Averting Expenditure on Malaria: Effects on Maize Labour Productivity in Bunkpurugu-Nakpanduri District of Ghana

Background Malaria has been one of the commonest diseases during farming season which affects farmers’ health resulting in number of days spend on the farm. Due to this, farmers always try to prevent malaria attack by averting. Motivated by this argument, this study sought to determine the effects of malaria averting expenditure on labour productivity of maize farmers in Bunkpurugu-Nakpanduri District in the Northern Region of Ghana. Methods A cross sectional primary data was collected from 194 maize farmers. Both descriptive and quantitative data analysis approaches were employed. Conditional Mixed Process was used to estimate the effects of malarial averting expenditure on maize labour productivity. Results The study revealed that maize farmers incurred an average averting expenditure amount of GH¢ 284.60 on malaria. The result shows that factors that significantly affect maize farmers averting expenditure include; households’ off-farm income, household size, presence of bushes around houses, presence of pregnant women and number of household members in school. Meanwhile, quantity of fertilizer, seed, weedicides, farming experience, age, ownership of motor bike and averting expenditure are significant determinants of maize labour productivity. The study revealed that as farmers spend more to avert malaria attack, the become more productive. Conclusions Therefore, this study recommends that Ministry of Health should increase a public advocacy to ensure a holistic approach on use of malaria averting strategies such as clearing of bushes around houses, draining of stagnant water, sleeping in treated mosquito nets among others.


Background
Malaria is prevalent and perennial in all parts of Ghana with seasonal variations that are more severe in the Northern part of Ghana. The duration of malaria transmission season in Ghana varies from one geographical region to another. This depends on the length of the dry season during which there is a little transmission. In the Northern part of the country, there is a 6-7 months' transmission season with the highest number (50-60%) of cases occurring between July and November [1].
It has been revealed by research that malaria imposes significant burden on the economic growth of developing countries. The effects of malaria on adult victims are very much disturbing. In addition to the time and money spent on preventing and treating malaria, it causes considerable pains and weakness among the victims. These therefore reduce people working capacity and hence decrease productivity. Ghana as a country is implementing a strategic action plan aimed at reducing the burden of malaria by 75% [2]. To be able to achieve this, the general populace especially farmers who are much exposed to the vector need to take a center stage. Farmers are often than not exposed to mosquitoes due to the nature of their work. Mosquitoes are in abundance during rainy season when farming activities are more pronounced. Farming is done in bushes where mosquitoes hide and breed.
Also, due to the nature of farmers' works, they are sometimes compelled to cross rivers, streams, ponds which are breeding places for the vectors of malaria disease. Above all, farming is done by rural households who stay in less mosquito-proof houses.
The above-mentioned predicaments of farmers are not different from what is happening in Bunkpurugu-Nakpanduri District. Malaria affects farmers and their children thereby resulting in substantial economic losses because of the days they have to spend at home or in hospitals treating the disease. Labour is lost due to farmers' inability to work when attacked by malaria. According to [3], health expenditures on malaria drain limited resources of household. [3] also intimated that when malaria prevalence is reduced, long time productivity would be improved substantially.
Household expenditures on malaria can be put into two main components; expenditure on averting and cost on malaria related treatment which include direct payment for drugs, consultation, laboratory test, transport fees to and from health care providers and cost of subsistence at distance health facilities [4]. The expenditure on malaria that is incurred by the farmers in the Northern Region of Ghana is a major challenge that hinder the economic development in the Region and the country at large. [3] explicitly said that "treating malaria is very expensive, preventing malaria is very cheap". This assertion corroborates the old saying that "prevention is better than cure".
Malaria makes people feel weak and a have general malaise hence their inability to work. Farmers are most likely to loss more on this because of the strenuous nature of their work. A study by [5] revealed that farmers who were given bed nets were able to increase their harvest value by 15%. This suggests that if farmers spend money on bed nets to avert the occurrence of malaria, they are likely to increase the revenue they will obtain from farming by 15%. This might only be beneficial if the money spent on bed nets is less than the 15% revenue obtains for averting. Many researchers have looked at the impact of malaria on agricultural productivity. In a study by [3] on the economic benefits of malaria eradication, he concluded that malaria renders people less productive in the short term, but the long term level of the impact is highly unpredictable.
According to [4], on the average, 3 work days are lost per fever episode by the patient and two work days by the caretaker. The monetary value of these lost work days to the management and treatment of fever per episode is USD 6.87 and this formed about 79 percent of the cost of seeking treatment in 1994. Research on whether or not averting cost expenditure improves labour productivity is limited.
Though several researches have been conducted to get the cost involve in treating and preventing malaria, there is still a wide gap to be filled. The annual averting expenditure on malaria among maize farmers in the Ghanaian context is a gap needed to be filled. Also, the socio-economic determinants of averting expenditure on malaria among farmers have not been given the needed attention. In addition, whether averting improves labour productivity or not is another bone of contention which needs to be unraveled. The effects of malaria on farmers in the Bunkpurugu-Nakpanduri District is a major concern which needs to be given attention. The main occupation of the majority in the district is farming. This implies that the livelihood of a household will be at threat when there is incidence of malaria because it will largely affect labour productivity. Therefore, this study seeks to unravel the determinants of averting expenditure on malaria in Bunkpurugu-Nakpanduri District and estimate the effects of averting on maize labour productivity.

