FOOD SECURITY AND NUTRITION IMPLICATIONS OF INTRAHOUSEHOLD BIAS: A REVIEW OF LITERATURE Lawrence Haddad, Christine Peña, Chizuru Nishida, Agnes Quisumbing, and Alison Slack FCND DISCUSSION PAPER NO. 19 Food Consumption and Nutrition Division International Food Policy Research Institute 1200 Seventeenth Street, N.W. Washington, D.C. 20036-3006 U.S.A. (202) 862-5600 Fax: (202) 467-4439 September 1996 FCND Discussion Papers contain preliminary material and research results, and are circulated prior to a full peer review in order to stimulate discussion and critical comment. It is expected that most Discussion Papers will eventually be published in some other form, and that their content may also be revised. ABSTRACT The success of development policy depends on the ability to successfully anticipate the response of individuals to changing incentives. Often, however, actual responses differ from anticipated responses. One important reason for this divergence is a poor understanding of how rights, responsibilities, and resources are allocated within institutions such as the household. The insights derived from intrahousehold research between the late 1970s and the mid-1980s on the determinants of food and nutritional status served as an important catalyst for the general development of the intrahousehold approach to development policy analysis. Despite serving as a building block for the wider study of intrahousehold resource allocation, there has not been an in-depth review of sex and gender differences in the food consumption and nutrition literature in the past 10 years. This paper seeks to fill this gap. In addition, the paper undertakes a review of the gender and poverty literature, because economic access to food is so fundamental to food security and nutrition. Why is this an important gap to fill? First, the availability of a series of new food consumption and nutrition studies from the past 10 years affords us an opportunity to get a clearer picture of where intrahousehold and sex differences in food and nutrition occur. Second, the availability of a number of intrahousehold studies from outside the food and nutrition community may have some important lessons for food and nutrition programming. Finally, a number of important measurement issues have emerged in the past 10 years and their importance can be illustrated well in a review of studies such as this. These three considerations, then, form the basis for formulating the objectives of the paper. Specifically, the paper aims to (1) critically review the existing literature and studies on the distribution of food and other proximate factors within the household (with an emphasis on boy-girl differences), (2) critically review the existing literature and studies in the areas of poverty and gender, gender and income earning, drawing out implications for food and nutrition programs, and (3) highlight some important methodological concerns related to poverty, income, and food consumption measurement. CONTENTS PREFACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v ACKNOWLEDGMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii 1. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2. CONCEPTUAL FRAMEWORK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 3. INTRAHOUSEHOLD BIAS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 EVIDENCE ON CONSUMPTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Food Distribution Within the Household . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Distribution of Nonfood Health Inputs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Distribution of Adult Goods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 EVIDENCE ON OUTCOMES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Anthropometric Outcomes Within the Household . . . . . . . . . . . . . . . . . . . . . . . 27 Mortality Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 PUBLICATION BIAS: THE UNDERREPORTING OF NEGATIVE RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 4. POVERTY AND GENDER BIAS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 A REVIEW OF TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 The Choice of Poverty Measure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 The Use of Adult Equivalents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 The Definition of Income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 THE REPRESENTATION OF FEMALES IN LOW-INCOME HOUSEHOLDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 FEMALE HEADSHIP: HOUSEHOLD COMPOSITION ISSUES . . . . . . . . . . . . . 43 Heterogeneity of Headship Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Demographic Composition, Labor Markets, and Headship . . . . . . . . . . . . . . . . 46 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 FEMALE INCOME: HOUSEHOLD EXPENDITURE ISSUES . . . . . . . . . . . . . . . 47 5. CONCLUSIONS AND POLICY IMPLICATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 iv TABLES 1. A summary of studies of food distribution relative to requirements within the household . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 2. Bias reported by specific studies on food distribution within the household (from Table 1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 3. Totaling the bias reported by specific studies on food distribution within the household (from Table 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 4. A partial summary of studies of the intrahousehold allocation of nonfood health inputs 23 5. A summary of studies of intrahousehold consumption bias, based on an "adult goods" analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 6. A summary of studies of within-household differences in anthropometric outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 7. A summary of studies of differential mortality rates by gender . . . . . . . . . . . . . . . . . . 35 FIGURE 1. A gendered conceptual framework of the determinants of nutrition outcomes . . . . . . . . 3 Lawrence Haddad is Director and Agnes Quisumbing is a Research Fellow, Food* Consumption and Nutrition Division, the International Food Policy Research Institute (IFPRI); Alison Slack is a Research Analyst at IFPRI; Christine Pêna is an Economist at the Africa Technical Human Development 1 Division of the World Bank (she was formerly a Visiting Researcher at IFPRI); Chizuru Nishida is a Nutrition Anthropologist in the Nutrition Unit, World Health Organization. PREFACE* In December 1992, the International Conference on Nutrition (ICN) was held in Rome, Italy. The ICN was the culmination of more than two years of joint effort by the World Health Organization (WHO) and the Food and Agriculture Organization of the United Nations (FAO) to increase awareness of the extent and seriousness of nutrition- and diet- related problems, and to achieve consensus on future methods of dealing with them. The ICN was attended by more than 1,300 participants from 159 Member States and the European Community, as well as representatives of 15 organizations and bodies of the United Nations system, and over 150 other intergovernmental and nongovernmental organizations. The ICN adopted the World Declaration and the Plan of Action for Nutrition (FAO/WHO 1992), which represents a vital step in the direction of a truly global commitment to action by countries and the international community alike. The World Declaration emphasizes the unacceptability of malnutrition and the determination of all governments to eliminate hunger and substantially reduce malnutrition . The declaration points to poverty and lack of education (rooted in underdevelopment) as fundamental causes and identifies social, economic and gender disparities as well as wars, civil strife, droughts and other natural calamities as major contributors. It affirms the need for major universal policy change if malnutrition is to be radically reduced. The goals and strategies delineated in the World Declaration and the Plan of Action for Nutrition (see the box below) provide a framework and guidelines for countries to develop and strengthen their national plans of action to promote the nutritional well-being of their populations. As a follow-up action to the World Declaration and Plan of Action for Nutrition, a collaborative work on the issues relating to intrahousehold resource allocation has been developed between WHO and the International Food Policy Research Institute (IFPRI). The importance of understanding the issues relating to resource distributions within households was addressed, in particular, in two strategy areas identified in the Plan of Action for Nutrition: improving household food security, and caring for the vi WORLD DECLARATION ON NUTRITIONWORLD DECLARATION ON NUTRITION (excerpt) As a basis for the Plan of Action for Nutrition and guidance for formulation of national plans of action, including the development of measurable goals and objectives within time frames, we (the Ministers and Plenipotentiaries) pledge to make all efforts to eliminate before the end of this decade: # famine and famine-related deaths; # starvation and nutritional deficiency diseases in communities affected by natural and man-made disasters; # iodine and vitamin A deficiencies. We also pledge to reduce substantially within this decade: # starvation and widespread chronic hunger; # undernutrition, especially among children, women and the aged; # other important micronutrient deficiencies, including iron; # diet-related communicable and noncommunicable diseases; # social and other impediments to optimal breast-feeding; # inadequate sanitation and poor hygiene, including unsafe drinking-water. PLAN OF ACTION FOR NUTRITIONPLAN OF ACTION FOR NUTRITION Strategies and ActionsStrategies and Actions # incorporating nutritional objectives, considerations and components into development policies and programs; # improving household food security; # protecting consumers through improved food quality and safety; # preventing and managing infectious diseases; # promoting breast-feeding; # caring for the socioeconomically deprived and nutritionally vulnerable; # preventing and controlling specific micronutrient deficiencies; # promoting appropriate diets and healthy lifestyles; # assessing, analyzing and monitoring nutrition situations. socioeconomically-deprived and nutritionally vulnerable. The present paper was developed as one component of this IFPRI/WHO collaboration on intrahousehold resource allocation. Meeting the health and nutrition needs of the family, particularly of mothers, infants, and young children, is fundamental to both IFPRI's and WHO's strategies to support nutrition activities in developing countries. vii ACKNOWLEDGMENTS The authors would like to acknowledge the useful and thoughtful comments made on earlier manuscripts by the following individuals: Alice Stewart Carloni (FAO), Patrice Engle (California Polytechnic State University), Cynthia Lloyd (Population Council), Richard Longhurst (Institute of Child Health, University of London), Beatrice Rogers (Tufts University), and Jay Willis and Lynn Brown (IFPRI). The usual disclaimers apply. This work was supported by the World Health Organization (WHO), the International Food Policy Research Institute (IFPRI), and the United States Agency for International Development, Office for Women in Development, Contract No. FAO-0100-G-00-5020-00. A revised version of this paper will be prepared as a joint WHO/IFPRI document to be published under WHO auspices. This information was, of course, not new to nutritional anthropologists. For example, the1 pro-male culture in parts of South Asia, and the consequences for nutrition, have been well- documented since the 1950s (see Miller [1981] for a synopsis). 