PROGRAM | Economics

By: Richard Takyi Amoah Chair: James Berry

ABSTRACT

My dissertation evaluates the effects of health and education reforms on child health and fertility. The first chapter examines the short and long-run impacts of insurance on child health by exploiting the National Health Insurance Scheme (NHIS) in Ghana that was introduced in 2005. The reform was aimed at increasing access to health care by removing user fees. Using distance to the registration center as an instrument, I employ an instrumental variable strategy to evaluate the effects of the reform. My results in the first stage suggest that living closer to a registration center increases mother’s probability of insurance. In the second stage, my results suggest that insurance affects child health in both the short and long runs. In the short run, insurance decreases 7-day and 1-month mortalities by 15 and 16 deaths per 1000 live births, respectively. In the long run,
insurance decreases 1-year and 5-year mortalities by 44 and 88 deaths per 1000 live births. Following the reform, I also find improved health among children who survive. I find that children born after the reform are 23 and 8 percentage points less likely to be stunted and wasted,
respectively. Examining possible pathways through which insurance affects health, I also find that insurance increases facility births, antenatal visits, and vaccination rates. Also, women with insurance sought early care during pregnancy and after delivery.

Health insurance can affect fertility positively or negatively. Fertility could increase if insurance decreases the cost of having a child, or fertility could decrease if parents believe that healthier children will grow old to take of them in their old age. Education, on the other hand, mainly decreases fertility. In the second chapter, co-authored with Sheila Afrakomah, we take advantage of the NHIS and an education reform, also introduced in Ghana in 2005, to estimate the effects of these concurrent programs on fertility. The Free Primary Education (FPE) removed
school fees in public primary schools. We combine an instrumental variable and a difference-indifference strategy based on the FPE and NHIS reforms in Ghana. We begin by separately estimating the effect of FPE and NHIS on fertility. We find that high exposure to FPE reduces the
total number of births by 0.39 births and reduces the probability of first birth by 27 percentage points by age 25. FPE also increases the timing of first marriage by decreasing the likelihood of first marriage by 8 percentage points by age 25. However, women more exposed to NHIS have
0.94 more births and are 35 percentage points more likely to have their first child by age 25. The results from the separate estimations suggest that education reduces fertility whiles insurance increases fertility. Finally, we measure the effect of exposure to both reforms on fertility by using
an instrumented difference-in-difference strategy. We find that the negative FPE effect on fertility lessens with increasing exposure to NHIS, while the positive NHIS effect on fertility is reinforced with increasing exposure to FPE.

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