Health and vulnerability to poverty in Ghana: evidence from the Ghana Living Standards Survey Round 5
© Novignon et al.; licensee Springer. 2012
Received: 22 January 2012
Accepted: 24 April 2012
Published: 6 May 2012
An understanding of the complex relationship between health status and welfare is crucial for critical policy interventions. However, the focus of most policies in developing regions has been on current welfare to the neglect of forward-looking welfare analysis. The absence of adequate research in the area of future poverty or vulnerability to poverty has also contributed to the focus on current welfare. The objectives of this study were to estimate vulnerability to poverty among households in Ghana and examine the relationship between health status and vulnerability to poverty.
The study used cross section data from the Fifth Round of the Ghana Living Standards Survey (GLSS 5) with a nationally representative sample of 8,687 households from all administrative regions in Ghana. A three-step Feasible Generalized Least Squares (FGLS) estimation procedure was employed to estimate vulnerability to poverty and to model the effect of health status on expected future consumption and variations in future consumption. Vulnerability to poverty estimates were also examined against various household characteristics.
Using an upper poverty line, the estimates of vulnerability show that about 56% of households in Ghana are vulnerable to poverty in the future and this is higher than the currently observed poverty level of about 29%. Households with ill members were vulnerable to poverty. Moreover, households with poor hygiene conditions were also vulnerable to future poverty. The vulnerability to poverty estimates were, however, sensitive to the poverty line used and varied with household characteristics.
The results imply that policies directed towards poverty reduction need to take into account the vulnerability of households to future poverty. Also, hygienic conditions and health status of households need not be overlooked in poverty reduction strategies.
According to the World Health Organization (WHO), health is a “state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity” . Health shocks constitute a sudden deterioration in the state of an individual’s health, caused by an illness and/or injury. The impact of health shocks on the welfare of individuals and households has been a major concern of policy makers. While shocks such as droughts and floods are seen to have significant effects on welfare, health shocks are unpredictable and pose a great challenge that any household has to face .
Somi et al  noted that health shocks and their associated costs have both short and long run impacts on household welfare. In the short-run, households that experience health shocks are forced to substitute consumption and production expenditure for health care. In the long-run, returns from investment in productive activities tend to reduce . This implies that rational individuals will not only work towards improving their current health status but also their future state of health [4, 5].Studies have shown that the occurrence of health shocks have significant negative impact on household current welfare [6–8]. In the case of Ghana, poor health has been shown to have devastating effects on economic growth and individual productivity [9, 10]. An understanding of the complex relationship between health shocks and welfare is crucial for critical policy intervention.
Vulnerability to poverty is seen widely as a better future oriented/forward-looking measure of welfare [11–15]. The only study that analysed ex-ante welfare or vulnerability to poverty in Ghana did not consider the impact of health shocks .
Summary of poverty incidence in Ghana
Poverty and vulnerability to poverty
In general, a household is considered to be poor if its current expenditure falls below a given threshold (poverty line). Specifically, the World Bank (WB) defines extreme poverty as living on less than US$1 per day and moderate poverty as less than US$2 or US$5 each day . While most poverty studies have been faced with the challenge of identifying an appropriate welfare measure, household consumption expenditure or income is considered to be an acceptable measure of standard of living .
However, vulnerability to poverty is defined to include the probability that a household or an individual, whether currently poor or not, may be poor in the near future. For instance, Duflo  defined vulnerability as “a probability: the risk a household will fall into poverty at least once in the next few years”. This implies that, unlike poverty, vulnerability is a more future-oriented concept that considers possible changes in a household’s future welfare. While the above definition suggests that both the current poor and non-poor may be vulnerable to poverty, the degree of vulnerability depends on the risks faced by households and their ability to respond to these risks . In Ghana, bush fires, infertile lands, snake bites and poor sanitary conditions have been identified as major risks faced by rural communities .
