Child Indicators Research

https://doi.org/10.1007/s12187-020-09734-8

Some Determinants of Infant Mortality Rate in SAARC

Countries: an Empirical Assessment through Panel
Data Analysis

Ujjal Protim Dutta 1 & Hemant Gupta 2 & Asok Kumar Sarkar 3 &
Partha Pratim Sengupta 1

Accepted: 30 March 2020/

# Springer Nature B.V. 2020

Abstract
The present study is an attempt to examine the distal determinants of Infant Mortality
Rate in South Asian Association for Regional Cooperation (SAARC) nations over the
period of 2000–2016. Instead of looking at individual nation model, the study tries to
develop a regional model to examine the determinants of infant mortality. Infant
mortality is modelled as a function of public health expenditure, educational status of
women, access to proper sanitation, GDP per capita and urbanisation. To attain this
objective, we have applied Pedroni’s cointegration test. Subsequently, to estimate the
long run relationship we have utilized the Fully Modified Ordinary Least Square
(FMOLS) and Dynamic Ordinary Least Square (DOLS) methods. The results of the
Pedroni’s cointegration test have shown the long run relationship among the selected
variables. Similarly, FMOLS and DOLS test results have indicated that health expen-
diture, GDP per capita, educational status of women and sanitation facilities have a
significant impact on Infant Mortality Rate of SAARC nations. The results of this study
led to the conclusion that Health Expenditure is one of the significant contributors in
decreasing the Infant Mortality Rate. Moreover, the results of our study shed light on
determinants such as GDP Per Capita, Female Education, Urbanisation and Sanitation
which have some clear policy implications for reducing Infant Mortality Rate in
SAARC nations.

Keywords Infant Mortality Rate . Determinants . SAARC . Panel data . Cointegration

* Ujjal Protim Dutta

ujjaldtt.06@gmail.com

Extended author information available on the last page of the article

 U. P. Dutta et al.

1 Introduction

Infant Mortality Rate (IMR) is generally outlined as the number of fatalities among
children within the first year of their birth for every one thousand live births in the given
year (Reidpath and Allotey 2003). IMR is a sensitive factor which is, directly or indirectly,
influenced by a number of factors. The probability of survival is much higher in case of
adults and elderly people as compared to the infants because their immunity system is not
well developed which makes them susceptible to all kinds of illnesses and they are not
developed enough to cope with the external changes. Due to this reason, factors such as
the status of healthcare services, lifestyle of the immediate family, access to nutritious food
and proper sanitation facilities have a major impact on IMR. According to Klinger (1985),
infant deaths form a major proportion of the total deaths in developing nations in contrast
to developed nations, where it accounts for a relatively smaller proportion of total deaths.
UNICEF (2018) reported that in the year 2017, an alarming figure of 4.1 million
infant deaths (within the first year of birth) were recorded, which formed 75% of the
total mortalities of children below the age of five years. The possibility of an infant not
surviving the first year in WHO African region was found to be highest at 51 for each
1000 births, which was more than six times that of the WHO European region (8 for
every 1000 births). At the global level, IMR has reduced from 65 deaths per one
thousand live births (1990) to 29 deaths (2017). Similarly, in the same report it has been
found that annual infant deaths have decreased over the years from 8.8 million (in
1990) to 4.1 million (in 2017). Although the figures have declined yet they are startling.
When we compare the figures of IMR of developed and developing nations for the last
15 years, the disparity is shocking. It is seen that the developed nations of Europe and
North American perform better as far as IMR is concerned with an average of 3.61 than
the developing countries of SAARC (South Asian Association for Regional Coopera-
tion) region with an average of 42. (See the fig. 1 & 2).
This high IMR of the SAARC region is a matter of concern for the governments,
policymakers, scholars and all the people. According to the UNICEF (2018), the infants
have a minimal chance of surviving in two of the SAARC nations- Pakistan and
Afghanistan. Similary, four SAARC nations are in the top 10 ranked countries accord-
ing to the number of new-born deaths in 2016 (see the table 1).

European Union North America

8.00
6.95 6.87 6.78 6.77 6.77 6.68 6.58 6.48
7.00 6.38 6.28 6.09 5.99 5.89 5.79 5.69
6.00
5.90
5.00 5.68 5.51 5.31 5.14
4.00 4.93 4.72 4.53 4.37 4.23 4.07
3.00 3.94 3.82 3.72 3.61
2.00
1.00
0.00
2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

Fig. 1 IMR in Developed Countries

Some Determinants of Infant Mortality Rate in SAARC Countries: an...

80.00 World South Asia

68.90
70.00 66.60
64.40
62.30
60.30
58.30
60.00 56.50
54.50
52.70
50.90
49.00
47.20
50.00 53.90 52.10 45.50
43.70
42.00
50.30
48.60
46.90
40.00 45.10
43.40 41.80 40.30 38.80 37.40
30.00 36.00 34.70 33.60 32.40

20.00

10.00

0.00
2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2011

2012

2013

2014

2015
2010
Fig. 2 IMR in South Asian Developing Countries

IMR is broadly divided into two components: Neonatal Mortality Rate (NNMR),
which refers to death within one month of birth, and Post Neonatal Mortality Rate,
which refers to death post first month of birth and before 12 months (NIMS 2012).
Over the last couple of decades, commendable progress has been made which is
reflected in the statistics pertaining to neonatal mortality. Neonatal mortality rate fell
from 58.7 for everyone thousand live births (2000) to 28.2 (2016) (You et al. 2015).
Following a similar trend, the number of deaths of new-born infants showed a decline
from 2.2 million in the year 2000 to 1 million in 2016. Even after this decline, nearly
2800 new-borns still face the threat of mortality in South Asia each day. The available
statistics show that the under-five deaths have declined yet the proportion of new-born
deaths which constitute the total number of deaths under the age of five has risen from
46% in the year 1990 to 59% in 2016 (You et al. 2015). The two most vulnerable
regions in terms of the risk associated with the death of infants are South Asia and sub-
Saharan Africa. An infant in every 35 infants born in South Asia dies within the first
month of their birth (You et al. 2015). Therefore, the likelihood of a child to not live
beyond one month in South Asia is nine times more than a child born in a country with
high-income and twice likely to die than a child born in North Africa and Middle East.