1. INTRODUCTION The success of development policy depends on the ability to successfully anticipate the response of individuals to changing incentives. Often, however, actual responses differ from anticipated responses. One important reason for this divergence is a poor understanding of how rights, responsibilities, and resources are allocated within institutions such as the household. Nutrition and food consumption were among the first areas of inquiry into the extent of intrahousehold differences in resource allocation (Sen 1984). Studies in Bangladesh, India, and the Philippines alerted the wider development community to the potential for sex and age biases in nutrition and food intake. The insights derived from intrahousehold1 research between the late 1970s and the mid-1980s on the determinants of food and nutritional status served as an important catalyst for the general development of the intrahousehold approach to development policy analysis. Today, intrahousehold analysis is being applied to a wider set of development issues, such as the protection of the environment, the design of public works schemes, the design of micronutrient interventions, preventing violence against women, the design of credit schemes for the poor, and the determinants of fertility, to mention but a few (IFPRI 1994; Rogers and Schlossman 1990). Despite serving as a building block for the wider study of intrahousehold resource allocation, there has not been an in-depth review of sex and gender differences in the food consumption and nutrition literature in the past 10 years. This paper seeks to fill this gap. In addition, the paper undertakes a review of the gender and poverty literature, because economic access to food is so fundamental to food security and nutrition. Why is this an important gap to fill? First, the availability of a series of new food consumption and nutrition studies from the past 10 years affords us an opportunity to get a clearer picture of where intrahousehold and sex differences in food and nutrition occur. Second, the availability of a number of intrahousehold studies from outside the food and nutrition community may have some important lessons for food and nutrition programming. 2 Finally, a number of important measurement issues have emerged in the past 10 years and their importance can be illustrated well in a review of studies such as this. These three considerations, then, form the basis for formulating the objectives of the paper. Specifically, the paper aims to (1) critically review the existing literature and studies on the distribution of food and other proximate factors within the household (with an emphasis on boy-girl differences), (2) critically review the existing literature and studies in the areas of poverty and gender, gender and income earning, drawing out implications for food and nutrition programs, and (3) highlight some important methodological concerns related to poverty, income, and food consumption measurement. Chapter 2 presents a conceptual framework for a gendered analysis of the determinants of malnutrition so as to place the literature review of Chapters 3 and 4 in context. Chapter 3 reviews the literature on the direct and indirect evidence of sex differences in food and nonfood health input consumption and in nutrition outcomes. Chapter 4 reviews the literature on the factors underlying intrahousehold bias, specifically the relationship of poverty and gender (including a discussion of the poverty status of female-headed households). In the process of reviewing the literature, several methodological issues are discussed. Chapter 5 summarizes the conclusions of the literature review and draws out their implications for poverty, food, and nutrition programs and policies. 2. CONCEPTUAL FRAMEWORK An intrahousehold/gender review of all the determinants of malnutrition is beyond the scope of this paper. It is important, however, to place the literatures this paper will review in a wider context. Using a standard conceptual framework for the determinants of malnutrition (ICN 1992) as a base, Figure 1 presents a gendered version of the framework of the determinants of nutrition status. The conceptual framework begins with the basic factors underlying nutrition status. If women are overrepresented in poor households, this is a strike against nutrition. Poor women are likely to be poorly nourished and this has serious implications for the nutrition status of their yet-to-be-born children. Adult female undernutrition also constrains the ability of women to earn income, which tends to impair the nutrition status of their 3 Figure 1—A gendered conceptual framework of the determinants of nutrition outcomes 4 existing children. Women with control over resources tend to have a large say in how the household allocates resources, and women are typically more likely to skew resources to the production of nutrition. If, however, the legal, political, and ideological structures in society do not reinforce women’s rights to, say, own land, get access to credit and to family planning, then this control can be usurped. Education is crucial for income generation and behavior change. If girls do not receive the same educational opportunities as boys, this has important negative consequences for their total fertility rate, their labor force participation, and their ability to promote child welfare. In terms of intermediate factors, women’s control of income is a key promoter of household food security and nutrition. Women are more likely than men to spend extra income on nutrition inputs such as food. Child care time is a crucial input to nutrition. In the event of an income or health shock, do women and men reduce their care time to girls more than they do to boys? Will they require girls to miss school more often than boys by calling on their labor to substitute for their own? Are boys breast-fed more optimally than girls? When children get ill, do boys receive treatment before girls do? Do boys receive higher quality treatment than girls? The allocation of child care by sex of the child is an understudied area. In terms of immediate factors, what is the evidence on intrahousehold food allocation? Are boys favored in terms of quantity and/or quality? Are there any boy-girl differences in the prevalence, incidence, and severity of specific illnesses? The net effect of differences and asymmetries in the basic, intermediate, and immediate causes of child survival and nutrition are manifest in nutrition outcomes. Are there differences in boy-girl nutrition outcomes as measured by anthropometric indicators? Finally, differences in nutrition outcomes for young children will have implications for their cognitive development and for their labor capacity and productivity as adults, and thus nutritional status contributes to the stock of potential resources in terms of the quality of human resources. This review will discuss 6 of the 12 boxes in Figure 1—potential resources (1), household food security (5), health services (7), the dietary intake of food (8), health (10), and child nutrition and survival (11). 5 Regions are defined as Latin America, Sub-Saharan Africa, South Asia (India, Bangladesh,2 Nepal, and Pakistan), and Southeast Asia (the Philippines). 3. INTRAHOUSEHOLD BIAS A review of issues of income, household structure, food consumption, and nutrition must take account of some of the shortcomings and limitations of commonly used measurement methodologies. Consequently, each section of the literature review discusses relevant measurement issues prior to an assessment of the evidence presented. In all sections, the evidence is organized by region, since prior reviews suggest that the nature of2 the evidence on intrahousehold differences is highly location-specific. EVIDENCE ON CONSUMPTION Intrahousehold bias in consumption can be measured directly in terms of the consumption of food and nonfoods by various household members. Alternatively, intrahousehold bias in consumption can be indirectly measured by observing the variation in the consumption of goods exclusively consumed by adults across different household structures. This section reviews both the direct and indirect evidence. Food Distribution Within the Household Apart from obvious concerns with equity, examining intrahousehold food distribution is relevant to the design of targeted interventions, that is, the choice between targeting at the household level or at the individual level. Appropriate targeting ensures not only cost- effectiveness, but also reduces the chance that the vulnerable groups are excluded from the intervention (Cornia and Stewart 1992; Haddad and Zeller 1996). At the household level, Haddad and Kanbur (1990) demonstrate that the undernourishment rankings of various socioeconomic and geographic household groups can change when individual-level food consumption information is used instead of household- level information. For example, although individual-level data may indicate that individuals from certain households (for example, landless rural households) are an important food poverty group, a reliance on household-level data might imply that they are not an important group. This result comes about because patterns of intrahousehold inequality differ between different household groups. If inequality was similar in all groups, then food poverty rankings would be identical, whether or not individual-level data were used to target the transfer. 6 Programs that use individual-level data for targeting purposes often assume that the food allocation mechanism within a household can be short-circuited by targeting the individual directly. Suppose there is concern regarding the well-being of young girls in a particular rural area; specifically, there is a perception that they do not get enough food to eat. A possible policy response is to implement a school meal program where girls are recorded as being particularly undernourished. The success of this intervention, however, cannot be ascertained in the absence of information on the pattern of food allocation among household members. Households might respond to this program by reducing the amount of food girls receive at home (and increasing the amount of food consumed by other household members). Understanding the existing patterns of intrahousehold allocation of food is a necessary prerequisite for determining the effectiveness of such policy interventions (Haddad and Kanbur 1992; Alderman et al. 1995). Conclusions drawn from the evidence on the distribution of food relative to requirements within the family are, however, sensitive to methods of assessing food intake and food requirements. Therefore, measurement issues are discussed before empirical evidence is presented. Measurement of Food Intake. The basic choice for the collection of individual food intake is between repeated recalls of food consumed in the past 24 hours and food weighing of ingredients prior to consumption. Each method has its fair share of supporters and critics. The survey data collection problems associated with intrahousehold nutrient analyses are well-illustrated in Brown (1984) and in Harriss-White (1996). Accurate measures of food intake are notoriously difficult to obtain due to meals eaten outside the home (how to assess their nutritional content); snacking behavior (Harbert and Scandizzo [1982] found that this type of food consumption is easy to omit, but when it is captured, it can have a large impact on measured nutrient intake, especially for children); modification of diet due to being observed; the uneven visual comparison between household utensil volumes and standard measures carried by the enumerators, especially when food is eaten from a common bowl; using an appropriate recall period (should the recall period be 24 hours or seven days?); and the number of repeated recalls (what is the optimal number in terms of accuracy, cost, and the ability of the analysis to attenuate random measurement error at individual and population levels?). Measurement of Food Requirements. The accurate determination of individual energy and nutrient requirements is difficult. For energy, problems include those related to activity patterns, weight changes, and individual variation in basal metabolic rates, to name but a few 7 (Randolph et al. 1991; Kumar and Bhattarai 1993). The basic choice for time allocation data