While various measures of vulnerability have been suggested in the literature, any measure of vulnerability should have two perspectives; the time horizon and the welfare measure. Hoddinott and Quisumbing  noted that the time horizon could vary, ranging from the next day to old age but consumption expenditure is mainly considered as the welfare measure. Three main concepts can be distinguished in measuring vulnerability to poverty; these are vulnerability as expected poverty (VEP), vulnerability as low expected utility (VEU) and vulnerability as uninsured exposure to risk (VER) [23, 24].
The VEP approach defines vulnerability based on household expected consumption expenditure above a given threshold. While the VEU approach measures vulnerability as utility derived from some certainty-equivalent level of consumption and expected utility of consumption, the VER approach captures household welfare loss due to lack of effective risk management tools .
Defining vulnerability to poverty as the probability that a household’s consumption will fall below some benchmark (poverty line) in the near future, the current study employed the VEP approach to measure vulnerability. Two reasons motivated this choice; first, unlike VEU, VEP allows the use of cross section data in the estimation of vulnerability to poverty. Secondly, VEP estimates ex-ante welfare loss as opposed to VER which estimates ex-post welfare loss .
Where represents vulnerability of household h at time t, is consumption of household h at time t + j and z shows poverty line of household consumption, ln is natural log.
Where C h is the per capita consumption expenditure for household h, X h is observable household characteristics, β is a vector of parameters and is a zero-mean disturbance term that captures household’s idiosyncratic factors contributing to differential level of per capita consumption for households that share the same characteristics.
The use of cross section data makes it necessary for some assumptions to be made. First, the disturbance term, is log-normally distributed which implies that consumption expenditure, C h is also log-normally distributed. Secondly, the structure of the economy is stable over time, ruling out the possibility of aggregate shocks (i.e. unanticipated structural changes in the economy). The first assumption is to enable the estimation of the probability that a household with characteristics, X h, will be poor (household vulnerability level). The last assumption implies that uncertainties about future consumption stems solely from uncertainty about idiosyncratic shocks that the household will experience in the future. Vulnerability estimates should therefore be interpreted under the assumption that current economic structures will prevail, at least, in the near future. These assumptions may not be necessary in the case of sufficient and rich panel data that identifies the stochastic process of the economy’s structure.
Where is estimated vulnerability to poverty (i.e. the probability that per capita consumption level will be lower than the poverty line conditional on some household characteristics), is the cumulative density of the standard normal distribution and is the standard error from equation (2).
Allowing for heteroscedasticity
Thus, the estimation of vulnerability to poverty depends on such elements as the distributional assumption of normality of log consumption, the choice of poverty line, the expected level of log consumption and the expected variability of log consumption. The level of vulnerability to poverty reduces as expected consumption and expected consumption variability increases.
Vulnerability to poverty threshold
The current study employed a vulnerability to poverty threshold of 0.5 as it is widely accepted as a reasonable threshold [26, 31, 32]. The following reasons justify the choice of the vulnerability threshold of 0.5. First, it makes intuitive sense to say that a household with a 50% probability of falling into poverty in the next period is vulnerable to poverty. Second, when a household - whose current level of consumption is equal to the poverty line - faces a zero mean shock; it has a one period ahead vulnerability of 0.5. In the limit, as the time horizon approaches zero then being currently poor and being vulnerable to poverty coincides . Also Zhang and Wan  found that a vulnerability line of 0.5 provides a more improved prediction. This implies that households with estimated vulnerability to poverty above or equal to 0.5 are considered to be vulnerable to poverty.
Two poverty lines were employed in the vulnerability estimations. These are an upper poverty line of GH¢370.891Ghana Cedi to US Dollar exchange rate in 2006 (i.e. the data year) was GH¢0.917 = US$ 1.00 per adult per year and a lower poverty line of GH¢288.47 per adult per year to allow for sensitivity analysis . The poverty lines were computed by the Ghana Statistical Service (GSS) from the Ghana Living Standards Survey (GLSS) and takes into account region-specific price differentials and nutritional needs of the population. Individuals whose consumption expenditure fell below the lower poverty line were considered to be extremely poor and were unable to meet their basic nutritional needs. On the other hand, individuals above the upper poverty line were considered as able to meet their nutritional requirements and purchase their basic non-food needs .
