Distance decay and persistent health care disparities in South Africa.

BACKGROUND: Access to health care is a particular concern given the important role of poor access in perpetuating poverty and inequality. South Africa's apartheid history leaves large racial disparities in access despite post-apartheid health policy to increase the number of health facilities, even in remote rural areas. However, even when health services are provided free of charge, monetary and time costs of travel to a local clinic may pose a significant barrier for vulnerable segments of the population, leading to overall poorer health. METHODS: Using newly available health care utilization data from the first nationally representative panel survey in South Africa, together with administrative geographic data from the Department of Health, we use graphical and multivariate regression analysis to investigate the role of distance to the nearest facility on the likelihood of having a health consultation or an attended birth. RESULTS: Ninety percent of South Africans live within 7 km of the nearest public clinic, and two-thirds live less than 2 km away. However, 14% of Black African adults live more than 5 km from the nearest facility, compared to only 4% of Whites, and they are 16 percentage points less likely to report a recent health consultation (p < 0.01) and 47 percentage points less likely to use private facilities (p < 0.01). Respondents in the poorest income quintiles live 0.5 to 0.75 km further from the nearest health facility (p < 0.01). Racial differentials in the likelihood of having a health consultation or an attended birth persist even after controlling for confounders. CONCLUSIONS: Our results have two policy implications: minimizing the distance that poor South Africans must travel to obtain health care and improving the quality of care provided in poorer areas will reduce inequality. Much has been done to redress disparities in South Africa since the end of apartheid but progress is still needed to achieve equity in health care access.

The Economic Consequences of AIDS mortality in South Africa.

We quantify the impact of adult deaths on household economic wellbeing, using a large longitudinal dataset spanning more than a decade. Verbal autopsies allow us to distinguish AIDS mortality from that due to other causes. The timing of the lower socioeconomic status observed for households with AIDS deaths suggests that the socioeconomic gradient in AIDS mortality is being driven primarily by poor households being at higher risk for AIDS, rather than AIDS impoverishing the households. Following a death, households that experienced an AIDS death are observed being poorer still. However, the additional socioeconomic loss following an AIDS death is very similar to the loss observed from sudden death. Funeral expenses can explain some of the impoverishing effects of death in the household. In contrast, the loss of an employed member cannot. To date, antiretroviral therapy has not changed the socioeconomic status gradient observed in AIDS deaths.

Schooling as a Lottery: Racial Differences in School Advancement in Urban South Africa.

This paper analyzes the large racial differences in progress through secondary school in South Africa. Using recently collected longitudinal data we find that grade advancement is strongly associated with scores on a baseline literacy and numeracy test. In grades 8-11 the effect of these scores on grade progression is much stronger for white and coloured students than for African students, while there is no racial difference in the impact of the scores on passing the nationally standardized grade 12 matriculation exam. We develop a stochastic model of grade repetition that generates predictions consistent with these results. The model predicts that a larger stochastic component in the link between learning and measured performance will generate higher enrollment, higher failure rates, and a weaker link between ability and grade progression. The results suggest that grade progression in African schools is poorly linked to actual ability and learning. The results point to the importance of considering the stochastic component of grade repetition in analyzing school systems with high failure rates.

The sensitivity to key data imputations of recent estimates of income poverty and inequality in South Africa.

Existing literature using South African censuses reports an increase in both poverty and inequality over the 1996 to 2001 period. This paper assesses the robustness of these results to a number of weaknesses in the personal income variable. We use a sequential regression multiple imputation approach to impute missing values and to explicitly assess the influence of implausible income values and different rules used to convert income that is measured in bands into point incomes. Overall our results for 1996 and 2001 confirm the major findings from the existing literature while generating more reliable confidence intervals for the key parameters of interest than are available elsewhere.

Health outcomes for children born to teen mothers in Cape Town, South Africa.

This paper analyzes whether children born to teen mothers in Cape Town, South Africa are disadvantaged in terms of their health outcomes because their mother is a teen. Exploiting the longitudinal nature of the Cape Area Panel Study, we assess whether observable differences between teen mothers and slightly older mothers can explain why first-born children of teen mothers appear disadvantaged. Our balanced regressions indicate that observed characteristics cannot explain the full extent of disadvantage of being born to a teen mother, with children born to teen mothers continuing to have significantly worse child health outcomes, especially among coloured children. In particular, children born to teens are more likely to be underweight at birth and to be stunted with the disadvantage for coloured children four times the size for African children.

Early childbearing, human capital attainment and mortality risk: Evidence from a longitudinal demographic surveillance area in rural-KwaZulu-Natal, South Africa.

Using a rich longitudinal dataset, we examine the relationship between teen fertility and both subsequent educational outcomes and HIV related mortality risk in rural South Africa. Human capital deficits among teen mothers are large and significant, with earlier births associated with greater deficits. In contrast to many other studies from developed countries, we find no clear evidence of selectivity into teen childbearing in either schooling trajectories or pre-fertility household characteristics. Enrolment rates among teen mothers only begin to drop in the period immediately preceding the birth and future teen mothers are not behind in their schooling relative to other girls. Older teen mothers and those further ahead in school for their age pre-birth are more likely to continue schooling after the birth. In addition to adolescents' higher biological vulnerability to HIV infection, pregnancy also appears to increase the risk of contracting HIV. Following women over an extended period, we document a higher HIV related mortality risk for teen mothers that cannot be explained by household characteristics in early adulthood. Controlling for age at sexual debut, we find that teen mothers report lower condom use and older partners than other sexually active adolescents.

