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

Governments in low-income countries have devoted substantial resources to promoting facility birth, yet early-life mortality remains high. I leverage an exogenous increase in travel costs to health facilities arising from the interaction between rainfall around the day of birth and distance to the nearest facility to study the impact of expanding access to facility birth in Malawi. I find that only high-risk pregnancies with access to high-quality care experience significant survival gains. The systematic mismatch between high-risk pregnancies and low-quality facilities at the last mile helps explain the limited mortality reductions achieved through access expansion. I further use facility birth to study how exogenous contact with formal healthcare shapes future behavior. Exposure to low-quality facilities decreases the likelihood of future healthcare visits, suggesting that expanding access to poor service quality can backfire by discouraging future engagement with formal care and worsening long-run health outcomes.

Medical Colleges and Front-line Health Workers with Sabareesh Ramachandran (2024 NEUDC Distinguished Paper Award)

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