Effect Of Malaria On Agricultural Labour Productivity
Averting expenditure is the cost one will incur in trying to avoid or prevent malaria. Studies have revealed that an annual investment target per person at risk amount to US$3.90 by 2020, US$4.30 by 2025 and US$4.4 by 2030 [6]. This therefore suggest that averagely, an annual amount of not less than US$3.00 will be require to spend on each person towards prevention and elimination of malaria.
The annual cases of malaria reports in Ghana are very alarming and have been a major concern to various stakeholders. In responds to this, an average amount of not less than US$20 million is spent annually to get rid of it. In 2018 fiscal year, an amount of US$26 was invested for malaria prevention and control [7]. The estimated cost of malaria to businesses in Ghana in 2014 was about US$658 million [1].
The incidence of malaria disease has a lot of significant effects on agricultural productivity as it leads to a loss of productive time by both the affected person and the caretaker. A study conducted in Nigeria has revealed that the direct economic cost comprises the effect of malaria caused by mortality, morbidity and debility on individual, household and national labour supply, productivity and output [8]. Poor health would lead to hardship on farming household including monetary expenditures, losses of labour days and sometimes death. Another study has shown that fisher men who were affected by malaria had lower productivity due to the number of days lost from the malaria infection [9]. Households that are inflicted with malaria are less productive than households who are not inflicted by malaria [10]. According to [11], farmers who are affected by malaria are normally characterized by late ploughing, sowing, weeding, harvesting among other farm activities which result into low productivity. respectively [12]. The District lies in the tropical continental belt with climate condition suitable for mosquitoes. The percentage of households in agriculture is about the same for the rural (98%) and urban (97.9%) localities. Most households in the District (97.9%) are involved in crop farming [12].

Sampling Procedure and Data Collection methods
The study used primary data which were collected semi-structure questionnaires. Simple random sampling technique was used to select 10 communities with 20 respondents for each community. This gave a total sample size of 200 respondents for this particular study.

Theoretical Framework of Averting Expenditure on Malaria
The theoretical framework of this study is backed by defensive behavior or averting behavior theory.
It is a revealed preference approach based on a health production function which was first propounded by [13] with an extension to the model by [14]. The model is based on the ideology that an individual experiences some health output, such as a number of days spent on sick bed and this enters into his/her utility function causing disutility [15]. To avoid this disutility, the individual tries to avert.
According to [16], averting behaviour models takes into account any action or expenditures that individual undertake to avoid an illness. Averting behavior models are preventive expenditures or actions that individual undertakes to avoid exposure to any undesirable outcome. This is an approach that says that the value of a small reduction in health state can in principle be measured by the amount an individual is willing to spend on some defensive or averting action to prevent it.
The assumption in the averting behaviour approach in this study is that farmers make choices in other to spend in preventing malaria which will help to maximize their crop labour productivity in the long-run. Farmer's crop labour productivity may be influence by various factors such as farm size, age, education, weedicides used, pesticides used, improved seeds used, and finally averting action taken by the individual to reduce the experiences as a negative health outcome.

