metadata: authors: 0: author: Aran,Ayse Meltem
1: author: Ersado,Lire
count: Egypt, Arab Republic of
docna: 0: docna: Inequality of opportunity among Egyptian children
docty: Policy Research Working Paper
subtopic: Health Care Services Industry,Reproductive Health,Early Child and Children's Health,Nutrition,Educational Sciences,Hydrology
teratopic: Education,Health, Nutrition and Population
abstracts: cdata!: This paper analyzes the level and trends
            in inequality of opportunity among Egyptian children during
            the 2000s. The analysis uses severall tools, including
            comparison of the distributions of early risks and outcomes
            across circumstance groups; estimation of the human
            opportunity index; measurement of the relative contributions
            of circumstances to inequality of opportunity; and
            decomposition of changes in inequality of opportunity and
            factors driving them over time. Egypt has made significant
            progress in the availability of and access to basic services
            for children and mothers, in some cases with an overall
            pro-poor effect. In particular, appreciable improvements
            have been made in healthcare utilization before and during
            pregnancy and immunizations. As a result, there has been a
            decline in inequality of opportunity over the past decade,
            largely attributable to increased coverage by basic services
            rather than through redistributive effects. However, there
            are areas of persistent and emerging concerns, including
            postnatal care utilization, nutrition, and schooling.
            Nutrition indicators have deteriorated during the 2000s,
            affecting a quarter of children regardless of their
            circumstances. Wide disparities in school enrollment
            persist, notably at the higher levels. Large regional
            disparities in access to basic infrastructure exist, with
            Upper Egypt and the Frontier Governorates lagging the rest
            of the country.  Family background, especially parents'
            education and wealth, and geographic factors are key factors
            affecting child development outcomes in Egypt. While
            interventions targeted at the less advantaged circumstance
            groups may offer significant potential for enhancing overall
            equity in postnatal care utilization and schooling, a more
            inclusive approach would be needed to improve child
            nutrition outcomes.
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repnme: repnme: Inequality of opportunity among Egyptian children
display_title: Inequality of opportunity among
            Egyptian children
listing_relative_url: /research/2014/09/20188963/inequality-opportunity-among-egyptian-children
topicv3: Water m1326522 137,Nutrition m1326779 644,Education m1327048 470,Stunting m1327504 1445,Health m1504661 3480
publishtoextweb_dt: 2014-09-01T00:00:00Z
historic_topic: Education,Health, Nutrition and Population
no_of_pages: 37
author_keys: 0: author_key: 757421
1: author_key: 457742
model_extractions: WPS7026 Policy Research Working Paper 7026

# Inequality of Opportunity Among Egyptian Children

_Lire Ersado Meltem Aran_ Social Protection and Labor Global Practice Group September 2014
Policy Research Working Paper 7026

# **Abstract**

This paper analyzes the level and trends in inequality of opportunity among Egyptian children during the 2000s. The analysis uses severall tools, including comparison of the distributions of early risks and outcomes across circumstance groups; estimation of the human opportunity index; measurement of the relative contributions of circumstances to inequality of opportunity; and decomposition of changes in inequality of opportunity and factors driving them over time. Egypt has made significant progress in the availability of and access to basic services for children and mothers, in some cases with an overall pro-poor effect. In particular, appreciable improvements have been made in healthcare utilization before and during pregnancy and immunizations. As a result, there has been a decline in inequality of opportunity over the past decade, largely attributable to increased coverage by basic services rather than through redistributive effects. However, there are areas of persistent and emerging concerns, including postnatal care utilization, nutrition, and schooling. Nutrition indicators have deteriorated during the 2000s, affecting a quarter of children regardless of their circumstances. Wide disparities in school enrollment persist, notably at the higher levels. Large regional disparities in access to basic infrastructure exist, with Upper Egypt and the Frontier Governorates lagging the rest of the country. Family background, especially parents’ education and wealth, and - geographic factors are key factors affecting child develop ment outcomes in Egypt. While interventions targeted at the less advantaged circumstance groups may offer significant potential for enhancing overall equity in postnatal care utilization and schooling, a more inclusive approach would be needed to improve child nutrition outcomes.

This paper is a product of the Social Protection and Labor Global Practice Group. It is part of a larger effort by the World Bank to provide open access to its research and make a contribution to development policy discussions around the world. Policy Research Working Papers are also posted on the Web at http://econ.worldbank.org. The authors may be contacted at lersado@worldbank.org.

_The Policy Research Working Paper Series disseminates the findings of work in progress to encourage the exchange of ideas about development issues. An objective of the series is to get the findings out quickly, even if the presentations are less than fully polished. The papers carry the names of the authors and should be cited accordingly. The findings, interpretations, and conclusions expressed in this paper are entirely those of the authors. They do not necessarily represent the views of the International Bank for Reconstruction and Development/World Bank and its affiliated organizations, or those of the Executive Directors of the World Bank or the governments they represent._ Produced by the Research Support Team
# **Inequality of Opportunity Among Egyptian Children**

Lire Ersado and Meltem Aran

**Keywords:** _health, education, nutrition, inequality and shared prosperity, early child development_ **JEL codes:** _D1, I3, H51_
# **1. Introduction and Motivation**

A large body of research shows that risks to human and cognitive development are not homogeneously distributed over the life-cycle. They are typically higher in earlier stages of life, with important long-term and sometimes irreversible consequences. In Egypt, as elsewhere, many of the critical inputs for early childhood development, such as the quantity and quality of food, early education and healthcare, and the availability of clean water and sanitation, are unequally distributed among children. For instance, Egypt’s children and youth, representing more than one-third of the country ́s population, face a higher risk of poverty than the general population; and the gap has widened during the past decade (World Bank, 2011). The unequal distribution of these factors contributes in turn to inequality in desirable early childhood development outcomes, and, as such, represents an important source of inequality later in life.

