Dissertation Title： "Maternal Health and Child Development Programs in the United States and Rwanda: An Evaluation of Policies to Improve Quality and Efficiency"Improving maternal and child health remains a significant policy challenge globally. This dissertation evaluates national programs in the United States and Rwanda that seek to strengthen maternal care and promote healthy child development.
Chapter one analyzes the impact of Rwanda’s national pay-for-performance (P4P) program on rewarded maternal and child health services and health outcomes, and tests for unintended consequences of P4P such as provider multitasking. In a difference-in-differences analysis using the Rwanda Demographic and Health Surveys, we find that P4P significantly increased the output of several rewarded maternal health services, including institutional delivery, tetanus vaccinations and contraceptive coverage. P4P had no significant impact on other rewarded services or health outcomes, and there was little evidence of multitasking. We also find mixed effects of P4P by baseline facility quality. Our results highlight the opportunities and challenges in implementing P4P in resource-limited settings.
Chapters two and three focus on Head Start, the largest federally funded child development program in the US. In chapter two, using experimental data from the Head Start Impact Study (HSIS) I compare the effect of Head Start on measures of child development relative to two distinct groups: children who received home-based care, and children who attended other non-Head Start centers. Relative to home-based care, I find that Head Start achieves larger gains across a range of developmental outcomes; relative to other center-based care, Head Start’s impacts are smaller and restricted to improvements in behavioral outcomes and access to health care. Compared to either group, gains from Head Start largely dissipate within one year of leaving the program. These findings suggest that Head Start improves measures of child development in the short-term, particularly in comparison to home-based care – but also raise questions about Head Start’s longer-term impacts.
Chapter three examines efficiency and equity trade-offs of targeting strategies that seek to increase Head Start’s average impact by prioritizing enrollment of children expected to have larger treatment effects. I identify child- and family-level characteristics that predict variations in Head Start’s impacts in the HSIS data, construct targeting strategies based on these characteristics, and simulate their effects on cumulative program impacts and equity measures (i.e., the baseline school readiness, relative economic disadvantage, and racial composition of the enrolled group). I find that targeting Head Start enrollment towards entering 4 year-olds who are otherwise likely to receive home-based care achieves the largest efficiency gains, but increases racial disparities in access to Head Start. Further prioritizing the enrollment of children from the most disadvantaged households, however, can eliminate these disparities while maintaining efficiency gains.