Table 1 Number of new-born deaths wise ranking of the SAARC countries.

Ranked Countries with the largest number of new-born Number of new-born deaths (in N e w - b o r n
deaths in 2016 thousands) mortality rate

1 India 640 25.4

2 Pakistan 248 45.6
8 Bangladesh 62 20.1
10 Afghanistan 46 40.0

Source: UNICEF (2018)

 U. P. Dutta et al.

The data reveals that Pakistan had the highest neonatal mortality rate (46 for every 1000
live births) in 2016, closely followed by Afghanistan (40 for every 1000 live births). In
addition to this, the number of stillbirths in South Asia is also very high (De Bernis
et al. 2016). The scenario is dismal as every year in South Asia alone around one
million infants are born still, which forms 37% of the world’s total stillbirths. Globally,
India and Pakistan feature among the top ten high-burden nations with 592,100 and
242,600 stillbirths respectively. Moreover, in South Asia, together they form 86% of
the total stillbirths (De Bernis et al. 2016).
Although the spread of technological improvements has helped us to safeguard the
extremely susceptible babies, yet a large number of these children remain vulnerable to
various health issues in the crucial years of their lives. So, along with decreasing the
IMR, our emphasis ought to be on improving the quality of life of the vulnerable
children and safeguarding their future (De Souza et al. 2006).
Regarding IMR as a whole, a lot of progress and improvement has been achieved
since 2000 but the progress has been slow as well as unequal within and between
nations. Fig. 3 has shown IMR in SAARC countries for the year 2018. Among the
SAARC countries, infant deaths for every one thousand live births stretched from as
low as 6.4 in Sri Lanka to a high of 57.2 in Pakistan (see Fig. 3).
For Sri Lanka, the issue of healthcare of the citizens has been a top priority since
many years which has been put to practice by implementing a universal healthcare
system (Björkman 1985). This is clearly evident from fig. 4 as the IMR of Sri Lanka in
2000 was also very low as compared to the other South Asian countries. Sri Lanka,
from the very outset, has been at an advantageous position as far as child and maternal
health is concerned mainly due to its progress in these areas, which is a result of
effective policies regarding healthcare formulated and implemented by the government
over the years (Zaidi et al. 2004).
It can also be observed from Fig. 4 that since 2000, out of all the South Asian
countries, Maldives has witnessed the greatest improvement, with a remarkable reduc-
tion in IMR (78.57%). Bangladesh follows with a 56.25% reduction from 66 deaths per
one thousand live births in 2000 to 28 in 2016. This is followed by Bhutan and Nepal
with 53.5 and 53% reduction respectively.
In India’s case, IMR has gone down by 48.04% from 67 deaths per one thousand live
births in 2000 to 35 in 2016. This slow pace of India’s progress is a result of inadequate

70
57.2
60 47.9
50
40 29.9
25.1 24.8 26.7
30
20
7.4 6.4
10
0

Infant Mortality Rate

Fig. 3 IMR of SAARC countries, 2018. Source: Authors own calculation using World Bank Data.
Some Determinants of Infant Mortality Rate in SAARC Countries: an...

100.00

90.00

80.00

70.00

60.00

50.00

40.00

30.00

20.00

10.00

0.00
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Afghanistan Bangladesh Indian Maldives

Pakistan Srilanka Nepal Bhutan

Fig. 4 IMR of SAARC countries, 2000–2016. Source: Authors own calculation using World Bank Data.

steps being taken to address the issues of infant and maternal health and nutrition.
According to Mundle (2011), the insufficient progress seen in case of India can be mainly
attributed to insufficient human capital and incompetent delivery system. Thus, it is evident
that there is a lot of scope for improvement in the areas of infant as well as maternal health
and nutrition in India. Unlike India, Bangladesh has undertaken many policies to address
child mortality as the Government has laid stress on health policies since the declaration of
the Millennium Development Goals (Shiffman and Sultana 2013). In spite of facing
constraints as far as financial and human resources are concerned, Nepal has shown
improvement in these areas. According to Campbell et al. (2003), this improvement can
be partly ascribed to the decentralized financial planning and efficient implementation.
Looking at this gloomy scenario of the SAARC countries, reducing IMR should be
given priority. Therefore, the objective of the research undertaken is to inquire into the
determinants of IMR in SAARC nations.
As the study undertaken consists of a panel of eight countries, there is a possibility that
there may be a presence of common shocks among the sample countries which may in
turn create cross section dependency in the panel of selected countries. It is essential to
ascertain the existence of cross sectional dependency before proceeding with the panel
data models as the size of the panel unit root may become distorted if cross sectional
dependency exists.
Thus, at the outset, the study has conducted a cross sectional dependency test to identify
the presence of cross-section dependency in our panel data set. Subsequently, to determine
the appropriate method of estimation we have applied panel unit root test to check whether
the variables are stationary or not and also to determine their order of integration. After
 U. P. Dutta et al.

determining the order of integration, the study has used Panel Cointegration Test to see the
long run relationship amidst the concerned variables, that is, IMR, Public Health Expen-
diture, Level of Female Education, Urbanisation, Sanitation and GDP per capita.
Finally, to measure the coefficients of the long run relationship, the study has applied
Fully Modified Ordinary Least Square (FMOLS) and Dynamic Ordinary Least Square
(DOLS) estimators. By utilizing these estimators in this study, problems of endogeneity
and serial correlation can be addressed which is not possible in case of Ordinary Least
Square (OLS) method, the details of which is discussed in Section 3.3.4.
In addition to the above mentioned methodological framework, to give the study a
theoretical foundation, a wide array of literature concerning the determinants of IMR was
surveyed. A concise review of the existing studies is given in the following section (Section 2).

