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Health and Development

Paper Session

Sunday, Jan. 7, 2018 10:15 AM - 12:15 PM

Marriott Philadelphia Downtown, Grand Ballroom Salon J
Hosted By: American Economic Association
  • Chair: Petra Todd , University of Pennsylvania

Reducing the Cost of Remoteness: The Effects of Community Health Workers Programs on Maternal and Children’s Health in Madagascar

Catalina Herrera Almanza
Northeastern University
Maria Rosales Rueda
University of California-Irvine


Lack of primary health care use can deter preventable maternal and child deaths in low-income countries. In poor-resource settings, community health workers programs have emerged as a supply alternative to deficient formal health care provision among underserved populations, but the empirical evidence on whether such interventions improve health outcomes is inconclusive. We analyze the short-term effects of a large-scale community-based health intervention on fertility and children’s health in Madagascar. This program aimed to generate demand for primary and preventive care through information and to decrease the non-monetary costs for remote households to increase their take-up of primary health care services by training volunteer community health workers in delivering modern family planning and managing childhood illness. To identify these effects, we use a triple difference model that combines the roll-out of the program across time and regions with geocoded data on the households’ distance to the closest health facility. Our findings indicate that the program decreased the risk of conception among women living close to the health facility but did not have a differential effect among targeted women living in remote areas. In contrast, we find that the program improved several measures of immunization status among children living in remote areas. Nevertheless, we do not find statistically significant effects of the program on the likelihood of birth delivery at a formal health facility. Our results are robust to several falsification and specification checks.

Indoor Air Pollution and Infant Mortality: A New Approach

Imelda Imelda
University of Hawaii-Manoa


I estimate the impact a kerosene to liquid petroleum gas (LPG) conversion program on infant mortality in Indonesia. In 2014, World Health Organization reclassified kerosene as a dirty fuel, the same category as biomass, but globally there is still approximately one billion people rely on kerosene for lighting and cooking. LPG produces significantly less indoor air pollution compared to kerosene. On average, 4 fewer infants died per 10,000 live births than would have in the absence of the program. In the developing world, one billion kerosene users switching to LPG can save about 7,000 infants per year.

The Price of Labor: Evaluating the Impact of User Fees on Maternal and Infant Health Outcomes

Anne Fitzpatrick
University of Massachusetts-Boston


In this paper, I test whether abolishing user fees at public health facilities in various sub-Saharan African countries affected maternal healthcare utilization and ultimately decreased child or maternal mortality. Despite the importance of this topic, the evidence on the effects of user fee removal is scant. Meta-analyses by Lagarde and Palmer (2008) and (Hatt et al., 2013) caution that existing studies analyzing user fee elimination for deliveries and c-sections are generally of low quality. Both conclude that the weak evidence suggests that user fee elimination increases health facility utilization with potentially negative impacts on quality, ranging from understaffed facilities to long lines to absences of medical supplies. Specifically, studies find long lines, stock shortages, and absentee staff at public health facilities (Palmer and Lagarde, 2008; Hercot et al., 2011; Ridde, 2011). However, whether those inputs translate into health, well-being, and decreased mortality are typically much more difficult to assess.

In this paper, I combine 24 DHS datasets from 10 sub-Saharan African countries that have all eliminated user fees in at least some part of the country. To identify the impact of user fees, I compare outcomes before and after the policy for the same mother (i.e., a maternal fixed effect). One limitation of this approach is that the effect on these outcomes are only measured on women who report giving birth both before and after the user fee removal. Therefore, I also employ an event-study framework and compare births occurring immediately before and after the policy within a small geographic area. To analyze maternal mortality, I compile all available DHS datasets with a maternal mortality module from these countries. I then analyze whether the rate of pregnancy-related deaths changes among all deaths for women age 16-45 at the time of their death after user fee elimination.

I find that user fee elimination is associated with a with a 1.5-7.4 percentage point increase in deliveries by a skilled attendant, a cost-effective proposal to improve maternal and neonatal outcomes. However, I also find that neonatal mortality increases; babies born after the policy took effect are 1.3 percentage points less likely to survive the first month. However, in some specifications there is no effect on mortality. In analyzing the explanations for these patterns, I find suggestive evidence that maternal mortality declines, potentially changing the composition of mothers giving birth at public health facilities. Overall, I conclude that abolishing user fees is effective at reducing the riskiness of births and may improve maternal healthcare outcomes.

Health Certification in the Market for Sex Work: A Field Experiment in Dakar, Senegal

Shanthi Manian
Washington State University


Female sex workers (FSWs) are disproportionately affected
by sexually transmitted infections
(STIs). In developing countries, estimates of STI prevalence among FSWs have ranged from
28 to 84 percent (Cwikel et al., 2008). A common approach to STI control is a health
certification program known as “legalization with regulation.” Under this policy, used in
over 20 countries, FSWs can avoid some criminal penalties if they obtain certification by
registering with the government, undergoing regular gynecological check-ups, and treating
any diagnosed STIs.
On first examination, legalization and regulation appears to be well grounded in economic
theory. In markets where suppliers possess important, unobservable information, theory
predicts that credible certification can improve welfare (Akerlof, 1970). Sex workers know
more about their STI status than their clients. Even if clients are willing to pay more
to transact with a sex worker who does not have an STI, they have no way of verifying
whether a given sex worker is STI-free. Sex workers then have limited incentives to invest
in their health, increasing STI prevalence. Certification mitigates this problem by providing
a credible mechanism for the sex worker to disclose her health status. Adapting a standard
information disclosure model from Leland (1979) and Spence (1973), I show that when sex
workers’ STI status is unobservable, certified providers should earn higher prices, and when
certification costs are low, all suppliers should choose to get certified.
I test these predictions using a novel randomized experiment among uncertified female
sex workers in Dakar, Senegal. In a sample of 291 uncertified sex workers, I oered
a one-time
monetary certification incentive to a randomly selected treatment group. Take-up of this
incentive was surprisingly low: only 7 percent of the treatment group got certified, relative
to 2 percent of the control group. This result is not driven by the time and transportation
costs of certification: the incentive amount was equal to compensation for participation in
surveys, which carried equivalent time and transportation costs. In contrast to certification
Susan Parker
University of Maryland
Petra Todd
University of Pennsylvania
Nava Ashraf
London School of Economics and Political Science
Rebecca Thornton
University of Illinois-Urbana-Champaign
JEL Classifications
  • I1 - Health
  • O1 - Economic Development