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FAMILY SIZE, UNWANTEDNESS, AND CHILD HEALTH

AND HEALTH CARE UTILISATION IN INDONESIA

Eric R. Jensen & Dennis A. Ahlburg

To cite this article: Eric R. Jensen & Dennis A. Ahlburg (2002) FAMILY SIZE, UNWANTEDNESS, AND CHILD HEALTH AND HEALTH CARE UTILISATION IN INDONESIA, Bulletin of Indonesian Economic Studies, 38:1, 43-59, DOI: 10.1080/000749102753620275

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ISSN 0007-4918 print/ISSN 1472-7234 online/02/010043-17 © 2002 Indonesia Project ANU

FAMILY

SIZE,

UNWANTEDNESS,

AND

CHILD

HEALTH

AND

HEALTH

CARE

UTILISATION

IN

INDONESIA

EricR.Jensen

CollegeofWilliamandMary,Williamsburg

DennisA.Ahlburg*

UniversityofMinnesotaandUniversityofSouthampton

Thispaperpresentsandestimatesamodelofthedeterminants ofchildhealthand health care utilisation in Indonesia. In particular, it estimates the impact of unwantedness andnumberofsiblingsonhealthoutcomesandtreatment.Itfinds evidencethatchildrenwhoareunwantedatbirtharemorelikelythanotherchil

-drentobecomeillandlesslikelytoreceivetreatmentforillnesses.Noevidenceis foundthatchildrenfromlargerfamiliessufferadversehealthconsequences.

Sinceatleastthe1970s,thegeneraltrend inIndonesiahasbeenoneofdeclining family size and improvements in the overall well-being of members of the

population.Lifeexpectanciesarelonger, earningsarehigher,andeducational at

-tainment has increased—by virtually

anymeasureofhumanwelfare,theav

-erage Indonesianisbetteroff than his or her parents. Certainly, over time, health and educational infrastructures haveexpandeddramatically.Anunder

-lyingprocessof‘modernisation’brought withitpreferencesforbothsmallerfam

-ily sizesandchildrenofhigherquality (e.g.withbetterhealthandeducation). Withworseningeconomicandpolitical conditionsattheturnofthe21stcentury, therewaswidespreadconcernthatthese gainscouldbe wipedout(Booth1999; Jones, Hull and Ahlburg 2000). How

-ever,itappearsthat,despitesignificant economicshocks,educationandhealth havesofarnotsufferedlargereversals.

Ouraim inthispaperistoexamine, atthefamilylevel,theimpactonchild healthandhealthcaredecisionsofthe numberofchildrenandwhetherachild waswantedatbirthbyitsparents.Our premiseis thatfamilyresourcesarefi

-nite,andthereforethatallocativechoices mustbe made.These choices, or their consequences,maybeobservableinsur

-veydataonchildhealth.Toexaminethis contention, we investigate diarrhoeal andrespiratorydiseaseincidenceinchil

-dren,andcurativecareprovisiontochil

-dren for either illness. If fertility is imperfectlycontrolled,unwantedbirths arelikelytooccur,andfewerfamilyre

-sourcesper child are available than is desiredbytheparents.Therefore,many choicesrequiringresourcecommitments by parents,including ourmeasures of childhealth,willbeaffectedbytheoc

-currenceof unwantedbirths.Weview theoccurrenceofanunwantedbirthas a largely exogenous shock occurring

outside the parents’ decision making calculus.InIndonesia,theproportionof unwantedbirthsislow,sofora parent todeclarethatachildisunwantedisa strongsignal.Thus,Indonesiaisagood country inwhich totestfortheimpact ofunwantednessonchildhealth.

CHILDWELFAREAND

RESOURCEALLOCATION

ChildHealthandEducation asIndicatorsofWell-Being

Educationalattainmentandchildhealth are two broad categories of indicators thathavebeenusedinthepasttoassess the human capital improvements ac

-companyingdevelopment (Kelley1996; Cassen1994).Literacyandnumeracyare important inmoving from traditional, largely agrarian economies to those based on modern manufacturing. Re

-turns to ed uc ation in the form o f increasedearningsprovideclearquan

-tificationofthevalueofattainingsuch education.Ontheotherhand,wellover adecadepassesbeforeanewbornchild completes his or her education. This makesitdifficulttoaddressdirectlythe impacts of fertility upon family-level

resource allocation and, through this mechanism,subsequently uponeduca

-tionalattainment.1

EvidencefromtheAsianeconomies, most notably Japan,shows theimpact ofchildhood nutrition onadult physi

-cal stature. When severe,malnourish

-mentinchildhoodcancausediminished intellectual function inadulthood,and alsomayharmtheperformance ofchil

-dren in school. Child malnutritionis problematic inAsia,which is hometo 75%ofthemalnourished childreninthe world (Ahlburg and Flint 2001). Ill healthandpoorgrowthinchildhoodare also related to adult morbidity and mortality (Fogel 1994), and to lower productivity andpoorerlabourmarket outcomes (Strauss and Thomas1998).

Childhealthisthusanimportantmeas

-ure of both current and future well

-being. Parents’ willingness and ability tocommit resourcestotheirchildren’s health is thereforeof interest. Empiri

-cally,examiningrelationships between fertilityornumberofsiblingsandchild healthisanappealingwaytogetatun

-derlying resourceallocation decisions, because observable consequences of thesedecisionsmaybegintoappearal

-mostimmediately afterachildisborn. The increasein mean adult heights observedinpostwarJapanshowsthat resourcesplayanimportantroleinhu

-mancapitaloutcomes.2_{Families,onav}

-erage, provided their children with moreprotein and calories thaninear

-liertimesbecausetheycould affordto doso.Thiswastrueinsuchalargepro

-portionoffamiliesthattheoverallim

-pact in the entire po pulatio n was significant.Incomesperfamilymember rose both because family incomes in

-creased with rising productivity and becausetheaveragefamilysizefell.His

-torically,these phenomenaare deeply intertwined,andinferringacausalrole forfertilitydeclineisdifficult.Certainly, inpresent-day Japan,theoverwhelm

-ingmajority of parents wouldbeable toprovide adequatenutritiontonum

-bersofchildrenmuchgreaterthanthe numberstheycurrentlybear.However, duringthepost-Meijifertilitydeclinein

Japan,incomesweremuchlowerthan theirpresentlevel.Plausibly,thetrade

-offsbetweennumbersofchildrenand the nutrition (and subsequent health conditions)thesechildrenenjoyedwere starkerthancurrentlyisthecase.Inthis sense,thehistorical trade-off between

numberofchildrenandtheirhealthsta

-tus was much like the present-day

trade-off betweennumber of children

andeducation, or betweennumber of childrenandsizeofbequests,inmany Asiansocieties.

