Long-term Effects of Health and Development Interventions:

The Matlab Health and Socioeconomic Survey 2

Independent University, Bangladesh17 February, 2010

Matlab Health and Socioeconomic Survey 2

• Background leading to MHSS2

• Our plans

•Results from MHSS1 1996

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Interventions• Maternal and Child Health and Family

Planning Program (MCH-FP), began 1977-78

• The Meghna-Dhonnagoda Irrigation Project (Embankment), began 1987

• Bangladesh Rural Advancement Committee (BRAC) microcredit and other programs, began 1992; other NGO programs

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Matlab Maternal and Child Health and Family Planning Program:

1977-

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Embankment to protect

from flooding

completed 1987,

repaired 1989

Embankment

•Protects villages on NW side of Dhonnagoda River from seasonal flooding

•Includes 220 km of irrigation canal, 125 km of drainage channel

• “Natural experiment” in that households were not formally assigned to treatment and control

•65 km earthen barrier

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BRAC Microcredit and other programs

began 1992

AIM: Assess impacts of Matlab MCH/FP Interventions

• Long-term health and welfare outcomes in two generations targeted by interventions

• Through intergenerational relationships and the intergenerational transmission of poverty

• In the context of social, demographic, and cultural changes in women’s education and empowerment, in religiosity, and in rural economic development.

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ICDDR,B DATA Matlab Health and Demographic Surveillance System

(MHDSS) began over 40 years ago – Households visited monthly for many years; now

every 2 months– Register of all vital events, 1966-

• Births, deaths, marriages, divorces, in- and out-migration episodes lasting 6 months or more

– Censuses or SES in 1974, 1982, 1993, 1996, 2005– Allows precise estimation of ages– Permits effective sample tracking, followup

Matlab Health and Socioeconomic Survey 1 - 1996

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Rural village barely above water

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Beautiful rivers

Collaborators in Bangladesh• ICDDR,B

– Abdur Razzaque– Abbas Bhuiya

• Mitra & Associates– SN Mitra– Fuad Pasha– Shahidul Islam

• Independent University, Bangladesh– Omar Rahman

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Collaborators in US

• University of Colorado– Jane Menken– Randall Kuhn (CU & University of Denver)– Nizam Khan (CU & Qatar University)– Tania Barham– Elisabeth Root

• Brown University - Andrew Foster

• University of North Carolina - Michael Emch

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Maternal Health

Family Planning

Child Health

Old Age Health

Child Quality

Child Quantity

Effects on Women Eligible for MCH-FP

Female health / survival

Direct Impacts Intergenerational Impacts

Spousal support

Maternal Health

Family Planning

Child Health

Labor, Marital

Outcomes

Human Capital

Parental Investment

Parental Support Burden

Economic Opportunity

Effects on Children Child or Mother Eligible for MCH-FP

Direct Impacts Intergenerational Impacts

Maternal Health

Family Planning

Child Health

Grandchild

Outcomes

Marriage timing,

Spousal match

Own Human Capital / Labor

Parental Support Burden

Effects on Grandchildren

Direct Impacts Intergenerational Impacts

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MCH-FP Program Interventions

• All vaccination given to age 5 and under

• Interventions provided in home by community health worker

• Minimal government health care in comparison area

• MHSS: Matlab Health and Socio-Economic Survey

1977 1982 1985 1986 1996

Measles(1/2

treatment area)

Family planning/

Oral rehydration

Measles(1/2

treatment area)

DPT Polio

Vitamin A Nutrition

MHSS Survey

1988

Acute Respiratory

Care

1989

Dysenteric Diarrhea

Treatment/Vaccination

in comparison

area

MCH-FP Program rapid uptake of contraception & measles vaccination

0

20

40

60

80

100

1975 77 79 81 83 85 87 89 91

%

Year

MVR- Group 2 MVR- Group1

CPR-Comparison Area CPR-Treat Area

Matlab Health and Socioeconomic Survey 1996

• Based on HDSS• Random sample of baris• One household chosen at random

~ 2400 primary households

• Second hh chosen by relationship to first• HHs of women in the Determinants of

Natural Fertility Study– Totalled ~ 6300hh in Matlab

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Effects of MCH-FP Program on Children

