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

Governments in low-income countries allocate substantial resources to promote facility birth as a strategy to reduce maternal and neonatal mortality. However, its causal effect is ambiguous because marginal users may only have access to low quality facilities that are unable to provide lifesaving care and may even discourage future use of the formal system. Using data from Malawi, I find that facility birth significantly reduces neonatal mortality for high-risk deliveries, especially when a doctor is present. In contrast, facilities without doctors can worsen outcomes for low-risk births. This suggests that the share of facility births is not a sufficient policy metric, as impact depends critically on facility quality and baseline risk. Facility birth also has lasting effects on health-seeking behavior: mothers are more likely to seek care in the future if their initial experience was with a high-quality facility, raising concerns that promoting facility birth without ensuring quality may discourage future use of the formal healthcare system. Finally, I find evidence of habit formation in childbirth: mothers tend to return to the same place for subsequent deliveries, regardless of quality, highlighting the potential multiplier effects of expanding access to facility birth.

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