Sexual risk-taking in the slums of Nairobi,Kenya, 1993-8

Relatively less attention has been paid to reproductive health problems facing deprived urban residents than to those facing rural residents in the sub-Saharan Africa. This is probably because the majority of Africans live in rural areas, where they are presumed to have poorer medical, educational, and other social services. Yet, the unprecedented rate of urbanization and the accompanying disproportionate growth in the proportion of poor city residents pose new challenges for health care in the region. This study examines differences in sexual behaviour between slum residents and non-slum residents in Nairobi city. The results show that slum residents start sexual intercourse at earlier ages, have more sexual partners, and are less likely than other city residents to know of or adopt preventive measures against contracting HIV/AIDS. The findings highlight the need to treat slum residents as a sub-population uniquely vulnerable to reproductive health problems and to expend more resources in slum settings.     

Sexual risk-taking in the slums of Nairobi,Kenya, 1993-98

Relatively less attention has been paid to reproductive health problems facing deprived urban residents than to those facing rural residents in sub-Saharan Africa. This is probably because the majority of Africans live in rural areas, where they are presumed to have poorer medical, educational, and other social services. Yet, the unprecedented rate of urbanization and the accompanying disproportionate growth in the proportion of poor city residents pose new challenges for health care in the region. This study examines differences in sexual behaviour between slum residents and non-slum residents in Nairobi city. The results show that slum residents start sexual intercourse at earlier ages, have more sexual partners, and are less likely than other city residents to know of or adopt preventive measures against contracting HIV/AIDS. The findings highlight the need to treat slum residents as a subpopulation uniquely vulnerable to reproductive health problems, and to expend more resources in slum settings.     

Organized Violence and Institutional Child Delivery: Micro-Level Evidence From Sub-Saharan Africa, 1989–2014

The conditions under which a mother gives birth greatly affect the health risk of both the mother and the child. This article addresses how local exposure to organized violence affects whether women give birth in a health facility. We combine geocoded data on violent events from the Uppsala Conflict Data Program with georeferenced survey data on the use of maternal health care services from the Demographic and Health Surveys. Our sample covers 569,201 births by 390,574 mothers in 31 countries in sub-Saharan Africa. We use a mother fixed-effects analysis to estimate the effect of recent organized violence events within a radius of 50 km of the home of each mother on the likelihood that her child is born in a health facility. The results indicate that geographical and temporal proximity to organized violence significantly reduces the likelihood of institutional births. Although the level of maternal health care overall is lower in rural areas, the negative effect of violence appears to be stronger in urban areas. The study further underscores the importance of household and individual resilience, indicating that the effect of organized violence on institutional child delivery is greater among poor and less-educated mothers.     

Left behind: intergenerational transmission of human capital in the midst of HIV/AIDS

This paper provides evidence on how adverse health conditions affect the transfer of human capital from one generation to the next. We explore the differential exposure to HIV/AIDS epidemic in sub-Saharan Africa as a substantial health shock to both household and community environment. We utilize the recent rounds of the Demographic and Health Surveys for 11 countries in sub-Saharan Africa. First, we find that an additional year of maternal education leads to a 0.37-year increase in children’s years of schooling in the developing economies in sub-Saharan Africa. Second, our results show that mother’s HIV status has substantial detrimental effects on inheritability of human capital. We find that the association between infected mothers’ and their children’s human capital is 30 % less than the general population. Finally, focusing only on noninfected mothers and their children, we show that HIV prevalence in the community also impairs the intergenerational human capital transfers even if mother is HIV negative. The findings of this paper are particularly distressing for these already poor, HIV-torn countries as in the future they will have even lower overall level of human capital due to the epidemic.     