methodologies lies between random-spot observations (a large number of observations as to the activity of each household when visited by the interviewer), repeated 24-hour recalls of activities, and "typical day" activity profiles (Paolisso and Regmi 1992). Additional requirement problems are highlighted when attempting to uncover inequalities in micronutrient availability. The difference between individual consumption and individual absorption can be due to a number of factors: combinations of vitamins and minerals (Gibson 1990, 76-77); antinutrients (for example, phytates, which block the absorption of iron); storage (for example, sunlight and infestation damage); processing (positive [for example, minerals added from utensils] and negative [for example, refining that removes nutritious components from the food]); and cooking (positive [for example, fermentation] and negative [for example, heat denaturing of proteins]). All of these factors may vary by individual (Gibson 1990). Accounting for individual energy requirements affects the measurement of biases in food distribution, since food may be allocated to individuals who perform more strenuous tasks. Pitt, Rosenzweig and Hassan (1990) find that, in Bangladesh, the higher level and greater variance in calories consumed by men relative to women reflect their greater participation in more energy-intensive activities where productivity is sensitive to health status. Evidence. Food allocation is the most studied dimension of intrahousehold inequality, and yet, outside of northern India and Bangladesh, evidence of pro-male biases in food consumption is scarce. The 43 studies summarized in Table 1 contain 103 male-female or adult-child comparisons. The majority of the studies (70 comparisons) do not adjust requirements for body weight or activity patterns. The remaining 33 comparisons are from studies that take activity patterns and body weight into account when determining requirements. When body weight and activity are not considered, of the 19 male-female preschooler comparisons, males are favored in 9 cases, females in 1 and neither sex in the remaining 9 cases. When studies adjust energy requirements for body weight and activity, of the 8 male-female preschooler comparisons, 2 are pro-male, none are pro-female, and 6 favor neither sex. In general, the adjustment for body weight and activity tends to support gender- neutrality of intrahousehold food distribution, although a slight pro-male bias persists. 8 Table 1—A summary of studies of food distribution relative to requirements within the household Measure of Study Country Food Consumption Sample Type Main Conclusion 1. Ahmad et al. Rural Food intake 1,200 individuals Male and female about same in kilocalories and protein in all age 1977 Bangladesh groups, although pregnant and lactating women had low percentage share of recommended daily allowances (RDAs). Younger children (4-9 years old) had low kilocalorie shares but high protein shares. 2. Pakistan Pakistan 24-hour recall of food 1,236 households The male head of household and a woman of childbearing age were 1978 (nationally intake asked separately about their individual food intakes. These data representative indicate that male head of households met 98 percent of their activity- sample) unadjusted calorie requirements. The corresponding figure for women was 101 percent. 3. Evenson, The Philippines Combination 24-hour 357 individuals "At all age levels, male children have more adequate diets than female Popkin, and food recall and record children, and . . . diets of adults are more adequate than those of King-Quizon method children" (p. 306). These conclusions seem strong, based on the data 1980 presented. Protein consumption seems to be the only diet component in which boys are clearly favored. Overall "diet ratings" are marginally higher for males than females (encompassing energy, protein, and seven micronutrients) for preschooler and schooler groups. The male-female differences seem more marked for adolescents and adults, but these may be due to nutrient requirements that do not reflect activity levels, and are hence underestimated for males. 4. Chula, Laguna, the Food intake Rural preschoolers No large differences by sibling order, although boys fare better (8 Karangka, Philippines (3-6 years old) in percent higher than RDAs for nine nutrients). and Onate 58 households 1980 5. Aligaen and Manila, the Food intake 100 urban Sex differences insignificant for calories but significant for protein. Florencio Philippines households Adults fare best relative to RDAs, while adolescents are worst off. 1980 6. Chen, Huq, Rural Food intake 135 families After corrections to calorie requirements using body weight and and d'Souza Bangladesh activity level, they found child calorie adequacy ratios to be 1981 significantly higher for boys compared to girls. 7. Carloni 1981 Primarily rural Food intake Review paper Review of nutritional surveys in rural Bangladesh suggests that Bangladesh females tend to be at a disadvantage, relative to males, leading to higher rates of female undernutrition. Increasing the supply of food is not enough to ensure the equitable distribution of resources within the family—the perceived economic value of females must be increased in rural societies in Bangladesh. (continued) 9 Table 1 (continued) Measure of Study Country Food Consumption Sample Type Main Conclusion 8. Harbert and Chile Method of collecting 400 households The distribution of nutrients across members of the household appears Scandizzo dietary intakes is not from the Metro- to be skewed in favor of adult males when the three main meals are 1982 explained politan Zone measured. When, however, additional snacks are taken into account, the results show that food allocation to family members closely conforms to nutritional requirements, and tends to favor younger children. 9. Brown, Black, Bangladesh Food intake Cross-sectional study of Bangladesh data provides evidence that boys and Becker in the 0-4 age-group consume more food relative to their requirements 1982 than girls. 10. Fabella The Philippines Food intake 100 households Both female and male children get higher proportions of food, the 1982 higher the income of the family. Increased education of the mother results in girls being better-off than their male siblings. 11. Chaudry Rural Food intake 1975-76 Rural Fathers over 45 years old had the highest reported calorie adequacy; 1983 Bangladesh Nutrition Survey calorie adequacy of females was higher than for males in all age-groups, except 0-1 and 15-29 years. For families with over eight children, male calorie adequacy is significantly higher than females in the 3-30 year age groups. 12. Kennedy 1983 Mexico Preschooler calorie Children do not seem to be favored or disfavored in terms of the intake allocation of extra calories received by the household; "in Mexico, increased income is associated with an increased energy intake in the child only to the extent that the income is used to purchase additional family calories" (p. 29). 13. Cowan and Rural Punjab, Individual food con- 911 index children More than three times as many girls as boys from privileged families Dhanoa 1983 India sumption (based on (2-3 years old) are malnourished. Twice as many girls as boys from underprivileged home visits and two- families were reported as undernourished. day recalls) 14. Hassan and Bangladesh 24-hour food weighing, 4,000 households On an overall household level, it was found that just under 50 percent Ahmad 1984 weight-for-height, of the households in the study had intake levels below 80 percent of height-for-age the recommended levels. "Socioeconomic factors such as landholding, income, and expenditure on food have a positive influence on energy adequacy . . . No regular relationship between anthropometry and household energy adequacy was immediately seen, probably because household adequacy did not ensure better nutrition for individual consumers. Unequal distribution within the family left many of the members malnourished" (p. 6). (continued) 10 Table 1 (continued) Measure of Study Country Food Consumption Sample Type Main Conclusion 15. Abdullah and Bangladesh Three-day recalls of 53 households with No evidence that women and older girls receive a lower share of Wheeler 1985 food intakes >=1 preschooler household calories, based on calorie requirements that are adjusted for body size and activity levels. However, the authors conclude "young children do not receive the share of household food which theoretical calculations of the re- quirements would prescribe; and that young girls receive a lower share than young boys." 16. Basu et al. Nepal One-day recall of Low-caste migrant Found mixed results for distribution of food, depending on the region 1986 dietary intakes as tea laborers and studied—in some areas, there was no difference; in others, there was reported by wives/ a landed caste a bias towards either males or females. mothers divided into high, medium, and low economic subgroups 17. Pettigrew Indian Breast-feeding, 55 children from Boys were fed first in all types of households, although girls were 1986 weaning practices, and rich, average, and breast-fed longer. Note a comment that "the richest people have a illness around weaning poor households great hatred for girls"—this is an observation by a village midwife time (based on partici- (breakdown of how on which Pettigrew does not comment. pant observation, home many kids belonged In weaning, supplementary milk is not willingly supplied to girls, visits, and weighing of to each income though it is more likely to be provided for boys. The level of income sample) class was not and ownership of land are important variables associated with child given) health (laborer families contained five out of the six children suffering from 3rd degree malnutrition and only two out of 18 healthy children). 18. Levine Northwest Child care measured 10 men and 10 Boys were given supplementary food sooner than girls, and mothers 1987 Nepal by infant feeding women from three were more frequently concerned about the adequacy of their milk for villages boys. 19. Haaga and Review Various Review From their review, the authors do not see any generalizations emerging Mason 1987 from empirical literature(for example, preschoolers are not always the losers in intrahousehold food allocation), although it seems that misallocation of food is most likely to be an important cause of malnutrition in South Asia. (continued) 11 Table 1 (continued) Measure of Study Country Food Consumption Sample Type Main Conclusion 20. Behrman India village- Nutrient intake from 400 pairs of During the surplus season, nutrients are distributed among children 1988a level studies 24-hour recall children < 15 within a household, regardless of individual endowments (unobserved data (VLS) years, from health propensity). During the lean season, however, the households with measurement of "inequality aversion" is significantly reduced, at least two rendering later-born and less well-endowed children more vulnerable kids when availability of nutrients is at lowest level. Standardized seasonal requirements satisfied do not differ significantly between boys and girls for calories, carotene, riboflavin, vitamin C, and calcium. 21. Behrman India VLS Nutrient intake from Children < 13 A male child parental preference bias of 5 percent was found only 1988b 24-hour recall years and from during the lean season. ". . . for the lean season, when food is households with scarcest, the combination of limited inequality aversion and pro-male at least two kids preferences—particularly for the lowest ranked castes—may leave (approximately those children who are less well-endowed, especially if they are low- 800 children) caste females, close to or even below the margin for survival" (p 52). 