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Health Outcomes in Pakistan: Empirical essays for Policy Assessment
In resource constrained settings, missing markets and unregulated externalities can have a significant impact on human capital outcomes. High out of pocket expenditure due to the inaccessibility of insurance markets limits the use of healthcare, just as the inability to borrow in the face of a cash constraint may lead to below subsistence levels of consumption. Policy instruments designed around some of these market imperfections are gaining traction in developing countries influenced in large part by international experience. Global discourse around universal health care coverage and minimum basic income has given momentum to programs that provide some form of financial and risk protection to vulnerable populations in low -income countries. Yet, gaps in regulatory protection, for instance, ineffectual implementation of health, safety and environmental policies are also exacerbating the risks for disadvantaged groups. This research examines the health implications of public policy around three instances of market failures in the context of a developing country – Pakistan.
The first study examines maternal healthcare utilization following the introduction of a public health insurance program for low-income families. The market for health insurance addresses the income shock that presents itself in the form of catastrophic expenditure due to a severe illness or injury. In developing countries, well-functioning private markets may not exist, or they may not cater to all segments of the population. Governments driven by equity concerns may then offer subsidized public insurance to protect families from high out of pocket costs. This paper is motivated by the consideration that institutional constraints within the health care system of a developing country may limit the effectiveness of even highly subsidized programs. Any gains in health outcomes are likely conditional on the adequate take up and low barriers to access for eligible population. Indeed, we find that the benefits of the program accrue largely to those in urban areas. The findings suggest that the lack adequately staffed health facilities may preclude the poorest groups from benefiting from such government initiatives. Given the potential of the program to improve health care utilization, complementary investment in infrastructure would make the program more inclusive and better address existing inequities in the use of healthcare.
Missing credit markets also impact household welfare by limiting their ability to borrow in the event of an income shock. As a safety net mechanism, cash transfer programs serve to mitigate the effects of extreme poverty and protect against deprivations caused by adverse shocks. In the second paper, I examine nutritional outcomes following the provision of supplemental income to cash constrained families. Existing evidence suggests that the under accumulation of human capital begins while the child is in utero (Black et al., 2013; Fink & Rockers, 2014; Sudfeld et al., 2015). Consistent with that body of evidence, our analysis highlights the importance of providing cash support during the prenatal period. Additionally, we find that positive nutritional impacts are linked to the birth order of the child. To improve child anthropometric outcomes, a complementary role of informational interventions is recommended for cash transfer programs implemented in low-income settings.
The third paper differs from the first two as it examines the public health implications of the absence of policy in regulating market failure. It explores the externality associated with the agricultural practice of stubble burning. In agriculturally productive regions with access to irrigation, residue burning is used to clear land between cropping cycles in order to plant two or more seasons of crops in a year. It is an unregulated source pollution that imposes a cost on society and on populations with already low access to healthcare. Findings suggest that individuals with high exposure to fire emissions experience higher incidence of respiratory illness. Together, these three papers highlight the health policy nuances that must factor into our efforts towards reducing inequities in health outcomes between countries and among populations
The Impact of Efficacy, Values, and Knowledge on Public Preferences Concerning Food–Water–Energy Policy Tradeoffs
Food, water, and energy (FWE) policies often entail contentious tradeoffs. For example, increasing food production may involve irrigation from riparian sources that may adversely impact fisheries habitats, the siting of solar energy on agricultural lands can impact food production, and increasing food production capacity may require pesticides in certain locations, resulting in environmental pollution. Because public preferences are an important component of support for and opposition to FWE policy design and implementation, it is important to understand the correlates of support and opposition to FWE policy tradeoffs. Using survey data from random household surveys conducted in western U.S. states during 2018, this study examined how environmental efficacy, values, and knowledge affected FWE public tradeoff preferences. The findings suggest that these characteristics do affect public FWE tradeoff preferences, with knowledge being a strong driver of support for food production over biofuels, water friendly crops over meat production and conservation over water intensive agriculture. Additionally, environmental efficacy and pro-ecological attitudes drive support for access to safe drinking water and sanitation over food security for a growing population