IDEAS EXTRA / JUEGO

Analysis of the 2010 MICS shows a clear link between higher education levels and better health indicators and outcomes. It also finds links between education and reduced poverty, which in turn is known to lead to better health outcomes. The Education Country Status Report states:

‘The net impact of education on human development is noteworthy. Many fertility and maternal and child health indicators improve with education: the average age at first childbirth rises, women have fewer children and the probability of at least one child dying drops. Gains are greater in urban areas, regardless of the availability of local health services. The probability of poverty also drops considerably. In spite of these positive impacts Sierra Leone ranks just 28th out of 37 SSA countries in terms of the impact of primary education on human development, which may be related to the comparatively low quality of education’.

In terms of links with fertility indicators, the analysis found that women who had completed upper secondary school or tertiary-level education were more likely to use contraception, had their first child at an older age, and had fewer children. The average age at first birth for those with no education or only primary education was less than 19 years, compared to 21 years for those with secondary or higher education.

Women with tertiary education were more than four times more likely to use contraception (40%) compared to those with no education (9%). The higher levels of education were also linked to smaller family sizes: 4.5 children for those with tertiary level, compared to more than six children for those without education.

MCH indicators also improved with increasing levels of education. Pregnant women with higher levels of education were more likely to receive components of antenatal care such as tetanus toxoid vaccinations and antimalarial preventative treatment. They were also more likely to deliver in a health facility.

The probability of losing at least one child was almost double for uneducated women compared with the most educated: two-thirds of mothers without primary education had lost at least one child, whereas for those with the highest levels of education the proportion was just over one-third. As with the information for health, there are many weaknesses with Sierra Leone’s education data. The Education Management Information System provided no reliable data from 2005 to 2010. In addition, the 2010 information was found by UNESCO to be overestimated by 18% for primary school data and 12% for secondary schools, before being subsequently adjusted. UNESCO also used a range of surveys in their analysis, although the different sources of data are not always consistent with each other.

Resources for education in Sierra Leone have been rising slowly. In relative terms, education spending rose from 3.3% of GDP in 2004 to 3.5% in 2011. However, these levels remain below the average of 3.9% for other low-income countries.

Participation in education has risen dramatically since the end of the civil war. In 2002, the government removed fees for primary school and this led to a doubling of numbers from 650,000 children in 2000 to 1,280,000 in 2004. However, since then numbers have remained broadly constant, with around 1,200,000 children in primary school in 2010.

There have also been large increases at secondary level. Numbers in junior secondary school rose by a factor of four from 60,000 in 2000 to 244,000 in 2010. The relative rise for senior secondary school was even higher, with numbers moving from 23,000 to 108,000 in the same period.

Despite these large increases in numbers, a significant percentage of children remain out of school. In 2003, 25% of children aged six to 14 were out of school and the figure was still 22% in 2010. The overwhelming majority of these out-of-school children – more than 90% – had never been to school.

Education outcomes for children in Sierra Leone are low. An Early Reading Assessment Survey was conducted among primary children in 2011. It found that more than half of children could not write their names after the first year of primary school. It also found that after three years of school the great majority had not yet mastered the alphabet and how it works. Reading and

comprehension levels were also low for primary school-aged children. Other studies have also shown that there are weak education outcomes through both primary and secondary levels.

In terms of adult literacy, Sierra Leone has low levels. Rates have risen from 35% in 2004 to 44% in 2012, but this is far lower than the average of 66% for sub-Saharan Africa. The gap between literacy rates for men (56% in 2012) and women (34%) has also not closed over this period.

The picture for younger adults is better. For those aged 15 to 24 years, overall literacy rates were 63% in 2012 and this represents a faster increase than for adults as a whole. Rates for young women are increasing faster than for young men: literacy rates for women aged 15 to 24 were up 17 percentage points in the eight years to 2012 compared to only 12 percentage points for young men. However, although the gap is closing young men remain more literate than young women.

In summary, education participation improved through the 2000s, albeit from very low levels and with serious constraints apparent to the quality of education. We have limited evidence from after

the FHCI with which to assess both how education contributed to better health outcomes and the reverse.

9.2.2

Water and sanitation

Access to clean water and adequate sanitation is another significant driver of better health for adults and children (Prüss-Üstün et al., 2008). Households in Sierra Leone have poor levels of access to improved water sources and sanitation (see Table 39). Access to an improved source of drinking water has been steadily increasing over the last two decades but at a very slow rate of about one percentage point a year. In 2010, 57% of households had access and this rose further to 63% in 2015. Rates were much higher in urban areas compared to rural: 85% compared to 48% respectively in 2015.

The situation is worse for sanitation. In 2015, only 44% of households had access to sanitation that hygienically separated human waste from human contact (68% in urban areas; 28% in rural

areas). The rate of improvement has also been extremely slow, with access typically increasing by only half a percentage point each year since 1990.

Progress in access to clean water and sanitation is likely to have contributed to the gains noted in health, although given the slow rate of progress, especially in rural areas, it is unlikely to have been a major factor.

Table 39: Trends in water and sanitation, 1990–2015

9.2.3

Fertility trends

As with education, fertility is both influenced by changing health indicators and is itself a determent of health. Fertility rates in Sierra Leone have been declining, but also very slowly. The total fertility rate (TFR) shown by the 2013 DHS was 4.9 compared to 5.1 in the 2008 DHS.

Rates were much higher in rural areas at 5.7 compared to 3.5 in urban. Northern, Eastern and Southern regions all had high rates above 5, compared to Western at 3.2.

Women with higher education had lower fertility rates; those with at least secondary education had a TFR of 3.0, while for those without education it was 5.6.

There was also a strong gradient by wealth quintile. The bottom three wealth quintiles all had rates above 5.5 compared to those in the highest wealth quintile who had a TFR of 3.0.