Search

On average, child health outcomes are better in urban than in rural areas of developing countries. Understanding the nature and the causes of this rural-urban disparity is essential in contemplating the health consequences of the rapid urbanization taking place throughout the developing world and in targeting resources appropriately to raise population health. We use micro data on child health taken from the most recent Demographic and Health Surveys for 47 developing countries. First, we document the magnitude of rural-urban disparities in child nutritional status and under-five mortality across all 47 developing countries. Second, we adjust these disparities for differences in population characteristics across urban and rural settings. Third, we examine rural-urban differences in the degree of socioeconomic inequality in these health outcomes. We find considerable rural-urban differences in mean child health outcomes. The rural-urban gap in stunting does not entirely mirror the gap in under-five mortality. The most striking difference between the two is in the Latin American and Caribbean region, where the gap in stunting is more than 1.5 times higher than that in mortality. On average, the rural-urban risk ratios of stunting and under-five mortality fall by respectively 53% and 59% after controlling for household wealth. Controlling thereafter for socio-demographic factors reduces the risk ratios by another 22% and 25%. In a considerable number of countries, the urban poor actually have higher rates of stunting and mortality than their rural counterparts. The findings imply that there is a need for programs that target the urban poor, and that this is becoming more necessary as the size of the urban population grows.This discussion paper has resulted in a publication in Social Science & Medicine, 2007, 65(10), 1986-2003.

Background Performance-based financing (PBF) has attracted considerable interest from governments and aid agencies in low-income countries as a means to increase productivity and quality of health-care providers. In Africa alone, more than 35 countries are in the process of introducing payment methods that reward performance. The Burundi Government has gradually rolled out PBF across all provinces between 2006 and 2010. Our aim was to evaluate whether this has led to changes in the quantity and quality of health-care services provided. Methods We exploited the staggered rollout of PBF to apply a difference-in-differences approach using data from 2006 (baseline), 2008, and 2010. Cross-sectional data were collected among a random sample of 3200 households and panel data among 75 randomly selected health-care facilities across intervention and control provinces. Findings We found that PBF increased the probability of women delivering in an institution by 21 percentage points (p=0·0001), the probability of using antenatal care by 7 percentage points (p=0·067), and the use of modern family planning services by 5 percentage points (p=0·002). The overall facility quality score as constructed by external audits increased by 46%, but no effect of PBF was found on the quality of care as reported by patients. We also found no effects of PBF on vaccination rates, and the satisfaction with waiting times decreased. There is no strong evidence for unequal effects of PBF across socioeconomic groups. Interpretation The introduction of PBF in Burundi has led to significant increases in mother and child care utilisation and in the quality scores of health-care facilities. Given the rising popularity of this financing strategy, more robust evidence on its effects is warranted. Funding We thank the BMG Innovation fund, the Rotterdam Global Health Initiative, and Cordaid Netherlands for funding this research. EvdP is a Postdoctoral Fellow of the Netherlands Organisation for Scientific Research—Innovational Research Incentives Scheme—Veni project 451-11-03.