2 Review of Literature

There exists a considerable corpus of literature regarding child health outcomes as

measured by morbidity and mortality which have mainly adopted the Mosley and Chen
(1984) framework. This analytical framelwork is conceptually based on the model
proposed by Davis and Blake (1956). Factors such as social, cultural, economic
backgrounds as well as health system variables affect a minor but exhaustive set of
factors which directly affect the outcome variable of the paper, that is IMR.
This approach is based on the belief that the existing socioeconomic status reveals itself
in proximate determinants. In turn, these determinants impact the threat of illness which
relates to the possibility of death. Mosley and Chen (1984) have categorized fourteen
proximate determinants into five sets. They are maternal factors (which includes age, birth
interval, etc.), environmental contamination factors (air, food/water, etc.), injury (acciden-
tal or intentional), nutrient deficiency (protein, calories, etc.) and, finally, personal illness
control (medical facilities and preventive measures adopted). Determinants taken in the
initial four sets influence the pace at which the infants go from being healthy to ill but the
determinants in the final category has twofold influence as it affects the previously
mentioned rate (by way of prevention) and also the rate of recuperation (by way of
diagnosis and treatment). The given set of proximate determinants is designed to be
exhaustive, in a way that infant health is subjected to change only if one or more than
one determinant change. This framework can be diagrammatically represented with the
help of the following flow-chart: Fig. 5

Back ground Determinants

Social, Economic, Cultural, Health System

Proximate Determinants
Maternal factors, Nutrient Deficiency, Environmental pollution, Injury, Personal Illness Control

Infant Health

Fig. 5 Mosley and Chen (1984) framework

Some Determinants of Infant Mortality Rate in SAARC Countries: an...

Source: Mosley-Chen (1984).

Similar to Mosley and Chen (1984) framework, Schell et al. (2007) and Sartorius
and Sartorius (2014) adopted similar kind of framework to analyse the determinants of
IMR. According to these researchers, IMR can be attributed to a series of determinants
that can be proximal (like accidents and infections), intermediate (like sanitation and
electricity) or distal (like socioeconomic conditions).
Factors like the health status of the mother, accidents, infections, availability of
healthcare services figure among the proximate determinants. Intermediate determi-
nants include factors such as provision of safe water, nutritious food, sanitation
facilities and electricity. Some other factors which are distal and yet crucial include
socioeconomic conditions such as infrastructure, poverty, education level of the parents
(mother, in particular), etc. Schell et al. (2007) and Sartorius and Sartorius (2014)
framework of determinants of child health can be represented with help of following
diagram: Fig. 6
According to a study published by NIMS, ICMR and UNICEF (2012), IMR is
affected more due to the distal factors such as socioeconomic development as compared
to NNMR. As our study aims to examine the determinants of IMR so it takes into
account the distal factors rather than proximate determinants. Thus, based on the above
theoretical framework, the present study tries to assess the strength of association
between IMR and five major distant and intermediate determinants (GDP per capita,
level of female education, public expenditure on health, Urbanisation and Sanitation),
using the panel of SAARC countries. The variables are chosen based on their

Distant Determinants
Income, Public health spending, Education, Inequality, Infrastructure

Intermediate Determinants
Access to food, Safe water, Sanitation, Electricity, Access to health
service

Proximate Determinants
Health service utilisation, Maternal Survival, Morbidly, Adolescent
Fertility

Infant Mortality Rate

Fig. 6 Schell et al. (2007) and Sartorius and Sartorius (2014) framework for Analysing IMR
 U. P. Dutta et al.

importance in the existing literatures (explained below) as well as keeping in mind the
context of the SAARC countries.
Public expenditure on health represents the accessibility of quality healthcare as well
as the adequacy of the public healthcare system. In many studies, the authors have
discussed that the health expenditure of various countries have a direct causal relation-
ship with their child mortality rate (Currie and Moretti 2003; Bokhari et al. 2007).
Looking into the trend of health expenditure, it can be noted that the condition of
health expenditure in SAARC countries is still far behind as compared to the OECD
(Organization for Economic Cooperation and Development) region. For instance, in
2014, the share of total health expenditure as percentage of GDP was only 4.37% in
South Asia whereas it was 12.36% in OECD countries (World Bank 2018). Health
Expenditure has a significant impact on the high-quality healthcare system and skills of
health service providers which are very important for reducing the mortality rate in any
nation. In table 2, the comparative observations have shown how the number of health
professional is directly correlated with the IMR. In the given table, the first column
shows the countries having highest IMR and the fourth column shows the countries
with the least IMR. Due to the unavailability of uniform data, we have taken the data
for skilled health professional for the respective countries from the data available from
the latest year which are given in the parenthesis (UNICEF 2018). For instance,
Pakistan has the highest IMR (45.6) in 2016 with 14 health professionals in 2014,
whereas Japan has the least IMR (0.9) in 2016 with 131 health professionals in 2012
per 10,000 population accordingly (See Table 2).
Apart from public expenditure on health, the level of female education is identified
as another significant explanatory variable. The literatures establish strong arguments
for the necessity of female education towards the child health status. Many researchers

Table 2 Comparison of mortality rate with numbers of skilled health professional country wise.

Highest Newborn Skilled health Lowest Newborn Skilled health

newborn mortality mortality rate professionals newborn mortality rate professionals
rates (2016) (2016) for every 10,000 mortality rates (2016) for every 10,000
people (2016) people

Pakistan 45.6 14 (2014) Japan 0.9 131 (2012)

Central African 42.3 3 (2009) Iceland 1.0 201 (2015)
Republic
Afghanistan 40.0 7(2014) Singapore 1.1 76 (2013)
Somalia 38.8 1(2014) Finland 1.2 175 (2012)
Lesotho 38.5 6(2003) Estonia 1.3 93(2014)
Guinea-Bissau 38.2 7 (2009) Slovenia 1.4 64 (2014)
South Sudan 37.9 No data is Cyprus 1.4 64 (2014)
available
Cote d’lyoire 36.6 6 (2008) Belarus 1.5 150 (2014)
Mali 35.7 5 (2010) Republic of 1.5 79 (2014)
Korea
Chad 35.1 4 (2013) Norway 1.5 218(2014)
Source: UNICEF (2018)
Some Determinants of Infant Mortality Rate in SAARC Countries: an...