Children’s access to essential basic services or lack thereof will determine their education, health and labor market outcomes, and thus their income-earning potential as adults. Longitudinal studies show that investments in children from poor and vulnerable families can translate into higher earnings in adulthood, thus helping break the cycle of poverty. Nationally, more equitable access to basic services in the early years could lead to more human capital accumulation, which in turn could translate into higher economic growth (see Galor and Zeira, 1993 for theoretical evidence; Birdsall and Londono 1997 and LoÂpez et al., 1998 for empirical evidence). While the acceptable level of inequality of outcomes (such as income) in a society is debatable, policies to give all children equal opportunity, regardless of their socioeconomic background, are embraced across the political spectrum. Early childhood development interventions are thus generally considered as some of the few policy areas where the traditional equity-efficiency trade-off does not exist (Heckman and Masterov 2007). It is therefore important to understand how children’s opportunities develop and identify policy interventions that contribute to reducing the impact of predetermined factors.

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The objective of this paper is two-fold: (i) to analyze the extent of inequality of opportunity among Egyptian children; and (ii) to identify the main circumstances that are beyond the control of children and affecting their development outcomes. Specifically, the paper aims to answer a simple question: what are the chances that an Egyptian child will have adequate access to critical basic services regardless of his or her circumstances at birth, such as gender, place of birth, and family background? It draws on the concepts and ideas developed in the _World Development Report_ (WDR) 2006: _Equity and Development,_ WDR 2007: _Development and the Next Generation,_ and the methodology developed in the recent and growing literature on inequality of opportunity (see, for example, John Roemer, 1998; Barros et al., 2009). The study follows a life cycle approach that identifies an individual’s outcomes and opportunities from conception to adulthood and analyzes the extent to which these outcomes are determined by circumstances beyond individuals ́ control. We use data from Demographic and Health Survey (DHS) and the Household Income, Expenditure and Consumption Survey (HIECS) over time.<sup>1</sup> In the particular case of Egypt, the essence of this paper can be illustrated by visualizing the following scenario. Imagine Amal, a six-year-old girl living in rural Suhag (in Upper Egypt), one of the poorest governorates. Amal has four siblings and lives with her widowed mother who has no formal education and works in subsistence agriculture. Now in turn imagine Karim, a boy, also six years old, living in Heliopolis, an upscale neighborhood in Cairo, Egypt’s largest megacity. Karim has one sibling and lives with his mother and father, both graduates from the American University of Cairo. Karim’s father works for a multinational corporation and his mother in the Egyptian civil service. What are the chances that both Amal and Karim will have access to basic services and early childhood development interventions that will have profound impact on their long term educational, health and labor market outcomes? The paper analyzes the difficulties faced by children like Amal due to circumstances beyond their control, such as their gender, place of birth, and family

> 1 See next section on data and methodology for description of the data sources.

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background. It presents empirical evidence on the levels and trends in inequality in access to basic services among children and the resulting inequality in development outcomes early in life.

The paper is structured as follows. Section 2 presents a brief literature review of the early risk factors and associated health and education outcomes for children. Section 3 presents the data and empirical methodology. Sections 4 and 5 present the main results and discussions, while Section 6 concludes the paper.

# **2. Literature Review**

The literature on inequality of opportunity emphasizes the differences in outcomes that arise from differences due to predetermined circumstances over which an individual has no control. An increase in the coverage of a basic service increases equality of opportunity and an increase in coverage for the disadvantaged group of children carries with it further reduction in inequality of opportunities (Barros et al., 2009).

Numerous studies have been undertaken to examine the extent of inequality of opportunity on early childhood development. In a study investigating the correlation between socioeconomic status and malnutrition among children under the age of 5 in South Africa, Zere and McIntyre (2003) analyzed household income and expenditure survey data and found that stunting and wasting were most highly concentrated in the poorest regions of the country. The study found wasting and stunting to be phenomena the poor suffered from the most. It also highlighted that inequality was highest along racial lines: among the white population, no significant inequities were observed, while nonwhite children from metropolitan areas displayed the highest levels of stunting. A similar study undertaken in Brazil analyzed the prevalence of child malnutrition in relation with income and basic services redistribution policies (Monteiro et al. 2009). The study found that over the 33 years examined, the gap between children from poor and rich households in terms of stunting had 4
narrowed significantly along with shrinking inequality in income distribution, a rise in purchasing power, and increase in access to healthcare and other basic services among the poor. Burgard (2002) also measures inequality of opportunities with a special focus on racial inequalities in child stunting in Brazil and South Africa. The paper finds that racial differences and household socioeconomic status are strongly correlated with stunting.

Singh (2011) uses inequality of opportunity indices to measure inequalities in malnutrition and immunization for children in India, and finds significant regional disparities. In another study, Pathak and Singh (2011) use bivariate analysis, poor-rich ratio and concentration indices to evaluate the trends for malnutrition. Mohan and Pathak (2009) use a similar methodological approach to measure the inequalities in access to maternal care services and child immunization. Both studies find significant disparities in these outcomes between the poor and rich in India.

Limwattananon et al. (2010) in Thailand and Axelson et al. (2012) in Vietnam use concentration indices to examine the inequities in maternal health and early child health outcomes. Both find significant inequalities between the poor and non-poor. In a study in Bangladesh, Anwar et al. (2008) employs multivariate logistics regression to examine inequities in the use of maternal healthcare services and finds that significant inequalities due to asset ownership, area of residence, and parental education.

There have been a few studies on inequality of opportunity in Egypt. Barros et al. (2012) find that Egypt is one of the least inequitable countries in terms of skilled birth attendant and measles immunization. It ranks 50<sup>th</sup> in a sample of 54 Millennium Development Goals (MDGs) Countdown countries based on the concentration index of selected indicators. Wagstaff (2003), analyzing a 1995/6 Egypt DHS, states in a cross-country analysis that Egypt has high concentration indices (i.e., high inequality) in under-five mortality rate and infant mortality rate compared to other countries. Another study by Boutayeb and Helmert (2011) analyzed disparities in maternal care between rich and poor women, as well as differences between women living in urban and rural regions in Egypt.

