Fighting Silent Killers: How India’s Public Healthcare Staffing Expansion Saves Lives by Improving Access and Market Quality

Abstract

Millions of adults in low- and middle-income countries die from treatable conditions every year. This paper highlights that an understaffed public healthcare system contributes to high premature mortality, both directly by affecting public provision and indirectly by allowing low-quality private providers to remain competitive. We evaluate a large-scale reform to India’s public healthcare system that adds a mid-level healthcare worker to village clinics. Exploiting quasi-experimental variation due to assignment rules, we find that adding a worker reduces all-age mortality in the catchment area by 10% within two years, making the reform highly cost-effective. Eighty percent of the decline is attributable to a decrease in deaths of adults aged 56+, increasing their life expectancy by at least three months. We conduct audit visits, patient exit interviews, and provider surveys to study mechanisms and find that the program improves performance and service availability in the public sector and also induces private providers to increase their quality. To quantify the importance of each of these channels and evaluate counterfactual policies, we estimate a structural model of patient demand. Ten percent of the decrease in all-age mortality can be attributed to the private sector response, while the remaining 90% is due to simultaneous improvements in public sector quality and access. Only improving public sector quality or access in isolation has limited effects. Model estimates further demonstrate large heterogeneity in predicted treatment gains; we show that an optimal reallocation of the new providers that accounts for local market conditions could achieve a substantially greater reduction in mortality.