The effects of health sector reform interventions in Egypt on family planning and maternal and child health

This thesis is composed of four essays that make empirical contributions to impact evaluations of health sector interventions in low- and middle-income countries, in light of the interventions introduced under Egypt#s Health Sector Reform Program (HSRP) between 2000 and 2014. We are mainly interested in the effects on family planning and maternal and child health. Different methods are used in this context: difference-in-differences (DD), DD propensity score matching (PSM), fixed effects (FE), random effects (RE) and pooled ordinary least-squares (POLS). In chapter 3, we estimate the effect of improving the quality of health care through facility accreditation on the family planning, maternal health and child health outcomes that we expect to reflect the effect of compliance with quality standards, policies and procedures. We found that accreditation had multiple positive effects, especially on delivery care and child morbidity prevalence. No significant effects were observed, however, with respect to most antenatal care (ANC) outcomes. In chapter 4, we estimate the medium-term effect of introducing user fees on the utilization of family planning, ANC and delivery care services, women's access to health care, and child health status. With respect to ANC, we found that the positive effect of increased willingness to pay for an improved quality of service outweighed the negative effect of the price elasticity of demand. Introducing user fees was associated with a higher likelihood of receiving ANC by skilled health personnel, a higher likelihood of receiving at least four ANC visits and a higher likelihood of receiving iron supplements during pregnancy. However, the two effects offset each other with respect to the outcomes that reflect the utilization of family planning and delivery care services, women's access to health care, and child health status. No net effect at all was observed on these outcomes. Chapter 5 complements the analysis of chapter 4 by allowing us to estimate the net effect of combining user fees and two quality improvement interventions: facility accreditation and performance-based financing (PBF). Again, we observe positive effects on both the utilization and the quality of ANC services. More notably, a positive effect on access to care was observed during our first study period that is more likely to reflect the effect of quality improvements. These effects, however, were reversed during the second study period that is more likely to reflect the effect of user fee introduction. The positive effects reported in chapters 4 and 5 were mainly with respect to ANC. No effects were reported on the outcomes that reflect the utilization of family planning and delivery care services, and child health status. In chapter 6, we estimate the effect of discontinuing provider incentives on health outcomes that reflect the health services targeted by the PBF scheme as well as the quality of these services. We found that discontinuing the incentives had a negative effect on four out of seven health outcomes: knowledge of contraceptive methods, receiving ANC by skilled health personnel, receiving iron supplements during pregnancy, and more importantly, under-five child mortality. Our findings, first, suggest that improving the quality of care through facility accreditation could be particularly effective in improving delivery care and child health. However, a high level of commitment from the central government is indispensable to sustain the positive effects of quality improvement interventions. Second, introducing user fees will not necessarily have negative effects on access and utilization of family planning, maternal health and child health services. However, user fees are ineffective, in general, as a stand-alone policy. Third, negative effects of introducing user fees in low- and middle-income settings on the utilization of healthcare services can be mitigated by officially exempting the poor from any fees at the point of service. More importantly, this exemption should be known to the population. Fourth, combining quality improvement interventions with user fees will not necessarily add to the few positive effects obtained when user fees are introduced as a stand-alone policy. Finally, provider incentives should be introduced carefully in low- and middle-income countries as negative effects are observed when these incentives are discontinued