaluation accompanied initial Mexican PROGRESA/Oportunidades program in late 90s. • Implementation of many similar programs. • Impact evaluations implemented in initial program stages.

  19. Literature on CCTs • Substantial literature on short-run impacts in different contexts. • Number of reviews of CCTs, most prominent probably 2009 WB PRR (Fiszbein & Schady). • Behrman, Parker & Todd (2011) focuses mainly on studies carried out since WB 2009.

  20. WB (2009) on CCTs • Focus on results for short-run educational indicators for 10 countries with CCTs and rigorous evaluations (mostly randomized). • Significant impacts on enrollment in all contexts with exception of Turkey. • Impacts range from 2 to 13 percentage points in Latin American countries and 11 to 31 percentage points for countries outside the region (Bangladesh, Pakistan, Cambodia).

  21. WB (2009) on CCTs • Enrollment impacts higher in countries and contexts with lower levels of schooling. • Impacts higher for poorer families than for less poor families. • Evidence on achievement scores and longer-term education indicators “disappointing.” • Few available studies show no impacts on achievement tests. • But only 2 based on achievement tests applied in the household.

  22. BPT (2011) on CCT Conditionality • Sig impacts on attendance/enrollment for Malawian girls 13-22 y old randomized to conditional transfers but not to unconditional transfers vs. control group (Baird, McIntosh & Ozler2010, WB Working Paper). • Impacts 5-10 percentage points higher for Mexican Oportunidades families who received enrollment forms vs. those not receiving enrollment forms (unconditioned) (DeBrauwand Hoddinott2010 JDE). • Morrocan J-PAL study (in process) • Appears conditionality plays main role in generating educational impacts, but conditionality has costs: • Individual compliance costs. • Program enforcement costs.

  23. BPT (2011) onCCTs in Urban Areas • Colombia (Bogota): Randomized (1) traditional CCTs for attendance, (2) some benefits delayed to beginning of next year & (3) some benefits linked to graduation and reenrollment in next level. Sig impacts on attendance in all 3 but higher impacts on reenrollment under (2) and (3). (Barrera-Osorio, Bertrand, Linden and Perez, 2011. American Economic Journal: Applied Economics). • Matched control Mexican urban evaluation: enrollment impacts on children 6 to 20, about 3 percentage points, 0.1 grades of schooling. (Behrman, Gallardo, Parker, Todd and Velez, 2010)

  24. BPT on Other Recent CCT Results • Gender: Impacts in some cases sig higher for boys (but schooling attainment conditional on some enrollment for girls >= for boys) (Grant and Behrman 2010 Population Development Review) • Spillovers on non-beneficiary children a priori could be either direction but in Mexican rural program are positive (Lalive and Cattaneo, 2009 ReStat and Bobonis and Finan, 2009 ReStat) • Sig impact on achievement tests in math and English for girls in Malawi (Baird et al 2010 WB Working Paper). • Longer-term impacts for initially 9 to 12 y olds after 6 y of benefits in rural Mexico: Boys 1 additional grade, girls 0.8; some evidence of increased work and substitution to non-agricultural work (Behrman, Parker & Todd, 2011 JHR).

  25. Conclusions on CCTs • Popular program, new efforts likely to continue. Evaluation challenging given bundle of goals including both current and long-run poverty alleviation • Substantial evidence on enrollment impacts. • Some evidence on nutritional and other health–related impacts. • Very limited evidence that improve learning and achievement. • Evidence on longer-term impacts limited.