22. Senauer, The Philippines Food intake 140 households Female wage rate has a positive and significant impact on children's Garcia, and (Pilot) and females' share of household calories and a negative impact on Jacinto husbands' share of household calories. Male wage rate has positive 1988 and significant impact on male and female share of household calories, but a negative significant impact on children's calorie share. The allocation of food seems to favor adults. Husbands fare better than wives in terms of unadjusted protein and energy adequacy ratios. 23. Brahman, India Food intake 1,878 households This study found no sex discrimination in the intrahousehold Sastry, and in 10 states, distribution of food. Any shortfalls in energy intake are attributed Rao 1988 1975-1980 to ignorance on the part of the parents, and not to the intentional selection of a few household members. Literacy level of the adult women had a significantly positive influence on the energy consumption of the preschool children in a household. 24. Behrman and India VLS Food intake Little or no evidence from this data that gender discrimination exists, Deolalikar such as a lower average nutrient consumption level for females, or 1990 greater variance in female and male nutrient consumption levels. "Of course, to the extent that the general risk of malnutrition or starvation is greatest during times of food shortage . . . the relatively greater vulnerability of female members at these times could be characterized as gender discrimination" (p. 693). Also, nutrient intakes are subject to greater variability for females than for males. (continued) 12 Table 1 (continued) Measure of Study Country Food Consumption Sample Type Main Conclusion 25. Pitt, Bangladesh Food intake 345 households Good consumption disparities reflect gender differentiation in the Rosenzweig, from 15 villages energy intensities of activities undertaken by men and women. Results and Hassan indicate that households seem to exhibit some inequality aversion 1990 (that is, even though the rate of calorie reinforcement for adult males was high compared with adult females, males with a higher probability of getting more calories were also more likely to undertake highly energy-intensive work--work in which productivity is sensitive to health status). 26. Ely et al. Mexico Food intake Children >7 years The basic conclusion of this study is that it cannot be assumed that, 1991 old simply because there has been a shortfall in the caloric consumption of an individual household member, that individual is at a greater risk of malnutrition. "Those household members with larger shortfalls eat less because they choose or are permitted to do less, not because their caloric intake has been restricted . . . Calories are not rationed in these households, although leisure may be" (p. 20). Hence, the use of shortfalls per se should not be used as an indicator of malnutrition or to identify target groups for nutrition intervention. 27. Gittelsohn Nepal Quality and quantity 767 individuals Adult women discriminated against (late position in serving order, 1991 of food consumed, from 115 house- channeling of special foods, lower overall food intake) in terms of food serving process, holds in six meeting requirements for energy, beta carotene, riboflavin, and decisionmaking about villages vitamin C, but no sex difference in small children. food selection and preparation 28. Bouis 1991 The Philippines Food intake 448 households Iron intakes are about the same for males and females, which implies (Bukidnon) much lower iron adequacy for females (80 percent higher requirements). Relative to calories (an equal distribution of calorie intake relative to activity pattern-adjusted requirements is assumed), vitamin A and vitamin C are reasonably equitably distributed across types of household members (based on age-sex adequacy ratios). (continued) 13 Table 1 (continued) Measure of Study Country Food Consumption Sample Type Main Conclusion 29. Leonard Peru Food intake and 101 individuals from Adults (males more than females), rather than children, are subjected 1991 anthropometric data 26 households of lower to higher levels of seasonal caloric stress. Sex differentials in (height, weight, socioeconomic status dietary intake or physical status are not apparent among children mid-arm circumference (defined as households (ages 12 years and under). and triceps, and whose head did not subscapular skinfold have a steady source of thicknesses) off-farm income) 30. Bull 1991 United Kingdom Food intake 22 males and 31 "Men and young boys appeared to be receiving more than their "fair females in 13 share" (of food), while women and girls over the age of 11 received families less" (p. 422). Based on age-sex RDAs. 31. Warrier 1992 India Food intake Individuals disaggregated Upper/middle caste groups favor sons more in food allocation than based on household lower status groups and tribal groups. income and ethnicity 32. Hardenbergh Madagascar Food intake, This study of subsistence slash-and-burn cultivators near 1992 anthropometry, Ranomafana National Park in Madagascar found no evidence of gender mortality bias against girls in mortality, anthropometry, or nutrient intake. The authors conclude that one implication of their findings, if accurate, is that the economic value to households of girls is more explicit and obvious in Sub-Saharan Africa than it is in Asia. 33. Bégin et al. Chad Food intake (energy 80 households No intrahousehold results reported on food intake. Body mass index 1992 requirements allow for (BMI) varied significantly by season for adults under the age of 60. differences in physical Women had lower BMIs than men in both the lean and harvest activity), anthropometry seasons. (continued) 14 Table 1 (continued) Measure of Study Country Food Consumption Sample Type Main Conclusion 34. Miller 1992 Survey of Review Review Primary conclusions from this review of case studies: "daughter literature on discrimination does not most characterize the poor, anywhere in Intrahousehold India. If anything, greater disparities and malnutrition (and perhaps food distribution malnutrition-caused mortalities) are found among propertied groups, in South Asia and among the more educated" (p. 9). In addition, there are many misunderstandings of the issues as a result of differences in approaches and findings. Even so, from the evidence that exists here, while there tend to be higher child mortality rates among the poor, it is not the case that female child mortality rates are consistently higher than those for males; in fact, a number of studies show more gender-egalitarian mortality among the poor. It does seem that daughters, especially in some countries, do put additional financial stress on families as a result of marriage and dowry costs, and not from food consumption. 35. Engle and Guatemala Food intake at midday 45 women with at It was found that when mothers expressed a preference for males or Nieves 1993a meal least one child at for equality with regard to food allocation, these preferences were local health centre's significantly associated with the actual allocation patterns, although food supplementa- those who stated a preference for equality tended to give a higher tion program proportion of food to children. 36. Engle and Guatemala Food intake 45 households, "Patterns for intrahousehold food distribution identified here are similar Nieves 1993b 230 individuals to those reported by other studies: slight underfeeding of adolescents, more protein for male head of household, and that the effect of including snacks is to diminish the differences between adult and child dietary adequacy" (p. 1610). Both male and female heads of household were more likely to have adequate diets compared to other household members. 37. Haddad, The Philippines Individual calorie intake 448 households This work illustrates the importance of estimating energy requirements Kanbur, and (Bukidnon) 24-hour recall for the study of intrahousehold calorie allocation. For a rural Philippine Bouis 1993 sample, the authors find that, once energy expenditures are accounted for, calorie intake shortfalls are equally borne within the family, irrespective of overall calorie adequacy. Using calorie adequacy based solely on age, gender, and physiological status, it appeared that children were receiving less than their required share of calories. (continued) 15 Table 1 (continued) Measure of Study Country Food Consumption Sample Type Main Conclusion 38. Ahmed 1993 Bangladesh 24-hour food weighing/ 553 households Calorie adequacy for male and female preschoolers is identical. adjusted calorie require- from eight widely Slightly higher calorie adequacy for boys in the 5-9 age-group ments for body weight dispersed sites compared to girls, but differences not significant (p. 37). The only and activity levels statistically significant male-female differences were found among adults, with females having lower calorie adequacy levels. 39. Rao and Rural South India Food intake of all mem- 149 households Results from the economic data suggest that there is a statistically Bloch 1993 (not VLS) bers, typical intake negative association between wife-beating and the caloric consumption of the children in the household. ". . . wife-beating not only reduces the well-being of women but also adversely affects the caloric allocation within the family to children whose mothers are being beaten" (p. 25). 40. Harriss-White India VLS Food intake 240 households Cautionary tale on the measurement of intrahousehold food allocation. 1996 from six villages Harriss-White assesses the policy recommendations that emerge from four studies of intrahousehold nutrient distribution, each of which use data collected from the same set of study households in southern India. The studies differ in their conclusions for a number of reasons: the individual classifications of data (for example, different age-group classifications), different treatments of seasonality, different nutrients studied, different aggregations of households (for example, different hectare cutoffs on what constitutes a smallholder), and finally different groups of individuals studied. Harriss-White notes that the disagreements among the studies are not trivial in magnitude, and that a policymaker would be "right to be very intervention-averse in consequence." 41. Kumar and Bangladesh Food intake 7,112 households "Analysis of intrahousehold allocation of dietary calories in rural Bhattarai 1993 Bangladesh shows that, for the majority of individuals of all ages and sex, the degree of individual adequacy matches the degree of household adequacy. . . Also, females appear to be relatively favored in the over-18 age-group. . . Areas with better infrastructure development tend to have a better level of caloric adequacy for all age-groups, and for both males and females. . ." (p. 43). (continued) 16 Table 1 (continued) Measure of Study Country Food Consumption Sample Type Main Conclusion 42. Senauer and The Philippines Food intake 840 households It was found that women of child-bearing age are most likely to have Garcia 1993 (PILOT) inadequate levels of iron intake and that teenagers are the most likely to be poorly nourished, overall. "The intrahousehold allocation of food, in terms of calories, initially appears to favor adults. But after adjusting for activity level, the calorie adequacy of adults is lower than that of children." 43. Bouis and Peña The Philippines Individual calorie 448 households The results indicate that young children (preschoolers) tend to be favored 1996 (Bukidnon) intake 24-hour recall in terms of the patterns of intrahousehold allocation of food. This result is different when only the energy adequacy levels patterns are examined (both corrected and uncorrected). It was found that nutrients were generally fairly evenly distributed among the family members, regardless of age and sex. This was attributed to the fact that "even though preschoolers have diets preferable (in a nonnutrient sense) to those of other age and gender groups, the latter are compensated by greater proportions of less-preferred foods" (p. 20). 