Dependence of health outcome on health expenditure in Africa

1 in 8 child dies before 51 in 8 child dies before 5in Africa 

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Soheila AbachiNovember 27, 2014 

Facts 

Life expectancy linked to economic growth (WHO) 

10% increase in life expectancy  0.35% increase in economic hgrowth 

Poor and rich countries economic growth difference due to health status of members (commission on microeconomics & health)health status of members (commission on microeconomics & health)

10 million <5 death in 2006, 5 million from Africa 

each min te 21 children < 5 die (UNICEF)each minute 21 children < 5 die (UNICEF)

~ 70% caused by diarrhea, malaria, neonatal infection pneumonia preterm delivery lack of oxygen at birthinfection, pneumonia, preterm delivery, lack of oxygen at birth (UNICEF)

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Facts 

~ 50% of global <5 death in five countries: India, Nigeria, Democratic Republic of the Congo, Pakistan, China

H l h $/ / 2001Health care $/person/year 2001 (Commission for Africa, 2004)

High‐income countries > US$ 2,000 

Africa US$13‐$21 in 2001 

To deliver basic treatment & care for major communicable diseases & earl childhood and maternal illnesses in s b Saharandiseases & early childhood and maternal illnesses in sub‐ Saharan Africa expenditure should rise to US$ 38 by 2015

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Data 

Health expenditure measured in PPP int. $ 

1995 Per capita total expenditure on health 

2005 Per capita total expenditure on healthIndependent variables

p p

1995 Per capita government expenditure on health 

2005 Per capita government expenditure on health 

Child mortality rates in thousandsChild mortality rates in thousands 

2000 Number of under‐five deaths 

2010 Number of under‐five deaths 

2000 Number of infant deaths 

2010 Number of infant deaths

2000 Number of neonatal deaths

Dependant variables

2010 Number of neonatal deaths

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Data 

Country Total $1995

Government $ 1995

< 5 D2000

Infant D2000

NeonatalD2000

Algeria 164.7 119 24 20 12Angola 84.2 59.5 143 86 36Benin 43.1 19.4 41 26 11Botswana 249.4 130.6 4 3 1B ki F 29 4 11 4 94 49 20Burkina Faso 29.4 11.4 94 49 20Burundi 24.3 7.8 40 25 11Cabo Verde 69.4 55.8 1 1 1Cameroon 52 12 1 95 58 23Cameroon 52 12.1 95 58 23Central African Republic 25.2 10.7 24 16 7Chad 36.6 12.7 76 43 18Comoros 43 6 27 6 2 1 1Comoros 43.6 27.6 2 1 1

WHO databases, African countries, 45 observations, 10 variables 5

Biological questions 

1. Impact of per capita government or total expenditure on health on neonatal death rates

2. Impact of per capita government & total2. Impact of per capita government & total expenditure on health on infant death rates

3 Impact of per capita government or total3. Impact of per capita government or total expenditure on health on < 5 children death ratesrates

6

900

1000 Nigeria

500

600

700

800

Per capita total &  government health expenditure 1995 and child mortality rate 2000

PC95TEXH PC95GEXH UFD00 ID00 ND00

Seychelles

200

300

400

500

0

100

Algeria

Angola

Benin

Botswana

rkina Faso

Burund

iabo Ve

rde

Cameroo

nral A

frican

 …Ch

adCo

moros

Congo

te d'Ivoire

emocratic

 …ial G

uine

aEritrea

Ethiop

iaGabon

Gam

bia

Ghana

Guine

ane

a‐Bissau

Kenya

Lesotho

Libe

ria

adagascar

Malaw

iMali

Mauritania

Mauritiu

szambiqu

eNam

ibia

Niger

Nigeria

Rwanda

Tome and …

Sene

gal

Seyche

lles

erra Leo

neuth Africa

Swaziland

Togo

Ugand

ad Re

public …

Zambia

Total health  <Five  Infant  Neonatal 

Bur

Ca CCe

ntr

Côt De

Equatori

Guin Ma M

Mo

Sao T S

Sie

SoS

United

expenditure 1995 D2000 D2000 D2000

Min  $6 1  1  1 

M $94 86 53 23

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Mean  $94  86  53  23 

Max  $629  934  567  245 

Scatter plots of original data

250

300

nds) 200

0

500

600

) 200

0

100

150

200

tal deaths (tho

usan

Neonatal death 2000

200

300

400

500

deaths (tho

usan

ds)

Infant death 2000

0

50

0 100 200 300 400 500 600 700

Num

ber o

f neo

nat

Per capita total expenditure on health (PPP int. $) 1995

0

100

200

0 100 200 300 400 500 600 700Num

ber o

f infan

t d

Per capita total expenditure on health (PPP int. $) 1995

Per capita total expenditure on health (PPP int. $) 1995 

600

700

800

900

1000

ousand

s) 200

0

Nigeria

200

300

400

500

600

der‐fiv

e de

aths (tho

< 5 death 2000

Seychelles

8

0

100

0 100 200 300 400 500 600 700

Num

ber o

f und

Per capita total expenditure on health (PPP int. $) 1995

Seychelles

Correlation of per capita expenditure on health & child mortality rate& child mortality rate 

