health inputs.<sup>2</sup> Most studies have found that higher education, in particular maternal education, results in improved child health (in terms of child mortality and child nutrition), although these findings are not unambiguous (Barrera 1990; Benefo and Schulz 1996; Bicego and Boerma 1993; Caldwell 1979; Desai and Alva 1998; Glewwe 1999; Hobcraft 1993; Hossain 1989; Lavy and others 1996; Wolfe and Behrman 1982, 1984). The relationship between education and health operates primarily through the impact of education on proximate determinants of health, such as feeding and health practices, sanitation, and utilization of health services. This mechanism has also been studied empirically. For example, studies have focused on the impact of education on food nutrient intake and sanitary practices (Cebu Study Team 1991), use and timing of prenatal health services (Behrman and Wolfe 1987; Gertler, Rahman, and Feifer 1993; Guilkey and Riphahn 1998; Panis and Lillard 1994; Pebley, Goldman, and Rodriguez 1996; Sandiford and others 1995; Schwartz and others 1988; Wong and others 1987), and child immunizations (Gage, Sommerfelt, and Piani 1997; Guilkey and Riphahn 1998; Steele, Diamond, and Amin 1996; Streatfield, Singarimbun, and Diamond 1990). Many of these studies also find education to be an important determinant.<sup>3</sup> Again, maternal education is often found to be more important than paternal education.<sup>4</sup> The primary importance of maternal education for child health outcomes and the use of health care services may be due to social and cultural factors, whereby there are gender differences in preferences or in the information and skills acquired through education. Alternatively, importance of maternal education may reflect the concentration of benefits from investment in maternal and child health on the mother.

The empirical analysis of these issues is fraught with problems, and these findings are not uncontested. Many studies do not adequately control for unobservables such as individual and household background and school characteristics. For example, there may be common unobservables—preferences or abilities—that determines both the amount of education acquired and human capital outcomes (Behrman and Wolfe 1987; Desai and Alva 1998; Hobcraft 1993). Similarly, for some issues, educational attainment or at least health knowledge may respond endogenously to unobserved health endowments. Although these factors may lead to bias in some contexts if not addressed in the analysis, there seems to be a general consensus that education is an important determinant of the demand for health inputs, including the utilization of health services (Strauss and Thomas 1995).

# **2.2 Intrahousehold Education and Literacy Externalities**

As noted, the focus on maternal education as the primary variable of interest in the analysis of health service use and child health may be justified on the basis of a 2 For reviews see Behrman and Deolalikar (1988), Schultz (1999) and Strauss and Thomas (1995; 1998).

3 In these studies education is typically measured by years of schooling or highest grade attained. These are, however, likely to be poor proxies for educational achievement, which is the product of a complex combination of educational inputs, including, years in school, daily attendance, grade repetition, home support and tuition, household expenditure on schooling supplies, school characteristics, and so forth. A few studies that have tried to assess the relative importance of different dimensions of educational achievement (specific knowledge, cognitive skills, norms and values). Glewwe (1999) and Thomas, Strauss, and Henriques (1990) comprise important exceptions.

4 The exception is breast-feeding, where better educated women are less likely to breast feed, and tend to breast feed for a shorter period (Cebu Study Team 1991; Wolfe and Behrman 1982).

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