Slum Residence and Child Health in Developing Countries

Continued population growth and increasing urbanization have led to the formation of large informal urban settlements in many developing countries in recent decades. The high prevalence of poverty, overcrowding, and poor sanitation observed in these settlements—commonly referred to as “slums”—suggests that slum residence constitutes a major health risk for children. In this article, we use data from 191 Demographic and Health Surveys (DHS) across 73 developing countries to investigate this concern empirically. Our results indicate that children in slums have better health outcomes than children living in rural areas yet fare worse than children in better-off neighborhoods of the same urban settlements. A large fraction of the observed health differences appears to be explained by pronounced differences in maternal education, household wealth, and access to health services across residential areas. After we control for these characteristics, children growing up in the slums and better-off neighborhoods of towns show levels of morbidity and mortality that are not statistically different from those of children living in rural areas. Compared with rural children, children living in cities (irrespective of slum or formal residence) fare better with respect to mortality and stunting but not with respect to recent illness episodes.     

Sub-Saharan Africa: population pressures on development

The population of sub-Saharan Africa, estimated at 434 million in 1984, is expected to reach 1.4 billion by 2025. The birth rate, currently 48/1000 population, continues to increase, and the death rate, 17/1000, is declining. Rapid population growth has curtailed government efforts to provide adequate nutrition, preserve the land base essential for future development, meet the demand for jobs, education, and health services, and address overcrowding in urban areas. Low education, rural residence, and low incomes are key contributors to the area's high fertility. Other factors include women's restricted roles, early age at marriage, a need for children as a source of security and support in old age, and limited knowledge of and access to modern methods of contraception. Average desired family size, which is higher than actual family size in most countries, is 6-9 children. Although government leaders have expressed ambivalence toward development of population policies and family planning programs as a result of the identification of such programs with Western aid donors, the policy climat is gradually changing. By mid-1984, at least 13 of the 42 countries in the region had indicated that they consider current fertility rates too high and support government and/or private family planning programs to reduce fertility. In addition, 26 countries in the region provide some government family planning services, usually integrated with maternal and child health programs. However, 10 countries in the region do not support family planning services for any reason. Unfortunately, sub-Saharan Africa has not yet produced a family planning program with a measurable effect on fertility that could serve as a model for other countries in the region. Social and economic change is central to any hope of fertility reduction in sub-Saharan Africa. Lower infant and child mortality rates, rising incomes, higher education, greater economic and social opportunities for women, and increased security would provide a climate more conducive to fertility decline. Given the limited demand, great sensitivity must be shown in implementing family planning programs.     

Health conditions in rural and urban areas of developing countries

The poor quality and meagre supply of data prohibit conclusions as to the relationship of health status to rural-urban residence in underdeveloped countries. Demographic indicators of health, specifically infant mortality and average life expectancy, do not seem to vary systematically according to rural-urban residence in the less developed countries ofAsia, Africa and Latin America. Further differences between rural and urban areas in availability of health services and facilities do not always conform with apparent differences between the areas in health status. However, nutritional standards, housing conditions, and sanitation, water supply and other pertinent environmental circumstances account to some extent for differences observed in health status between rural and urban inhabitants of these countries.     

户籍类型与城乡居民医疗服务利用 ——基于Andersen模型的经验分析

本文利用中国社会科学院经济研究所2018年城乡居民入户调查数据,从户籍改革角度分析户口类型改变对城乡居民医疗服务利用的影响。研究发现:与户口类型未发生改变的城乡居民相比,户口类型发生过改变(农转非)的城乡居民门急诊服务利用的可能性更高,住院医疗服务支出水平更低。从户籍改革与参保类型交互效应看,相对于户口类型未发生过改变的居民医保参保人群,户口类型发生改变(农转非)会显著提高居民医保参保人群门急诊服务利用,同时降低其住院服务利用。进一步采用PSM方法进行稳健性检验,户籍改革对提高城乡居民门急诊服务利用,降低住院医疗服务利用的结论依然成立。此外,本文还发现,直接结算提高了城乡居民门急诊和住院的就诊概率;健康自评状况越差,门急诊和住院医疗服务利用可能性越高,门急诊医疗支出、住院医疗支出和跨省异地就医支出也越高。本文认为,相对于推行基层分级诊疗制度,以户籍改革推动农村居民自由流入医疗资源更丰富的城镇地区,改革基层卫生院制度,以及改变基层医疗服务提供激励机制,可能更有助于改善农村居民健康状况。     

