Essays on Health and Family Economics in India

Abstract

A person's health not only influences her chance of surviving to adulthood and her life expectancy, but also her economic decisions, her productivity, and her well-being. Since a healthy population is a major factor in economic development, it is important to understand the determinants of individuals' health-related decisions and outcomes. The three essays that comprise this dissertation make advancements in this direction and focus on the Indian subcontinent. The first and second essays analyze how intra-household decision making affects individuals' health outcomes and welfare, with a special attention towards within family gender inequality. The third essay studies how exposure to historical medical facilities affects individual health outcomes across generations. From a methodological point of view, this dissertation highlights the advantages of combining economic models with data from a wide range of sources, theory with empirics. I employ both quasi-experimental and structural estimation methods, using the former to uncover relevant causal links and policy levers, and the latter to estimate deep parameters, overcome data limitations and perform counterfactual policy analysis. More broadly, with this work I stress the importance of research in development economics being open to a variety of methodologies and empirical approaches. The ratio of women to men is particularly low in India relative to developed countries. It has recently been argued that close to half of these missing women are of post-reproductive ages (45 and above), but what drives this phenomenon remains unclear. In the first essay, titled “Why Are Older Women Missing in India? The Age Profile of Bargaining Power and Poverty”, I provide an explanation for this puzzle that is based on intra-household bargaining and resource allocation. I use both reduced-form and structural modeling to establish the critical connections between women's bargaining position within the household, their health, and their age. First, using amendments to the Indian inheritance law as a natural experiment, I demonstrate that improvements in women's bargaining position within the household lead to better health outcomes. Next, with a structural model of Indian households, I show that women's bargaining power and their ability to access household resources deteriorate at post-reproductive ages. Thus, at older ages poverty rates are significantly higher among women than men. The analysis indicates that gender inequality within the household and the consequent gender asymmetry in poverty can account for a substantial fraction of missing women of post-reproductive ages. Finally, I demonstrate that policies aimed at promoting intra-household equality, such as improving women's rights to inherit property, can have a large impact on female poverty and mortality. The first essay contributes to a wide literature showing that a relevant determinant of the household decisions and outcomes is the relative bargaining position of the decision makers. Although this link is well-accepted in this literature, intra-household bargaining power is de facto an unobserved variable. In the second essay, joint with Arthur Lewbel and Denni Tommasi and titled “Women's Empowerment and Family Health: A Two-Step Approach”, we propose a novel two-step approach to overcome this data limitation and to directly assess the causal link between women's empowerment and family health. In the first stage, we structurally recover a dollar-based measure of women's intra-household empowerment, with a clear interpretation provided by economic theory; in the second stage, we identify the causal effect of women's decision power relative to men's on household members' health. We demonstrate that women's bargaining power improves their own health outcomes, while not affecting their spouses'. When we turn to children, we find that improvements in women's position within the family does not affect their weight or height, but it increases their likelihood to receive vaccinations. The determinants of individuals' health, however, go beyond the family, and trace back to historical developments. In the third essay, joint with Federico Mantovanelli and titled “Long-Term Effects of Access to Health Care: Medical Missions in Colonial India”, we examine the long-term effect of access to historical health facilities on current individual health outcomes. To this aim, we construct a novel and fully geocoded dataset that combines contemporary individual-level data with historical information on Protestant medical missions. We exploit variation in the activities of missionary societies and use an instrumental variable approach to show that proximity to a Protestant medical mission has a causal effect on individuals' health status. The investigation of potential transmission channels indicates that the long-run effect of access to health care is not driven by persistence of infrastructure, but by changes in individual habits regarding hygiene, preventive care and health awareness, which have been bequeathed over time. Important policy implications can be drawn. First, policies aimed at promoting gender equality within families, such as improving women's property and inheritance rights, can have positive spillovers on women's health, poverty and mortality, and can boost health investments in children. Second, as the population in India and in other developing countries ages, gender asymmetries among the elderly need to be further investigated and promptly addressed by the development practitioners. Third, intra-household inequalities, between genders and across ages, should be taken into account when measuring poverty and evaluating the effect of policies to alleviate it. Finally, in light of the existence of long-run effects, the expansion of health care access in India should become an even more prominent goal for policy makers, as it can beneficially affect both current and future generations.