1. Reproductive and Overall Health Outcomes and Their Economic Consequences for Households in Accra, Ghana Allan Hill and Günther Fink Harvard Center for Population & Development Studies Ernest Aryeetey and Isaac Osei-Akoto Institute for Statistical, Social and Economic Research Third Annual Research Conference on Population, Reproductive Health and Economic Development Dublin, Jan 16-18, 2009

2. 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?

3. 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….

4. 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)

5. Original Sampling Framework SES of EA Survey Age groups Total 18-2425-3435-5455+ Low class 259299219199976 Low middle class 207169203164743 Upper middle class 189182187184742 High class 189167176179711 Total 8448177857263172

6. 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…

7. Health topics covered in the home interview

8. 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

10. Age group Self- reported obesity %N Measured with BMI>30 %N 18-240.785211.0191 25-341.581729.1189 35-442.846940.0210 45-546.031744.7206 55-644.636843.0230 65 & over6.435936.4228 All2.8318234.61254

12. Microeconomic Study 2008/2009

13. 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

14. 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

15. Rolling Sample Time Line IV 1 round 1 Week 1 Week 2 Week 3 October 08 December 09 IV 2 round 1 IV 3 round 1 12 weeks IV 11: round 4 IV 12: round 4 IV 13: round 4 Week 52 Each “cohort” consists of - 20-25 households - 3-5 different EAs

16. 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)

17. 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

18. 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

19. Daily Diary Example

20. 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!

21. Data Collection: Status and Projection More coming soon…

22. Thank you!