Beyond Access: Facility Birth, Healthcare Use and Early-life Mortality in Malawi (Job Market Paper)

In recent decades, governments in low-income countries have allocated substantial resources to promote facility birth as a strategy to reduce maternal and neonatal mortality. These efforts have expanded access to delivery care, yet newborn health outcomes remain far behind those in high-income countries. The causal effect of these policies is unclear, since marginal users might only have access to low-quality facilities that fail to provide life-saving care and may backfire by discouraging future use. I use an exogenous increase in travel cost to healthcare facilities to study when access to facility birth improves health outcomes and how exposure to formal healthcare shapes future utilization in Malawi. I find that access to facility birth reduces neonatal mortality only for high-risk deliveries that have access to a doctor, but worsens outcomes for low-risk births. I also find lasting effects on healthcare use: mothers show persistence in delivery choices, sticking to the same place of delivery for the subsequent child; however, for those with access to facilities with limited resources, giving birth in a facility reduces the likelihood of future visits.

Medical Colleges and Front-line Health Workers with Sabareesh Ramachandran

Proximity to providers is essential for non-tradable services like health and education. However, the distribution of providers per capita is skewed towards cities with better amenities. Training the locals to become providers could be more effective than moving qualified providers to remote areas. In this paper we study the impact of opening a medical college in a district on access to care, take-up of care, and in turn on health outcomes in the same district. A two-way fixed effects regression is used to study the 5x growth in medical colleges in India between 1980 and 2020. One additional batch of students graduating from a college in the district is associated with a 4.3pp increase in health facilities and health workers. This increase is almost entirely in the private sector in urban areas. This leads to an increase in healthcare visits by pregnant women. However, we do not see any significant improvements in morbidity or mortality outcomes. Reforming public hiring to post some of the additional health workers in well-equipped public health facilities may be a promising strategy to make improved access translate into better health outcomes.

Traditional Medicine and Demand for Modern Healthcare with Graça Cumbi,  Andre Gray,  and Sara Lowes

Integrating Traditional and Conventional Medicine for Improved Healthcare Access, with Graça Cumbi, Andre Gray, and Sara Lowes