InferringResourcesDevoted toChildHealth

One major problem in inferring re

-sources devotedto childhealth is em

-pirical. Child health, and indeed the broaderconceptofchildwell-being,has

manydimensions, andin thissense is difficulttomeasure.Thetiebetweenre

-sourcesdevotedtochildhealthandac

-tual health outcomes is a ‘noisy’ one. Genetic endowments and chance play animportantroleinmorbidity,forex

-ample. Very well nourished, well fed and clean children still get diarrhoeal and respiratory infections and, con

-versely, poorly nourished children are notalwaysill.Thepresumption under

-lyingouranalysisofchildmorbidityis thattherelativefrequencyofillnessde

-clineswithincreasesinresourcescom

-mitted to c hildren. Other in direct measuresofchildwelfareareavailable, butareequallyimperfect.Forexample, weight-for-height measurements are

takenaspartofsomesurveys(although notinthesurveyweuseforthispaper). Justaswithhealthoutcomes,thetiebe

-tween inputs, in theform of nutrition and so forth, andanthropometric out

-comes depends on a range of unob

-served facto rs , includ ing geneti c, metabolicandotherfactors.

Anadditional confounding factoris theoretical innature,andleadstostatis

-ticalproblemsofidentification. Parents aremakingchoicesaboutahostoffac

-torssimultaneously.Inthebroadestof terms,theyaremakingdecisionsabout numbersofchildren,resourcecommit

-mentper child, and non-child expen

-ditures. Som e parents may choose relativelymorechildren,withrelatively less committed per child, than other parents. As Montgomery and Lloyd (1996a)pointout,thesimplefindingof aninverserelationship betweenfertility andchildwell-beingthereforedoesnot,

of itself, constitute justification for

policy. Itis completelyconsistentwith standardeconomicmodelsoffamilyfor

-mation (e.g.BeckerandLewis1974)in which parents with a taste for lower quality perchild choose tohave more children, becausethepriceperchildis lower than that for children of higher quality. To show that fertility affects childwell-being,whatisneededisevi

-dence that changes the in number of children affect quality per child inde

-pendentlyoftheunderlyingvariationin tastes,incomeor pricesgeneratingthe initialdistributioninthenumberofchil

-dren.Such independent effects,by the nature ofthe quality–quantity interac

-tion inchildren,areinherentlydifficult toteaseout,renderingstatisticalidenti

-ficationofstructuralquantityandqual

-ityequationsdifficult.

Littleworkhasbeendoneonestimat

-ingthequantity–qualitytrade-offusing

child health as a measure of quality. Someworkontheimpactoffertilityon educational attainmenthas focusedon thequantity–quality trade-off,branch

-ingintwodirectionstowardanalysisof the within-household impactsof large

familysizes.

One path focuses on average well

-being within families, examining,for example,differencesinaverageeduca

-tionalattainmentofchildrenasafunc

-tion ofnumberofsiblings. Oneof the closestrelationshipsbetweenthenum

-berofsiblingsandaverageeducational attainment by family members is re

-portedintheworkofKnodel,Havanon and Sittitrai(1990)forThailand.Other studiesbasedonessentiallysimilarcon

-ceptionsofwithin-familyallocationin

-cludethosebyBaueretal.(1992)forthe Philippines; BehrmanandWolfe(1987) for Nicaragua; and Rosenzweig and Wolpin(1980)forIndia.Alloftheseau

-thorsfindthatchildrenfromlargefami

-lies receive less education than do childrenfromsmallfamilies.Theeffects

are oftensmall, and again,causality is difficulttoinfer.Itmaybethatincreas

-ing competition among siblings forfi

-nitefamilyresourcesdecreasesaverage accesstoeducation.Thisisthe‘resource dilution’ modelassociated withJudith Blake(1981).

A second approach acknowledges thatparentswithapreferenceforlarger familiesmaybethosewhoseelessneed toeducatetheirchildren,sothatthecor

-relation between family size and chil

-dren’s educationalattainment reflects tastes and is not causal (Montgomery and Lloyd 1996a; Becker and Lewis 1974). The unsuitability of empirical models that do not account for the endogeneity offertilityinparents’deci

-sionsliesattheheartofreviewers’criti

-cismsofmuch oftheworkinthefield (e.g. King 1987; Kelley 1996). Models that pay carefulattention tostatistical identification tendtofindsmalleffects offamilysizeonhouseholdresourceal

-location.Forexample,inanattemptto examinetheimpactofthepurelyexog

-enous componentof fertility, Rosen

-zweig andWolpin(1980)use asample oftwinbirths,andfindasmallimpact of exogenous fertility on subsequent educational attainment.3 _Behrmanand Wolfe(1987)useasampleofadultsis

-terstowardsimilarstatisticalends.Work todatehasgeneratedlittlefirmsupport forthenotionthatnegativewithin-fam

-ily consequences of familysize on the welfare offamily membersareimpor

-tant,atleastwhenmeasuringwelfareby educational attainment.