Models and Method of Data Analysis 3.4.1 Simple Arithmetic Summation
Simple arithmetic summation was used to estimate the annual averting expenditure for malaria. This was done by multiplying a quantity of the items used by the household in averting malaria with their respective prices. After getting the amount spent on each method of averting, their total summation was computed to obtain the total annual averting cost as shown below.

Conditional Recursive Mixed Process (CMP)
Conditional Recursive Mixed Process (CMP) is a system of equations which estimate recursive effects of variables on the overall outcome variable. To estimate the impact of malaria averting expenditure on maize labour productivity, one needs to estimate two sets of equations. The first equation deals with factors influencing amount of money farmers spend to avert malaria attack. The second equation looks at the effects of malaria averting expenditure on maize labour productivity of farmers. Malaria averting expenditure is an endogenous variables and failure on the part of a researcher to account for the endogeneity may lead to inconsistent estimates. Also, self-selection of some farmers to avert more as compared to others due to certain characteristics that distinguish them can result in sample selection bias. With such a problem, the real impacts of malaria averting expenditure on maize labour productivity may be exaggerated. To deal with this sample selection bias and endogeneity without going through the problem of finding a good instrument, CMP developed by [17] is used to jointly estimate the two equations.
CMP follows the concept of seemingly unrelated regression which assumes that there are high levels of independence among different systems of equations [17, 18 and 19]. It has the ability to deal with incidence of endogeneity [18 and 19]. In this study, a CMP with Ordinary Least Square (OLS) Estimator was used. The first equation of CMP which looks at factors influencing the amount of money farmers spend to avert the incidence malaria is give as: To estimate the effects of averting expenditure on maize labour productivity, the outcome model which is the second equation of CMP is stated as: The definition, measurement and a priori expectations of the variables are illustrated in Table 1  This finding underscores the fact that most rural farmers are still engaged in subsistence level of farming which confirms the findings of [8]. Whilst the average age of a farmer is 51.3years, the average farming experience was 38.1 years. This implies that farmers in Ghana are aging. This can be attributed to the fact that the youth do not see farming as an attractive occupation. The reason can also be that most of the youth have received some level of formal education and hence migrate to cities in search for 'non-existing' white-collar jobs. The mean household size is 7.9 (approximately 8 members) which means that farm household will often depend on the workforce of the family labour for their farming activities. This is in line with [8] who state that farm household will depend on a pull of family labour for farm operations.
This could be that the youth of today are not interested in farming. The number of extension visit per farmer is very low thus 0.7 times per annum. Out of 194 farmers interviewed, 53% were males.
Though women are noted to be largely engaged in farming than men in Northern Ghana they do not have access and control over land due to the nature of land tenure system in Northern Ghana which confirms the findings of [20] that a majority (75.7%) of women believe not to have access and control over land. This is one of the reasons why the percentage of women engage in maize farming in the study area is low.
The percentage of household heads who hat at least primary school education was 56%. The sanitation and hygiene is poorly observed by the respondents are 64% and 67% had bushes and stagnant water around their houses respectively. This suggests that most farmers will spend more in clearing the bush to reduce breeding of malaria which can raise their averting expenditure.
Simple arithmetic summation was used to estimate the averting expenditure among maize farmers in the Bunkpurugu-Nakpanduri District. As depicted in Table 1, the mean annual malaria averting expenditure is GH¢ 284.6. The results corroborated with the findings of [21] that household's expenditure on malaria is GH¢554.40 (for both prevention and treatment). The minimum and maximum expenditures of households in preventing malaria are GH¢24.00 and GH¢990.00 respectively. The vast differences between the minimum and the maximum averting expenditure is attributed to some of the demographic characteristic differences such as bush, stagnant water around houses, household size, income among others.

Determinants of averting expenditure on malaria and labour productivity
In order to identify factors influencing malaria averting expenditure as well as maize production labour productivity, CMP framework with ordinary least square regression model was used (see Table 2). This was done to solve the problem of endogeneity of averting expenditure variable. The atanhrho_12 is negative but insignificant. This implies that there are no unobserved factors affecting malaria averting expenditure as well as maize production labour productivity. Hence there is no selectivity bias. The 1% significance of the likelihood ratio test suggests that there is correlation between the error terms of the malaria expenditure and the maize labour productivity models.
Therefore, the two models could not have been estimated individually [22].