17 South Asia. Evidence for pro-male and pro-adult biases in food intake appear to be strongest in South Asia, although with considerable variation within the region. Working from the first panel of Table 2, of the 34 male-female comparisons, with no adjustment for activity and body weight, 11 show a pro-male bias, 4 show a pro-female bias, and 19 show neither sex as favored. The corresponding figures for the studies that do make these adjustments are 5, 1, and 16, respectively. Of the two adult-preschooler comparisons in the no-adjustment category, one is pro-adult and one shows neither age-group as favored. The adult- preschooler comparison in the adjusted calories category shows one pro-adult result. While the evidence for a pro-male bias is not uniform, studies that adjust for body weight and activity suggest that food consumption disparities reflect sex differentiation in the levels of energy-intensive activities undertaken by men and women. In Bangladesh, households seem to exhibit some inequality aversion. The rate of calorie reinforcement for adult males, however, was high compared with adult females and males who had a higher probability of obtaining more calories were more likely to undertake highly energy-intensive work (Pitt, Rosenzweig, and Hassan 1990). In Nepal, while small children are not discriminated against, adult women are discriminated against in terms of meeting requirements for energy, beta carotene, riboflavin, and vitamin C. Mechanisms for discrimination include a late position in serving order, the channelling of special foods to men, and lower overall food intake. Boys may also be favored in India by being given first priority in breast-feeding and in food supplementation (Pettigrew 1986). The results in South Asia also run counter to the trend of decreasing inequality as incomes increase, although inequality increases among the poor during the lean season (Behrman 1988a). In India, upper-middle caste groups favor sons more in food allocation than lower status groups and tribal groups (Warrier 1992). Indeed, Miller's (1992) review of the intrahousehold food distribution in South Asia also finds that greater disparities and malnutrition are found among propertied groups and among the more educated. Discrimination against daughters may reflect the additional financial stress on families as a result of marriage and dowry costs, and not from food consumption of the daughter, per se. Southeast Asia. All the intrahousehold studies in this region are from the Philippines. In the unadjusted category, of the 16 male-female comparisons, 8 show a pro-male bias, none show a pro-female bias, and 8 show neither sex as favored. The pro-male bias disappears once body weight and activity are considered (the corresponding numbers are 0, 0, and 4, respectively). Of the nine adult-preschooler comparisons in the no- 18 Table 2—Bias reported by specific studies on food distribution within the household (from Table 1) Comparisons When Energy Requirements ARE NOT Adjusted for Activity and Body Weight Preschoolers: Children: Adolescents: Adults: Adults versus Special Groups Region Male versus Female Male versus Female Male versus Female Male versus Female Children/Preschoolers Disadvantaged South Asia Males favored Males favored (31,38) Males favored (11,27) Adults favored (39) Pregnant and (9,11,13,17,18,21,31) lactating women Females favored (11) Females favored (11) Females favored (2,11) (1,6) Neither favored Neither favored Neither favored Neither favored Neither favored (1) (1,20,21,23,24,27) (1,20,21,23,24) (1,20,21,23,24) (1,23,24) Later born children in lean season (20, 21, 24) Southeast Asia Males favored (3,4) Males favored (3) Males favored (3) Males favored Adults favored (3,22,28,42) (3,5,22,28,42) Neither favored (5,43) Neither favored (5,43) Neither favored Neither favored (5,43) Preschoolers favored (5,43) (8,43) Children favored (10,28) Sub-Saharan Africa Neither favored (32) Neither favored (32) Latin America Males favored (36) Neither favored (36) Comparison When Energy Requirements ARE Adjusted for Activity and Body Weight South Asia Males favored (6,15) Males favored (6) Males favored (27,38) Adults favored (15) Pregnant/ Females favored (41) lactating women Neither favored Neither favored Neither favored Neither favored (38) (23,25,27,38) (23,25,26,27,38) (23,25,26,27) (23,25,26) Southeast Asia Neither favored (37) Neither favored (37) Neither favored (37) Neither favored (37) Neither favored (37) Children favored (42) Sub-Saharan Africa Latin America Neither favored (29) Neither favored (29) Children favored (29) Note: The number in parentheses refers to study number in Table 1. 19 Table 3—Totaling the bias reported by specific studies on food distribution within the household (from Table 2) Comparisons When Energy Requirements ARE NOT Adjusted for Activity and Body Weight, by Number of Cases Preschoolers: Children: Adolescents: Adults: Adults versus Special Groups Region Male versus Female Male versus Female Male versus Female Male versus Female Children/Preschoolers Disadvantaged South Asia Males favored: 7 Males favored: 2 Males favored: 0 Males favored: 2 Adults favored: 1 Pregnant and Females favored: 1 Females favored: 1 Females favored: 0 Females favored: 2 Preschoolers favored: 0 lactating women: 2 Neither favored: 6 Neither favored: 5 Neither favored: 5 Neither favored: 3 Neither favored: 1 Later-born children in lean season: 3 Southeast Asia Males favored: 2 Males favored: 1 Males favored: 1 Males favored: 4 Adults favored: 5 Females favored: 0 Females favored: 0 Females favored: 0 Females favored: 0 Preschoolers favored: 2 Neither favored: 2 Neither favored: 2 Neither favored: 2 Neither favored: 2 Neither favored: 0 Children favored: 2 Sub-Saharan Africa Males favored: 0 Males favored: 0 Females favored: 0 Females favored: 0 Neither favored: 1 Neither favored: 1 Latin America Males favored: 1 Adults favored: 0 Females favored: 0 Children favored: 0 Neither favored: 0 Neither favored: 1 Total Males favored: 9 Males favored: 3 Males favored: 1 Males favored: 7 Adults favored: 5 Pregnant and Females favored: 1 Females favored: 1 Females favored: 0 Females favored: 2 Preschoolers favored: 3 lactating women: 2 Neither favored: 9 Neither favored: 8 Neither favored: 7 Neither favored: 5 Neither favored: 2 Later-born children Children favored: 2 In lean season: 3 Comparisons When Energy Requirements ARE Adjusted for Activity and Body Weight, by Number of Cases South Asia Males favored: 2 Males favored: 1 Males favored: 0 Males favored: 2 Adults favored: 1 Pregnant/lactating Females favored: 0 Females favored: 0 Females favored: 0 Females favored: 1 Preschoolers favored: 0 women: 1 Neither favored: 4 Neither favored: 5 Neither favored: 4 Neither favored: 3 Neither favored: 0 Southeast Asia Males favored: 0 Males favored: 0 Males favored: 0 Males favored: 0 Adults favored: 0 Females favored: 0 Females favored: 0 Females favored: 0 Females favored: 0 Preschoolers favored: 0 Neither favored: 1 Neither favored: 1 Neither favored: 1 Neither favored: 1 Children favored: 1 Neither favored: 1 Sub-Saharan Africa Latin America Males favored: 0 Males favored: 0 Adults favored: 0 Females favored: 0 Females favored: 0 Preschoolers favored: 0 Neither favored: 1 Neither favored: 1 Children favored: 1 Neither favored: 0 Total Males favored: 2 Males favored: 1 Males favored: 0 Males favored: 2 Adults favored: 1 Pregnant/lactating Females favored: 0 Females favored: 0 Females favored: 0 Females favored: 1 Preschoolers favored: 0 women: 1 Neither favored: 6 Neither favored: 7 Neither favored: 5 Neither favored: 4 Children favored: 2 Neither favored: 1 20 adjustment category, five show a pro-adult bias and two show a pro-children bias. Of the two adult-child/preschooler comparisons in the adjusted category, one shows a pro- child/preschooler bias, while the other shows no favoritism by age. These results are consistent with the relatively egalitarian household structure in the Philippines (Medina 1991), and they show the importance of taking energy requirements into account. For example, in a rural Philippine sample, using calorie adequacy based solely on age, sex, and physiological status, it appeared that children were receiving less than their required share of calories. Once energy expenditures are accounted for, however, calorie intake shortfalls are equally borne within the family, irrespective of overall calorie adequacy (Haddad, Kanbur, and Bouis 1993). Likewise, Senauer and Garcia (1993) found that the intrahousehold allocation of food, in terms of calories, initially appears to favor adults. But after adjusting for activity level, the calorie adequacy of adults is lower than that of children. In fact, women of child-bearing age are most likely to have inadequate levels of iron intake and teenagers are most likely to be poorly nourished overall. Bouis and Peña (1996) also find that even though preschoolers have diets preferable (in a nonnutrient sense) to those of other age and gender groups, the latter are compensated for by greater proportions of less- preferred foods, and thus, nutrients were, generally, fairly evenly distributed among the family members, regardless of age and sex. Latin America. The single study with a male-female comparison for unadjusted calorie intakes shows a pro-male bias and the single preschooler adult comparison shows no differences. Where the pro-male bias is reported (Guatemala), more protein is allocated for the male heads of households and adolescents are slightly underfed (Engle and Nieves 1993b). For the three comparisons that use adjusted intakes (all from Peruvian data), two show neither sex as favored, while one shows children favored over adults. Indeed, these results support those of Pitt, Rosenzweig, and Hassan (1990) for Bangladesh: adults (males more than females), rather than children, are subjected to higher levels of seasonal caloric stress. Sex differentials in dietary intake or physical status are not apparent among children (aged 12 years and under). Sub-Saharan Africa. In the two male-female comparisons within the unadjusted intake group, neither sex is favored. There are no studies that adjust for calorie adequacy, or that compare adult and preschooler intakes. Hardenbergh's (1992) study of subsistence slash- and-burn cultivators near Ranomafana National Park in Madagascar found no evidence of sex bias against girls in mortality, anthropometry, or nutrient intake. This may be because of a more explicit and obvious economic value to households of girls in Sub-Saharan Africa 21 than is the case in Asia. The study by Bégin et al. (1992) in Chad, however, finds that body mass index (BMI) varied significantly by season for adults under the age of 60 and that women had lower BMIs than men in both the lean and harvest seasons. Conclusion. The summary of the results presented in Tables 1-3 is difficult for several reasons: 1. Only some of the studies control for activity pattern and body weight when calculating nutrient (particularly energy) requirements (studies 5, 14, 22, 24, 25, 26, 28, 36, 37, and 40), although it is not clear to what extent, a priori, this affects micronutrient requirements or the energy and nutrient requirements of preschoolers in general. The adjustment barely affects the pattern of results in South Asia, but it does seem to reduce the number of sex differences found in the Southeast Asia group. 2. Results differ by season (studies 19, 20, 23, and 28) with the greatest inequality during lean periods. 3. Results differ within the four broad regions used. For instance, Miller (1981) notes the differences between north (pro-male) and south (no sex preference) India. 4. Results differ by family composition. A number of studies (Miller 1981; Lloyd 1995) note that the first-born child is usually treated well, irrespective of its sex. It is later-born girls that are likely to face discrimination relative to brothers and relative to older sisters (Ware 1984). 5. Boy-girl discrimination is not necessarily a feature of the poorest of the poor (see, for example, Cowan and Dhanoa 1983). 