In considering the decision making process of parents, we have thus far spent little time discussinghow their decisions translate into actual fertility. Conceptioncarrieswithitasubstantial elementofrandomness,andthereforeso does contraception im perfectly em

-ployed.4_{Desiredbirthsmaynothappen,}

undesired births may occur, or births maycomeearlierorlaterthandesired. The occurrence of an unwanted birth representstheexogenousimpactoffer

-tility. Unless one makes the heroic assumptionthatparentsanticipate(per

-fectly)notonlythelikelihood, butthe actualoccurrence, ofcontraceptive fail

-ure, the unplanned nature of an un

-wantedbirth implies thatthe event is independent of the parents’ decision making calculus. Therefore, a ‘pure’ causal impact of unwanted births on measures of child quality may be estimable. For instance, in Thailand, Frenzen and Hogan (1982, cited in MontgomeryandLloyd1996b),found that children wantedby both parents have a significantly higher probability ofsurvivingtheirfirstyearthandochil

-drenwantedbyonlyoneorneitherpar

-ent.Theimpactmaybefeltbythechild inquestion,oritmaybedistributedover alargergroupofchildren.

Inconsideringwithin-familyresource

allocation, a more fully developed strandintheliteratureexaminesdiffer

-entialallocations offamilyresourceson thebasisofanindirectmeasureofwant

-edness:thechild’ssex.Thisstrand,ina sense,isalogicalextensionofthework byRosenzweigandWolpin,inthatthe birth o f a gir l is o utside the pre

-conceptiondecisionmakingcalculusof parents. Work by Chen et al. (1981), Simmons et al. (1982) and Dasgupta (1987)hasshownthatSouthAsiangirls receivelessfoodthantheirmalesiblings, and are less lik ely to survive their childhood.TheSimmonset al.workis noteworthyin demonstratingtherela

-tionshipbetweensiblingcompetitionfor resources and the impact of an un

-wanted daughter’s birth. Rosenzweig andSchultz(1982)tiethistounfavour

-ablelabourmarketoutcomesforsome Indiangirls. Consistently in thelitera

tureforSouthAsia,oneseesarelation

-shipbetweenthesexofabirthandre

-sourceallocation, asmeasuredbyfood, educationorothercostlyresourcesde

-votedtothechild.

MontgomeryandLloyd(1996b)cite aFinnishstudybyMyhrmanetal.(1995), inwhich mothersinterviewed intheir sixth or seventh month of pregnancy wereaskedwhetherthepregnancywas wanted, mistimed or unwanted. The timingofthequestionsguaranteesthat theresponsesarenotinfluencedbythe characteristics ofthechild,becausethe wantednessinformation was collected beforethechildwasborn,andthecon

-sequencesweremeasuredonafollow

-upsurveydonemorethantwodecades later. Myhrmanet al. foundthatlower educational attainment for unwanted daughtersoccursforanynumberofsib

-lings,whileforunwantedsonsitoccurs only if therearetwo or moresiblings. Thisshowsastrongelementofparental choice, coupled with a resource con

-straint that appears to bind as the numberofsiblingsincreases,albeitwith differingstrengthsforsonsanddaugh

-ters. Thatresource constraints (meas

-ured by number of siblings, all else constant)bindlesstightlyforsonsthan for daughters shows that parents are abletocompensate, tosomedegree,for anincreasingnumberofsiblings.Onthe otherhand,thefactthatnumberofsib

-lingsmatters,evenforsons,impliesthat resource constraints are increasingly important as the number of siblings grows.

Wantednessofbirthsplaysakeyrole inouranalysis.MothersinIndonesia’s D em ographic and Health Surveys (DHS)areaskedspecificallyaboutwant

-ednessatthetimeofconceptionforeach livebirthinaperiodofthreetofiveyears precedingthesurvey.Becausetheyare askedretrospectively,responsestothese

questionsare oftenthoughttobe sub

-jecttopost-hocrationalisation. Thedirec

-tion ofsuchrationalisation isnotclear, however. Knodel and Prachuabmoh (1973), for example, believetheir Thai dataunderstatethe degreeofunwant

-edness,asmothersarereluctanttosay thatagivenchildwasinfactunwanted. Rosenzweig andWolpin(1993),onthe other hand, claim that their US data show the opposite.On the basisofan undesirable outcome such as an un

-healthy baby,Rosenzweigand Wolpin claimthatsomewomen(perhapsnearly one-fourth) who, prior to conceiving,

said thattheywanteda birth changed their post-partum response to ‘un

-wanted’.Itseemsprudenttotakeboth arguments into account by allowing wantedness (potentially) to be endog

-enous,thatis,dependentuponcharac

-teristicsofmother,ofsiblings,andofthe reference child, and we do so in our empiricalwork.

THEMODEL

Wemodeltwomeasuresofchild well

-beingas functionsofchild,familyand community characteristics: probability ofillnesswitheitherdiarrhoeaorfever/ cough;anduseofcurativecareforthese conditions. Pragmatic concernsdictate this strategy,asdiarrhoea andrespira

-toryinfectionsarethetwoillnessesmost readily observedinsurveydata.How

-ever,theyarealsoofpolicyinterest,as thesetwodiseasecategoriesaccountfor roughly one-third of infant and child

mortality inthedevelopingworld.We constructamodelbaseduponthecon

-cept of a child-specific index of ‘child

value’, orparents’ willingness tocom

-mitresourcestoaparticularchild.This indexis positedtobe afunctionofex

-ogenous individual, household and community variables. Household re

-source commitments are measured

directlybyuseofhealthcare,withasso

-ciated monetary, time and othercosts; and indirectly by the incidence of morbidity.