Socio-economic determinants of averting expenditure on malaria
Results from the analysis showed that off-farm income, presence of pregnant women in a household and number of children in school are statistically significant at 5% each. Whilst presence of bushes around the houses was statistically significant at 1%, household size was statistically significant at 10%. This suggests that off-farm income, household size, number of children in school, presence of pregnant women and bushes around the houses significant determinants of averting expenditure on malaria.
The coefficient of off-farm implies that if a household off-farm income increases by GH¢1.00, the amount spent by the household in averting will increase by GH¢0.014 ceteris paribus. This suggests that people become more conscious about malaria as their level of income increases. This is in line with the findings of [23] that, household level of expenditure in preventing malaria will increase as their income level increases.
Also, the coefficient of household size is 7.32 which means that if one person is added to the household, their averting expenditure will increase by GH¢7.32 all other things being equal. This makes an economic sense because as household size increases, their averting materials will equally increase as well and hence the results. In addition, the coefficient of households with bushes is 50.68.
This implies that households that are having bushes around their houses are more likely to spend GH ¢50.68 more than their counterparts ceteris paribus. This is because bushes breed mosquitoes and household will put more effort to get rid of it and hence spending more to avert than houses without bushes. The findings of this study corroborate with the work of [24] that clearing bushes around houses sustainably empowers and strengthens rural communities to reduce mosquito breeding sites.
The clearing of bushes around houses require financial expenditure hence the positive direction of its effects of annual malaria averting expenditure.
The coefficient of presence of pregnant women in a household is 45. 18. This suggests that households with pregnant women are more likely to spend GH¢45.18 more than households without pregnant women. It is in connection with the findings of [25] that most pregnant women are willing to try new method of malaria prevention although cost related barriers to such method were stressed. This is because pregnant women are more susceptible to malaria, and hence households need to employ all means to get rid of mosquitoes and as a result spend more to avert than households without pregnant women. Lastly, if the number of school children in a household increases by one, the amount of money the household will spend to avert malaria will increase by GH¢11.21. School children sometimes educate the parents about the importance of malaria averting as compared to prevention.

Effects of Malaria Averting Expenditure on Maize Labour Productivity
The results show that malaria averting expenditure, farming experience, age of household head, and ownership of motor bike were the significant socioeconomic factors that influence labour productivity.
The coefficient of malaria averting expenditure suggests that if farmers increase their malaria averting expenditure by GH¢1.00 their maize labour productivity will increase by 0.024% Mt/man-day ceteris paribus. Malaria is the common disease during farming season which has a lot of effects on farm labour productivity. Farmers who avert malaria are at less risk to malaria infection and are likely to be more productive as compare to their counterparts who did not avert malaria. This is based on the positive relation of malaria averting expenditure with maize labour productivity which agrees with the findings of [10] that households afflicted with malaria have lower crop output compare with households that are not afflicted with malaria. This further confirms the findings of Ibrahim et al.
(2017) that for every naira spent on malaria prevention, farmers' productivity will increase by N1.85 k.
Farming experience variable suggests that as number of years of farming increases by one, the maize labour productivity of the farmer decreases by 0.19% Mt/man-day ceteris paribus. Experience is an important factor in determining labour productivity and as a result of that, its contribution cannot be overlooked. This might be that farmers who are relatively older and hence are less productive in maize farming. As farmers' advance in age, they become weak and are no more effective as they were young and hence the negative relationship of farming experience with labour productivity. This agrees with the findings of [26] that an increased in age is not conducive to improving agricultural output. This is at variance with the findings of [27] that farmers who are more productive may have spent a greater part of their formative years on the farm and have at least learnt a lot of skills (at least in traditional way) in making good use of available inputs at their disposal. The coefficient of age implies that the labour productivity of farmers will increase by 0.16% Mt/man-day for a 1-year increase in the age. Also, farmers who own motor bikes are relatively highly productive than their counterparts. As shown in Table 2, a farmer who owns a motor bike is 1.78% more labour productive than his or her counterpart.
For production variables, whilst the level of significance of quantity of fertilizer is 1%, seed, and weedicides are statistically significant at 5% each. A 1 kg increase in the quantity of fertilizer applied will increase maize labour productivity by 0.01% Mt/man-day. Similarly, maize labour productivity increases with quantity of weedicides and seeds used. Table 3 depicts the percentage distribution of farmers responds which comprises strongly agree, agree, neutral, disagree and strongly disagree of the various perceived benefits of averting malaria.