have argued the importance of mother’s education for the vaccination, proper nutrition,
and nourishment of the infants. Furthermore, it is also important for reducing the
fertility rate in developing nations (Currie and Moretti 2003). Moreover, many studies
have found that education empowered the adolescent girl, mother or family to ask for
better health services and they are equipped to make informed decisions regarding
health care for the infants and themselves in an improved manner (Zakir and Wunnava
1999; Baldacci et al. 2004).
Another noteworthy determinant of IMR is urbanisation. Many researchers have
emphasized on the demographic factors such as urban or rural population, the location
of birth, etc. (Roberts 2003; Baldacci et al. 2004). These studies have discussed that the
accessibility to health care is easier in an urban location in contrast to the rural areas. In
addition to this, Schultz (1993) has explained that the IMR is more in agricultural and
rural households having low income because of high transportation cost, low accessi-
bility and irregularity in health services in the poorer countries.
The recent study conducted by UNICEF (2018) has explained the essentiality of
fresh drinking water and sanitation facilities for the healthy life of a child. Moreover,
many researchers in the past have also supported the view that by improving the water
and sanitation facilities, there is a reduction in child mortality (Preston 1979; Woods
et al. 1988; Szreter 1999; Cutler and Miller 2005; Watson 2006). A meta-analysis study
has illustrated that by improving the safe water supply, the government can reduce the
risk of diarrhoea morbidity by 25%, by improving the sanitation facilities by 32% and
combined intervention by 33% (Fewtrell et al. 2005).
The relationship between the economic condition and the rate of mortality has been
validated through a number of studies (Preston 2007). The path-breaking works of
Preston (1975) and Pritchett and Summers (1996) established that people in possession
of wealth are heathier as manifested by their life expectancy and lower child mortality
in the concerned countries, along with establishing that higher income in the country is
related closely with higher health standards in the entire population. The seminal work
of Pritchett and Summers in 1996 concluded that a rise in per capita GDP resulted in
positive effect on health outcome. In their cross-national study, it was found that with
an increase of 5%in the GDP, there was a decline in IMR by 1%. Considering the
national level, as the wealth of a nation increases then it is in a position to invest more
on health programs like clean water, sanitation facilities and other awareness programs.
On the other hand, at the individual level, people will have more income which will
equip them to buy nutritious food and afford better medical facilities. This would
invariably lead to a marked improvement in the individual health resulting in an
aggregate improvement in the health of the nation. Keeping these studies in view,
GDP per capita can be considered as a key determinant of IMR.
Most of the earlier studies that were looked into while surveying the existing
literature make use of cross-sectional data. The contribution of the present study lies
in the exploitation of panel data models while exploring the determinants of IMR across
nations. Panel data, also referred to as longitudinal or cross-sectional time series data,
enables us to observe the behaviour of nations across any given time period. Using
panel data models have a number of advantages over cross-sectional study. For
instance, by employing panel data model, we can take into account the country specific
fixed effects which will help in dealing with heterogeneity among the cross-sectional
units. Thus, in the study presently undertaken, it helps in avoiding potential bias for
 U. P. Dutta et al.

measuring the determinants of IMR and at the same time retaining the cross-sectional
dependence and panel heterogeneity. Additionally, in case of large panel such as the
one used in this study, it is mandatory to check the stationarity of the variables under
consideration. Keeping in view the shortcomings of the cross sectional studies, the
study utilises panel data model which helps in examining issues which cross-sectional
or time series data individually are not equipped to address.

3 Materials and Methods

3.1 Empirical Model

To attain the research objective, the study has looked at the SAARC nations over the
period of 2000–2016. To measure how IMR responds to the variation in Public
Expenditure on Health (PHE), Level of Female Education (FE), Urbanisation (U),
Sanitation (SN) and GDP Per Capita (y), the study has utilised the given model.

lnIMRi;t ¼ αi þ β1 lnðPHEÞi;t þ β2 lnðFEÞi;t þ β3 lnðU Þi;t þ β 4 lnðSN Þi;t

þ β5 lnðY Þi;t þ εi;t ð1Þ

Whereas, IMRi, t=Infant Mortality Rate; PHEi, t= Public Expenditure on Health; FEi, t=
Level of Female Education; Ui, t= Urbanisation; SNi, t = Sanitation; yi, t=GDP per capita; εi, t=
Random disturbance term. As all variables are converted into their respective natural
logarithm form, we have used the prefix " ln " before each variable. The subscript "i, t" of
each variable stands for country i at time t. Moreover, the coefficients βi, ( i = 1, 2, 3, 4,
5) correspond to the elasticity of IMR with respect to Public Expenditure on Health, Level of
Female Education, Urbanisation, Sanitation and GDP per capita respectively. Whether these
variables have positive or negative impact on IMR will depend on the sign of the coeffi-
cients of respective variables.

3.2 Data and Variables Used

The present study has utilized the yearly data of eight SAARC nations over the period of
2000–2016. The data has been obtained from the World Bank, World Development
Indicator (WDI 2018). The details of the variables and their source is shown in Table 3.

3.3 Methods

3.3.1 Cross Section Dependence Test

The present study has applied four most frequently used tests namely; “Breusch-Pagan
Lagrange Multiplier” (LM) (1980), “Pesaran scaled” LM (2004), “Pesaran Cross-Sectional
Dependence” (CD) (2004), and “Baltagi, Feng, and Kao Bias-Corrected scaled Lagrange
Multiplier” (LM) (2012) to examine the cross-section dependency in the panel dataset. The
null hypothesis of no cross-section dependence is tested with the help of above-mentioned
statistics.
Some Determinants of Infant Mortality Rate in SAARC Countries: an...