This study argues that the certainty of the probability that a household or an individual will become poor exactly one period ahead is impractical and hence the time horizon should be any period in the future. The time horizon was therefore specified in this study as t + j instead of t + 1, where j ≥ 1 [26, 34].
Data and variables
The study used 2005/2006 data reported in the Fifth Round of the Ghana Living Standards Survey (GLSS 5) conducted by the Ghana Statistical Service (GSS) with technical assistance from the WB and the European Union . Nationally representative sample of 8,687 households in 580 enumeration areas (EAs), containing 37,128 household members were covered in GLSS 5 . The EAs were first stratified into the 10 regions of the country and further into rural or urban place of residence. Ecological zones (i.e. Coastal, forest and northern savannah) of the country were also considered in the classification . The GLSS 5 is the single largest country-wide household data available in Ghana and collects information on various aspects of household’s living conditions including education, health and employment. Furthermore, detailed information on household income and expenditure make the data very vital for a vulnerability study like this one. For the purpose of GLSS 5, a household is defined as a person or a group of persons, who live together in the same dwelling, share the same house-keeping arrangements and are catered for as one unit .
Household total food and non-food expenditure was used as the dependent variable in the expected consumption estimation. The variable includes a summation of all items purchased directly by household or indirectly (such as output from own production activities, batter exchange, transfer/remittances etc). Household health status was used as the main explanatory variable. The variable was proxied by standardizing the occurrence of illness and/or injury (i.e. the number of household members who had illness and/or injury during the two weeks preceding the survey divided by the total number of household members). This standardization presents a more representative measure of household health as far as the GLSS 5 in concerned. Admittedly, self-reported illness may contain some bias. However, this does not invalidate the results [37, 38]. Household hygienic condition dummy was also included to complement household health status. The variable was measured by the presence or absence of safe drinking water and sanitary latrine in a household. Households without safe drinking water and sanitary latrines were considered to have unhygienic condition .
Other dependent variables include household size which is measured as the number of members in the household. Household head education dummies were included in four categories (no formal education, primary, secondary and tertiary education). Sex of household head was a dummy with a value of 1 if household head is male and 0 otherwise. Similarly, place of residence dummy was 1 if urban and 0 for rural residence. Age of the household head, measured in years, was also included in the model.
Summary of descriptive statistics
Age of head
Consumption expenditure (GH¢)
Vulnerability to poverty in Ghana
Vulnerability to poverty profile for various population characteristics
Vulnerability to population ratio
Gender of household head
Vulnerability to poverty profile for various population characteristics
Vulnerability to population ratio
Gender of household head
The vulnerable and the poor (percent)
Pearson Chi2 (1): 1.8233
Determinants of vulnerability to poverty
Determinants of vulnerability to poverty
Ex-ante mean consumption
Ex-ante variance consumption
Head age square
Tertiary and above
Use communication facility
No. of Observations
Table 3 shows that 56% of the Ghanaian population was vulnerable to poverty compared to the observed poverty level of about 29%. The estimate, however, reduced to about 49% when the lower poverty line was used (Table 4) . This finding implies that even though current policy on poverty alleviation considers the observed 29%, it is important not to focus all attention on this observed figure to the neglect of the twice that number that may be vulnerable to poverty in future. Otherwise, poverty alleviation becomes a programme that would be needed at all times (i.e. now and in the future). Considering both the current poor and the future poor ensures that poverty is tackled from a broader perspective in current and future generations.
Interestingly, rural households had lower average vulnerability to poverty than urban households. This means that, though current rural poverty stands at 39% - higher than urban poverty of 11% - urban households are comparatively more vulnerable to (future) poverty. This result contradicts the findings of earlier studies that vulnerability is higher in rural areas than in urban areas [12, 16]. One reason that could be speculated for this result is the increase in rural–urban migration. The GLSS report indicated that about four in every ten residents in urban areas were in-migrants . Such in-migrants face an enormous challenge posed by the high standard of living and lack of jobs. Further, the finding supports the premise that poverty and vulnerability to poverty are not necessarily the same and need to be treated as such.