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In a more recent study, Assaad et al. (2012) examines the patterns of inequality of opportunity in child health outcomes in Egypt and a number of Arab countries and Turkey using several DHS data. The outcome variables used in this study as indicators for stunting or wasting are standardized height and weight of children. They find that for Egypt, total inequality is increasing over time and geography is the most prevalent circumstance affecting height and weight of children, followed by demographic variables and parents' education. Our study differs from Assaad et al. (2012) and the other existing studies in that we consider several other health outcome variables in addition to stunting and wasting, including maternal health outcome variables, such as antenatal care, the presence of skilled birth attendants in delivery, as well as postnatal care and immunization.

Inequality of opportunit in education has also received considerable attention in the literature on early childhood development. A number of cross-country studies that included Egypt, such as Filmer and Pritchett (1999), Filmer (2005), Smits (2007), and Huisman and Smits (2009), find socioeconomic status to be an important variable affecting access to and achievements in education. Filmer (2005) also noted that the prevalence of gender gaps in educational enrollment varies by regions across the world. Al-Qudsi (2003) finds household wealth to be an important factor affecting school enrollment. Zhao and Glewwe (2010) in China and Tansel (2002) in Turkey reach similar conclusions on the importance of household wealth/income and parents' education status in influencing a child's enrollment in school. Salehi-Isfahani et al. (2012) has looked at inequality of opportunity in education in Egypt, alongside several other Middle East and North Africa countries, using the Trends in Mathematics and Science Study data.

# **3. Data and Methdology**

## **Data**

The paper uses data from two main sources: (a) the Egypt DHS for 2000 and 2008; and (b) the Egypt HIECS for the corresponding years. The DHS is a nationally representative population and health 6
survey conducted on households with ever-married women aged 15 to 49 and provides data on key indicators such as fertility, use of contraceptives, infant and child mortality, immunization, coverage of antenatal and delivery care, nutrition, and prevalence of anemia. In addition, height and weight measures were collected for children under six years of age and never-married youths and young adults aged 10 to19 in all households in the survey. The Egypt DHS included interviews with 15,573 ever-married women in 2000 and 16,527 in 2008. The paper specifically focuses on children in the early age group (ages 0-4) living in these households.

The HIECS, on the other hand, is a large scale and nationally representative household consumption, income and expenditure survey conducted by CAPMAS every five years since 1995 and every year since in 2008. The HIECS is the main (and the only official) source for poverty and inequality data in Egypt. The HIECS data are used to impute the per adult equivalent consumption expenditures at the household level. The imputed consumption expenditure is used as a proxy for wealth and hence a circumstance variable for children, along with those circumstance variables directly obtained from the DHS data. By combining information in the DHS and HIECS, the report analyzes the impact of circumstances on access to basic services and human development outcomes for children and documents their changes over time.

# **_Outcome Variables_**

A total of 18 indicators and three composite indicators have been identified from both data sources on four main outcome categories. The categories include: (i) access to healthcare (during pregnancy, birth and early postnatal period); (ii) nutrition (malnutrition, micronutrient intake); (iii) access to basic services (housing, clean water, sanitation); and (iv) school enrollment. Under the first category, the following variables are analyzed: (i) lack of antenatal care (proxied by incidence of mother not having any blood tests during pregnancy); (ii) birth not taking place at a health facility; (iii) birth not being assisted by a skilled health professional; (iv) child not having a postnatal checkup within two months after birth; and (v) immunizations within one year after birth.

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The second set of outcomes is related to levels and trends in malnutrition and micronutrient intake in the early years. Anthropometric measures such as height-for-age<sup>2</sup> (stunting), weight-forheight<sup>3</sup> (wasting) and weight-for-age<sup>4</sup> (underweight) are used to analyze the differences in malnutrition levels across circumstance groups. Malnourishment increases the risk of death, inhibits cognitive development, and affects health status later in life (O’Donnell et al. 2008). In connection with the above, it is also important that children have the necessary level of micronutrient intake for healthy development. Access to iodized salt, iron tables during pregnancy and Vitamin A in early infancy are important indicators for micronutrient intake. In this paper, we use two variables available in the DHS and that are important for determining and supplementing iron deficiency anemia during pregnancy: (i) whether the mother has had blood tests during her pregnancy; and (ii) whether she has taken any iron supplementation tablets.

The third set of outcomes is related to access to basic infrastructure and services that determine children’s health and the development of cognitive potential. The WHO estimates that every year 1.4 million children under the age of five die from diarrheal diseases attributed to unsafe water supply and inadequate sanitation and hygiene (Molinas, de Barros, and Saavedra 2010). Two infrastructure variables have been analyzed in this analysis, by circumstance group: (i) access to improved water; and (ii) a proxy variable for sanitation (i.e., whether the household has its own toilet).

> 2 Height -for-age (H/A) reflects cumulative linear growth. Height for age deficits indicate past or chronic inadequacies of nutrition and/or chronic or frequent illness, but cannot measure short-term changes in malnutrition. Low H/A relative to a child of the same sex and age in the reference population is referred to as “shortness.” Extreme cases of low H/A, in which shortness is interpreted as pathological, are referred to as “stunting.” H/A is used primarily as a population indicator rather than for individual growth monitoring (World Bank, 2008).

> 3 Weight-for-height (W/H) measures body weight relative to height and has the advantage of not requiring age data. Normally, W/H is used as an indicator of current nutritional status and can be useful for screening children at risk and for measuring short-term changes in nutritional status. At the other end of the spectrum, W/H can also be used to construct indicators of obesity. Low W/H relative to a child of the same sex and age in a reference population is referred to as “thinness.” Extreme cases of low W/H are commonly referred to as “wasting.” Wasting may be the consequence of starvation or severe disease (in particular, diarrhea) (World Bank 2008).