Mortality in South Africa - socioeconomic profile and association with self-reported health.

This paper exploits the first two waves of NIDS to describe the socioeconomic profile of mortality and to assess whether self-rated health status is predictive of mortality between waves. Mortality rates in NIDS are in line with estimates from official death notification data and display the expected hump of excess mortality in early and middle adulthood due to AIDS, with the excess peaking earlier for women than for men. We find evidence of a socioeconomic gradient in mortality with higher rates of mortality for individuals from asset poor households and with lower levels of education. Consistent with evidence from many industrialized countries and a few developing countries, we find self-rated health to be a significant predictor of two year mortality, an association that remains after controlling for socioeconomic status and several other subjective and objective measures of health.

Orphanhood and Schooling in South Africa: Trends in the vulnerability of orphans between 1993 and 2005.

Using 10 nationally representative surveys conducted between 1993 and 2005 we assess the extent to which the vulnerability of orphans to poorer educational outcomes has changed over time as the AIDS crisis deepens in South Africa. In line with the existing literature we find that at every point in time orphans are at risk of poorer educational outcomes with maternal deaths generally having stronger negative effects than paternal deaths. However, despite a significant increase in the number of orphans over the last decade, we find no evidence of a systematic strengthening of these negative effects. In order to understand this we explore patterns of care giving for orphans. We find that these patterns have shifted over time. While orphans are still absorbed into extended families, single orphans are increasingly less likely to live with the surviving parent and there is an increasing reliance on grandparents as caregivers. Up to this point, these changing patterns of care giving within extended families seem to have avoided further worsening in the educational outcomes for the increasing number of orphans.

The impact of AIDS on intergenerational support in South Africa: Evidence from the Cape Area Panel Study.

This study uses panel data from Cape Town to document the role played by aging parents in caring for grandchildren who lose parents due to illnesses such as AIDS. We quantify the probabilities that older adults and their adult children provide financial support to orphaned grandchildren. We find significant transfers of public and private funds to older adults caring for orphans. Perhaps because of these transfers we find no differences in expenditure patterns between households with orphans and other older adult households. We also find no impact of either the death of a child or taking in orphaned grandchildren on adult well-being as measured by ability to work, depression, or self reported health. Our findings suggest that the combined public and private safety net in South Africa mitigates many of the consequences older adults could suffer when an adult child dies and leaves behind grandchildren needing care.

Labor supply responses to large social transfers: Longitudinal evidence from South Africa.

In many parts of the developing world, rural areas exhibit high rates of unemployment and underemployment. Understanding what prevents people from migrating to find better jobs is central to the development process. In this paper, we examine whether binding credit constraints and childcare constraints limit the ability of households to send labor migrants, and whether the arrival of a large, stable source of income - here, the South African old-age pension - helps households to overcome these constraints. Specifically, we quantify the labor supply responses of prime-aged individuals to changes in the presence of pensioners, using longitudinal data collected in KwaZulu-Natal. Our ability to compare households and individuals before and after pension receipt, and pension loss, allows us to control for a host of unobservable household and individual characteristics that may determine labor market behavior. We find that large cash transfers to elderly South Africans lead to increased employment among prime-aged members of their households, a result that is masked in cross-sectional analysis by differences between pension and non-pension households. Pension receipt also influences where this employment takes place. We find large, significant effects on labor migration upon pension arrival. The pension's impact is attributable both to the increase in household resources it represents, which can be used to stake migrants until they become self-sufficient, and to the presence of pensioners who can care for small children, which allows prime-aged adults to look for work elsewhere.

The impact of parental death on school outcomes: longitudinal evidence from South Africa.

We analyze longitudinal data from a demographic surveillance area (DSA) in KwaZulu-Natal to examine the impact of parental death on children's outcomes. The results show significant differences in the impact of mothers' and fathers' deaths. The loss of a child's mother is a strong predictor of poor schooling outcomes. Maternal orphans are significantly less likely to be enrolled in school and have completed significantly fewer years of schooling, conditional on age, than children whose mothers are alive. Less money is spent on maternal orphans' educations, on average, conditional on enrollment. Moreover, children whose mothers have died appear to be at an educational disadvantage when compared with non-orphaned children with whom they live. We use the timing of mothers' deaths relative to children's educational shortfalls to argue that mothers' deaths have a causal effect on children's educations. The loss of a child's father is a significant correlate of poor household socioeconomic status. However, the death of a father between waves of the survey has no significant effect on subsequent asset ownership. Evidence from the South African 2001 Census suggests that the estimated effects of maternal deaths on children's outcomes in the Africa Centre DSA reflect the reality for orphans throughout South Africa.