  26. 1D. Performance Incentives & Vouchers • Randomized cash grants for performance on matriculation exams in 40 Israeli secondary schools. Students in treatment schools were 6 to 8 percentage points more likely to pass high school matriculation exam after one year (Angrist and Lavy, 2009 AER). • Randomized scholarships for 15% highest scoring girls per district on standardized test in Kenya led to improvements of 0.2 standard deviations on achievement tests. Though students lower in the distribution had little chance of obtaining scholarship, they also showed significant impacts. (Kremer, Miguel and Thornton, 2009 ReStat)

  27. Aligning learning incentives (ALI) with randomization among 88 Mexican high schools of alternative monetary incentive payments based on level and improvement in curriculum-based math test scores: students only, teachers only, both students and teachers with own and group components. After two years if students receive incentives improvement of 0.4 to 0.7 SD, but no significant effect if teachers alone receive incentives. (Behrman, Parker, Todd & Wolpin, 2011).

  28. Randomized teacher incentive program in 500 government rural primary schools in Andhra Pradesh, India. Bonus payments (mean 3% of annual pay) based on average improvement of students' test scores. After two years students in incentive schools had significantly higher test scores by 0.28 and 0.16 SD in math and language, as well on subjects for which no incentives. Incentive schools performed significantly better than other randomly-chosen schools that received additional schooling inputs of a similar value. (Muralidharan, Karthik and VenkateshSundararaman, 2008, “Teacher Performance Pay: Experimental Evidence from India,: San Diego, CA: U. of CA and Washington, DC: World Bank )

  29. School Vouchers • Most evaluations of vouchers in developing countries focus on Chile, with universal program introduced in 1981; limited impact on student achievement even in communities where private schools expanded most (Mizalaand Romaguera, JHR 2000; MacEwan Ed Ec 2001; Hsieh and UrquiolaJPubEc 2006) • Colombia used lotteries to distribute vouchers subsidizing cost of private secondary school (PACES); lottery winners 10 percentage points more likely to finish 8th grade and with significantly higher achievement tests cores (0.2 SD). (Angrist, Bettinger, Bloom, King and Kremer, 2000 AER)

  30. 1E. Conclusions • Apparently substantial short-run impact of ECD programs. • FFE and CCT incentive programs to students and parents do seem to get kids to go to school more. • But effects on learning via standardized tests more elusive. • Perhaps most promising intervention is direct linking of incentives to achievement and other desirable indicators such as graduation.

  31. Caveat: One size does not fit all • Differences in: • Program objectives • Initial conditions • Prices and other policies • Resource costs, NOT governmental budgets • Therefore search for “best practices” needs to be calibrated for such differences

  32. For Such Reasons: • At minimum such a table must include some of characteristics of key relevance, such as prevalence of worms, misinformation and enrollments. Still may be quite misleading. • But perhaps most important lesson of PROGRESA/Oportunidades and subsequent J-PAL and other studies is the importance of systematic evaluation of programs on significant scale, NOT that the program should or should not be applied in other contexts that may vary in important dimensions.

  33. 2. Longer-run impacts of human capital investments and some benefit/cost ratios

  34. 2A. Better early life nutrition 2B. Expanded ECD programs 2C. School programs

  35. 2A. Better early life nutrition 2008 Lancet review* of existing studies and new estimates based on five cohort studies (Brazil, Guatemala, India, Philippines, South Africa) suggests longer-run positive effects. *Victora, CG, L Adair, C Fall, PC Hallal, R Martorell, L Richter, HS Sachdev, 2008, “Maternal and Child Undernutrition: Consequences for Adult Health and Human Capital,” The Lancet 371 (Issue 9609), 340-357.

  36. Long-term effects of a nutrition intervention in early childhood: Guatemalan INCAP studies • Better (atole) and less good (fresco) nutritional supplements randomly available across small number of villages in 1969-77; follow-up surveys in 2002-4 and 2006-7 of children (0-7y) in 1969-77 after about 35 years and their children.

  37. Impact on education of exposure to improved nutrition from 0–3 y of age* Schooling attainment: Effects found for women only • Improved by 1.2 grades (0.36 SD) Reading: For men and women (25-42y), improved Inter-American Reading scores by 0.28 SD Cognition: For men and women (25-42y), improved Raven’s Progressive Matrices scores by 0.24 SD *Maluccio J, Hoddinott J, Behrman JR, Martorell R, Quisumbing A, and Stein A. 2009 “The impact of improving nutrition during early childhood on education among Guatemalan adults ,” Economic Journal 119 (April), 734–763.