> 4 Weight-for-age (W/A) reflects body mass relative to age. W/A is, in effect, a composite measure of height-for-age and weight-forheight, the term “underweight” is commonly used to refer to severe or pathological deficits in W/A. W/A is commonly used for monitoring growth and to assess changes in the magnitude of malnutrition over time. However, W/A confounds the effects of shortand long-term health and nutrition problems (World Bank, 2008).

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The final set of outcomes of interest for this study is educational enrollment. Educational enrollment rates are calculated for the basic education level age group (6-14 year olds) and the secondary education level (15-17 year olds) in the sample. In addition, three composite indicators for healthcare utilization, nutrition, and access to basic infrastructure are used to measure exposure to multiple risk factors.

# **_Circumstance Variables_**

This study identifies seven circumstances that may affect child's access to basic services. They are:

- a) Location: Metropolitan, urban Lower Egypt, rural Lower Egypt, urban Upper Egypt, rural Upper Egypt, Frontier Governorates (6 categories);

- b) Mother's education: No formal education, primary/preparatory, secondary, higher education (4 categories);

- c) Father's education: No formal education, primary/preparatory, secondary, higher education(4 categories);

- d) Number of siblings: 1-2 children, 3-4 children, 5 or more children (3 categories);

- e) Household wealth (asset) quintiles: 5 quintiles (5 categories);

- f) Gender of child (2 categories); and

- g) Imputed household consumption obtained by combining the DHS and HIECS data (a continuous variable).

# **Empirical Methodology**

The literature on inequality of opportunity emphasizes the differences in outcomes that arise from differences due to predetermined circumstances over which an individual has no control. Differences in adulthood outcomes, such as educational attainment and income may not only be explained by individual efforts and choices but also depend on initial endowments or circumstances. One way to differentiate between the impact of circumstances and individual efforts is to look at inequality in 9
outcomes across circumstance groups. Circumstances, such as those listed above, should be morally irrelevant and should not matter. In other words, on average, outcome indicators between circumstance groups should be approximately equal in value, and all variation in outcomes should come from within circumstance groups, i.e., determined by individual efforts within the group (Bourguignon et al., 2007). For children in the early years (such as ages 0-4), it is not appropriate to speak about inequality in “efforts" since children are too young to exert relevant effort to influence outcomes. Hence, all differences across early childhood outcomes can be attributed to circumstances beyond their control, i.e., inequality of opportunity.

There are a number of techniques to measure inequality of opportunity, once the outcomes of interest and the exogenous circumstances are identified. First, the paper analyzes the relationship between early risks and outcomes and circumstances at birth and compares the distributions of outcomes across circumstance groups. Second, the paper draws on the concept of the human opportunity index (see Barros et al., 2009; Molinas et al., 2010). The human opportunity index (HOI) measures how successful a country is in equitably supplying basic services or opportunities (such as access to education, healthcare, adequate clean water and sanitation) to its children. Third, the paper attempts to measure the relative contributions of each circumstance to total inequality of opportunity. To estimate the contributions of individual circumstances to total inequality of opportunity, the study applies Shapley value decomposition. The procedure allows measuring how individual circumstances such as gender, location and parental characteristics contribute to inequality in access to critical services. Finally, the paper assesses the changes in inequality of opportunity in Egypt during the 2000s and the factors driving the observed trends. This is done by decomposing the changes in HOI by scale and distribution effects, given the index is additively decomposable (Barros et al., 2009).

# **_Human Opportunity Index_**

10
p <!-- Start of picture text --> p<br><!-- End of picture text --> HOI = pti — D) <!-- Start of picture text --> HOI<br>= pti — D)<br><!-- End of picture text --> <!-- Start of picture text --> p<br><!-- End of picture text --> p (1—-D) <!-- Start of picture text --> TH<br><!-- End of picture text --> TH <!-- Start of picture text --> p<br><!-- End of picture text --> p 1 TTL D -—(> cane) - px) 2P ‘Po, ay <!-- Start of picture text --> 1 TTL<br>D -—(> cane) - px)<br>2P ‘Po,<br><!-- End of picture text --> <!-- Start of picture text --> P=P,x<br><!-- End of picture text --> P=P,x <!-- Start of picture text --> Pr<br><!-- End of picture text --> Pr
“misallocated” in favor of (against) circumstance groups that have coverage rates higher (lower) than .

HOI and D have a number of important properties. For a given level of D, HOI increases with an increase in the coverage of services or opportunities (i.e., a higher ). Similarly, a more equitable distribution of existing services or opportunities (i.e., a lower D) increases the index. HOI is Paretoconsistent, in the sense that it increases if the overall access to a given service or opportunity increases, no matter how access is distributed, as long as no one is worse off. D, on the other hand, gives more weight to those services or opportunities allocated to a less advantaged group of the population than to those allocated to a more advantaged group, and is therefore a distributionsensitive measure. D ranges from 0 to 1 (0 to 100 in percentage terms), and in a situation of perfect equality of opportunity, D will be 0. Therefore, the maximum value HOI can take is the average coverage rate by a particular basic service (i.e., ). It also implies that an HOI of 100 is possible only when access is universal (i.e., is 100 and D is 0).