DefineZ tobetheindexvalue fora givenchild,where,forX,avectoroffam

-ilyandchild-specificvariables,suchas

age,educational attainmentandwealth holding,w,ascalarindexofwantedness, ands,ascalarcountofnumberofsib

-lings,

Z = f(X, w, s) (1)

anddefineAtobeavectorofvariables measuringfamilyaccesstohealthcare, andRtobeavectormeasuringrisksof illness. Then the following conditions characterise theincidenceofillnessand subsequentuseofcurative careforliv

-ingchildren:

Illness observed : I = 1

if Z *₁ ³ Z | X, w, s, R (2)

Treatment observed : T = 1

if Z *₂ £ Z | X, w, s, A, I = 1 (3)

whereZ*denotesunobservedthreshold variables.Thesearetheusualthresholds underlying discrete choice models which,althoughtheyarenotobserved directly,carryobservableconsequences. Inthissetting,illnessoccursiftheindex ofchildvalue,conditioned onchildand family specific covariates and risks of illness, falls below an unobserved thresholdvalue,andcurativetreatment occursifchildvalue,conditioned onac

-cess, covariates and illness, exceeds a minimum(unobserved) threshold.The presumption is that, all else constant, wantednessisassociatedwithdecreased probabilityofillnessandincreasedprob

-ability of curative treatment, while numberofsiblingsisassumedtowork in the opposite direction. Family-level

covariates associated with increased

wealth,income or socio-economicsta

-tusareexpectedtoexertasimilareffect towantedness,andincreasesinaccessi

-bilityandriskarepresumedtoincrease theprobability oftreatmentandillness, respectively.5

Wantednessresponses,becausethey are given after the birth has occurred, may be subject to the sort of post-hoc rationalisation we have dis cussed previously, and we therefore model wantednessasafunctionoffamilychar

-acteristics and number of sib lings. Numberofsiblingsisareflectionofpast valuesofchildvalueindices.Theseval

-ues arelikely to behighly correlated withcurrentvalues.Therefore,tocom

-pletethemodel,wehave:

w = g(X ,s)w (4)

s = h( Z )-T (5)

whereXwisavectorofvariablesmeas

-uring family-specific considerations,

includingcharacteristicsof thechild, such as sex, birth weight and non

-singleton status. Number of siblings is a function of Z–T,notational short

-handfor the setof past valuesofthe indexofchildvalue Z.

AnimportantpartoftheRosenzweig andWolpin(1993)study istheirclaim thatwantednessresponsesaresubjectto post-birth adjustment, conditional on

childcharacteristics (including, butnot limited to, child morbidity). Because DHS surveys only have information aboutchildmorbidityintheimmediate pre-survey period,it is notpossible to

subject the morbidity aspect of the RosenzweigandWolpinfindingtofull scrutiny. It is po ssible to ex amine whetherrecentorcurrentillnesshasan impactonwantednessresponses,how

-ever.Todoso,onewouldspecifywant

-edness as an endogenous structural determinantof equations (2) and (3).

Ourmeasureofhealth,limitedasitisto the immediate pre-survey period,is a

somewhat‘noisy’measureofchild en

-dowments.Afailureofthistesttoreject thehypothesisofexogeneitylendssup

-port to the notion that our outcome measuresarenotdeterminantsofwant

-edness,butsuchatestis lesspowerful than one might like inexamining the contention that child endo wments (broadlydefined)donotaffectwanted

-ness.Similarly,itisfeasibletoallowfor endogeneityofnumberofsiblings,6_and toteststatistically forsuchapossibility. Comparable caveats apply,as the test specifically relates totheimpact ofill

-nessintheimmediatepre-surveyperiod

(or treatment for this illness) upon numberofsiblings,andnottheimpact ofsomemoregeneralmeasureofchild endowmentsuponnumberofsiblings. Abirth generates anincrease in the numberofsiblings,andeachbirthmust be classified as either wanted or un

-wanted.Therefore,wantedbirthscarry with them only a (relative ly pure) number of siblings effect, while un

-wantedbirths areaccompanied by the differential impacts upon child well

-beingofanunwantedbirthintothefam

-ilyandoftheaccompanying increasein numberofsiblings.Exceptwhereocca

-sionally contaminated by unwanted births,numberofsiblingsisareflection ofparents’desires.Unwantedbirths,on the otherhand, are reflective of exog

-enous shocks to the family-formation

process, and therefore areexpected to generatelargerimpactsonsubsequent resourceallocations.

The within-family mechanism

throughwhichunwantednessoperates could be one in which per capita re

-sourcedeclinesarespreadmoreorless evenlyoverhouseholdmembers,or,as seems more likely given models of within-householdallocation(Simmons et al. 1982; Rosenzweig and Schultz

1982), unequally according to prefer

-encesorpastinvestments.Childrenwho are older or otherwise relatively fa

-vouredarelesslikelytofeeltheconse

-quences of the birth of an unwanted youngersibling,thereforeconcentrating the observable response on younger children, particularly the unwanted birthitself.Iftheresourcepressuresac

-companying an unwanted birth are spreadevenlyoverallchildrenandone examines—aswedo—theconsequences

only forthechildinquestionofhis or herunwantedness,theeffectwillbeto understate the apparent effect of un

-wantedness. Sincethe impacton only onechildisincludedinouranalysis,the estimated impacts ofunwanted status onthemost recent birthpresentedbe

-low are low er bounds to the total intrahousehold allocative response to unwantedness.7

DATAANDSETTING

Thedatacomefromthe1991Indonesian Demographic andHealthSurvey(Indo

-nesiaCentralBureauofStatistics, State MinistryofPopulationandMinistryof Health and MacroInternational 1992). Thesurveyusesinterviewswith22,909 ever-married women,ofwhom 21,109

weremarriedatthetimeofthesurvey, andreportsbirthsof14,393childrenin the fiveyears preceding theinterview date.Theestimatedtotalfertilityratefor 15–44year-oldswas2.99.