Quality of life declines in big and growing cities. Poverty in cities

The quality of life in developing countries during the first couple of decades after the Second World War was higher in cities than in small towns and villages. However, the relative advantage of city dwellers in developing countries has declined since the 1970s, with high-growth rate cities experiencing a more severe decline. Infant mortality levels in Latin America and sub-Saharan Africa in the 1990s are as high in large cities as in the smallest towns and villages. In most developing regions, big city residents are increasingly disadvantaged, such that researchers and policymakers can no longer assume that the quality of life in urban areas is better than in rural areas. The urban transformation of the developing world is similar to the 19th century urbanization of now-developed countries, but today many more people are crowding into far bigger cities. Using survey information from 43 countries representing 63% of the developing world's urban population outside of China and India, Martin Brockerhoff of the Population Council and Ellen Brennan of the UN Population Division found that rapid population growth and big size have overwhelmed the capacity of cities to provide essential goods and services.     

Likelihood of African American Primary Caregivers and Care Recipients Receiving Assistance From Secondary Caregivers: A Rural-Urban Comparison

We examine rural-urban differences in reliance on secondary caregivers for African American female primary caregivers (250 rural, 242 urban) and their care recipients. Logistic regression was used to identify caregiver and care recipient characteristics significantly associated with the likelihood of having a secondary caregiver within rural and urban samples. Post hoc Wald chi-square tests were used to identify significant between-sample differences in regression coefficients. Secondary caregivers were more common in urban than rural contexts. Having a secondary caregiver was more strongly related to primary caregivers' poorer physical health and nonresidence with care recipients in rural than urban contexts. Findings suggest that policy initiatives, such as the National Family Caregivers Support Act and the cash and counseling model, may benefit rural and urban residents, particularly rural residents as the majority of them lacked secondary caregiver assistance.     

Three faces of international inequality

Recent studies of international inequality have focused mostly on the trend in international income inequality. This article extends the analysis of international inequality to also include inequalities in education and health. Analyses of time-series data for more than 100 countries show that international income inequality declined from 1980 to 2003 as several large, poor Asian countries outpaced many Western countries in national income growth. By contrast, international health inequality followed a U-shaped trend, falling in the 1980s before rising in the 1990s. The turnaround in health inequality coincides with a trend of declining life expectancy in sub-Saharan Africa. International educational inequality experienced the sharpest recent decline, spurred by the global expansion of formal schooling. These findings confirm that there is more to international inequality than income inequality alone and suggest that patterns of inequality in the current era of globalization are likely more complex than many leading theories suggest.     

Birth and death in cities in the developing world

City dwellers in Sub-Saharan Africa have increased roughly 600% in the last 35 years. Throughout the developing world, cities have expanded at a rate that has far outpaced rural population growth. Extensive data document lower fertility and mortality rates in cities than in rural regions. But slums, shantytowns, and squatters' settlements proliferate in many large cities. Martin Brockerhoff studies the reproductive and health consequences of urban growth, with an emphasis on maternal and child health. Brockerhoff reports that child mortality rates in large cities are highest among children born to mothers who recently migrated from rural areas or who live in low-quality housing. Children born in large cities have about a 30% higher risk of dying before they reach the age of 5 than those born in smaller cities. Despite this, children born to migrant mothers who have lived in a city for about a year have much better survival chances than children born in rural areas to nonmigrant mothers and children born to migrant mothers before or shortly after migration. Migration in developing countries as a whole has saved millions of children's lives. The apparent benefits experienced in the 1980s may not occur in the future, as cities continue to grow and municipal governments confront an overwhelming need for housing, jobs, and services. Another benefit is that fertility rates in African cities fell by about 1 birth per woman as a result of female migration from villages to towns in the 1980s and early 1990s. There will be an increasing need for donors and governments to concentrate family planning, reproductive health, child survival, and social services in cities, particularly in Sub-Saharan Africa, because there child mortality decline has been unexpectedly slow, overall fertility decline is not yet apparent in most countries, and levels of migration to cities are anticipated to remain high.     