# **_Changes in HOI over Time_**

The paper also assesses the changes in inequality of opportunity in the 2000s and the factoring driving the trend. Once the level of HOI for each outcome variable is estimated for 2000 and 2008, it is possible to decompose the changes in the index by scale and distribution effects and try to understand the drivers of the estimated change over time (Barros et al., 2009). One property of the HOI is that changes are additively decomposable. Any improvement in the index can be attributed either to an increase in the coverage rate, (scale effect), or a reduction in the index of inequality of opportunity, D (distributional effect): Change in HOI: (3) Scale effect: ) ) (4) Distribution effect: ) ) (5) 12
We apply equations (4) and (5) to measure changes in HOI during the two survey years, i.e., 2000 and 2008, for four main categories of outcomes: (i) healthcare utilization before, during and after pregnancy and a child's access to healthcare services in the early years; (ii) nutrition and micronutrient intake; (iii) access to basic services and housing; and (iv) education enrollment and attainment.

# **_Shapley Value Decomposition_**

To measure the contributions of different circumstance variables to inequality of opportunity, we employ the decomposition procedure proposed by Shorrocks (2012), which is based on the concept of _Shapley Value_<sup>5</sup> in cooperative games. The procedure allows us to measure how much individual circumstances (such as gender, location, parental characteristics) contribute to inequality in access to critical services. Shapely decomposition consists of computing the marginal effect on the inequality index, in this case HOI, of adding or removing each contributing factor in a given sequence of elimination <u>(Betti and Lemmi 2008; Shorrocks 2012). The decomposition involves calculating the</u> marginal impact of each of the circumstances as they are eliminated in succession, and then averaging these marginal effects over all the possible elimination sequences. The contribution of all circumstances yields an exact, additive decomposition of between group inequalities (in this case the dissimilarity index). The resulting formula is formally identical to the _Shapley Value_ in a cooperative game.<sup>6</sup> To illustrate, note that the value of D is dependent on the set of circumstances considered. Moreover, HOI (D) decreases (increases) when more circumstances are taken into account. For example, if we have two sets of circumstances C1 and C2, and set C1 and C2 do not overlap, then

> 5 In game theory, the Shapley Value solution generates a unique distribution of the total surplus generated in a cooperative game among the participants. In a setup where a coalition of players produces certain gains (where some players may contribute more to the coalition than others or may possess different bargaining power), Shapley Value provides a unique solution that satisfies all participants.

> 6 The Shapley decomposition has two useful properties: The first is symmetry, ensuring that the contribution of each factor is independent of the order in which it appears in the initial list or sequence of factors. The second property is exactness and additivity; whereby the contributions of all s circumstances (or factors) add up to 1.

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HOI (C1,C2)≤HOI(C1). Similarly, D(C1,C2)≥D(C1). The impact of adding a circumstance A can be given by: Where _N_ is the set of all circumstances, which includes _n_ circumstances in total; _S_ is a subset of _N_ (containing _s_ circumstances) that does not contain the particular circumstance C1. _D(S)_ is the dissimilarity index estimated with the set of circumstances _S_ . D(S∪{C1}) is the dissimilarity index calculated with set of circumstances _S and_ the circumstance C1. We can define the contribution of circumstance C to the dissimilarity index as: In other words, the sum of the contributions of all circumstances to the dissimilarity index adds up to 100 percent – a critical property satisfied by the Shapley value decomposition.

To measure the contribution of each circumstance to inequality in access to a basic service, we apply the above procedure on the dissimilarity index (equation (2)). We apply it for all seven circumstances and the outcomes of interest. Consider any outcome (e.g. whether a blood sample taken from the mother during pregnancy ), defined as a discrete (0-1) variable, with “1” denoting “yes” and “0” denoting “no”. Our objective is to obtain the conditional probabilities of access to this opportunity for each child based on his/her circumstances. In order to do so, a simple logistic model, linear in the parameters β, where the event I corresponds to “whether a blood sample taken from the mother during pregnancy” and C is the set of circumstances. The following logistic regression is fitted using DHS data: Where ck denotes the row vector of variables representing n circumstances and βk a corresponding column vector of parameters. From the estimation of the above regression one obtains estimates of 14
(B } <u>Exp(c ° )</u> 1+ Exp(c ° ) = w o ~~s~~ lp -¢|

~ =p(1-D) (12)
<!-- Start of picture text --> 100% (22 ofbirths where duringpregnancy, no bloodsample was taken from mother)<br>80% m2000 2008<br>60%<br>40%<br>20%<br>0%<br>education | education |Education |Education<br>Urban/Rural Location Mother's Education TOTAL<br><!-- End of picture text -->
<!-- Start of picture text --> Share of irths that were not attendedby skilledheatthstaff (4)<br>100,0%<br>20,0%<br>60,0% 52% 52%<br>40,0% 69% 35% 4%9 40% 39%<br>18% 16% 9 oe "6<br>20,0%Ms 10% 8% 5%<br>0.0%<br>Urban Rural Urban, LowerEgypt | UpperEgypt | Frontier TOTAL<br>Govemorates Govemorates<br>Urban Rural Location Region<br>5000 m>008<br><!-- End of picture text -->

<!-- Start of picture text --> 100,0%<br>56 of the births in<br>20,0% quintile using facility<br>60.0% and attendant<br>40,0% Na<br>20.0%<br>0.0%<br>Public Health Private Health) Home Public Health|Private He alt Home<br>Facility Facility Facility Facility<br>Quintile 1 Quintiles<br>@doctor mMnurse/midwife mtraditional birth attendant mnoone mother<br><!-- End of picture text -->
Share of children that were notfaken jor postnatal checkups within 2 months after birth (24) <!-- Start of picture text --> 100%<br>85% 88% 84% ota<br>so% | 75% 749% 76% 73H OH 70%<br>64% 63% 63%<br>60%<br>40% m= 2000<br>20% 2008<br>0%<br>Urban Rural No education Primary Secondary Higher Educatio TOTAL<br>education Education<br>Urhan/Rural| oration Mother's Fducation TOTAI<br><!-- End of picture text -->
The prevalence of stunting is more strongly associated with geographic (regional) disparities than household characteristics. In 2008, a child in Lower Egypt is about 12 percentage points (in Frontier Governorates about 7 percentage points) more likely to be stunted), compared to a child with the same household characteristics in the Urban governorates. There is almost no difference in stunting and severe stunting prevalence by household wealth: stunting prevalence among the poorest quintile was 25 percent in 2008, compared to 24 percent for the top quintile. The situation was quite different back in 2000 when wealth quintiles as well as father’s education were significant correlates of stunting, in addition to regional variables.