Table 3 Variables Description, their Symbols and Source of Data

Variables Symbols Description Data Sources

Infant Mortality IMR IMR is the number of infants not surviving for a year since their WDI, World
Rate birth for every 1000 live births in a any year. Bank 2018
Public PHE Public Health expenditure refers to the public and private WDI, World
Expenditure expenditures as a ratio of total population of a given place. Bank 2018
on Health Among others, it includes provision of health services,
nutrition activities, and emergency aid designated for health.
Data are in current U.S. dollars.
Level of Female FE Percentage of female students enrolled at the primary level. WDI, World
Education Bank 2018
Urbanisation U Urban population (people inhabiting urban areas) as percentage WDI, World
of the total population has been taken as a proxy for Bank 2018
Urbanisation.
Sanitation SN Percentage of total population having access to basic drinking WDI, World
water has been taken as a proxy for Sanitation. Bank 2018
GDP-per capita y GDP per capita has been taken as a proxy for the income. WDI, World
Bank 2018

3.3.2 Stationarity Test

At the outset, the study conducted LLC (2002) and IPS (2003) tests to detect the order of the
concerned variables. LLC test is an extension of the ADF (Augmented Dickey Fuller) test.
This test is administered to check the null hypothesis, which can be expressed as H0 : ρ = 0,
against the alternative hypothesis of H1 : ρ < 0. This test assumes homogeneity of the
autoregressive (AR) process across all panel members. IPS test is the extension of the LLC
test. It allows heterogeneity of the AR process across the panel members. The null hypothesis
for IPS test is that H0 :ρ = 0 for all i′s. Whereas, in case of H1 :ρ < 0 for some i′s or for at least
one i. The study applied these tests to all the selected variables i.e., IMR, Public Expenditure
on Health, Level of Female Education, Urbanisation, Sanitation and GDP per capita at their
levels and first difference. This was done to overcome the problem of spurious regression as
applying regression to non-stationary variables will lead to spurious regression.

3.3.3 Panel Cointegration Test

The study conducted Pedroni conitegration test to explore the cointegrating association amid
IMR, Public Expenditure on Health, Level of Female Education, Urbanisation, Sanitation
and GDP per capita. This test helps us to deal with the problem of spurious regression. For
applying cointegration in panel data, Pedroni (1999) constructed seven test statistics which
are divided into two parts. The first four of the seven statistics are known as “Panel Statistics
test” (Within Dimension Approach), while other three are known as “Group Statistics test”
(Between Dimensions Approach). “Panel Statistics test” or “Within Dimension Approach”
assumes homogeneity of the Auto Regressive term. On the other hand, “Group Statistics
Test” or “Between Dimension Approach” is less restrictive as it allows heterogeneity of the
Auto regressive term.
 U. P. Dutta et al.

Pedroni cointegration test can be estimated using the given equation:

yi;t ¼ αi þ δi t þ β1 X 1;i;t þ β 2 X 2;i;t þ …… þ βn X n;i;t þ εi;t ð2Þ

Subsequently, a regression of the given form has been applied to examine the presence
of cointegration,

εi;t ¼ ρi εi;t−1 þ μi;t ð3Þ

Both “Panel Statistics Test” and “Group Statistics Test” assume null hypothesis of no
cointegration (H0 : ρi = 1 for all i). “Panel Statistics test” presumed H1 : ρi < 1 for all i
and “Group Statistics Test” assumed alternative hypothesis of H1 : ρ i < 1 for
atleat one i.

3.3.4 FMOLS and DOLS

Having established the cointegrating relationship amid the selected variables, the study
can measure the coefficients of the long run relationship with the help of panel FMOLS
and DOLS estimators. We can elucidate the idea of both FMOLS and DOLS estimators
by using the given panel regression model:

IMRi;t ¼ αi þ xi;t β þ ui;t ð4Þ

Where, αi= country specific effects, IMRi, t is the Infant Mortality Rate, β is the (k, 1)
vector of parameters and ui, t denotes the disturbance term. xi, tare vector of regressors. It
presumes that explanatory variables (Public Expenditure on Health, Level of Female
Education, Urbanisation, Sanitation and GDP per capita) used in the model, i.e., xi, tare
integrated of order one, i.e., (I (1)) and is expressed in the given form:

xi;t ¼ xi;t−1 þ εi;t ð5Þ

The FMOLS estimator is the non-parametric approach and it can control the problems
of serial correlation and potential endogeneity problems. It can be shown in the given
form:
  2 −1    
*
bFM ¼
β ∑Ni¼1 ∑Tt¼1 X i;t −X i d −T b
∑Ni¼1 ∑Tt¼1 X i;t −X i IMR δ εu ð6Þ
i;t

Where,
*
d denotes the converted variable of IMRi, t for correcting endogeneity and
IMR i;t
b
δεu denotes correction term for serial correlation.
DOLS estimator has been extended by Kao and Chiang (2001) for panel
analysis. Under this framework, the issue of endogeneity can be corrected by
extending the cointegration regression through incorporating lead and lagged
differences of Public Expenditure on Health and other regressors of the model
(Saikkonen 1992).
Some Determinants of Infant Mortality Rate in SAARC Countries: an...

DOLS framework can be expressed in the given form:

p q
IMRi;t ¼ αi þ xi;t β þ ∑k¼−p
2
1
δk ΔIMRi;t−k þ ∑k¼−q
2
1
λik Δxi;t−k þ ui;t ð7Þ

Where,
αi= specific effects of the country, λik represents the coefficient of a lead or lagged of
first differenced regressors of the model and ui, t is the disturbance term.

4 Results

4.1 Outcomes of Cross-Section Dependency and Panel Stationary Tests

Before conducting the panel unit root tests, it is essential to identify the presence of
cross-section dependency in our panel data set. To examine the cross-sectional depen-
dency of the variables, we have applied four test statistics as mentioned in this section.
Table 4 shows the results of cross section dependency tests. The results indicate that the
entire test statistic rejected the null hypothesis of no cross-section dependence at 1 %
significance level. Thus, there is a presence of cross-section dependency in the data set.
After the evaluation of the cross-sectional dependency, we have applied the LLC
and IPS stationary test statistics to identify the order of integration and the outcome of
the same has been displayed in Table 5. From Table 5, it can be perceived from the
table that in case of all the selected variables, the null hypothesis of non-stationary
cannot be discarded in level. Notwithstanding, in first difference, both the unit root tests
rejected the null hypothesis at 1 % significance level.

4.2 Cointegration Test Results

Table 6 has shown the outcomes of cointegration test. Four of the seven statistics
discarded the null hypothesis of no cointegrating relationship. Under “Panel Statistics
test”, two test statistics namely “Panel PP-Statistic” and “Panel ADF-Statistic” have
discarded the null hypothesis of no cointegration at 1% significance level. Similarly,
under “Group Statistics Test”, “Group ADF-Statistic” and “Group PP-Statistic”

Table 4 Outcomes of “Cross- section dependence tests”.