• 20-30 percentage points higher on vaccination

• Less malnutrition (wasting and stunting) in MCH-FP area

• Girls still more likely to be malnourished

• Boys’ schooling, but not girls, higher in MCH-FP area– Not surprising because of the strong

education programs directed toward girls

MCH-FP Eligibility by Age in 1996 MHSSAge in

MHSSYear Born Eligibility

25+ Pre - 1972 Not Eligible for MCH-FP (baseline group)

20-24 1972-1976 Not Eligible for MCH-FP but potentially affected through sibling competition

15-19 1977-1981 FP and Non-intensive health treatment: Measles vacc. after recommended age

8-14 1982-1988 FP and Intensive health treatment: All vaccines and some received other child health interventions

6-7 1989-1990 Some interventions now available in comparison area from government

Note: breaking 8-14 group into 8-11 and 12-14 year olds gives same results

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Cognitive function

• 6-15 % higher cognitive functioning (measured by the Mini Mental State Exam - MMSE) for those who, as children, were eligible for the highest intensity health interventions at the right ages

• Effect over and above increases in level of education

• (Barham 2008)

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Mean MMSE by 1997 Age

0

5

10

15

20

25

30

6-7 8-14 15-19 20-24 25+

Age

MM

SE

(o

ut

of

30

)

Treatment Comparison

Intended effects of embankment

• Crops: – increased number of growing seasons– Irrigation and protection led to Increased rice

crop yields in seasons previously flood-affected

• Economic Increased income Increased assets, including land value Economic risk effect – Flood control reduces

risks associated with planting

(Mobarak, Kuhn, Peters unpublished 2009)

Health effects of embankment

• Moderate effects on mortality (Myaux et al 1997)

• Lower death rate from diarrhoeal diseases among adults

• Lower death rates from infectious diseases for adult men

(Mobarak, Kuhn, Peters 2009)

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Marriage Market Effects• Little effect on age at marriage

• Protected husbands command larger dowries after embankment creation

• People from protected households become 10% more likely to marry into wealthy families relative to the unprotected– Effects confirmed in a triple difference (pre/post

un/protected by occupation)

• Slower fertility decline among protected HH

Unexpected effect:Consanguineous marriage

• 33% larger drop (nearly 3 percentage point decrease) in consanguineous marriages among the protected (calculated at the mean)

• A child married after the embankment was constructed was 40% less likely to be married to a biological relative than an older siblng who married prior to embankment construction (results based on household fixed effect DID regression)

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Unexpected effect

• Two separate studies have found that families in MCH-FP area gave higher dowries for their daughters

• The argument is that women have a greater stake in wanting to use family planning – and a higher dowry is needed to persuade men to participate

» Arunachalam and Naidu 2008» Peters 2008

Contents of MHSS2

• Similar to MHSS1 – but shortened questionnaires

• Will use existing HDSS and MHSS1 data to pre-populate individual questionnaires

• NO biomarkers to be collected – only non-specimen health indicators

• GIS data for households and facilities

• Arsenic?

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Matlab Health and Socioeconomic Survey 2 -2012

HOUSEHOLD SURVEY• Bk1: Household Roster & Characteristics• Bk2: Household Economy• Bk3: Individual Life History – Adult• Bk4: Individual Life History – Children• Bk 5: Observed Health Measures

COMMUNITY/FACILITIES SURVEY

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Projected Sample Size – MHSS2~ 4100 HH in Matlab

Household Type

# HHHS1

Member

Birth to HS1

member

Marriage to HS1

New to MHPSS Total

Original HS1 2,400 8,200 1,500 1,100 600 11,400

MHDSS Split-off

700 1,400 1,200 500 200 3,300

MHDSS Migrant

900 900 1,400 900 1,000 4,200

National Migrant HH

1,800 2,500 1,400 900 n/a 4,800

In-Migrant 100 0 0 0 400 400

Total HH 5,900 13,000 5,500 3,400 2,200 24,100

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Arsenicin

Tube-wells