Forbirthsinthefiveyearspreceding the survey, detailed information on health was collected. Mothers were askediftheirchildrenhadexperienced diarrhoea or cough/fever in the two weeksprecedingthesurvey,aswellas whattreatmentthechildrenweregiven. Treatmentscanconsistofcommodities, advice,orsomecombinationofboth.As inmanydevelopingcountries,thereis anactivetraditional sectorinIndonesia providinghealthcare.Weareunableto

differentiate among various folk cures inmanyinstances.Forexample,‘herbs’ as atreatmentforanillnessisdifficult to assessin termsof effectiveness. We have therefore focused on treatment suppliedbythemodernsector.Thepre

-sumptionis thatmodernmethodscost atleastasmuchastraditional methods and areless accessible. Therefore, use of modern-sector treatments reflects

greaterwillingness on thepart of par

-ents to seek out effective care and commitresourcesthandoesuseoftra

-ditionalmethods.8

The DHS question on wantedness comesinasectionofthequestionnaire extracting detailed information on re

-centbirths.Themotherisaskedwhether shewantedthecurrentbirthatthetime she became pregnant, whether she wantedthe birthbut wouldhave pre

-ferredthatithadcomelater,orwhether shewouldhavepreferredthatthebirth had not occurred at all. Inour regres

-sion analyses, we classify a birth as ‘wanted’ifthemotherreportsthatitwas wantedeitheratthetimeofconception orlater.Ofalllivebirths,95%wereclas

-sifiedinthiswayinthesurvey.

RESULTS

We first discuss the impacts of areal (community-levelandprovincial-level),

family, and individual-level determi

-nants,includingwantednessandnum

-berofsiblings,onchild morbidity.We thenexaminetheimpactofasimilarset of determinants on curative care. We employa linearspecification fornum

-berofsiblingsintheequationsformor

-bidity and treatment. We test for the potential endogeneity of wantedness andnumberofsiblingsonbothmorbid

-ity and treatment equations, again based onresidualsfromreduced-form

equationsonwantednessand number ofsiblings.

Ideally,onewouldestimatethepara

-metersoftheillness/treatmentsequence jointly.Thatis,iftheunderlyingissueis oneoftheresourcecommitments ofpar

-ents,thenthesusceptibility ofchildren to illnessand their subsequent use of care, conditional on illness, are two manifestations of an unobserved re

-sourceallocationdecision.Giventhebi

-naryoutcomes ofthetwo measures,a bivariateprobitmodelofsampleselec

-tion is most efficient. However, the processissufficiently ‘noisy’thatthebi

-variatelikelihoodfunctiondoesnotcon

-vergereliably.9_{Wethereforeestimatethe} determinants oftreatmentintwoways. Weestimateaunivariate probitforthe probabilityofreceivingtreatment,ignor

-ingthatthechildmustfirstbeillbefore receiving treatment.As analternative, weestimatethetreatmentequationasa lin ear probability with a two-stage

Heckman sample selectivity correc

-tion.10,11 _{Whentransformed toderiva}

-tives evaluated at sample means, the simple probit gives virtually identical results totheHeckman estimates,and subsequentdiscussionoftheestimates appliestoeither formulation. Ineither instance,weestimateaunivariateprobit transformation ofthe determinants of morbidity.

Table1presentsdescriptivestatistics. Many variables are familiar,but some bearfurtherexplanation.Thefirstisour measureofpermanentincomeorwealth. DHSsurveysdonotcollectdirectdata onincomeorwealth.Instead,theyuse a collection of questions about asset ownership (vehicles and appliances), housingquality(roofandfloormateri

-als and plumbing) and access tofresh water. Usingfactor analysis, we have combined the responses to many of these questions into two factors. This makesthesubsequentregressionresults lesscluttered,whileallowingustocon

trolforvariationsinafairlylargenum

-berofassetvariables.‘Ownershipoftel

-evision or refrigerator ’ and housing attributes‘non-dirtfloor ’and‘in-house

electricity’ loadonthefirstfactor,while ‘ownershipofautomobileorstove’and ‘numbersofroomsforsleeping’loadon thesecond.Taken together,thesevari

-ables captureasset ownership, and as suchareproxiesforpermanentincome. Therearethreevariablesconstructed as provincial-level means: themean inci

-dence of fever/cough and diarrhoea, and themeantraveltime tohealth fa

-cilities.Theseareconstructed usingre

-sponses for children of every eligible respondent in the province except the referencebirth,andthereforeareindica

-tive ofthecommunity-levelconditions

faced by thereference birth. The vari

-ables for water and type of toilet are household-specific.Sinceweareexam

-ining caregiventolivingchildren,the sample is restricted tocurrently living children.12

Twosetsofresultsarediscussedhere. Thefirstsetrelatestotheimpactofareal, family and individual-level determi

-nants,includingwantednessandnum

-berofsiblings,onchildmorbidity.The secondrelatestotheimpactofasimilar set of determinants on curative child healthcare.Theresultsarebasedupon modelspecifications thatemployactual valuesofwantednessandnumberofsib

-lings rather than their instruments. TABLE1 Description ofVariablesUsedintheAnalysis,Indonesia,1991

Variable Definition Mean Standard

Deviation

Fever/cough Childillwithfeverorcoughinthelasttwoweeks 0.35 0.48 Fevercare Modernadvicesoughtormoderncaregivenfor

fever/cough 0.83 0.38

Diarrhoea Childwithdiarrhoeainthelasttwoweeks 0.10 0.30 Diarrhoeacare Modernadvicesoughtormoderncaregivenfor

diarrhoea 0.78 0.42

Wantedbirth Dummyforbirthwantedness:1ifthebirthwas

wanted,thenorlater 0.95 0.22

Siblingsalive Numberofsiblingsaliveattimeofbirth 1.58 1.70 Male Dummyformale:1ifbirthismale 0.52 0.50 Child’sage Child’sageinmonths 29.24 16.92 Mother’sage Ageinyearsofmotheratchild’sbirth 29.09 6.15 Mother’seducation Mother’seducationinyears 6.22 5.29 Husband’seducation Educationofmother’scurrenthusbandinyears 7.40 5.47 Assets1 Factorscorebasedonassetownershipa

–0.07 0.98

Assets2 Factorscorebasedonassetownershipa

–0.08 0.98

Water Dummyforaccesstopipedorwellwaterfor

drinking:1ifyes 0.09 0.29

Typeoftoilet Dummyforflushorpittoiletaccess:1ifyes 0.18 0.39 Traveltime Meantraveltimetofamilyplanningservice

provisionpointinminutes 32.16 7.41

a

Seetextforamorecompletedescription oftheconstructed variables.