Again, vulnerability to poverty was found to be higher among male-headed households than in female-headed households . This finding confirms the findings of Appiah-Kubi et al.  who reported a lower vulnerability estimate of 36.3% for female-headed households compared to male-headed households with estimated vulnerability of 54.4%. Current poverty estimates show that out of the ten regions in Ghana, Upper West Region and Eastern Region have the highest and second lowest poverty estimates (Table 1). However, this study found that with respect to vulnerability to (future) poverty, Eastern Region is most vulnerable to poverty (73.47%) whilst Upper West Region is least vulnerable to poverty (21.41). A possible reason for this finding is the role of health status (discussed below) in influencing vulnerability to poverty. In Ghana, Eastern Region has consistently reported the highest HIV prevalence (with 4.9% in 2006) whilst Upper West Region reports lower HIV prevalence - 2.5% in 2006 i.e. the second lowest prevalence in the country . While this result may not be intuitively appealing, it confirms the hypothesis that the current poor are not necessarily the vulnerable.
The results of the study further show that the current health status of a household plays a crucial role in determining the household’s vulnerability to poverty; as the general household health declines, future consumption is expected to reduce, making the household vulnerable to poverty in future. A complement of this finding was seen in the household hygiene condition variable which implies that households with good hygienic conditions were more likely to have good health, hence improved welfare. This finding confirms that health is both a consumption and investment commodity as good health enables individuals to engage in productive activities that translate positively into their consumption and investment activities. Similar result was found by Azam and Imai  in Bangladesh. Thus, better health status is an important vulnerability-reducing variable which has to be taken into consideration in designing policy interventions. In Ghana, health workforce and infrastructure are still relatively inadequate and sanitation conditions are relatively poor . Hence, efforts at improving access to basic health services are crucial as argued by Nonvignon and Aglobitse  and Nonvignon et al. . Good hygiene practices also need to be promoted at the household level. These interventions will not only facilitate the achievement of the health-related Millennium Development Goals but also translate into improving current and future welfare by reducing future poverty.
The results further suggest that education and household size are significant determinants of vulnerability to poverty apart from health status. These results are expected as education and family size directly or indirectly influence household consumption and welfare. Thus, the inclusion of strategies that improve the education of households in policies directed towards reducing vulnerability to poverty is not out of place. Such policies may include the reduction in cost of education and the provision of improved facilities, while encouraging female education at higher levels in both rural and urban areas.
A limitation of the study was the lack of panel data with sufficient length and richness which would have provided inter-temporal consumption expenditure for household vulnerability assessments. That is, changes in household expenditure and shocks overtime are better capture in panel data that provide information on the same household over time. The study was also limited by its inability to control for the existence of a possible simultaneity problem due to the lack of a good instrument in the data. Simultaneity problem occurs when a dependent and independent variables influence each other at the same time.
In this study, this problem may exist in the sense that, while health status may affect vulnerability to poverty, a reverse relationship may also exist. While the effect of health on vulnerability may be overstated, in the presence of simultaneity, the focus of this study is to establish a causal relationship between the two variables.
Further, while broader concepts of poverty exist (e.g. household income, assets etc), this study employs household expenditure as a measure of poverty. Future research could consider the above mentioned limitations.
It must also be noted that, in addition to estimating vulnerability to poverty, a major contribution of the current study lies in estimating the relationship that exist between vulnerability and health status which has received very little attention, especially in developing countries. However, generalizing the findings of this study should be with caution as countries may have different situations of poverty and issues of sensitivity relating to poverty.
The study sought to examine the effect of health status on vulnerability to poverty among households in Ghana. The study findings underscore the significance of future poverty and confirmed the notion that poverty and vulnerability to poverty are different concepts. The study also found that health status affects vulnerability to poverty as the occurrence of illnesses is likely to reduce household future consumption.
An important step in improving household welfare and enhancing development will, therefore, be to adopt integrated programmes for the education and health sector. This will go a long way to improve health status and human capital which are critical to the growth and development of any population.
aGhana Cedi to US Dollar exchange rate in 2006 (i.e. the data year) was GH¢0.917 = US$ 1.00.