6. Diets are not only evaluated by the households on the basis of nutrients, but also on the basis of variety and prestige foods. The evidence concerning food distribution within the household suggests that, while there is some pro-male and pro-adult bias in terms of the quantity of food intake, this seems to be primarily located in South Asia, with considerable variation within that region. The differences arise due to a combination of an unequal distribution of food within the household, the unequal nature of food requirements within the household, and the unequal nature of the perceived requirements by age and sex. Thus, equal distribution of food within the household can lead to unequal distribution of nutrient adequacy within the household. 22 Because breast-milk consumption is difficult to measure, the focus is more on duration and3 frequency of breast-feeding. For this reason, breast-feeding is classified in the nonfood category. IFPRI’s research program is, however, placing a greater emphasis on access issues relating4 to water and sanitation (Hoddinott 1996) and caring behavior (Engle, Menon, and Haddad 1996). The conclusions here do not differ very much from those of Lipton (1983). Lipton notes the dearth of evidence regarding systematic age-sex differences in caloric adequacy in Africa or Latin America and provides counterexamples from Asia. Distribution of Nonfood Health Inputs Compared to food inputs into good nutrition, economic studies (including those at the International Food Policy Research Institute) have not examined the intrahousehold allocation of nonfood health inputs closely for gender bias. Largely, this is due to the3 difficulty of measuring nonfood health inputs. The main problem is that self-reported measures of health and morbidity are routinely used by economists in behavioral models. There is, however, considerable evidence that self-reported measures do not accurately reflect clinical assessments of health status. More importantly, the differences between clinical and self-reported morbidity measures are not random (Butler et al. 1987). Often, self-reported morbidity increases with household income and educational status. The very poor only report “illness” when ill-health is severe; the less poor will report milder episodes of ill-health as “illness.” One way around this is to focus more on specific self-reported limitations on functional activity such as walking, going to work, or undertaking “normal activities” (Schultz and Tansel 1995). Table 4 presents a partial summary of studies from the literature. A full study of male- female differences in access to nonfood inputs such as health care, clean water, adequate sanitation, and caring behavior is beyond the scope of this paper.4 South Asia. Studies of sex bias in the intrahousehold allocation of nonfood health inputs in South Asia are few, relative to studies on the intrahousehold allocation of food, but appear to have stronger and more consistent results. Duration of breast-feeding, quantity 23 Table 4—A partial summary of studies of the intrahousehold allocation of nonfood health inputs Measure of Study Country Nutrition Input Sample Type Main Conclusion Heller and Colombia Degree of diarrhea, age 1,270 preschool There does not appear to be parental discrimination against girls with respect to Drake at weaning, per capita children the probability of illness. Regression-based. 1979 food expenditures Miller 1981 India Breast-feeding duration Preschool children Breast-feeding duration is longer after a boy, in part, because there is less urgency to have another child after a boy. Sabir and Pakistan Breast-feeding, 151 households— Longer breast-feeding for boys, boys are relatively heavier, girls are more stunted Ebrahim anthropometry mostly laborer and and wasted. 1984 artisan households Das Gupta Indian Punjab Food intake and 400 households Wider sex differentials existed for medical care than in food allocation. Food 1987 utilization of medical (approximately allocation data indicate that, although infant girls and boys have approximately care 2,400 individuals) the same calorie intakes, the former are given more cereals while the latter have more milk and fats (highly valued and expensive foods) with their cereal. Fauveau et al. Bangladesh Diarrhea prevalence This study showed that the potential for death due to diarrhoea among children 1990 who are severely malnourished was much greater than for those who are not severely malnourished. In addition, "the risk of dying from severe malnutrition was more than twice as high among girls as among boys" (p. 215). Alderman and Pakistan Utilization of health 3,430 individuals Lower income households seek care more often for boys than for girls. There is a Gertler 1994 services from five regions itendency to use high quality providers (private doctors) more often for males than females. Differences disappear as income rises. Although the differences in health care are not dramatic, they pertain to an environment in which the price of health care is low. Moreover, most of the illness incidents from which their estimates are derived are the general day-to-day ailments to which children are susceptible. They suggest that the comparatively high price for life-threatening treatments that often require more expensive hospitalization may lead to even greater gender discrimination and possibly fatal delays in seeking care. Bouis et al. The Philippines Health care utilization Adolescents (10-19 Gender did not affect the probability of seeking any of the alternatives to 1993 (Bukidnon) years old) from 448 traditional health care providers. However, compared to children, both male and rural households female adolescents seem less likely to be brought to formal health care providers. Haddad and Côte d'Ivoire Health infrastructure Preschoolers < 72 Improvements in access to public service are gender-neutral in their effects on Hoddinott (doctors per person, months child health. 1994 distance to health services) 24 and quality of health care, and survival probabilities after diarrhea episodes are all reported to favor boys. Indeed, in India, breast-feeding duration is longer for boys, partly because there is less urgency to have another child after a boy (Miller 1981). Boys are heavier than girls of similar age and tend to be allocated more expensive foods than girls (Sabir and Ebrahim 1984; Das Gupta 1987). While the risk of dying from diarrhea is higher among the severely malnourished, the risk of dying from severe malnutrition is more than twice as high for girls than for boys (Faveau et al. 1990). In Pakistan, lower income households seek care more often for boys than girls, and are likely to use higher quality providers for boys (Alderman and Gertler 1996). This difference in frequency and quality of care, however, disappears as income increases. Southeast Asia. The main result from the study by Bouis et al. (1993) in the Philippines is that there are no sex biases in seeking alternatives to traditional health care providers, but there may be some age biases in that adolescents seem less likely than children to receive health care. Latin America. Heller and Drake (1979) report no boy-girl differences in terms of the degree of incidence and severity of diarrhea or age at weaning. Sub-Saharan Africa. No evidence could be found that tested boy-girl differences in access to health care. Haddad and Hoddinott (1994) do, however, find that, in the Côte d'Ivoire, improvements in access to public health service are gender-neutral in their effects on child health. Conclusions. Outside of South Asia, evidence of boy-girl discrimination in the allocation of nonfood health inputs is scarce. Within the South Asia region, the few studies that have examined this issue found strong evidence of pro-male biases. Distribution of Adult Goods Not every method for examining intrahousehold consumption bias relies on the availability of individual consumption data (see Table 5). An analysis of household expenditures on goods consumed exclusively by adults (an "adult good") has been proposed as a parsimonious technique for examining discrimination within households. The basic idea is, do parents reduce expenditures on these adult goods more severely for an extra girl than for an extra boy? This technique, however, relies on the existence of an adult good in the expenditure data. Usually, expenditures on these goods, such as 25 Table 5—A summary of studies of intrahousehold consumption bias, based on an "adult goods" analysis Measure of Study Country Discrimination Sample Type Main Conclusion Deaton 1989 Côte d'Ivoire Adult goods Nationally No boy-girl discrimination on results from adult goods. representative sample, 1985-86 Subramanian and India Adult goods Representative Some evidence of discrimination against girls under 5 from rural households. Deaton 1990 sample from the State of Maharashtra, 1983 Ahmad and Bangladesh Adult goods, 1988 household No boy-girl discrimination on resultsfrom adult goods. Morduch 1993 anthropometry expenditure survey Dobbelsteen and Peru Adult goods Nationally No boy-girl discrimination on results from the single potential adult good Kooreman 1993 representative (alcoholic beverages). sample Haddad and Burkina Faso Adult goods Samples: Urban, No boy-girl discrimination on results from adult goods, in any disaggregation. Reardon 1993 rural—by low and high development potential, by upper and lower income groups Haddad and Côte d'Ivoire Adult goods Nationally No boy-girl discrimination on results from adult goods. Some evidence sample, Hoddinott 1992 representative 1986-87 of discrimination against fostered versus nonfostered girls. Bouis et al. 1993 The Philippines Adult goods 448 rural Using a 2-to-12-year-old age group, no consistent pattern of discrimination could be (Bukidnon) households found. Eighteen potential adult goods combinations are studied, but no tests for credibility of adult goods were performed, and there are no tests for any significant male- female differences on adult goods share. 26 tobacco or alcohol, are of a sensitive nature and are susceptible to misreporting. Random misreporting is not problematic for the regression analysis, but if misreporting is associated with another factor, such as income, education, or location, biased estimates will be generated. South Asia. Subramanian and Deaton (1990) employ a representative sample of some 11,000 households from the State of Maharashtra, collected in 1983. They find some evidence of discrimination against girls under five years of age who live in rural households, but only in one (tobacco and paan) of the two identified adult goods (the other being alcohol). Ahmad and Morduch (1993) use data from Bangladesh and find no boy-girl discrimination based on results from their adult goods analysis. Their study is richer than others in this genre, however, in that they are able to examine other dimensions of discrimination with the same data set. They also find that (1) there was 11 percent more males than females in their sample, and (2) an extra unit of money aided the health outcomes of boys significantly more than that of girls (in terms of weight-for-height and weight-for- age). Southeast Asia. The only adult goods study that could be found for Southeast Asia is the study by Bouis et al. (1993), which did not select the most appropriate age-groups (that is, they selected a wide age range) and did not test if goods designated as “adult” were, in fact, credible adult goods. No sex differences were found. Latin America. The evidence from Latin America is scarce. Dobbelsteen and Kooreman (1993) conducted an adult goods analysis on nationally representative Peruvian data, but they do not test whether their potential adult good (alcohol) is, in fact, a credible adult good. In addition, they do not use instrumental variable techniques when estimating the budget share equation for alcohol. At face value, their results indicate no boy-girl discrimination, but their results are