Becauseofthepossibleendogeneity of these variables, we generated instru

-mentsfor wantedness and numberof siblings by usingreduced-form equa

-tionstopredicttheirvalues.13 _Wethen usedtheresidualsfromtheseequations asregressorsinourstructuralequations formorbidityandhealthcare,inorder to carryout Hausmantests forexoge

-neityofwantednessandnumberofsib

-lingsineachofthestructuralequations. Innocaseswereweabletorejectthenull hypothesis of exogeneity for either wantedness or number of siblings. In otherwords,wehavenoevidenceinthis samplethatillnessinthelasttwoweeks orhealthcareprovision tochildrenaf

-fectspost-hocwantednessornumberof siblings responses.14 _{Therefore,there}

-sults wepresentdonotemployinstru

-mental variables for wantedness or numberofsiblings.

An additional question of model specification is the manner in which numberofsiblingsmightinfluence al

-locations to child ren. Kelley (1996) claims thatfailureto include potential non-linearitiesinstudiesoftheeffectof

number of siblings on educational at

-tainmentofchildrenisanerrorleading to overstatement of the impact of the number of siblings on resources allo

-catedperchild.Wefindnoevidencefor such scale effects on the incidence of morbidityorallocationofhealthcare.To testtheproposition, wespecifiedavari

-able that equalled 1 forlarge families and0otherwise,where‘large’wasde

-finedas‘havingsixormorelivingchil

-dren’.15 _{We used this ‘large family’} dummyvariable,interactedwiththefull setofcovariates, toperformWaldtests on jointly restricting the coefficients acrossvaluesofthelargefamilydummy, and were unable to reject the null hypothesisthattheywerethesame.In

-dividually,thesignsandroughmagni

-tudesoffamilysizecoefficientsandtheir

associatedstatistical significance levels alsowerethesame.Inotherwords,we have no statistical groundstosupport thecontentionthattheimpactofanad

-ditional child differed between small andlargefamilies.Therefore,wepresent estimatesthatincludetheimpactoffam

-ily size(alone and untransformed) on illnessandtreatment.

ChildMorbidity

Diarrhoea. Table2showsthatwanted

-nessatbirthplaysanimportantrolein reducingmorbidity in Indonesia.The impactofwantednessistodecreasethe chanceofcontractingdiarrhoeabyap

-proximately 50%comparedtotheover

-allprevalencelevelofdiarrhoea,avery large and statistically significant ef

-fect.16 _{Assetavailability,asmeasuredby} theconstructed factors,shows noim

-pactondiarrhoeaincidence.Mother’s education,accesstoflushtoiletsandthe mean provincial prevalence of diar

-rhoeaareallstatistically significantand largely operate in expected fashion: children of more educated mothers, withaccess toflushtoilets, andliving inareaswherediarrhoeaprevalenceis lower, experience less diarrhoeal dis

-ease,allelseconstant.Childrenfroman areawith a prevalence rateone point higher than another area have a pre

-dictedprobability ofcontracting diar

-rhoea seven-tenths of a point higher

thanchildrenfromthelatterarea.This iscomparabletothediarrhoeamorbid

-itydifferentialexperiencedbychildren whose mother ’s educational attain

-ments differ by three and one-half

years,roughlyhalfthediarrhoeamor

-bidityreductionattributabletohaving access to flush toilets, and approxi

-mately one-seventh of the diarrhoeal

morbidityimpactofwantedness. Highernumbersofsiblingsareasso

-ciatedwithasmallbutstatistically sig

-nificantdecreaseintheprobabilitythata

child willcontract diarrhoea.The esti

-mateddeclinein diarrhoeal morbidity is approximately 4% per sibling. Two possible explanations suggest them

-selves.Oneconjectureisthatthisisnot duetoenhancedresistancetodiseaseof childrenwithlargenumbersofsiblings (inpartbecausetherearefewlargefami

-liesinthedata)but,rather,thatchildren with few or no siblings have higher morbidity. This draws on the well

-known claim of John Bongaarts(1987)

that familyplanning programs,when successful, increase mean infant and child mortality rates; this occurs be

-cause,asfertilityfalls,theproportionof birthsthatarefirstbirthsincreasesand, forphysiological reasons,firstbirthsare at higher risk of mortality. Unfortu

-nately, family sizes are so small that therearenotenoughcasestoallow us to say anything definite on this point, otherthanthatasmallereffectpersists when one-child families are removed

TABLE2 Coefficients ofProbitModelsofChildMorbidity,Indonesia,1991

ProbitPartialDerivative(p-value)

Variablea _{Diarrhoea Fever/Cough}

Wantedbirth –0.047 –0.083

(0.00) (0.00)

Numberofsiblings –0.004 –0.011

(0.01) (0.00)

Male 0.009 0.018

(0.08) (0.05)

Child’sage 0.012 0.022

(0.10) (0.08)

Child’sagesquared –0.008 –0.103

(0.00) (0.00)

Mother ’seducation –0.002 –0.000

(0.00) (0.94)

Husband’seducation 0.001 0.001

(0.03) (0.15)

Assets1 0.006 0.019

(0.14) (0.01)

Assets2 –0.002 0.001

(0.41) (0.81)

Urban 0.001 –0.019

(0.94) (0.17)

Water 0.011 0.027

(0.25) (0.10)

Toilet –0.016 –0.038

(0.06) (0.01)

Provincialmeanprevalence 0.754 1.02

(0.00) (0.00)

Samplesize 13,118 13,231

a_{Seetable1forvariabledefinitions.}

fromthesample.Inthe1991Indonesia sample,mediannumberofsiblingswas 1, and mean number of siblings was 1.58.Ofthechildreninthesample,33% werefirstbirths,and59%hadeitherno siblingsoronesibling.Asecondpossi

-bilityisalearningeffect.Motherslearn from theirexperiences with their first child,and so motherswho havemore children are better at keeping them healthy.

