Infant Mortality and Desired Fertility: The Case of the Free Health Care Initiative in Sierra Leone

Abstract

Sierra Leone launched the Free Health Care Initiative, which abolished health user fees for pregnant and breastfeeding women and children under five years of age, in 2010. Combining data from the Demographic and Health Survey and a geocoded dataset for the distribution of public health facilities, I design a difference-in-differences study involving birth timing and transportation cost to investigate its impact on infant mortality and desired fertility. I find that the program does not achieve its goal of reducing infant mortality, with the lack of vaccination being a major problem. Notwithstanding the lack of reduction in infant mortality, the program leads to a significant decline in desired fertility, implying that parents may overestimate the program’s benefits and change their expectations of infant mortality accordingly. Heterogeneous effects by household wealth suggest that poor households are more adversely affected by the program than wealthy ones.

Keywords:

• Health reform
• infant mortality
• desired fertility
• Sierra Leone
• Africa

JEL CLASSIFICATION CODES::

• I18
• J13
• O12

Disclosure statement

No potential conflict of interest was reported by the author(s).

Notes

1 The MDG4 is to reduce child mortality. Relevant information is available at https://www.undp.org/content/undp/en/home/sdgoverview/mdg_goals/mdg4/. The SDG3 is good health and well-being. Its targets related to infant and child health are available at https://www.un.org/sustainabledevelopment/health/. Both data sources were accessed on December 20, 2021.

2 The under-five mortality data from UNDP are available at http://hdr.undp.org/en/data#. They were accessed on December 20, 2021.

3 The under-five mortality data from UNDP are available at http://hdr.undp.org/en/data#. They were accessed on December 20, 2021.

4 The fertility data from the World Bank are available at https://data.worldbank.org/indicator/SP.DYN.TFRT.IN?end=2019&locations=SL&start=1960. They were accessed on December 20, 2021.

5 The document can be found at https://unipsil.unmissions.org/sites/default/files/old_dnn/free_services_framewk_nov09.pdf, accessed on December 20, 2021.

6 More information on Standby Task Force can be found at https://standbytaskforce.wordpress.com/, accessed on December 20, 2021.

7 Sierra Leone is divided into 13 health districts corresponding to its administrative districts, except for the Western Area Rural and the Western Area Urban, which are combined into the Western Area Health district.

8 In my sample, mortality before the age of one comprises 80% of the deaths before the age of five. Recommended vaccinations before the age of one are BCG, polio (three doses), DPT (three doses), and measles. The number of doses given to a child is added up and standardized by the total of eight doses.

9 I compare only two cohorts born before April 2010 because the sample size of children born in each month of each year is too small to conduct an event study by birth timing (see Supplementary Materials Appendix Table 2).

10 $C_{\mathit{imhdt}}$ controls for the last child’s characteristics in this specification.

11 Although the Western Area with rich medical resources is the most attractive place for migrants (20% of recent in-migrants), some districts with less medical resources also attract a large proportion of migrants (Supplementary Materials Appendix Table 4). For example, 8% of Bo’s residents were rent in-migrants, probably because it is an early administrative and educational center.

12 There is no ideal number of children reported by husbands in the dataset. Hence, I use a variable indicating whether the husband desires more children than his wife to capture the intrahousehold disagreement about desired fertility. This dependent variable gives me a husband sample smaller than the mother sample.

13 The binary variable for the poor household is equal to one if the household is the poorest, the poorer, or in the middle, according to the wealth index. It is equal to zero if the household is the wealthiest or the wealthier according to the wealth index. The five categories of household wealth are reported in Table 1. While $R_{\mathit{imhdt}}$ and $H_d$ are fully absorbed by birth-timing fixed effects (${\mu }_t$) and district fixed effects, respectively, their interactions with the binary variable for the poor household are not. So in addition to the three-term interaction between $R_{\mathit{imhdt}}{*H}_d$ and the binary variable for the poor household, $R_{\mathit{imhdt}}$ and $H_d$ are also interacted with the binary variable for the poor household, respectively.