Farmers perceive benefit of averting expenditure on malaria
with regards to, averting malaria helps to increase the number of times one goes to farm, 59.50% strongly agreed, 38% of the respondents agreed with 2.50% been neutral and disagreed and strongly disagreed are 0.00% each. The responds indicate that most of the respondents believed they would enjoy that benefit if they averted.
Also, with reference to, averting malaria will help one to save income, the responds to that benefit was also positively skewed with 43.50% of the respondents strongly agree, 51.50% of the respondents agree, 5.00% respondents been neural whiles 0.00% were recorded for both disagree and strongly disagree each. Most of the farmers were of the view that when they avert malaria, they will save their income for other purposes.
In addition, averting malaria helps one to increase labour productivity also received positive responds with 46.00%, 50.50%, 2.00%, 1.00% and 0.05% for strongly agree, agree, neutral, disagree and strongly disagree respectively. The farmers believed that the only way one can be productive is to be free from malaria infection during farming season.
Another perceived benefit is that averting malaria will help a farmer not to spend money in treating malaria. 35.50% of the respondents strongly agree, 62.50% agree, 5.00% of the respondents were neutral whiles disagree and strongly disagree are 0.00% each. Farmers motive was that one can only spend money in treating malaria if the person is infected with malaria but if you avert malaria you will be free from malaria attack and hence don't need to spend money on that.
Moreover, averting malaria will help one to be healthy and active is one of the perceived benefits of averting. 51.50% of the respondents strongly agree, 41.50% agree, 2.00% neutral, with 0.00% of the respondents disagree and 1.00% of the respondents strongly disagree. The general body weakness caused due to malaria infection is undisputable and it always make the victim inactive over time.
Farmers who will spend more in averting will be free from this canker and hence will always be healthy and active.
Averting malaria will help reduce farmer's expenditure on health. 48.00% of the respondents strongly agree, 49.00% of the respondents agree, 2.50% of the respondents were neutral, 0.00% disagree and 0.50% of the respondents strongly disagree. Malaria is the common disease affecting farmers during farming season as most hospitals always record high malaria cases. This suggest that farmer's expenditure on malaria is always high than any other diseases and due to that, their expenditure in treating malaria will drastically reduce if they avert malaria.
Furthermore, averting malaria will help avert other diseases. 48.00% of the respondents strongly agree, 47.50% respondents agree, 3.50% of the respondents were neutral, 1.00% disagree and 0.00% of the respondents strongly disagree. It is undoubtedly clear that malaria comes with it related other diseases such as headache, stomach upset among others. This Implies that once farmers avert malaria then they will possibly do away with its related diseases.
Last but not least, averting malaria helps to reduce the occurrences of sickness in one house. As depicts in Table 3, 48.50% of the respondents strongly agree, 48% of the respondents agree, 1% of the respondents were neutral, 0.00% disagree whiles 0.50% of the respondents strongly disagree. As stated earlier on that malaria cases are the most recorded cases in health centers and is said to be the common occurring sickness in a household, averting malaria implies that the number of times household record sickness within a year will drastically decline.

Conclusions
The research has unraveled that all the farmers interviewed spend some money and effort to avert malaria. They use one or more malaria averting strategies. This can be inferred from household average malaria averting expenditure of GH¢284.60. This is further confirmed by the farmers perceived benefit of averting malaria with more than 90% of the respondents strongly agree and agree with the various perceived benefits. The research has also discovered that averting expenditure on malaria leads to an increase in maize labour productivity. Malaria averting expenditure means that farmers will be free from malaria infection and therefore the number of days lost due to ill health will reduce and hence lead to an increase in their labour productivity.
There should be interventions by Government and relevant stakeholders in formulating and implementing policies and programmes that will promote awareness and measures that will ensure an effective averting of malaria in other to increase labour productivity. The study also recommends intensification of malaria education during the farming season of the year when malaria prevalence is at its highest point.