On the other hand, with a successful fortification program, Egypt has achieved a significant reduction in iodine deficiency over the 2000s. For instance, in 2000, three in four children under the age of five lived in households where salt was not adequately iodized, compared to only one in four by 2008.<sup>9</sup> The rapid expansion in availability of iodized salt benefited households in all regions, and across all income groups. In rural areas, the share of children living in households with inadequately iodized salt declined from about 83 percent in 2000 to 28 percent in 2008, and from 87 to 44 percent among the poorest quintile (Figure 5). However, disparities in access to iodine based on wealth still persist. While less than 11 percent of children in the top quintile are reported to have insufficient iodine, over 44 percent of children in the bottom quintile live in households with inadequate (or no) iodized salt.

Similarly, the use of iron supplements by pregnant mothers improved significantly between 2000 and 2008. In about 43 percent of pregnancies that ended in birth in 2008 mothers did not receive iron supplementation tablets, which represents a significant improvement from the 72 percent registered in 2000 (Figure 6). Similar to the antenatal care section, mother’s education and wealth are strong correlates of whether blood samples are taken from the mother during pregnancy. In 2000, a child born to a mother with no formal education and in the poorest wealth quintile was 36 percentage

> 9 Inadequate iodization is defined as <=.15 ppm iodine in salt consumed by the household. (EDHS 2008 report)

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<!-- Start of picture text --> ‘sof chideer ages 4) rer inin‘aitTooke hudetvth inaclepeitelywoized<br>fe=.15ppm iodine)<br>es ae .<br>oe 7 all Bon 8 7%<br>cum 4 1%<br>Peam | ea 1%<br>ue<br>att pant? ped uel 4 opin TOTAL<br><!-- End of picture text -->

<!-- Start of picture text --> Scot children (ages 4jutiose pregnancymothers didnot receiveiron tablets during<br>Ne) pn<br>een 4 Te in ice<br>re Bra<br>amare} i" a2once<br>Qk + = = = - ‘<br>Hewhaaton | Pamaey | Sesoenlary: HyperEiknatio = TOTAL<br><!-- End of picture text -->
<!-- Start of picture text --> Households without access to an improved water source (%)<br>100% 2000 2008<br>80%<br>60%<br>40% 30%<br>20% 13% 10%<br>1% 1% "4% 1% 0% i0 2% 8% 4,% % Sh24<br>O%<br>Urban Rural Urban LowerEgypt | Upper Egypt Frontier TOTAL<br>Governorates Governorates<br>Urban/Rural Location Region TOTAL<br><!-- End of picture text -->
percentage points (from 70 to 80 percent) for the basic education age group, and close to 12 percentage points (from 46 to 58 percent) for the secondary school age group. While the most advantaged group of children accumulate on average one year of education for each year from age 6 onwards all the way up to age 22 (reaching 15.2 years of educational attainment), in the least advantaged group, educational attainment remains less than 7 years on average.

**Figure 8:  The enrollment and educational attainment gap between least and most advantaged circumstance groups is large, but narrowed in the 2000s.**

<!-- Start of picture text --> Enrollment by Age Level Educational Attainment by Age Level<br>(indicates lower enrollment and early drop-out) (indicates lower total educational attainment)<br>6 8 10 12 14 16 18 20 22 6 8 10 12 14 16 18 20 22<br>Age Age<br>Least advantaged group Most advantaged group Least advantaged group Most advantaged group<br>Source data: Egypt DHS 2000 (sample of children ages 6-22) Source data: Egypt DHS 2000 (sample of children ages 6-22)<br>Enrollment by Age Level Educational Attainment by Age Level<br>(indicates lower enrollment and early drop-out) (indicates lower total educational attainment)<br>6 8 10 12 Age14 16 18 20 22 6 8 10 12 Age14 16 18 20 22<br>Least advantaged group Most advantaged group Least advantaged group Most advantaged group<br>Source data: Egypt DHS 2008 (sample of children ages 6-22) Source data: Egypt DHS 2008 (sample of children ages 6-22)<br>1 15<br>.8<br>10<br>.6<br>.4<br>Enrollment Rate 5<br>.2 Educational Attainment<br>0 0<br>1 15<br>.8<br>.6 10<br>.4<br>Enrollment Rate 5<br>.2 Educational Attainment<br>0 0<br><!-- End of picture text -->

# **5. Inequality of Opportunity in Access to Basic Services**

This section presents the measures of inequality of opportunity in access to basic services among Egyptian children. As described in Section 3, inequality of opportunity is defined as inequality in access to basic services due to differences in circumstances beyond children’s control. While Section 4 looked at the availability of and access to these services and its trends during the 2000s, 22
<!-- Start of picture text --> 100<br>80 = Childreceived all<br>immunization<br>60 @ Birth assisted by trained<br>40 health staff<br>= Birth given at public or<br>20 private health facility<br>0 =Blood samplewas taken<br>from mother<br>p = Coverage D= Human p=Coverage D= Human = Bab stnatal check<br>Dissumilarity|Index OpportunityIndex DissimilarityIndex OpportunityIndex witha.:tnonth . ctbirth<br>(HOD = p* (HOT = p * = Composite indicator of<br>(1-D) (1-D) healthcare access<br>2000 2008<br><!-- End of picture text -->
Therefore, the top right hand corner of the graph represents a situation of perfect coverage (100%) and equal distribution of opportunities (where the dissimilarity index=0). It can be observed that most health utilization indicators moved toward better coverage and reduced inequality in access between 2000 and 2008. Immunizations coverage was already high in 2000 and remained that way in 2008. The post-natal checkup variable remains at lower levels of coverage (with only about 30 percent of children in the 0-4 year age group) and falls below the 40 percent threshold for HOI in 2008, while the other healthcare utilization variables are all above the 60% threshold. While inequality of opportunity in healthcare utilization during birth decreased, there are persistent regional differences in healthcare utilization. Upper Egypt and the Frontier Governorates significantly lag behind the other regions.