RespiratoryInfection. Thepatternfor respiratory infections is much the same.Wanted birthsareroughly13% less likely to contract respiratoryin

-fections than are unwanted births. Onemeasureofassetownershipissta

-tistically significant but has an esti

-mated coefficient of the wrong sign. It is of little practical impo rtance, however: a one-standard deviation

increaseinwealth,which whencom

-pared to the mean implies leapfrog

-gi ng o v er ab o ut o ne-thi rd o f th e

income distribution, would yield an increase of only 5% in fever/cough m o r b i d i ty. A s w a s th e c a s e w it h diarrhoealdisease,respiratoryillness ismorelikely tooccurinareaswhere itsprevalenceishigh.Accesstoapri

-vate flush toilet decreases the prob

-ability of contracting a respiratory illness. It is doubtful thatthis repre

-sentssodirectalinkindiseasereduc

-tion:perhapsthisvariableisactingas somesort of proxy forhousing qual

-ity.Boysare(barely)statisticallymore likelytocontractrespiratoryillnesses than girls. As was the case for diar

-rho ea, chi ldren w ith man y l ivi ng siblings arelesslikely tocontractres

-piratory disease than are those from smallerfamilies.Onceagain,themag

-nitude issmall, with each additional siblingaccountingforadropof3%in the probability of illness. Theappar

-ent beneficial impact of siblings is swampedifthatchildisunwanted.

CurativeHealthCare

Ofill children,78% of those with di

-arrhoeaand83%ofthosewithfever/ cough received modern sector treat

-ment.InthePhilippines,Costelloand Lleno (1995) found a preference for (typically incorrect) antibiotic-based

treatm ent regimens fo r diar rhoea. Thereis someevidence thatthis ten

-dencyalsoprevailsinIndonesia,with only about 20% of children ill with diarrhoea receiving oral rehydration salts(ORS).Itthereforeseemsunlikely thattherelativelyhightreatmentrates inIndonesiaareattributabletoadher

-encetotheORSprotocol.

Themarginaleffectofbeingwanted wastoincreasetheprobabilityof be

-ing treatedfor diarrhoea by roughly 0.13(table3).Alternatively,compared to the mean probability of treatment ofdiarrhoeaof0.83(table1),awanted child was17% more likely to receive treatm ent th an was an un wan ted child. Children from larger families were less likely to receive treatment, although the latter variable was not statisticallysignificant.Theseimpacts wereverysimilarforbothestimation approaches.However,the size ofthe impactofthesevariablesontreatment forfever/coughwasnotstableacross d i ffe re n t e s ti m a ti o n a pp r o ac h e s. Household assets and prenatal care did have statistically significant and consistent im pacts. Mother ’s use of prenatal care inc reased treatment probabilityby13%.Bothassetowner

-shipfactorshadpositive,statistically significantcoefficients,withasimulta

-neousone standarddeviation change accounting for an increase of 8% in treatment probability. None of the othervariablescouldaccountforade

-viation of more than 1% from mean treatmentprobability.

Thelarger and more consistentim

-pactofwantednessondiarrhoeatreat

mentthanonfever/cough treatmentis puzzling,sincediarrhoea treatmentis, atleastintheory,somewhatcheaperand easier to obtain. Possibly, parentstake

fever/cough more seriouslythandiar

-rhoea (so thatcosts play a lessimpor

-tantroleinassessingtreatmentchoices). Ifso,onemightexpectfever/cough to TABLE3 Coefficients ofModelsofTreatmentforChildMorbidity,Indonesia,1991

TreatmentforDiarrhoea TreatmentforFever/Cough

Heckman ProbitPartial Heckman ProbitPartial Coefficient Derivative Coefficient Derivative Variablea _(p

-value) (p-value) (p-value) (p-value)

Wantedbirth 0.127 0.137 0.218 –1.49

(0.05) (0.04) (0.60) (0.01)

Siblingsalive –0.002 –0.005 0.018 –0.063

(0.83) (0.66) (0.37) (0.01)

Male 0.001 0.014 0.011 0.008

(0.97) (0.65) (0.31) (0.53)

Child’sage 0.108 0.135 0.089 0.091

(0.03) (0.01) (0.00) (0.00)

Child’sagesquared –0.016 –0.026 –0.010 –0.014

(0.16) (0.01) (0.01) (0.00)

Mother ’sage 0.001 0.001 –0.003 –0.002

(0.68) (0.68) (0.07) (0.19)

Mother ’seducation 0.003 –0.001 0.002 0.004

(0.48) (0.78) (0.12) (0.01)

Husband’seducation 0.004 0.005 0.002 0.003

(0.20) (0.16) (0.03) (0.05)

Assets1 0.030 0.046 0.037 0.060

(0.15) (0.06) (0.00) (0.00)

Assets2 0.047 0.055 0.029 0.292

(0.01) (0.00) (0.00) (0.00)

Prenatalcare 0.054 0.046 0.053 0.079

(0.10) (0.18) (0.00) (0.00)

Traveltime –0.005 0.009 –0.000 –0.001

(0.01) (0.01) (0.93) (0.192)

Urban –0.011 0.009 0.053 0.025

(0.80) (0.85) (0.00) (0.208)

Outerislands –0.057 –0.052 0.013 0.003

(0.13) (0.19) (0.27) (0.83)

Java/Bali 0.031 0.066 0.046 –0.085

(0.45) (0.14) (0.18) (0.07)

Constant 0.840 0.682

(0.00) (0.14)

Selectioncoefficient –0.137 –0.279

(0.12) (0.00)

Samplesize 989 4,665

a_{Seetable1forvariabledefinitions.}

be morelikelytobetreated inany cir

-cumstance,butinoveralltreatmentlev

-elscleardifferentials bydiseasearenot evidentinIndonesia.

DISCUSSION

Ouraiminthispaperhasbeentodem

-onstratetheimpactofwithin-familyre

-source pres sures on allocations to children. We use onemeasure of such pressures,numberofsiblings,whichis potentially endogenous to the overall decision makingprocess ofthefamily. Oursecondmeasure,unwantednessat conception, ismoreareflectionofexog

-enousshocksoutsidethedecisionmak

-ingcalculusoftheparents.Wefocuson the impacts upon measures of child health,becausehumancapitalimprove

-mentsappeartoaccount foranimpor

-tantshareoftheeconomicgrowththat has occurred in many societies. Such human capital increases come from a willingness to commit resources to children.

