Essays on Health in Developing Countries
Abstract: Health plays an essential role for human and economic development. This thesis consists of four independent empirical papers on health and health care in developing countries. The first paper investigates the relationship between globalization, democracy, and child health in low- and middle-income countries. Using panel data for 70 developing countries between 1970 and 2009 we examine how globalization and a country's democratic status and historical experience with democracy, respectively, affect infant mortality. In line with previous research, our results suggest that globalization reduces infant mortality and that the level of democracy in a country generally improves child health outcomes. Additionally, democracy influences the the extent to which globalization can affect child health. If, e.g., C\^ote d'Ivoire had been a democracy in the 2000-2009 period, this would translate into 1,200 fewer infant deaths in an average year compared to the situation without democracy. Nutrition is the most important mediator in this relationship.The second paper evaluates the effects of a multilateral debt relief program on child health. The International Monetary Fund and the World Bank launched the Heavily Indebted Poor Countries (HIPC) Initiative in the late 1990s to reduce the debt burdens of poor countries, and explicitly linked the initiative to poverty reduction and social targets. The paper employs micro data on infant mortality from 56 country-specific Demographic and Health Surveys to investigate the effects of the HIPC Initiative on child health. Specifically, I use the within-mother variation in the probability of survival of babies before and after different stages of the initiative. The results suggest that after a debt-ridden country enters the program, which is conditional on reform and pro-development policies, and receives interim debt relief, the probability of infant mortality goes down by about 0.5 percentage points. This translates into about 3,000 fewer infant deaths in an average HIPC. The findings are particularly strong for infants born to poor mothers and mothers living in rural areas, and are driven by access to vaccines early in life and during pregnancy.The third paper analyzes health worker competence in Sub-Saharan Africa. I investigate how variations in health worker competence across categories of curative care depend on medical training and work cadre along with work environment characteristics such as location and institutional affiliation. I use novel and detailed data on health worker knowledge from the World Bank's Service Delivery Indicators project. Health workers' medical knowledge is measured across four categories (background questions including examinations and tests, diagnosis, treatment, and health education) by performance in so called vignettes. The findings suggest that health worker competence is very low across all categories of care. Higher work cadres are better in almost all competence categories compared with health workers with no medical training. Treatment knowledge variation is particularly low. For example, doctors and specialists are more competent than the next health worker category in terms of treating patients. Competence is higher in public facilities among doctors and specialists, and nurses and midwives. Furthermore, community health workers in rural facilities are more competent than their counterparts in urban locations.The fourth paper investigates how patients can evaluate the quality of care at health facilities in Nigeria. Information failure may contribute to the problem of low-quality health services in low- and middle-income countries, as patients may have insufficient knowledge to discern the quality of health services. This paper investigates whether patients can evaluate health service quality effectively. We demonstrate that although more than 90 percent of the patients agree with any positive statement about the quality of their local health services, satisfaction is significantly associated with the diagnostic ability of the health workers at the facility. Satisfaction is not associated with infrastructure quality or prescriptions of medicines. This suggests that patients may have sufficient information to discern some of the most important elements of quality, but that alternative measures are crucial for gauging the overall quality of care.
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