Comparison of household-survey estimates with projections of mortality and orphan numbers in sub-Saharan Africa in the era of HIV/AIDS

The United Nations publishes estimates of HIV prevalence, AIDS mortality, and orphan numbers for all countries of the world. It is important to assess the validity of these model-based estimates since they underpin much policy concerned with care and prevention. Household surveys that ask questions about the survival of children's parents (orphanhood) offer an independent source of data with which these estimates can be compared. Survey estimates of maternal and paternal orphans are significantly lower than model estimates for 40 surveys in 36 countries of sub-Saharan Africa (p < 0.001, p = 0.002). This is probably because adult mortality from causes other than AIDS is lower than assumed in the models, although under-reporting of orphanhood in surveys may also play a role. Reducing adult mortality from causes other than AIDS brings the model estimates into close agreement with the surveys. This suggests that the fraction of orphans attributable to AIDS is greater than estimated previously.     

Son preference, use of maternal health care, and infant mortality in rural China, 1989-2000

This study assesses the effects of socio-economic conditions and the interaction between son preference and China's one-child family planning policy on the use of maternal health care services and their effects on infant mortality in rural China, using nationally representative data from the 2001 National Family Planning and Reproductive Health Survey. The results show that while the use of maternal health care services has continued to increase over time, large gaps still exist in the use of these services and in infant survival by mother's education, community income, and parity. Further improvements in the reproductive health of all women and in infant survival will require effective reduction of the obstacles to the use of maternal health care among those women in rural China who are less educated, poor, and of higher parity.     

我国城乡贫困人口医疗保障研究

城乡贫困人口虽然都存在医疗保障覆盖率低、卫生服务利用不足的现象,但其制度根源却不同。城市医疗保障制度的主要问题在于虽有医疗保障制度,但是保障资源在各个收入层间分配不公平,向中高收入层倾斜,贫困人口从中获益的可能性较小;农村医疗保障的主要问题在于近几年农村医疗保障的制度建设刚刚开始,过去长久以来农村几乎没有任何医疗保障,大多数农民一直处于无保障状态,因病致贫比率较高。今后城市医疗保障制度建设的重点在于提高公平性,满足贫困人口的医疗保障需求;农村医疗保障制度建设的重点在于搭建制度框架,使医疗保障覆盖大多数农村居民,防止因病致贫。     

Environmental influences on African migration to Canada: focus group findings from Ottawa-Gatineau

There is limited empirical evidence of how environmental conditions in the Global South may influence long-distance international migration to the Global North. This research note reports findings from seven focus groups held in Ottawa-Gatineau, Canada, with recent migrants from the Horn of Africa and francophone sub-Saharan Africa, where the role of environment in migration decision-making was discussed. Participants stated that those most affected by environmental challenges in their home countries lack the financial wherewithal to migrate to Canada. Participants also suggested that internal rural–urban migration patterns generated by environmental challenges in their home countries underlay socioeconomic factors that contributed to their own migration. In other words, environment is a second- or third-order contributor in a complex chain of interactions in the migrant source country that may lead to long-distance international migration by skilled and educated urbanites. These findings have informed the scope and detail of a larger, ongoing empirical study of environmental influences on immigration to Canada.     

