Essays in Health Economics

Abstract

My dissertation broadly relates to the low uptake of preventive health services in developing countries despite the services’ low cost and potential to avert subsequent catastrophic expenses. In the first two chapters, I answer two key questions on preventive health that are of general interest to health researchers and policymakers.

First, can we improve the uptake of health services by the traditionally marginalized groups through the use of differential financial incentives to outreach workers? I answer the question using a field experiment in Nepal. In the experiment, I varied the amount of financial incentives provided to the health outreach workers by the ethnicity of the client they recruited for a free sugar-level assessment. I also varied the amount of incentives the clients received for appearing for the assessment. I find that the barriers due to ethnicity are high. Even a highly skewed differential incentive (in the ratio of 5:2) favoring cross-ethnic interactions is insufficient to offset the barriers. Encouragingly, differential incentives to the advantaged workers, geared toward encouraging them to refer disadvantaged individuals, have the potential to improve access for the disadvantaged groups.

Second, what are the long-term consequences of preventive health measures undertaken in childhood? There is now a critical threshold of evidence documenting the relationship between one’s exposure to shocks in early life and outcomes in adulthood. However, there is limited evidence on pathways and mechanisms and the role of critical periods. In the second chapter, I attempt to fill this gap by evaluating the long-term effects of Nepal’s vitamin A supplementation program. The primary goal of the program was to reduce mortality associated with the nutrient’s deficiency. The sequential rollout of the program between 1993 and 2001 and the age eligibility provide an exogenous variation in exposure to the program. Utilizing that variation, I find that the program reduced the probability of having a disability or blindness, kept children in school longer, and enabled them to complete different grades by an expected age. The positive effects on disability and education seem to have improved marriage prospects. The program also had different effects on individuals based on their timing of the exposure to the program, with a longer exposure usually strengthening the positive effects. As expected, effects also differed by the individual’s gender and ethnicity, with more pronounced effects for men and individuals from traditionally advantaged ethnic groups.

In the third chapter, I evaluate an existing program broadly aimed at reducing child mortality and improving women’s health behavior using a rigorous econometric technique. I evaluate the impact of Community-Based Neonatal Care Package, which Nepal’s government piloted in 2009 in 10 of the 75 districts. The causal effect of the program is established using a before-and-after comparison of outcomes in program districts relative to those in non-program districts. I find that the program was successful in encouraging cleaner deliveries for births that took place at home and in increasing prenatal visits to the health center by pregnant women significantly. Despite these positive effects on intermediate outcomes, the program’s overall effect on neonatal mortality was limited. There is also no evidence that the program increased institutional or professional-attended deliveries. The lack of an effect on other supply-dependent indicators suggests that supply-side constraints may have dampened the program’s overall effect.