Are all children born equal in Egypt?

                   This blog has been co-authored by Lire Ersado and Iqbal Kaur.

Meet Hania, a newborn baby girl from rural Suhag, one of the poorest governorates in Upper Egypt. Hania has six siblings and lives with her widowed mother who works in subsistence agriculture. Now meet Abdallah, also a newly born, baby boy from Heliopolis, an affluent Cairo neighborhood. Abdallah has just one sibling and lives with his parents, both graduates from the Cairo University. Abdallah’s father works for a multinational corporation and his mother in the Egyptian civil service. Then ask yourself: What are the chances that Hania and Abdallah will have adequate access to basic services that are crucial for their growth and development? What are the difficulties that children like Hania face due to factors, such as gender, birthplace, and family wealth, which are beyond their control? How does Egypt perform in ensuring equitable access to basic services for all of its children?

A recently completed World Bank study attempts to answer some of these questions.  The study uses the concept of the Human Opportunity Index (HOI) to measure how circumstances influence a child’s access to basic services that are necessary to succeed in life.  HOI is a composite measure of coverage of children by basic services and how equitably these services are distributed among circumstance groups. It runs from 0 to 100, with 100 indicating universal access. As children cannot be held responsible for the circumstances they face on the day of their birth, every child deserves to have access to all critical basic services and an equal chance to succeed in life, i.e., Egypt’s HOI for each basic service needs to be close to 100.   


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From Figure 1, it is evident that Egypt made important gains in improving children’s access to basic services between 2000 and 2008.  The decomposition of the changes in HOI between 2000 and 2008 shows increased coverage of services (scale effect) and improved distribution among children from different circumstance groups (distributional effect). Egypt has a good track record of immunizations, with rates that are on par with countries with similar per capita income. Impressive gains were made in HOI for access to health facilities and trained staff during birth, and for postnatal checkups. HOI for access to prenatal care also increased.  Egypt’s largest gain has been in access to iodized salt, whose HOI increased more than three-fold. Finally, HOI for on-time completion of 6^th grade increased from 60 to 79.

However, despite the above improvements, a large number of children still lacks access to many basic services. More than one-in-five of births are not attended by skilled staff, with the associated risk of complications to the mother and child.  Majority of the newborn babies are not taken for a postnatal doctor visit. Incidence of malnutrition worsened during the 2000s, with about a quarter of children now stunted. Inequality of opportunity due to circumstances of birth, as measured by dissimilarity index (D-index), while declined by half or more for most basic services, still remains substantial (Figure 2). The D-index, which ranges from 0 in the case of perfect equality to 100 for perfect inequality, is 10 or higher for birth by trained staff, birth at health facilities, prenatal care, enrollment in secondary levels, and on-time completion of 9^th grade.  


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While many circumstances at birth played a role in inequality of opportunity, none are more important than parental education, wealth and location (Figure 3).  Births assisted by traditional birth attendants are still the most common phenomenon among the poorest and in rural areas, particularly in Upper Egypt and the Frontier Governorates. A woman with no formal education is 13 times more likely to give birth not attended by skilled staff, compared to a woman with a university degree. Location explains most of the variations in access to cleaner and safer water at home. Parental education, particularly a mother’s, is the most important factor explaining variation in enrollment rates, followed by family wealth.  While the inequality in the incidence of malnutrition is overall low, gender is the most important factor of the inequality of opportunity. Girls are more likely to be stunted and underweight than boys.


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What do the findings mean for Egypt?

Despite the impressive improvements during the 2000s, basic services are still unfairly distributed among children. It is important that Egypt’s social and economic policies are directed at improving access among the most disadvantaged children. Evidence shows that interventions to equalize opportunity early in life are far more cost effective than those later in life.  The study points to the need to intervene on multiple fronts, with immediate attention on malnutrition and on strengthening early childhood development (ECD).  In Egypt, the current ECD interventions tend to be limited to kindergarten education. Targeted interventions for the most disadvantaged groups could offer significant potential to enhance overall access. Regional disparities could be addressed through targeted investments in regions that exhibit significantly lower and unequal access or utilization of basic services.

Circumstances at birth will vary greatly, but they should not condemn a child to poor development. Ensuring equal access to basic yet critical services would go a long way in giving children like Hania a fair chance at health and prosperity.