  38. Improved nutrition in early childhood and adult economic activity* Exposure to improved nutrition before, but not after 3 years, improved wage rates (income/hour) for men but not women. Exposure from 0–2 years had the greatest impact: Wages increased by US $ 0.67 (CI: 0.16,1.17) or 0.45 SD *Hoddinott J, Maluccio JA, Behrman JR, Flores R, and Martorell R. Effect of a nutrition intervention during early childhood on economic productivity in Guatemalan adults. Lancet 2008; 371:411-16.

  39. P = 0.009 P = 0.007 P = 0.406 Exposure to improved nutrition in early childhoodand income (in US$) earned per hour; n=602 men; age 25-42 y* US$/hr Window of exposure (months) *Hoddinott J, Maluccio JA, Behrman JR, Flores R, and Martorell R. Effect of a nutrition intervention during early childhood on economic productivity in Guatemalan adults. Lancet 2008; 371:411-16.

  40. Exposure to early childhood nutritional supplements & intergenerational effects* • Exposure for females, but not for males, affected their children 0-12 y. Significant increases in: • Birth weight of 116 g (CI: 17 g to 215 g) • Height 1.3 cm (CI 0.4 cm to 2.2 cm) • Head circumference 0.63 cm (CI 0.37 cm to 0.89 cm) • But NOT in weight, BMI, arm circumference, triceps and subscapular skinfold thicknesses • (Estimates robust to alternative treatments of standard errors and attrition.) *Behrman JR, Calderon MC, Preston S, Hoddinott J, Martorell R and Stein A. 2009. “Nutritional Supplementation of Girls Influences the Growth of their Children: Prospective Study in Guatemala,” American Journal of Clinical Nutrition .

  41. Cognitive skills (brain) production functionsBehrman, JR, J Hoddinott, JA Maluccio, E Soler-Hampejsek, EL Behrman, R Martorell, M Ramirez and AD Stein, 2008, “What Determines Adult Cognitive Skills? Impacts of Pre-School, School-Years and Post-School Experiences in Guatemala”, Washington, DC: IFPRI Discussion Paper No. 826. Informative about whether schooling dominant or possibly exclusive determinant of adult cognitive skills , as often (implicitly) assumed. Given wage function estimates below, informative of whether cognitive skills a channel through which early-life nutrition works. Also informative about other topics, ranging from cross-country regressions to “Flynn effect” (increasing ability measures over time). (Estimation IV or 2SLS with good diagnostics & robust to alternative treatment of standard errors/attrition.)

  42. Results—Reading Comp Scores (SDs)

  43. Results – Non Verbal Skills (SDs)

  44. Conclusions for Cognitive Skills Production Function Estimates Most previous empirical investigations of importance of and determinants of adult cognitive skills assume that (1) cognitive skills produced primarily by schooling (2) schooling predetermined in statistical sense But may lead to misleading inferences about impact of schooling & also about importance of pre-schooling and post-schooling experiences on what adults know.

  45. Brain versus brawn in wage functionsBehrman, Jere R., John Hoddinott, John A. Maluccio and Reynaldo Martorell, 2009, “Brains versus Brawn: Labor Market Returns to Intellectual and Physical Human Capital in a Poor Developing Country,” Philadelphia, PA: University of Pennsylvania, mimeo. Vast literature assessing “return” to intellectual human capital (typically schooling) in labor market (Psacharopoulos & Patrinos 2004) Some of it incorporates physical human capital (short-term measures or height), often for developing countries (Strauss 1986; Thomas & Strauss 1997) Other studies incorporate more proximate measures, particularly for intellectual human capital (Boissiere, Knight & Sabot 1985; Murnane, Willet & Levy 1995; Alderman et al. 1996; Glewwe et al. 1996) Here endogenize proximate measures of two HC types

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