Variables Breusch-Pagan LM Pesaran Scaled LM Bias-Corrected scaled LM Pesaran CD

LIMR 464.1420* 58.2819* 58.0319* 21.5412*

LPHE 403.8100* 50.2197* 49.9530* 20.0808*
LFE 142.0823* 15.2448* 14.9948* 7.6807*
LU 414.5234* 51.6513* 51.4013* 12.3978*
LSN 421.2999* 52.5569* 52.2902* 10.6233*
LY 440.7206* 55.1521* 54.9021* 20.9838*

Note: One, five and 10 % level of significance are denoted by*, ** and *** respectively
 U. P. Dutta et al.

Table 5 Outcomes of Stationary Tests

Variables Test Level First difference

LIMR LLC −0.922 −5.208*

IPS 2.137 −2.672*
LPHE LLC −1.628 −8.336*
IPS 1.840 −6.890*
LFE LLC −1.048 −7.670*
IPS 0.074 −3.545*
LU LLC 0.479 −5.321*
IPS 1.888 −26.579*
LSN LLC 7.454 −7.631*
IPS 0.019 −10.240*
LY LLC −0.442 −8.398*
IPS 1.904 −6.415*

Note: One percent, 5 % and 10 % level of significance are denoted respectively by*, ** and ***

rejected the null hypothesis at 1 % level of significance. From the results obtained, a
marked cointegrating association amid the variables has been noticed.

4.3 Outcomes of FMOLS and DOLS

After identifying the cointegrating relationship amidst the variables, the study has used
FMOLS and DOLS methods to measure the IMR retention coefficient. The pooled
version of FMOLS is based on the FMOLS model suggested by Phillips and Hansen
(1990) which gives the estimators after rectifying the deterministic components in
dependent and independent variables. While the grouped version of FMOLS estimator
as given by Pedroni (2001) is estimated by calculating the average of the individual
cross-section that the FMOLS is estimating. Kao and Chiang (2001) further suggested
pooled DOLS wherein the extended cointegration regression permits the dynamics of
short run relationship so that it is cross nation specific. Lastly, Pedroni expounded the
grouped version of DOLS by calculating the average of the individual cross-section.

Table 6 Outcomes of the cointegration test

Test Statistic Probabilities

“Panel v-Statistic” −1.658 0.951

“Panel ρ-Statistic” 2.844 0.997
“Panel t-Statistic” −3.905 0.000*
“Panel t-Statistic (ADF)” −2.688 0.003*
“Group ρ–Statistic” 3.895 1.000
“Group t-Statistic” −6.084 0.000*
“Group t-Statistic (ADF)” −2.547 0.005*

Note: One, five and 10 % level of significance are denoted by*, ** and *** respectively
Some Determinants of Infant Mortality Rate in SAARC Countries: an...

The paper has used the pooled and the group versions of the FMOLS and DOLS
estimators and the outcomes of the same are shown in the Table 7. It has been seen
from the outcomes that the coefficients of Public Expenditure on Health (−0.0240*
and-0.0657*) are negative and significant at 1% level for both pooled and grouped
version of FMOLS. Thus, an increase in the Public Expenditure on Health affect IMR
in a way that a 1 percentage-point increase in health expenditure is linked with the
reduction of IMR by 0.024% per 1000 live births in case of the pooled version of the
FMOLS estimator while it is 0.065% per 1000 live births where group version of the
FMOLS estimator is concerned. Similarly, in case of DOLS, the coefficients of health
expenditure (−0.3737* and − 0.0830**) are negative and significant at 1% and 5%
level of significance respectively. Thus, the outcomes of the study empirically show the
importance of health expenditure on IMR for the selected SAARC nations. In addition
to Public Expenditure on Health, the outcomes also indicate the significance of Level of
Female Education, Sanitation, Urbanisation and GDP per capita on reducing IMR (See
the table 7).

5 Discussion

As mentioned earlier, to determine the appropriate method of estimation it is essential to

check the stationary properties as well as the order of integration of the variables.
However, cross sectional dependence of the concerned variables should be identified
so as to choose the panel unit root test which is suited for the study. The results of the
cross sectional dependence test indicate that there is a presence of cross-section depen-
dency in the data set as all the test statistic undertaken in this study have rejected the null
hypothesis of no cross-section dependence for all the variables at 1 % significance level.
The presence of cross sectional dependence will be addressed when panel unit root test
is taken into consideration. Thus, we have utilised IPS Panel Unit root Test along with
LLC Test to identify the stationary properties of the variables being studied. It can be
deduced from the results that all the variables are non-stationary at levels and they
become stationary at the first difference, i.e., I (1). As all the variables were seen to be
integrated of order 1, we can choose to apply panel cointegration test to identify the long
run relationship amid the variables of the study. The results of the study affirm the

Table 7 Outcomes of FMOLS and DOLS.

Variable FMOLS DOLS

Pooled Grouped Pooled Grouped

LPHE −0.0240* −0.0657* −0.3737* −0.0830**

LFE −0.3497* −0.7260* 1.1782* 1.8058*
LU −1.0365* −3.8122 −0.6210** 3.4267**
LSN −0.6723* 0.0375* −0.8989* −0.4951***
LY −0.0197* 0.0605* −0.1981** 0.0984**
Adj-R2 0.998 – 0.997 –

Note: One, five and 10 % level of significance are denoted by*, ** and *** respectively
 U. P. Dutta et al.