difficult to interpret. Sub-Saharan Africa. Deaton (1989), using data from the 1985-86 Côte d'Ivoire Living Standards Surveys (CILSS), found little evidence to support the hypothesis that boys are treated differently than girls with respect to the amount of adult goods expenditure foregone by the household. Haddad and Hoddinott (1992) extend the adult goods analysis by refining the household demographic groups into offspring of household head and non-offspring children (who tend to be adopted or are residing with the family for school purposes). Of primary 27 interest is whether a child's sex or relationship to the head of household affects the magnitude of the decline in the budget shares of adult goods. Here, again, there is no evidence to reject the null hypothesis of no discrimination against girls. There is, however, some evidence of bias against fostered girls under the age of 6. Haddad and Reardon (1993) disaggregate the adult goods-outlay equivalent analysis by agroecological zone and income group, but find little sex discrimination in Burkina Faso. They are unable to reject the null hypotheses that discrimination varies by the level of agricultural and nonagricultural economic opportunities for women, or by the level of household income. Conclusions. Only in India (Subramanian and Deaton 1990) has this technique demonstrated such discrimination against girls. In contrast, similar analyses from Sub-Saharan Africa (Côte d'Ivoire and Burkina Faso) show no discrimination. Ahmad and Morduch (1993) speculate as to the reasons for the discrepancies between the adult goods approach and the more direct approaches to measuring discrimination. They suggest three alternatives: (1) there is no bias in health inputs, but girls have greater physical needs than boys at certain ages; (2) there is no continuous bias but, at critical times, bias is demonstrated in favor of boys (such as in the provision of curative health care); and (3) there is sex bias, but the adult goods-outlay equivalent method cannot pick up important age/sex/birth-order interactions. EVIDENCE ON OUTCOMES Anthropometric Outcomes Within the Household The study of human body measurements is not as straightforward as one might think. Issues of age misstatements and the use of appropriate reference standards need to be recognized. Potential inaccuracies in measures of anthropometric status across gender are of two types: (1) the underreporting of girls' ages; and (2) the use of inappropriate anthropometric reference standards. In a society that puts a premium on the birth of a male, the birth of a female might be considered less of a family “event.” As a consequence, a girl's birth date might be less accurately remembered than a boy's. Moreover, there is a tendency to underestimate girls' ages. If stated age is less then actual age, the prevalence of low weight-for-age and height- for-age will be underestimated if they are based on reported female ages. The case for the systematic understatement of girls' ages, however, needs to be made more convincingly than it has been to date (Bouis and Mahmood 1993). 28 The use of anthropometric measures that are independent of age (such as weight-for- height) solves one potential source of misinterpretation, but not the problem of comparison across sex-specific anthropometric standards. For example, the simple comparison of male and female anthropometric Z-scores has been criticized because anthropometric standards used are different for boys and girls, and so "gender differences can only be identified relative to the standards" (Thomas 1991, 2). In other words, sex differences in the reference population cannot be factored out. One way of making Z-score comparisons across gender groups more meaningful for a given household is to rank standardized Z-scores within age and gender groups (Ross 1993). For households with more than one preschooler, the rankings can be compared. For example, what percentage of the preschoolers with the lowest Z-score ranking within their age-sex group are female? Simple comparisons of age-specific anthropometric indicators across gender are confounded by doubts as to the applicability of sex-specific anthropometric standards, derived from one healthy population, to developing country populations. Many analysts try to control for these effects in regression equations where anthropometric outcomes are “explained” by a number of right-hand-side variables. Many authors find that, after controlling for individual, parental, household, and community characteristics, the sex of the preschooler has no impact on anthropometric outcomes. This should not come as a surprise; if sex is an important determinant of anthropometric status, it will be significant in its interactions with parental, household, and community characteristics. For example, will the provision of public services have a bigger impact on a boy's or a girl's anthropometric status? Will the provision of increased educational opportunities for girls have a bigger impact on a boy's or a girl's anthropometric status? One example of this type of analysis is provided by Haddad and Hoddinott (1994), as described in the section on nonfood inputs. Table 6 presents results from studies of intrahousehold differences in anthropometric outcomes. South Asia. The results regarding male-female differences in anthropometric outcomes for India are weak; one study (Nilsson and Nycander 1986) found different effects in each region studied. In Andhra Pradesh, there were no male-female differences for preschoolers, but in Tamil Nadu, girls were worse off. Another study on tribal groups in India (Christian et al. 1989) found that girls had significantly better nutritional status than boys. For Bangladesh, Ahmed (1993) found preschool girls to have lower levels of weight-for-age than male preschoolers, but the differences were not significant. Helen 29 Table 6—A summary of studies of within-household differences in anthropometric outcomes Measure of Study Country Nutrition Status Sample Type Main Conclusion Nilsson and India Anthropometry Children in two In Andhra Pradesh, the rate of undernutrition did not differ between the Nycander (height-for-age) villages sexes. In Tamil Nadu, female malnutrition was more prevalent--more girls 1986 than boys were stunted. Kennedy and Kenya Anthropometric 1,171 preschoolers Girls (6-72 months) favored for weight-for-age, weight-for-height, height- Cogill 1987 measures for-age (regression results).a Horton 1988 The Philippines Reduced forms on 2,374 children "The results suggest that the effects of birth order on long-run nutritional whether or not Z- < 15 years status for children are considerably greater than those observed in current score for height-for- nutritional status. This suggests that the reason for birth-order effects is age or weight-for- not that parents discriminate among children of different birth orders when age are < 3 deciding on the allocation of current resources. Rather, they are unable to standard deviations allocate resources over time in such a way as to offset the inevitable below median advantages accruing to children in earlier birth order who are born when per capita resources . . . are greater" (p. 350). Christian et al. Rural and tribal Anthropometry 4,223 children Girls were found to have a significantly better nutritional status than boys. 1989 India (weight-for-age) (0-6 years old) The same factors(for example, mother's nutritional knowledge, size of family, birth order) explained variability in both girls' and boys' nutritional status. Kennedy 1989 Kenya Anthropometric 712 preschoolers No sex difference for weight-for-age, height-for-age, weight-for-heighta measures (from regression). von Braun, Hotchkiss, Guatemala Anthropometric 387 preschoolers No sex difference (0-60 months) in weight-for-age, height-for-age, and Immink 1989 measures weight-for-height (from regression).a von Braun, Puetz, The Gambia Anthropometric 712 preschoolers Girls (7-120 months) favored for height-for-age (regression results). and Webb 1989 measuresa Bouis and Haddad The Philippines Anthropometric 448 households Girls (6-60 months) favored for weight-for-height; girls in corn households 1990a , 1990b measures 1,118 preschoolers favored for height-for-age.a a (continued) 30 Table 6 (continued) Measure of Study Country Nutrition Status Sample Type Main Conclusion Thomas 1990b Zimbabwe Anthropometry 4,201 women 15-49, In the rural areas . . . "If the first born is a girl, she is likely to be (national sample) (height-for-age, 2,500 children 3-60 significantly lighter (given height) than her female siblings; this is not true weight-for-height) 3 - 60 months for sons" (p. 20). On de facto female-headed households,". . . children in (de facto) female-headed households are no worse off, on average, than children in households with a father present, at least in terms of anthropometric indicators" (p. 19). "Maternal education and household assets have the same effect on child health, whether or not the father is present in the household" (p. 20). ". . . fathers with some high school education have a large and significant impact on child height if they are at home, whereas the education of those away from home has a small and insignificant effect" (p. 19). Pelletier, Msukwa, Malawi Anthropometry 530 households Objectives: to test assumptions (1) "that the nutritional status of older and Ramakrishnan (weight and height) household members is reflected in that of young children" and (2) 1991 of all household "that the socioeconomic factors which are statistically associated with members child nutritional status are similar to those associated with the status of older household members" (p. 127). The general finding was that assumption number 1 was better supported than assumption number 2. Svedberg 1991 African countries Differential weight Secondary sources The data are presented as a "comparison of anthropometric performance ratio, differential from 50 different data between males and females in three age-groups: preschool children, school height ratio, body sets (data sets from children/adolescents, and adults" (p. 7). The paper, a comprehensive look mass index, height- 20 Sub-Saharan at data from many African countries, appears to show that females do not for-age, weight-for- African countries) have a nutritional disadvantage with respect to males. In fact, most of the age, and weight- data sets showed that there was a slight bias against males in terms of for-height ages to be relatively shorter and lighter than females; there are relatively few cases where the opposite applies" (p. 14) Similar trends were found for infant mortality rates. With respect to economics, the bride price in Africa, unlike the dowry in India, is viewed as a financial asset. In addition, females tend to be more efficient than men when it comes to production of food. Teklu, von Braun, Sudan Anthropometric 30,000 preschoolers Girls (0-60 months) favored for weight-for-age (regression results). and Zaki 1991 measuresa (continued) 31 Table 6 (continued) Measure of Study Country Nutrition Status Sample Type Main Conclusion Thomas 1991 Ghana Child weight-for- Number of Intergenerational effects tend to run along gender lines: father's education height households: 3,200, has a stronger effect on son's anthropometric status, and mother's education 1987-88 has a stronger effect on daughter's anthropometric status. Thomas finds that, in Ghana, women's education has a strong positive effect on their daughters' height but not on sons', and fathers' education has a positive effect on their sons' height but not on daughters'. Further, he states (p. 16), "relative to other mothers, the education of a woman who is better educated than her husband has a large and significant effect on her daughters' height." These results are consistent with the argument that better educated women are better placed to direct household resources towards commodities they prefer - in this case, daughters' health. von Braun, de Haen, Rwanda Anthropometric 238 preschoolers Girls (6-72 months) favored for height-for-age, weight-for-age (regression and Blanken 1991 measures results).a Schnepf 1992 Rwanda Z-scores on weight- Preschool children The female children studied had higher measures of malnutrition than for-height and males for each of the indicators in the rural sample, but only for chronic weight-for-age, malnutrition (height-for-age) in the urban sample. The multivariate mid-upper arm analysis, however, showed no sex differences in the nutritional status of circumference the children. Ahmed 1993 Bangladesh Z-score on weight- Preschool children 31.5 percent of girls have Z-score weight-for-age < -3, compared to 27.7a for-age percent for boys. Differences not found to be statistically significant. Alderman and Garcia Pakistan Anthropometric 880 households No sex differences in weight-for-age, height-for-age, weight-for-height 1993 measures (from regression).a Basu 1993b South Asia Anthropometric Preschool children Finds incidence of sex differentials in childhood nutritional levels in South indicators Asia to be uneven. Helen Keller Bangladesh Anthropometric Found higher rates of undernutrition among girls compared to boys. No International 1993 indicators information as to whether the differences are statistically significantly. Johnson and Rogers Dominican Anthropometric Preschool children Finds few significant differences in boy-girl nutrition status. 