**Policy, Research, and External Affairs**

# **PopulatIon, Health, and Nutrition**

# WPS 766

- This paper a product of the Population, Health, and Nutrition Division, Population and Human Resources - Department is part of a larger study undertaken by PRE of African health policy. Copies are available free froim the World Bank, 1818 H Street NW, Washington DC 20433. Please contact Otilia Nadora, room S6-065, extension 31091 (73 pages).

Diop, Hill, and Sirageldin applied two types of analysis to two types of data to try to quantify any short-term cffect economic crisis and adjustment might have had on child mortality in Sub-Saharan Africa.

First they analyzed aggregate data for ten countrics covered by the Demographic and Health Surveys project. Then they analyzed an elaborate data ;et for Cote d'lvoire collected in the mid- 1980s. Both analyses used time-period dummy variables to identify the etfec.ts of crisis and adjustment. Despite very different methodologies and data sets, the two analyses produecd surprisingly similar results.

They found that in the short run, neither crisis nor adjustment increased child mortality at the national level, relative to countries not undergoing adjustment (but not necessarily avoiding crisis).

Because of economic decline and adjustment policies, real income declined in urban areas. But rural incomes among producers of cash crops may not have been negatively affected, because the agricultural policy components of structural adjustment have been relatively protective of agricultural incomes.

The effect of structural adjustment on the health sector in CMte d'lvoire is unclear. The structure of public health spending in 1985 suggests that the emphasis on curative care, based disproportionately in Abidjan hospital centers, has not shifted. And immunization coverage showed no signs of improvement between 1980 and 1984. As subsidies to urban consumers have becn curtailed and real urban income has declined, child health in the urban areas has deteriorated, particularly in the postneonatal period. This deterioration has disproportionately affected families in the top 40 percent of urban income distribution -mostly civil servants.

The LSMS daum suggest that families with no savings have been severely affected by these changes in child health. In the rural areas, child health has not been significant ly affected by the economic crisis or adjustment policies. This finding is consistent with the notion that when families are insulated from (or marginally affected by) public services and subsidies. they will also be insulated from changes in these services and subsidies during adjustment.

It would be surprising if economic crisis and adjustment, both of which imply falling real wages for some components of society, had no effect on child mortality. But countries of Sub-Saharan Africa have not **yeC** reached the levels of development and industrialization that now-developed countries **had** reached when the linki between their economic and health indicators weakened.

Diop, Hill, and Sirageldin found no across-theboard increase in mornality. Rather, they found a change in relative levels among groups that favors itic rural nonpoor at the expense of the urban middleincome and the urban poor, with little net effect at the national level.

Of course, child survival interventions expanded greatly in the 1980s, and would have had their greatest impact in rural, poorl) served areais. How much the efiect of crisis and adjustment has been cancellcd out by immunizations and oral rehydration therapy it is impossible to tell.

Diop, Hill, and Sirageldin examined only shortterm effects - the only ones they could expect to measure. The long-run cifects ol crisis and adjustment will depend on adjustment's success in boostiig sustained long-term giowth. Such growth should reduce child mortality and speed the reduction of fertility as well, thus reiniorcing declines in chil(d mortality.

Thc PRE Working Paper Scries disseminates **thc** Findings of work under waay in **the** Bank's Policy. Rcsear. **Ii.** andl Extemral AffairsComplex. Anobjectivc oftcCSCTieS is togetthese findings out quickly, even ifpresentationis are less than fully polished. Thc lindings, intcrprctations, and conclusions in thesc papers do not necessarily represent official Bank policy.

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