Negative, Low  PC95  PC05  PC95  PC05 g ,TEXH TEXH GEXH GEXH

UFD00 ‐0.21  ‐0.19 ‐0.20 ‐0.21UFD10 0 18 0 16 0 18 0 19UFD10 ‐0.18  ‐0.16 ‐0.18 ‐0.19ID00 ‐0.20 ‐0.19 ‐0.20 ‐0.21ID10 ‐0 18 ‐0 16 ‐0 17 ‐0 19ID10 0.18  0.16 0.17 0.19ND00 ‐0.21  ‐0.20 ‐0.20 ‐0.21ND10 ‐0.18 ‐0.17 ‐0.18 ‐0.19

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Transformation 

Square root 

Did not help with the normalityDid not help with the normality 

Log 10 

Induced the normality considerably 

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Q1: Impact of per capita government or total expenditure on health on neonatal death ratesneonatal death rates

Adjusted R‐squared p‐value AICND10 ~ PC05GEXH + PC05TEXH + PC95GEXH + PC95TEXH

0 2808 0 0016 51 530.2808 0.0016 ‐51.53ND10 ~ PC05TEXH + PC95TEXH

0 2226 0 0019 ‐49 830.2226 0.0019 49.83ND10 ~ PC05GEXH + PC05TEXH + PC95GEXH + PC95TEXH +  ID10 + UFD10

0.9183 0.0000 ‐147.74ND10 ~ ID10

0 9192 0 0000 152 640.9192 0.0000 ‐152.64

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Q2: Impact of per capita government & total expenditure on health on infant death ratesinfant death rates

Adjusted R‐squared p‐value  AIC

ID10  ~  PC05GEXH + PC05TEXH

0.2438 0.0010 ‐41.53

ID10  ~ PC05GEXH + PC05TEXH + PC95GEXH + PC95TEXH0.3177  0.0006 ‐44.35

ID10 ~ PC05GEXH + PC05TEXH + PC95GEXH + PC95TEXH + ND10 +  UFD10

0.9866  0.0000 ‐219.53

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Q3: Impact of per capita government or total expenditure on health on < 5 children death rates< 5 children death rates

Adjusted R squared p value AICAdjusted R‐squared p‐value AICUFD10 ~ PC05GEXH + PC05TEXH + PC95GEXH + PC95TEXH

0.3379 0.0003 ‐41.69UFD10 ~ PC05GEXH + PC05TEXH + PC95GEXH + PC95TEXH + ID10 + ND10

0.2226 0.0019 ‐49.83UFD10 ~ PC05GEXH + PC05TEXH + PC95GEXH + PC95TEXH + ID10 + ND10ID10 + ND10

0.9809 0.0000 ‐199.65UFD10 ~ PC05GEXH + ID10

0.981 0.0000 ‐203.2413

Quality of fit of the models 

Assumptions 

Normality of error termsy

Constant variance of residuals vs. fitted values

Independence of error termsIndependence of error terms

Influential observations

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Significance of the factors in full models

p‐values of factorsImpact of health expenditure on health 

outcomes of 2010ND10 ID10 UFD10

Shapiro‐Wilk normality 0.014 0.019 0.069PC05GEXH 0 806 0 758 0 669PC05GEXH   0.806 0.758 0.669PC05TEXH   0.394 0.513 0.425PC95GEXH 0.097 0.088 0.089PC95GEXH 0.097 0.088 0.089PC95TEXH   0.696 0.860 0.779

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Principal component analysis  

Correlation matrix

Eigenvalues >= to 1 

1 2 97pc1: 2.97

pc2: 1.57

Cumulatively account for 68

Cumulatively account for 94.4% of variance

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2

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Comp.1 Comp.4 Comp.7 Comp.10

Scores plot h ld d h l l d d tChild death rates are positively loaded on 1st comp.

Per capita health expenditures are negatively loaded on 2nd comp.

Comoros Eritrea

Liberia

p

02

com

pone

nt

Benin

Burundi

Cabo Verde Central African Republic

ChadCongo Democratic Republic of the Congo

Gambia

Guinea

Guinea-Bissau

LesothoMadagascarMauritania

NigerRw anda

Sao Tome and Principe

Togo

-20

d pr

inci

pal c

Botsw anaBurkina FasoCameroon

Chad

Côte d'Ivoire

Equatorial Guinea EthiopiaGabonGhana Kenya

Malaw iMaliMauritiusMozambique

Namibia

gRw andaSenegal

Seychelles

Sierra LeoneSw aziland

UgandaUnited Republic of TanzaniaZambia

-4

2n AlgeriaAngola

Nigeria

South Africa

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-5 0 5

1st principal component

Summary 

Health expenditures have statistically relatively low but significant effect on infant, neonatal and under‐five mortality in AfricaAfrica

Health expenditure only one of the many factors important in improving the health status of a member

per capita health spending & health outcomes negatively correlated

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Future studies

Female & parent’s educationFemale & parent s education

Income & income equity  

Access to vaccines & HIVAccess to vaccines & HIV prevalence

Access to safe drinking waterg

Hunger, sanitation 

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Thank youThank you. 

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