From 1992 to 2005, stunting rates in children under five in Rwanda have remained constant at nearly 50%, even as some other health and economic indicators have improved. Such malnutrition leads to an increased burden of disease, which combines to weigh heavily on the ability of children to acquire the human capital necessary for economic development. Its persistence may be evidence of a health-driven poverty trap. A poverty trap is formally defined as a system where a threshold level of income (or related variables) is necessary to generate a self-perpetuating chain of economic development. The concept of a disease-driven poverty trap has enormous implications for global health, but the evidence of their existence is elusive. This study will measure the specific economic consequences of expanded community-based integrated primary healthcare in Rwanda by measuring the partial effects of malnutrition, disease, schooling and socioeconomic status on each other. A recent grant to Partners in Health in Rwanda supports a new data collection system as health interventions are being expanded to 20 health centers over the next 5 years along with support for paid community health workers. These data include an over-sampling of 1500 households for the 2010 and 2015 Demographic and Health Survey in the study area, and a longitudinal cohort study of 800 households in control and comparison areas between 2010 and 2015. This study will estimate three separate structural equations for 1) stunting, 2) education and 3) socioeconomic status from household data. Socioeconomic status will be estimated based on a wealth index from household durable assets. Two-stage least square regression analysis with instrumental variables will be used to estimate each of these equations, where the health interventions themselves along with specific household data will be used as the instrumental variables. If the product of each of the parameter estimates for the effects of child health, schooling, and socioeconomic status on each other is greater than one, then the model predicts that the expanded health interventions will lead to sustained economic growth;i.e., a good system of community based integrated primary care in Rwanda can permanently break cycles of poverty and disease.
Based on a newly developed theory on feedbacks between economics and health, the proposed study will measure the economic impacts of an expanded community-based integrated primary healthcare system in rural Rwanda. The economic impacts are estimated from household data based on the partial effects of child health, education, and socioeconomic status on each other.
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