Why Healthcare CCTs may not Improve Children's Health:Insights from India's Janani Suraksha Yojana

This paper evaluates a conditional cash transfer program, Janani Suraksha Yojana, which drove a large expansion in the use of public health facilities by mothers and their newborn children in India.The program did not improve children’s mortality (as previous research documents and I confirm). I focus on understanding why. Using birth-histories from the Indian Human Development Survey (2011 and 2005), I estimate within-mother effects of the staggered arrival of the program across districts in India. The key finding is that families’ preference for sons over daughters has an important bearing on the program’s effects, especially in regions where the health system is less developed. A triple difference strategy reveals that families that were more likely to desire a son - those with no sons at baseline - increased fertility under the program (relative to the other families), and, exhibited a worsening of newborn mortality for daughters, but not for sons. This finding holds for under-developed regions where healthcare is of poor quality. This highlights a challenge for demand-side interventions in healthcare: the character of demand may reflect social biases that undermine children’s health in the first place. In settings where the quality of healthcare is low, this may have stark consequences.