Health Selection,Migration, and HIV Infection in Malawi

Despite its importance in studies of migrant health, selectivity of migrants—also known as migration health selection—has seldom been examined in sub-Saharan Africa (SSA). This neglect is problematic because several features of the context in which migration occurs in SSA—very high levels of HIV, in particular—differ from contextual features in regions that have been studied more thoroughly. To address this important gap, we use longitudinal panel data from Malawi to examine whether migrants differ from nonmigrants in pre-migration health, assessed via SF-12 measures of mental and physical health. In addition to overall health selection, we focus on three more-specific factors that may affect the relationship between migration and health: (1) whether migration health selection differs by destination (rural-rural, rural-town, and rural-urban), (2) whether HIV infection moderates the relationship between migration and health, and (3) whether circular migrants differ in pre-migration health status. We find evidence of the healthy migrant phenomenon in Malawi, where physically healthier individuals are more likely to move. This relationship varies by migration destination, with healthier rural migrants moving to urban and other rural areas. We also find interactions between HIV-infected status and health: HIV-infected women moving to cities are physically healthier than their nonmigrant counterparts.     

Population distribution and economic development in Africa: The need for urbanization policies

Many countries in Africa are facing severe development problems because of high rates of population growth, stagnant or declining agricultural productivity, and increasing migration of the rural poor to large cities. Most demographic studies of Africa ignore problems arising from the spatial distribution of population and public allocation of investment. Strategic planning of the location of development investments in ways that will prevent or reduce excessive concentration of population and productive activities in large primary cities is becoming increasingly important for many African governments. In this article it is argued that the excessive growth of primary cities in predominantly rural countries can be detrimental to their economic recovery. Policies encouraging more widespread distribution of population in secondary cities and towns and policies promoting investment in physical infrastructure, marketing, small-scale manufacturing, and agroprocessing in secondary cities and towns can provide a stronger base for both rural and urban development in many African countries in the future.     

Prime-age adult mortality in sub-Saharan Africa: examining trends in Demographic and Health Surveys conducted between 1990 and 2014

Adult mortality rate is a critical indicator used to assess the level of national development in most sub-Saharan African countries. However, estimation of adult mortality rates requires comprehensive and accurate reporting of adult deaths, which is one of the challenges faced by most sub-Saharan African countries. Using data from Demographic and Health Surveys conducted between 1990 and 2014 in 25 countries in sub-Saharan Africa, we examine trends in all-cause prime adult mortality (measured by the probability of dying between exact ages 15 and 50) and sex differences in adult mortality by region. Our paper provides a basis for tracking progress in reducing adult mortality and improving overall health. The median probability of dying was 173 per 1000 for women in the latest surveys, an increase from 166 per 1000 during the initial surveys. The median value for men was 177 per 1000; a decrease from the initial surveys which was 202 per 1000. Across all countries, the average annual increase in the probability of dying was higher for women (1.08%) than men (0.49%). Intensive efforts are needed to improve adult survival and ensure that sub-Saharan Africa achieves the Sustainable Development Goals by 2030. In particular, efforts to mitigate the premature risk of dying among women need to be intensified.     

Caregiver Decision-Making: Household Response to Child Illness in Sub-Saharan Africa

We draw upon a framework outlining household recognition and response to child illness proposed by Colvin et al. (Soc Sci Med 86:66–78, 2013) to examine factors predictive of treatment sought for a recent child illness. In particular, we model whether no treatment, middle layer treatment (traditional healer, pharmacy, community health worker, etc.), or biomedical treatment was sought for recent episodes of diarrhea, fever, or cough. Based on multinomial, multi-level analyses of Demographic and Health Surveys from 19 countries in sub-Saharan Africa, we determine that if women have no say in their own healthcare, they are unlikely to seek treatment in response to child illness. We find that women in sub-Saharan Africa need healthcare knowledge, the ability to make healthcare decisions, as well as resources to negotiate cost and travel, in order to access biomedical treatment. Past experience with medical services such as prenatal care and a skilled birth attendant also increases the odds that biomedical treatment for child illness is sought. We conclude that caregiver decision-making in response to child illness within households is critical to reducing child morbidity and mortality in sub-Saharan Africa.