1Ghana Cedi to US Dollar exchange rate in 2006 (i.e. the data year) was GH¢0.917 = US$ 1.00
We are grateful to the Ghana Statistical Service (GSS) which conducted the survey from which data for this study came and the African Economic Research Consortium (AERC) for funding JN(1)’s masters programme and the research that produced this manuscript.
- WHO: Constitution of the World Health Organization. Geneva: World Health Organization; 1946.Google Scholar
- Narayan D, Chambers R, Shah MK, Petesch P: Voice of the poor: crying out for change. Oxford: Oxford University Press; 2000.View ArticleGoogle Scholar
- Somi MF, Butler JRG, Vahid F, Njau JD, Abdulla S: Household response to health risks shocks: A study from Tanzania raise some methodological issues. J Int Dev 2009, 21: 200–211. 10.1002/jid.1555View ArticleGoogle Scholar
- Grossman M: The demand for health: A theoretical and empirical investigation. New York: Columbia University Press; 1972.Google Scholar
- Osei R, Quartey P: The HIPC Initiative and Poverty reduction in Ghana: An assessment. 2001. UNU/WIDER Discussion Paper No 2001/119Google Scholar
- Monk C, Teal T: Health shocks, job quality and self employment in Africa. Research consortium on education outcomes and poverty working paper No13 2008 2008.Google Scholar
- Lucas H, Bloom G: Protecting the poor against health shocks. In what works for the poorest: knowledge, policies and practices International Conference. Rajendrapur; 2006. http://www.bracresearch.org/publications/protecting_poor_against_health_shocks.pdf Google Scholar
- Devereux S, Baulch B, Maccauslan I, Phiri A, Sabates-Wheeler R: Vulnerability and Social protection in Malawi. Institute of Development Studies Discussion Paper No 387 2007.Google Scholar
- Asante FA, Asenso-Okyere K: Economic Burden of Malaria in Ghana. A technical report submitted to the WHO African Region Office (AFRO) 2003.Google Scholar
- GSS: Ghana living standards survey: Report of the Fifth round. Accra: Ghana Statistical Service; 2008.Google Scholar
- Ligon E, Schechter L: Measuring Vulnerability. Econ J 2003, 113: 95–102. 10.1111/1468-0297.00117View ArticleGoogle Scholar
- Azam S, Imai KS: Vulnerability and poverty in Bangladesh. Chronic Poverty Research Centre Working Paper No141 2009.Google Scholar
- Lindelow M, Wagstaff A: Health shocks in China: Are the poor and uninsured less protected? World Bank Policy Research Working Paper 3740 2005.Google Scholar
- Chaudhuri S: Assessing vulnerability to poverty: Concepts, empirical methods and illustrative examples. New York: Columbia University; 2003.Google Scholar
- Tendon A, Hasan R: Conceptualizing and Measuring Poverty as Vulnerability: Does it make a difference? Asian Development Bank Economic and Research Department Policy Brief Series No41 2005.Google Scholar
- Appiah-Kubi K, Oduro DA, Senadza B: Understanding Poverty in Ghana: Risk and Vulnerability. In The economy of Ghana: Analytical perspective on stability, growth and poverty. Edited by: Aryeetey E, Kanbur R. Oxford: James Currey Publishers; 2005.Google Scholar
- WHO: World Health Statistics Report. Geneva: World Health Organization; 2009.Google Scholar
- WB: Understanding poverty. Washington D.C: The World Bank; 2007.Google Scholar
- Vecchi G: The concept of poverty: principles and practice. In Bosnia and Herzegovina poverty analysis workshop. Sarajevo; 2007. www.siteresources.worldbank.org/PGLP/Resources/introduction.pdf Google Scholar
- Duflo A: Health shocks and economic vulnerability in rural India: breaking the vicious circle. In Center for micro finance research working paper. Chennai: Institute of Financial Management and Research; 2005.Google Scholar
- Alwang J, Siegel PB, Jorgensen LS: Vulnerability: as viewed from different disciplines. In Social protection discussion paper No 0115. Washington, D. C: The World Bank; 2002.Google Scholar
