How Policy Reaches the Household: Health Effects of Governance and Economic Reform
Paper Session
Sunday, Jan. 3, 2027 8:00 AM - 10:00 AM (EST)
- Chair: Marcella Alsan, Stanford University
The Electoral Returns to Investing in Healthcare
Abstract
This paper investigates whether voters reward politicians for investments in primary health care. We study Rio de Janeiro, the Brazilian city that experienced the fastest rollout of the Family Health Program (FHP) between 2009 and 2012, when population coverage rose from 3% to 37%. The reform combined the construction of Family Clinics with the expansion of traditional health units, offering a unique opportunity to understand whether service delivery improvements translate into electoral returns in a large, unequal urban area.To measure exposure, we use geocoded administrative data on FHP catchment areas, voting behavior, and household locations. Our strategy exploits the staggered rollout of catchment areas, which shifted the composition of exposed and non-exposed voters within polling booths over time. We link polling-booth-level voting to residential addresses, identifying how FHP coverage affected incumbent vote share in 2012. The specification controls for differential pre-trends, spatially correlated shocks, socioeconomic characteristics, and concurrent programs.
We find that voters reward primary health care improvements. A one-standard-deviation increase in FHP coverage raises the incumbent's vote share by 1.02 percentage points, a 3.2% increase relative to baseline. Moving from zero to full coverage yields approximately 3.3 percentage points. Robustness checks using alternative exposure denominators, spatial standard errors, and placebo tests confirm results are not driven by pre-trends. Night-time light data rule out local economic shocks or population movements as confounders.
We then examine why primary care expansion generated electoral gains. Proximity to facilities is not the main channel. Service type and quality drive the results. Expansions through newer Family Clinics produce significantly larger electoral returns than traditional units. Linking facilities to detailed procedure records, technologically intensive and infectious-disease-related services generate the strongest effects, categories that are immediate, salient, and perceived as higher quality. Voters assess health policy through the effectiveness of services, not coverage alone.
Do Men’s Wage Gains Improve Women’s Health? Minimum Wages and Biomarker Evidence from Indonesia
Abstract
Can labor-market policy improve women’s health even when women are not the direct labor-market beneficiaries? This paper studies sustained minimum-wage growth in Indonesia, using province-level variation in real minimum wages between 2000 and 2007 linked to adult labor-market outcomes and biomarkers from the Indonesian Family Life Survey. I compare adults in provinces with above-median minimum-wage growth to those in lower-growth provinces using the Callaway and Sant’Anna difference-in-differences estimator with inverse-probability weighting. The design uses 1997–2000 as a pre-treatment placebo period and 2000–2007 as the treatment period, allowing a direct test of whether high- and low-growth provinces were already diverging before the wage shock.The results reveal a striking gendered transmission mechanism. Minimum-wage growth increased men’s monthly earnings by roughly 190–225 thousand Indonesian rupiah, with little change in men’s employment or hours. Women, by contrast, experienced no meaningful gains in their own employment, paid hours, earnings, or hourly wages. Yet women’s biological health improved: hemoglobin increased by approximately 0.30 g/dL and anemia declined by 8.9 percentage points. Placebo estimates provide little evidence of comparable pre-treatment divergence in women’s hemoglobin or men’s earnings, strengthening the interpretation that the post-2000 changes reflect the minimum-wage growth episode rather than pre-existing trends. Health gains are larger among poorer households, where income constraints and nutritional returns are likely to be more binding: among poor households, women’s hemoglobin rises by 0.326 g/dL and anemia falls by 11.6 percentage points.
The paper contributes to health economics in three ways. First, to my knowledge, it provides the first evidence on the effects of minimum-wage policy on adult biomarker health, using hemoglobin and anemia as direct measures of women’s biological health. Existing minimum-wage-and-health studies largely focus on self-reported health, health behaviors, obesity, mortality, mental health, infant outcomes, or access to care. Second, the paper provides rare evidence on a household-incomepathway
Who Bears the Health Costs of Fiscal Reform? Evidence from Nigeria’s Fuel Subsidy Removal
Abstract
We study how removing a universal, untargeted subsidy affects healthcare utilization across the full sequence of early-life contact with the health system. Using Nigeria's May 2023 petrol subsidy removal—a sharp, nationally unanticipated shock—we examine three outcome domains: antenatal care, birth outcomes, and childhood vaccination. Each domain uses a distinct identification design matched to data structure. For ANC and birth outcomes, we exploit variation in conception-cohort exposure: children born at different dates have different shares of their nine-month gestation window falling in the post-reform period, generating continuous within-cluster treatment variation conditional on birth-month seasonality. Post-reform exposure reduced ANC quantity and content quality, with proportionally larger effects in rural areas. Greater in-utero exposure widened urban-rural disparities in categorical birth size: rural births shifted toward smaller reported categories, while urban births shifted toward larger ones, consistent with an offsetting reduction in combustion-related PM2.5 that disproportionately benefited urban areas. For childhood vaccination, we exploit a within-child design: children born at different times face the same national immunization schedule, so comparing vaccine windows exposed before and after the reform—within the same child—controls for all child-level time-invariant unobservables. Post-reform coverage fell for vaccines requiring return clinic visits, with shortfalls expanding monotonically across the dosing schedule. Three pieces of evidence converge on disrupted physical access—not demand withdrawal—as the dominant mechanism. Rotavirus—newly added to the free national immunization schedule in 2022—and IPV, sustained by externally funded polio-eradication outreach, both maintain coverage despite the access shock. Rural households with older siblings show smaller vaccination shortfalls, consistent with transportation costs being shared across children. These results illustrate a broader pattern: the households capturing the largest implicit transfer under an untargeted subsidy need not be those bearing the largest adjustment cost when it is removed.JEL Classifications
- I1 - Health