**Figure 10: Human Opportunity Index for Healthcare Utilization**

<!-- Start of picture text --> 100 Immunizations<br> Antenatal care Immunizations<br>(blood sample)<br> Postnatal Check up Birh attended by<br>90 skilled staff<br> Birth at health facility<br>Composite health Antenatal care HOI = 80%<br>utilization (blood sample)<br>80 Postnatal check up Birh attended by<br>skilled staff<br> Birth at health facility<br>Composite health HOI = 60%<br>70 utilization<br>60<br>HOI = 40%<br>50<br>HOI = 20% 2000 2008<br>40<br>10 20 30 40 50 60 70 80 90 100<br>Coverage (%)<br>Source: DHS 2000 and 2008; HIECS 2000 and 2008 used for the imputation of household consumption.<br>Equality of Opportunity<br>(1-Dissimilarity Index) (%)<br><!-- End of picture text --> The decomposition of the changes in inequality of opportunity between 2000 and 2008 shows that the scale effect (increase in the coverage of services) dominates the improvement in 24
<!-- Start of picture text --> Child received all immunizations q<br><!-- End of picture text --> Burth assisted by trained health staff Blood sample during pregnancy | 9 Burth at public or privatehealth facility [8 | Postnatal check within 2 months of birth | 8 Composite indicatorfor access to health services 6);3

Human20 Opportunity-. . idex2 40 60 80 100 BHOTin 2000) =OScaleeffect ONistributional effect
particularly mother’s education, play an important role in the utilization of health services during pregnancy and birth (one-fifth of the variation in the D-index is attributable to mother’s educational attainment).

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**Figure 12: Family and mother’s education are key factors of access to healthcare**

<!-- Start of picture text --> 100%<br> 5<br> 12 Region<br>90% 21 22<br> 24<br>80% 21 42 Mother's<br>Educational<br>70% 21 20 Attainment<br>Father's<br>60% 12 19 Educational<br>50% 12 10 7 5 AttainmentWealth<br> 23<br>40%<br> 31 Consumption<br>30% 1 32 34 27<br>20% 3 Number of<br>10% 31 3 3 11 4 6 children at home<br> 10 11 7 9 Gender of child<br>0% 0 1 1<br>During Birth assisted Birth given at Baby postnatal Child received<br>pregnancy, by trained health facility check within 2 all<br>blood sample health staff months of birth immunization<br>was taken from<br>mother<br>Shapley decomposition<br><!-- End of picture text --> _Source:_ DHS 2000 and 2008; HIECS 2000 and 2008 used for the imputation of household consumption.

# **Malnutrition and Micronutrient Intake**

While malnutrition indicators such as stunting, wasting and underweight prevalence have deteriorated in Egypt, inequality of opportunity for these indicators remains low, suggesting no significant disparity among circumstance groups. Similarly, the HOI for nutrition indicators does not vary widely across regions. The decomposition of the variability in anthropometric measures explained by circumstances further shows that circumstances explain only a small percentage of their variance. Therefore, malnutrition is a problem for Egyptian children regardless of their circumstances. On the other hand, equality of opportunity concerning micronutrient intake has largely improved between 2000 and 2008 (see Figure 13). The increase in the HOI has been mainly due to the scale effect with more households overall having access to adequately iodized salt. The Shapley decomposition of inequality of opportunity in malnutrition indicators shows that females are more likely to be stunted than males, while household wealth explains the largest portion of the variation in access to micronutrient intake in 2008.

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**Figure 13: Human Opportunity Index for nutritional status indicators**

Not underweight Not wasted No stunting 100 Composite variable No stunting Not wasted for having adequate nutrition Iodized salt Not underweight Iron tablets 90 Iron tablets Iodized salt 80 I ron tablets 70 HOI = 60% Composite indicator of having adequate nutrition 60 HOI = 40% 50 **2000 2008** HOI = 20% 40 10 20 30 40 50 60 70 80 90 100 HOI = 80% Coverage (%) _Source_ : DHS 2000 and 2008; HIECS 2000 and 2008 used for the imputation of household consumption

# **Housing and Access to Basic Infrastructure**

Access to an improved water source, electricity and a non-shared toilet at the household level, as well as children ́s possession of an identity card, all show high human opportunity indexes. These indicators are associated with quite high coverage levels and low dissimilarity indexes (Figure 14). In addition, there have been improvements in the coverage of some of these services (such as improved drinking water at the household level) over the time period analyzed, which had a positive impact on HOI measures. However, disparities still remain across circumstance groups, particularly by location, with rural Upper Egypt and the Frontier Governorates generally showing lower levels of HOI for all categories. Regional variables mostly explain the variation in access to improved water at home and whether the child is registered, while wealth is the main explanatory factor of the differences in access to a non-shared toilet and electricity at home.

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**Figure 14: Coverage, HOI and D for access to basic infrastructure**

<!-- Start of picture text --> Improved water Electricity 2000 Registration<br> Non-shared toilet Electricity 2008<br> Non-shared toilet<br> Registration Composite indicator<br> Improved water<br>C omposite indicator<br>HOI = 80%<br>HOI = 60%<br>Coverage (%) HOI = 40%<br>Housing and Basic Services 2000<br>Housing and Basic Services 2008<br>Source: DHS 2000 and 2008; HIECS 2000 and 2008 used for imputation of household<br>HOI = 20 %<br>HOI = 20%<br>Equality of Opportunity<br>(1-Dissimilarity Index) (%)<br><!-- End of picture text --> The Shapley decomposition reveals that regional variables explain the largest share of the variations in access to improved water at home and in whether the child is registered. In fact, regional variables explain more than half of the variation in access to improved drinking water at home and about a third of the variation in whether the child is registered (Figure 15). For access to a non-shared toilet and electricity at home, the asset index of the household is the main indicator that explains variation in outcomes.