- Kunfaa EY: Consultations with the poor: Ghana country synthesis report. Kumasi: Center for the Development of People; 1999.Google Scholar
- Hoddinott J, Quisumbing A: Methods of measuring microeconometric risk and vulnerability assessments. In Social Protection Discussion Paper No 0324. Washington D.C: The World Bank; 2003.Google Scholar
- Christiaensen L: Measuring household vulnerability: conceptual issues and illustrative examples. In PADI conference on measuring, understanding and alleviating household vulnerability. Dar es Salam; 2004. www.worldbank.org/afr/padi/Measuring%20Vulnerability.pdf Google Scholar
- Christiaensen LJ, Boisvert RN: On measuring food vulnerability: case evidence from northern Mali. Department of Economics, Resource and Managerial Economics Working Paper No 2000–05 2000.Google Scholar
- Chaudhuri S, Jalan J, Suryahadi A: Assessing household vulnerability to poverty from cross sectional data: a methodology and estimates from Indonesia. Department of economics discussion Paper No 0102–52 University of Columbia 2002.Google Scholar
- Chaudhuri S: Empirical methods for assessing household vulnerability to poverty. In Mimeo. New York: Columbia University; 2000.Google Scholar
- Suryahadi A, Sumarto S: Poverty and vulnerability in Indonesia before and after the economic crises. Asian Econ J 2003, 17: 45–64. 10.1111/1351-3958.00161View ArticleGoogle Scholar
- Jamal H: Assessing vulnerability to poverty: evidence from pakistan. Social Policy and Development Centre Research Report No 80 2009.Google Scholar
- Amemiya T: The maximum likelihood estimator and the non-linear three-stage least squares estimator in the general non-linear simultaneous equation model. Econometrica 1977, 45: 955–968. 10.2307/1912684View ArticleGoogle Scholar
- Pritchett L, Suryahadi A, Sumarto S: Quantifying vulnerability to poverty: A proposed measure with application to Indonesia. In Mimeo. Jakarta: Social Monitoring and Early Response Unit; 2000.Google Scholar
- Zhang Y, Wan G: Can we predict vulnerability to poverty. World Institute for Development Economics Research Paper No 2008/82 2008.Google Scholar
- GSS: Patterns and trends of poverty in Ghana: 1991–2006. Accra: Ghana Statistical Service; 2007.Google Scholar
- Christiaensen LJ, Subbarao K: Towards an understanding of household vulnerability in rural Kenya. J Afr Econ 2005, 14: 520–558. 10.1093/jae/eji008View ArticleGoogle Scholar
- GSS: Ghana living standards survey: Data of the fifth round. Accra: Ghana Statistical Service; 2005–06.Google Scholar
- GSS: Ghana living standards survey: Study document for the fifth round. Accra: Ghana Statistical Service; 2009.Google Scholar
- Novignon J, Mussa R, Msonda T, Nonvignon J: The use of non-prescription medicine versus self-assessed health: evidence from Malawi. Int Arch Med 2011., 4: Google Scholar
- Kawada T: Self-rated health and life prognosis. Arch Med Res 2003, 34: 343–347. 10.1016/S0188-4409(03)00052-3PubMedView ArticleGoogle Scholar
- Alayande B, Alayande O: A quantitative and qualitative assessment of vulnerability to poverty in Nigeria. In CSAE conference on poverty reduction, growth and human development in Africa. Oxford: St. Cathrine's College; 2004.Google Scholar
- GAC: Ghana's progress report on the United Nations General Assembly Special Session (UNGASS) declaration of commitment on HIV and AIDS. Accra: Ghana AIDS Commission (GAC); 2010.Google Scholar
- Nonvignon J, Aglobitse PB: The Choice of Health Care services by households in selected regions of ghana. Ghana Pol J 2008, 2: 34–50.Google Scholar
- Nonvignon J, Aikins KSM, Chinbuah AM, Abbey M, Gyapong M, Garshong NAB, Fia S, Gyapong OJ: Treatment choices for fevers in children under-five years in a rural Ghanaian district. Malar J 2010., 9: Google Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.