Abstract
We document the impact of the AIDS crisis on non-AIDS-related health services in 14 sub-Saharan African countries. Using multiple waves of Demographic and Health Surveys (DHS) for each country, we examine antenatal care, birth deliveries, and rates of immunization for children born between 1988 and 2005. We find deterioration in nearly all these dimensions of health care over this period. The most recent DHS survey for each country collected data on HIV prevalence, which allows us to examine the association between HIV burden and health care. We find that erosion of health services is the largest in regions that have developed the highest rates of HIV. Regions of countries that have light AIDS burdens have witnessed small or no declines in health care, using the measures noted above, while those regions shouldering the heaviest burdens have seen the largest erosion in non-HIV-related health services for pregnant women and children. Using semiparametric techniques, we can date the beginning of the divergence in the use of antenatal care and in children’s immunizations between high- and low-HIV regions to the mid-1990s.
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Notes
In two cases, the data are not drawn from the standard DHS, but from AIDS Indicator Surveys (AIS). All data for Cote d’Ivoire in 2005 are drawn from an AIS. The data used to construct regional HIV prevalence for Tanzania were drawn from the 2005/2006 Tanzanian AIS. See http://www.measuredhs.com/aboutsurveys for a description of the DHS and AIS. In this article, we do not distinguish between AIS and DHS, but refer to both as “DHS.”
All results presented here are robust to the exclusion of Zimbabwe, which may have seen more upheaval and displacement of persons than other countries examined.
No information on miscarriages is provided.
We exclude 133 cases where information on mother’s education is missing and 3,509 cases where information on the household’s location (region) within a country is missing.
The rates are calculated using data on HIV testing for men and women ages 15–49. These are weighted using sample weights given in the DHS HIV data set for each country.
Although it is difficult to date the beginning of the AIDS crisis in Africa, there is evidence of a “marked increase in cases in Africa during the late 1970’s and early 1980’s” (Quinn et al. 1986:956). The countries we study reported their first cases of AIDS in the early- to mid-1980s. Later, we discuss how our results change if we use a later date—1985 rather than 1980—to impute regional HIV prevalence.
For the final country, Ethiopia, UNAIDS data show increases in HIV prevalence that taper off around 1996, whereas Oster’s estimates are imprecise, showing large year-to-year variation, possibly because of small sample sizes combined with low HIV rates.
Estimates using probit models yield similar results. For almost all outcomes, Hausman tests reject the equality of coefficients between random effect and fixed effect specifications. At a p value of .05, this is true for antenatal care (chi-square test statistic = 328.44); blood pressure taken during antenatal care (9.76); blood tested during antenatal care (11.46); weight taken during antenatal care (7.12); clinic delivery (25.73); public clinic, conditional on clinic delivery (17.02); trained birth attendant at delivery (39.78); BCG vaccine (10.70); and DPT vaccine (11.12). At a p value of .10, we reject equality of random- and fixed-effect coefficients additionally for two outcomes: urine tests during antenatal care (chi-square = 3.58, p value = .0668) and polio vaccine (chi-square = 4.83, p value = .0894). Hausman tests fail to reject equality of the random-effect and fixed-effect coefficients for the measles vaccine (chi-square = 2.04, p value = .3602). Given these results, we present the country-region fixed effect results for our parametric estimation of Eq. (2) throughout the analysis. However, random-effect coefficients and fixed-effect coefficients are very similar for all outcomes. These results are available upon request.
For the majority of our health service measures, results are robust to the inclusion of country-by-year fixed effects. This is true for reporting any antenatal care, and conditional on care reporting having had a urine test and blood pressure taken. It is true also for reporting a clinic delivery and the presence of a trained attendant at birth. In addition, our results continue to hold for reporting polio at birth and for children receiving polio, measles, BCG and DPT vaccines. When country-by-year fixed effects are included, HIV prevalence becomes insignificant in analyzing weight taken during antenatal care. For reports of having blood taken during antenatal care and reports that a public clinic was used, conditional upon a clinic delivery, the sign on HIV prevalence flips (from negative to positive). We prefer the specifications that do not include country-by-year fixed effects because they remove a lot of the signal in the data and may obscure the impact of HIV.
Results in Table 4 are significant for the presence of a trained birth attendant, whether one relies on fixed-effect standard errors or those that are also clustered at the country/region. However, results for delivering at a clinic, or conditionally a public clinic, are not significant when fixed-effect standard errors are additionally clustered on the country/region.
A finding that wealth and HIV prevalence are negatively associated would not provide conclusive evidence on this issue, since it could be either that wealth declines caused increases in HIV or that increases in HIV caused wealth declines. However, a finding of an absence of a negative association between wealth and HIV would provide evidence against the hypothesis that the association between HIV prevalence and health care quality was driven by wealth declines that worsened both.
Information on the vital status of the mother is unknown or missing for 341 of 138,486 children younger than 5 in the sampled households in these surveys.
We restricted the ages of orphans to be in the same range of the ages of non-orphans in the same survey wave. For example, in survey waves in which mothers reported on antenatal care for children born in the past five years, we included only orphans under the age of 5; in survey waves in which mothers reported on antenatal care for children born in the past three years, we included only orphans under the age of 3.
Zambia and Tanzania are excluded.
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Acknowledgment
We acknowledge funding from the National Institute of Aging (P01 AG005842) and the Demography of Aging Center at Princeton University, funded under the National Institute of Aging Grant P30 AG024361. We thank Kimberly Bryan for expert research assistance, Jane Fortson for sharing her code and her knowledge of the DHS data, Helen Epstein for helpful discussions, and seminar participants for many useful suggestions.
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Case, A., Paxson, C. The Impact of the AIDS Pandemic on Health Services in Africa: Evidence from Demographic and Health Surveys. Demography 48, 675–697 (2011). https://doi.org/10.1007/s13524-011-0026-3
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DOI: https://doi.org/10.1007/s13524-011-0026-3