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# **Figure 15: Location explains the largest share of inequality in access to basic infrastructure**

<!-- Start of picture text --> 8<br> 22<br> 15 32<br> 51<br> 9<br> 15<br> 9 19<br> 38<br> 11 14<br> 3<br> 45<br> 19<br> 25<br> 22<br> 6<br> 2<br> 7 6 8 9<br> 1 1 1 2 0<br><!-- End of picture text --> _Source:_ DHS 2000 and 2008; HIECS 2000 and 2008 used for the imputation of household consumption.

# **Education**

Four main educational indicators are used to assess inequality of opportunity in access to education. The first two are related to enrollment separately for compulsory and non-compulsory levels: (a) the probability of enrollment for children in the age group 6-14 years old in primary and preparatory levels; and (b) the probability of enrollment for children in the age group 15-17 years old in noncompulsory secondary school education. The third and fourth indicators are related to educational attainment: (c) the probability of completion of 6th grade on time; and (d) the probability of completion of 9th grade on time (preparatory).

The HOI for enrollment in compulsory primary education and non-compulsory secondary education have both improved over the 2000s. The HOI for enrollment in the age group of 6-14 years old increased from about 85 to over 92 percent between 2000 and 2008 (Figure 16). The enrollment rate and the HOI indicators for the older age group (15-17 year olds) are lower, increasing from about 61 to 66 percent between 2000 and 20008. At the secondary school level (ages 15-17), the 30
degree of inequality of opportunity is higher than at the basic education level, as shown by a higher dissimilarity index. Inequality of opportunity in enrollment for both age groups varies significantly by region, although the disparities have declined over time. For example, in 2000, rural Upper Egypt presented the lowest HOI at about 76 percent and 48 percent for 6-14 and 17-17 age groups respectively. On the other hand, urban Lower Egypt had the highest HOI at about 92 and 75 percent for 6-14 and 17-17 age groups. Similar improvements can be noticed in 6<sup>th</sup> and 9<sup>th</sup> grade on-time completion rates. On time completion of 6<sup>th</sup> and 9<sup>th</sup> grade rates show similar improvements over the period, although the HOI for both is lower than that of enrollment (Figure 16). The changes in HOI in the education sector are mostly a result of the expansion of coverage for children overall (the scale effect) rather than the distribution effect. Inequality of opportunity in enrollment for both age groups varies significantly by region.

**Figure 16: Human Opportunity Index for Educational Enrollment and Attainment**

<!-- Start of picture text --> 100 Enrolment ages 6-14<br> Complete 6th grade on time<br>90 Enrolment ages 15-17 Enrolment ages 15-17 Enrolment ages 6-14<br> Complete 6th grade on time HOI = 80%<br>80 Complete 9th grade on time<br>Complete 9th grade on time<br>HOI = 60%<br>70<br>60<br> HOI = 40%<br>2000 2008<br>50<br>HOI = 20%<br>40<br>10 20 30 40 50 60 70 80 90 100<br>Coverage (%)<br>Equality of Opportunity (%)<br><!-- End of picture text --> _Source_ : DHS 2000 and 2008; HIECS 2000 and 2008 used for the imputation of household consumption Parental education variables are consistently the most important factors explaining variation in enrollment rates in Egypt, at both the basic and secondary education levels. Mother and father’s educational attainment combined explains more than half of the variation in the probability of being 31
<!-- Start of picture text --> 100% a ee<br>90%<br>o- = Mother's<br>80% Educational<br>Sg - Attainment<br>= 70% Father's<br>‘B Educational<br>Es 60%. Attainment<br>= 27 26 = Wealth<br>o 50% 25 26<br>=<br>B 40% = Consumption<br>=r)<br>= o;<br>Bw 20%30% os aNumberchildren ofat home<br>10% ye hen 8 Gender ofchild<br>[es Ls] iso<br>0% 4 6<br>Enrolmentrate Enrolmentrate Completionof Completion of<br>forages 6-14 forages 15-17 sixth grade 9th grade ontime<br>ontime<br><!-- End of picture text -->
However, there are some areas of persistent and emerging concerns where further efforts are required to ensure a more equitable access to basic services among children. These include postnatal care utilization, nutrition and schooling. The findings confirm that wide differences in school enrollment persist, notably at the higher levels, and mostly based on the family's socioeconomic background. Large regional disparities in access to household-level basic infrastructure and healthcare utilization continue to exist, with Upper Egypt and the Frontier Governorates lagging behind other regions.

Children's nutrition in Egypt emerges as a key area where large room for improvement is apparent. It is noteworthy that the levels of malnutrition and stunting have worsened over the 2000s and reached high levels for all children in Egypt, regardless of circumstances. Nutritional deficiencies combine with other risk factors, such as lack of cognitive stimulation, for a large share of the least advantaged children, which makes this group particularly vulnerable.

The paper’s findings point to family background, especially the level of parents' education and wealth, and geographic factors as key factors determining child development outcomes in Egypt. Targeted interventions aimed at enhancing access for these groups could thus offer significant potential to enhance overall and relative postnatal care utilization and access to education. In the case of nutrition, a more inclusive approach would be needed, since no significant differences across circumstance groups exist. Regional disparities in access to health services and proper householdlevel basic inputs should be addressed in a systematic way, for instance through targeted investments in the regions that exhibit significantly lower and unequal availability or utilization levels. Special efforts would be needed for those children exposed to multiple risk factors.

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