1993 Republic indicators Vosti and Witcover Ethiopia Z-score on weight- 0-72 months Girls from lowest income tercile households do significantly better than boys in 1993 for-age all seasons. Boys from highest income tercile households do significantly better thana girls in all seasons. Multivariate analysis shows different Z-score weight-for-age determinants for boys and girls, but girls' Z-score weight-for-age is very poorly explained by the explanatory variables available. IFPRI study.a 32 Keller International (1993) also found greater undernutrition among preschool girls in Bangladesh, but it is not clear whether this difference is significant by sex. Southeast Asia. In the Philippines, Bouis and Haddad (1990a, 1990b) found no significant differences in preschooler anthropometric outcomes by sex. Horton (1988) found that earlier-born children are worse off than later-born children, due to the relative poverty of households early on in their life cycle. Latin America. For Guatemala, von Braun, Hotchkiss, and Immink (1989) found no significance for a dummy variable for gender in regressions explaining Z-scores on weight- for-height, weight-for-age, and height-for-age. Sub-Saharan Africa. Svedberg's (1991) survey shows that boys are slightly worse off, in terms of anthropometry, than girls. He hypothesizes that this reflects the payment of bride prices to girls' families in much of Sub-Saharan Africa (unlike dowries in South Asia, which are paid out by the family of the daughter). One other reason for this result, however, might be the use of biased external standards. Svedberg does investigate the use of external standards other than the U.S. National Center for Health Statistics (NCHS) standards—namely standards derived from well-to-do Nigerian and Kenyan samples—and finds the results sensitive to the choice of standards. In Zimbabwe, Thomas (1990b) stresses how child gender interacts with birth order. If the first born is a girl, she has a lower weight-for-height than her female siblings; this is not true for boys. Thomas also finds that maternal characteristics (education) affect child anthropometrics equally strongly, regardless of whether the father is present; children in de facto female-headed households are no worse off, on average, than children in households with a father present. Father's education, however, affects child anthropometrics only if the father is at home. In Ghana, intergenerational effects tend to run along gender lines; father's education has a stronger effect on sons' anthropometric status, and mother's education has a stronger effect on daughters' anthropometric status. Moreover, a woman who is better educated than her husband has a large and significant effect on her daughter’s height. These results are consistent with the argument that better-educated women are better placed to direct household resources towards commodities they prefer—in this case, daughters' health. 33 A more interesting analysis would be to interact gender with other health inputs to examine5 whether increases in these inputs will have gender-differentiated effects. The IFPRI studies cited in Table 6 either find sex differences or find girls to have significantly higher Z-scores for height-for-age, weight-for-age, and weight-for-height. To5 what extent is this a reflection of the use of external (NCHS) standards? The Ethiopia study by Vosti and Witcover (1993) disaggregates preschoolers by gender for the purposes of the regression analyses. In terms of anthropometric measures, they find that girls from the poorest households do better than boys from the poorest households, in all seasons. For girls in the best-off households, the results are reversed. The authors find that the factors explaining anthropometric outcomes are very different for boys and girls in their sample. In Malawi, Pelletier, Msukwa, and Ramakrishnan (1991) find no significant age or sex differences in anthropometric outcomes within the household. They test whether the nutritional status of older household members is reflected in that of young children, or whether socioeconomic factors that are statistically associated with child nutritional status are similar to those associated with the status of older household members. They found that the association of older household members' nutritional status with young children's nutrition was supported, while the second hypothesis was not. In rural Rwanda, Schnepf (1992) finds that in terms of weight-for-age, height-for-age, and weight-for-height, female preschoolers are worse off than boys. In urban Rwanda, the anthropometric indices are similar for boys and girls, with the exception of Z-scores of height-for-age, which, again, are worse for girls. Conclusions. The studies that show that females have worse anthropometric scores than males tend to come from South Asia. Studies from Africa, however, consistently show girls to be better-off than boys. Important caveats to all the results in this section include (1) the need to test the sensitivity of results to the choice of external standards, (2) the need to explore sex differences, controlling for birth order and age effects, and (3) the need to test whether the mechanisms that produce good nutritional status are different for boys and for girls. Mortality Rate Low female-to-male ratios in the countries of South Asia (950-970 females for every 1,000 males) (Oldenberg 1992) have been attributed to (1) a skewing of resources away from 34 This explanation seems less plausible when high male outmigration and high female-to-male6 ratios coexist, as in Sub-Saharan Africa. This is not surprising, as Bangladesh, China, India, and Pakistan are the largest countries,7 containing more males than females (although between the four countries, they account for one-third of the world's population). females to males (Sen and Drèze 1989), (2) an error in the measurement of nutrition outputs (see previous section), and (3) an error in the head-counting of females. It has been suggested that the generation of inaccurate female-to-male head counts may be caused by (1) outmigrated males who are double counted and (2) the undercounting of females from outside enumerators (Miller 1992). In areas with high outmigration, it is conceivable that in a nationally representative sample, these migrants could be double counted. It is difficult for household surveys to define household membership by residence period so as to exclude counting an outmigrated male as a member of two households. The6 undercounting of females is certainly plausible (the difficulty of enumerating females, even by females from the locale, is well known) but has not been rigorously tested. All of the studies reported in Table 7, with the exception of Ram's (1984) cross- country study of aggregate data, are from South Asia. Here, in spite of higher neonatal7 mortality rates for boys arising from inherently greater biological risks at birth, mortality of girls between 1-4 years of age is higher. Discrimination against girls is evidenced by higher mortality rates of girls born after other daughters, compared to sons born after other sons. Muhuri and Preston (1991) suggest that this is not primarily a result of cultural practices that treat all girls differently from boys, but rather from conscious, selective neglect of individual children. Indeed, parents appear to value diversity in gender composition. Girls with older brothers and boys with older sisters have relatively low levels of mortality, although the strong bias in favor of sons prevails. Such patterns may be due to the disparity in economic returns to males and females. Rosenzweig and Schultz (1982) find that in India, a rise in the expected adult male employment rate increases the male-female survival differential. Likewise, Ram's (1984) study, using cross-section data for 118 countries for 1970 and cross-section and annual observations data of the United States, finds that higher Labour force participation rates of females results in the reallocation of household resources toward working females, which then leads to higher survival rates and a greater life span for females. 35 Table 7—A summary of studies of differential mortality rates by gender Study Country Outcome Sample Type Main Conclusion Chen, Huq, Bangladesh Mortality, 130 Muslim families in During the neonatal period, male children mortality rates were higher and d'Souza morbidity rates, six villages with children that those for females: "consistent with the established higher 1981 health care under 5 years of age biological risk of male children" (p. 57). Between the ages of 1 to 4 utilization years, the pattern is reversed such that the mortality rates of female children are higher than males. Rosenzweig India Sex-specific 1,331 children ". . . a rise in the expected adult male employment rate exacerbates the and Schultz survival survival differential in favor of boys, other things equal . . ." (p. 809). 1982 differentials Regression-based. Ram 1984 Cross- Child mortality Three sets of cross- The results suggest that the effect of the higher participation rates of country section data for 118 females in the work force is a shift in the allocation of household countries for 1970, and resources toward these working females, which then leads to higher cross-section and annual survival rates and life span for females. observations data of the United States Das Gupta Indian Mortality 400 households (approx. Daughters born after other daughters have significantly higher mortality 1987 Punjab 2,400 individuals) rates than sons born after other sons. Also, rates of mortality are higher for both males and females among the landless, although the disparity between male and female rates is greater among the landed. Sex differentials seem to be stronger in this region compared to others in India, due to the exceptionally strong patrilineal and patrilocal societal structures—daughters have virtually no capacity for transferring resources to their natal home in later life. Economic hardship is not an important reason for male favoritism. (continued) 36 Table 7 (continued) Study Country Outcome Sample Type Main Conclusion Muhuri and Bangladesh Mortality Demographic and health "The fact that mortality is so much higher among girls with older sisters Preston survey in Matlab for the than among those without suggest that higher female mortality is not 1991 1982 Census primarily a result of a general pattern of cultural practices that treats all girls differently from boys. Instead, it points to a pattern of conscious, selective neglect of individual children" (p. 431). A similar