Abstract:
This paper examines the rollout of one of the world’s largest healthcare reforms: the assignment of a new mid-level provider (non-physician practitioner) to each public primary healthcare facility across rural India, impacting healthcare provision for more than 450 million people. Using a matched difference-in-differences strategy based on provider assignment rules and large-scale administrative data covering all villages in the state of Rajasthan up to two years post-reform, we document that the labor inputs increased monthly patient loads at public primary healthcare facilities by 58%. All-age mortality declined by 10%, driven by a decrease in elderly deaths. Results from audits and patient exit surveys document improvements to public healthcare quality and availability of services. We also survey private providers and find that the increased competition from the public sector incentivized private providers to invest in quality upgrades. Estimates from a structural model of patient demand suggest that around half of the decline in mortality is driven by improvements to public healthcare quality alone, while only increasing the availability of public health services would have no effect. Ten percent of the decrease in elderly mortality can be attributed to improvements in the private sector.