existence of long run relationship amongst IMR, Public Expenditure on Health, Level of
Female Education, Urbanisation, Sanitation and GDP per capita. Having affirmed a
cointegrating relationship, the study has utilised FMOLS and DOLS estimators to
measure the coefficient that explain the variations in the IMR. The results of the study
conducted have shown a significant impact of Public Expenditure on Health on IMR in
SAARC nations over the period of 2000–2016. For both FMOLS and DOLS tests, the
coefficient of Public Expenditure on Health is negative and statistically significant. Our
results regarding the impact of Health Expenditure on IMR are similar to the study
conducted by Nixon and Ulmann (2006). Increasing Health Expenditure in the SAARC
nations is an important part of progressive policy as it has the potential to ensure medical
facilities, improvements in nutritional programs and proper sanitation that will help to
reduce the various risks that threaten the infants and maternal health.
Availability of clean and safe water and proper sanitation facilities is seen to affect
IMR (see the table-7). The results suggest that availability of clean and safe drinking
water reduces the chances of infant deaths in the SAARC countries. Other studies
(Watson 2006; Cutler and Miller 2005; UNICEF 2018) are in line with our results. The
findings of these studies have explained that the IMR was lower among children living
in families who had access to clean and safe water and proper sanitation facilities as
compared to those who could not access the same.
Further, it has been observed from the results that GDP per capita significantly
affects IMR. A one percentage-point increase in GDP per capita is associated with a
decrease in death of infants by 0.0191% per 1000 live births in case of a pooled version
of the FMOLS estimator (see Table 7). Similarly, in case of pooled version of DOLS
estimator, the coefficient of GDP per capita is negative and statistically significant at
5% level of significance. Increase in income leads to a greater consumption of health-
enhancing public and private goods (Summers and Pritchett 1996). Again, according to
Gwatkins et al. (2007), the richer individuals have more purchasing power and are in a
better position to buy necessities such as nutritious foodstuffs, mosquito nets, and
medicines which safeguards the maternal health and infants.
Our results also indicate the importance of female education for child health. The
coefficient of level of female education is negative and statistically significant at 1%
level of significance in case of both the version of FMOLS estimator (see the table 7).
As we have observed a significant relationship between the Level of Female Education
and IMR, laying stress on education of women may be an effective intervention
towards reducing IMR. According to Levandowski et al. (2006) the education level
of mother is instrumental in guiding the different choices (related to child health) that
she takes during her pregnancy and afterwards. Moreover, our results are also consis-
tent with Song and Burgard, (2001), who had conducted a study in China over the
period of 1970–2001 and found a significant association between women education
and IMR. Along with the above mentioned variables, Urbanisation also appears to
positively affect the IMR (see table 7). A better standard of life might have an effect on
prenatal care, birth weight and health behavior, while living in an urban area is linked
with access to medical facilities and preventions of diseases for infants (Pampel Jr and
Pillai 1986). We have seen that after incorporating the linear time term into the
equation, a strong effect of these variables was visible. Thus, it is seen that the
outcomes are not majorly impacted because of coincidental linear increases in due
course of time. The results presented in table 7 are robust and consistent because the
Some Determinants of Infant Mortality Rate in SAARC Countries: an...

coefficients of the variables are remain same for the subset of the countries and are not
greatly affected due to the incorporation of time term into the equation.
In brief, the present study has elaborated the significance of Public Expenditure on
Health, GDP per capita, Level of Female Education, Urbanisation and Sanitation for
explaining the variations in IMR in the SAARC nations. Besides these determinants,
simultaneous improvements in medical interventions such as vaccination of infants,
administration of the anti-tetanus vaccine to the pregnant woman, etc. are also required
to reduce the chances of infant deaths.

6 Limitations

The data made available by the World Development Indicators (WDI) is collected from
the member nations individually and then it is collated by various international
organizations. However, the available data is dependent on how efficiently the national
systems disseminate information individually. Due to this limitation, we cannot over-
look the fact that the differential data credibility by different countries may have some
impact on the findings of the study. Initiatives have been taken by the World Bank to
assist the developing nations in improving their statistical collection methods which
would enhance the quality of the data. Due to these efforts over time, changes in the
quality of the available data may have impacted the temporal trends observed in the
results of the study. There is a major lacuna regarding data for certain important
indicators like maternal survival rate, which has not been considered in the model
adopted for our study. This is also a limiting factor for the study and the possible
implications of these prospective high impact factors could not be taken into
consideration.

7 Conclusion

Last century experienced a huge and unprecedented decline in the IMR in most parts of
the world. Understanding the determinants of this change is essential for the
policymakers to design policies addressing the needs of the people in the countries
where IMR remains very high as compared to the other countries. The present study
analyses the determinants of IMR in SAARC nations over the period of 2000–2016.
The results of the study shed light on determinants such as public expenditure on
health, GDP per capita, and sanitation on reducing IMR in selected SAARC nations.
The findings of the study have some policy implications which have been elaborated
further. Based on these results, an increase in health expenditure must be encouraged so
as to enhance the status of health in a country. However, the appropriate and efficient
use of public health fund is essential in this regard to maximize the effect. Efforts
should be made by the concerned authorities to achieve transparency and accountability
in utilization of public health fund. In addition to an increase in health expenditure,
female education should also be prioritized while formulating policies and intervention
strategies. An educated woman will be equipped with more specific knowledge and
awareness about pregnancy and delivery care and will be less likely to face complica-
tions during childbirth. Though the study has found a significant impact of urbanisation
 U. P. Dutta et al.

on IMR in case of only FMOLS estimator, yet urbanisation is considered as a crucial

determinant of IMR as it enhances the availability and accessibility to public health care
services, improved infrastructure and medical facilities along with skilled personnel.
Thus, it comes upon the governments to formulate policies and intervention strategies
for provision of proper infrastructure and easier access to public healthcare services,
especially in rural areas. The association between improved sanitation facilities and
lower IMR is widely recognised in the literature. Our study also reveals that improving
sanitation facilities would have significant effect on reducing IMR. Improvement in
sanitation facilities has been considered as one of the key public health interventions as
it not only reduces the risk of various infant related diseases but also cuts down
economic losses associated with the treatment of sanitation related diseases.
IMR is a global health challenge which cannot be tackled just by planning policies
on the basis of the factors considered in the paper. The focus should be on improving
the overall conditions where both quantitative and qualitative determinants of IMR like
living conditions, social and political stratifications and other factors should be taken
into consideration by the policymakers at various levels.

Acknowledgments The authors would like to acknowledge the Ministry of Human Resource Development
(GOI) and National Institute of Technology Durgapur, India for providing fellowship to the first and second
authors of this study.