Incomesarelow in Indonesia,and low incomes can imply harsh trade

-offs betweennumbersand qualityof

children,anddifferentialtreatmentof children.Thesetrade-offscantakethe

formofreductionsincalories,protein orothermeasuresofnutritionthatcan generate observable implications for child morbidity. Indeed we find that unwantedness leads to increases in morbidityanddecreasesinhealthcare treatment.Themorbidityimplications arequitelargeinapolicycontext.We do not find a consistent impact on treatmentprobabilitiesfornumberof siblings.Itappearsthat,inIndonesia, large families who face pressing re

-source constraints make other sacri

-fices to protect the health of their children. However, childrenwho are unwanted,a quite rare phenomenon inIndonesia,aredisadvantaged,and aremorelikelythanotherchildrento become ill, and less likely to receive treatmentwhen ill.Tothe extentthat continuingeconomicandpoliticalin

-stability in Indonesia leads to an in

-crease in unwanted births, a larger proportionofchildrenmaysufferthe adverse treatment identified in this paper.

NOTES

* Theauthorsthank RonLee,AndyMa

-son,JerryRusso,AmyTsui,andseminar participantsattheEast–WestCenter,Col

-legeof Williamand Mary and World Bank for helpful comm ents, and Jeff Brown,Shi-JenHeandLixiaXuforca

-pableresearchassistance.

1 Oneattempttoaddressthisisastudyfor FinlandbyMyhrmanetal.(1995),which usesdatafromabaselinesurveyandtwo revisits,thelatterofwhichcame24years aftertheinitialsurvey.

2 SeeSteckel(1995)forasurveyofthelit

-erature on the relationship between childhoodnutritionandadultphysical stature.

3 Giventheextremelysmallnumberof multiplebirthsinthesurveytheseau

-tho rs e m ploy, the f in d ing of n on

-significanceshouldbeinterpretedwith caution.

4 Trusselland Kost (1987)provide esti

-mates ofannual contraceptivefailure rates,largelyfortheUS,thataretypically anorderofmagnitudegreaterthantheir theoretical minima.

5 Themodelisoneofresourceallocation tolivingchildren.Clearly,priorsibling mortalityisrelevantinselectingthesam

-pleofchildrenforwhomtheallocation decisionsarebeingmade,andnon-ran

-dompriormortalityhasthepotentialto bias empirical results based on this model.However,inourinitialempirical work,wefoundnoevidenceofmortal

-ityselectivity.Inrelatedwork,Pitt(1997) foundonlyverysmallimpactsofafail

-uretoincludetheself-selectivity offer

tilityinmodelsofchildmortality.There

-fore,wetreatsurvivaltoselectioninour sampleasexogenously determined. 6 Onereasonthatthismightbedesirable

isthatpastfertilitycontributestothecur

-rentnumberofsiblings,andthepastand currentdeterminantsof fertility,espe

-ciallyinsurveydata,maybedifficultto separate.

7 Itwouldbedesirabletoincorporatesome sortoffamily-leveleffectinthismodel.

However,dataconstraintsmakesuchef

-fectsimpossibletoestimateusingDHS

-style datasets, as thereare very few multiple-birthhouseholdsreportingthe

datawerequire.

8 Areviewerofferedanalternative inter

-pretation:more‘traditional’parentsal

-waysseek out modern care as a ‘last resort’.Ifthisistrue,useof traditional caredoesnotnecessarilyindicatelessde

-termination toseekouteffectivecare;it ratherreflectsmoretraditional waysof viewingtheworld.

9 Pitt(1997)reportssimilardifficultiesina modeloffertilityandmortality. 10 Thelinearprobabilitymodelyieldscon

-sistentestimators, evenwiththe Heck

-man l _{as a covariate. However, itis}

inefficient,heteroscedastic (inknown fashion),andcanyieldpredictions out

-sidetheunitinterval(see,forexample, VandeVenandVanPraag1981). 11 For each illness, we firstestimatethe

structuralequation for morbidity,and thenusetheestimatedparametersincon

-structingtheinverseMillsratiotermfor thetreatmentequation.

12 Ifmorbidityisareflectionofchoice,then mortality might be a reflectionof the same phenomenon. Therefore, in an analysisnotreportedhere,weexamined thepossibilityofselectivitybiasinduced

by excluding dead children. Using a two-stageHeckmanapproachinmod

-elsofmorbidity,wewereconsistently androbustlyfarfrombeingabletore

-ject the null hypothesis of random mortality.Inotherwords,hadthechil

-dren who died in fact survived, we wouldnotpredicttheincidenceofdis

-ease to be any greater among them thanamongtheactualsurvivors. 13 Reducedformsforthesevariablesare

estimatedandusedtogenerateinstru

-mentsforsubsequentHausmantests. Allpredeterminedvariablesfromthe structural equations for illness and treatment, aswellas yearssincefirst marriage,whetherparentsexpectedto receive financial suppor t from their childrenortolivewiththeminretire

-ment, birth w eight categories , and whetherthereferencebirthwasoneof a multiplebirth,are used inestimat

-ingthereduced-formequations.

14 Note that child healthand theprovi

-sionof care are indicatorsof quality, w hic h in the B e ck e r–L e w is ( 19 7 4)

framework determine the price per child.It is thereforepossiblefor cur

-renthealthtoplayacausalroleinthe determination of numberof siblings, althoughwefindnoempiricalsupport forthisnotion.

15 This value was chosen because it is slightly larger than the current total fertility rate.The findings are robust to a variable definedon family sizes oftwo and seven children,which we chose to represent low and high ex

-tremesoffertility.

16 Thenegativeimpactsofunwantedness onchildhealtharealsofoundwhenin

-strumentalvariablesareusedforun

-wantednessandnumberofsiblings.

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