Appendix: Figures representing the trend of individual determinants

used in the study

Fig. 7 has shown the public health expenditure of the SAARC nations over the period
of 2000–2016. In this study, Public Health expenditure refers to the public and private

Public Health Expenditure of SAARC

countries, 2000-2016
14
12
10
8
6
4
2
0
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016

Afghanistan Bangladesh Indian Maldives

Pakistan Srilanka Nepal Bhutan

Fig. 7 Public Health Expenditure of SAARC countries, 2000–2016

Some Determinants of Infant Mortality Rate in SAARC Countries: an...

expenditures as a ratio of total population of a given place. Among others, it includes

provision of health services, nutrition activities, and emergency aid designated for
health. Data are in current U.S. dollars. Health Expenditure has a significant impact
on the high-quality healthcare system and skills of health service providers which are
very important for reducing the mortality rate in any nation. Looking at the trend of
health expenditure as evident in the above figure, it can be noted that out of all SAARC
countries, Maldives, Nepal and Afghanistan allocates a larger portion of their GDP to
the health sector. On the hand, public health expenditure of India, Bangladesh, Paki-
stan, Sri Lanka and Bhutan are comparatively low.
Fig. 8 has shown the trend of female education in the SAARC countries over the
period of 2000–2016. Percentage of female students enrolled at the primary level has
been taken as proxy to see the level of female education in the SAARC countries. The
level of female education helps in enhancing a woman’s position and well-being by
giving them the agency to voice their opinions and asserting their will and decisions.
Despite the awareness regarding the benefits of female education, the level of female
education still remains low as compared to the male in the SAARC countries. From the
above figure, it has been observed that Afghanistan and Pakistan report very low
female education enrolment rate in primary level. In comparison to these two nations,
India, Bhutan and Maldives have higher enrolment of female students at primary level
yet it demands more efforts towards the desired results. Bangladesh and Sri Lanka have
shown a very impressive rate of enrolment of female students at primary level over the
last few years.
Fig. 9 has shown the trend of urbanisation in SAARC countries over the period of
2000–2016. Urban population (people inhabiting urban areas) as percentage of the total
population has been taken as a proxy for Urbanisation in this study.

Level of Female Education in SAARC countries, 2000-

2016
Afghanistan Bangladesh Indian Maldives

Pakistan Srilanka Nepal Bhutan

60

50

40

30

20

10

0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Fig. 8 Level of Female Education in SAARC countries, 2000–2016

 U. P. Dutta et al.

Urbanisation in SAARC countries, 2000-2016

Afghanistan Bangladesh Indian Maldives
Pakistan Srilanka Nepal Bhutan
50.00
45.00
40.00
35.00
30.00
25.00
20.00
15.00
10.00
5.00
0.00
2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016
Fig. 9 Urbanisation in SAARC countries, 2000–2016

From the figure, it can be observed that the rate of urbanisation in Maldives has
increased rapidly than the other SAARC nations. Bangladesh has also shown a trend
similar to Maldives.
India as well as Pakistan show moderate level of urbanisation while Sri Lanka
reveals a low rate of urbanisation. In case of India, the urban population has increased
considerably over the years but since the total population of India is very high, the
percentage of urban population appears low in comparison to the other SAARC
countries. Nepal, Bhutan and Afghanistan reveal a moderate increase of urban
population.
Though urbanisation has increased in the SAARC countries yet the conditions that
the people living in the urban areas receive determines their well-being. So, there is an
intricate relationship between the conditions of urban areas and IMR.
Fig. 10 has shown the sanitation facilities in SAARC countries over the period of
2000 to 2016. Percentage of total population having access to basic drinking water has
been taken as a proxy for Sanitation in the study as clean drinking water is one of the
important indicators of sanitation facility. Despite considerable progress been achieved
over the years, much remains to be done. A large percentage of population has limited
accessibility to safe drinking water, which is one of the prime reasons of poor health in
general and high IMR. For instance in Afghanistan, as observed in Fig. 4, the
percentage of population having access to clean water is very low and at the same
time we observe that Afghanistan also experiences high IMR. Bhutan, Maldives and Sri
Lanka has experienced a continuous improvement while in case of Pakistan the
percentage of population having access to clean water remains stagnant. In case of
India, there has been a moderate rise.
Fig. 11 has shown the GDP per capita of SAARC countries over the period of 2000
to 2016. GDP per capita has been taken as a proxy for the income in this study. Income
is an important determinant of IMR as having a high income entails having access to
Some Determinants of Infant Mortality Rate in SAARC Countries: an...

Sanitation facilities of SAARC countries, 2000-2016

Afghanistan Bangladesh Indian Maldives
Pakistan Srilanka Nepal Bhutan
100.0

90.0

80.0

70.0

60.0

50.0

40.0

30.0

20.0

10.0

0.0
2002

2015
2000

2001

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2016
Fig. 10 Sanitation Facilities in SAARC countries, 2000–2016

better facilities and nutritious food. Therefore, the GDP per capita is an important factor
that the study has taken into account to get an idea regarding this.
It has been observed from the figure that Maldives has shown a significant rise in
GDP per capita amongst the SAARC nations. Sri Lanka and Bhutan have also
experienced a continuous increase in GDP per capita over the years. Sri Lanka has
shown an impressive increase in the per capita GDP specifically in between 2003 to

GDP per Capita of SAARC countries, 2000-2016

Afghanistan Bangladesh Indian Maldives
Pakistan Srilanka Nepal Bhutan

12000.00

10000.00

8000.00

6000.00

4000.00

2000.00

0.00
2011
2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2012

2013

2014

2015

2016

Fig. 11 GDP per capita of SAARC countries, 2000–2016 (in current US$)
 U. P. Dutta et al.

2016 while Bhutan has also shown an impressive rate of growth in the last few years.
For India and Pakistan, there has been a very slow rise in the GDP per capita while for
Bangladesh, Afghanistan and Nepal it has remained stagnant.

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institutional affiliations.

Affiliations

Ujjal Protim Dutta 1 & Hemant Gupta 2 & Asok Kumar Sarkar 3 & Partha Pratim
Sengupta 1

Hemant Gupta
hemant.bpm13@gmail.com
Asok Kumar Sarkar
asok.sarkar@visva-bharati.ac.in

Partha Pratim Sengupta

parthapratims@yahoo.co.in
 U. P. Dutta et al.

1
Department of Humanities and Social Sciences, National Institute of Technology Durgapur, Durgapur,
India
2
Department of Management Studies, National Institute of Technology Durgapur, Durgapur, India
3
Department of Social work, Visva-Bharti University, Sriniketan, India