This article explores the impact of female political representation in national parliaments on child health through a multilevel analysis. Using available Demographic and Health Surveys, we employ both cross-sectional data for 51 low- and middle-income countries and longitudinal data for 20 countries with multiple surveys. For both the cross-sectional and longitudinal analyses, female representation is negatively related to infant mortality and positively related to measles vaccination status. To explore potential mechanisms, we control for state spending on health and analyze whether the impact of female representation depends on a critical mass of female representatives. The analysis offers evidence that state spending accounts for some of the mediation effect and that the impact of female representation on infant death depends on a critical mass.

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Background Starting in 2006 to 2007, the Government of Bangladesh implemented the Maternal Health Voucher Scheme (MHVS). This program provides pregnant women with vouchers that can be exchanged for health services from eligible public and private sector providers. In this study, we examined whether access to the MHVS was associated with maternal health services utilization, stillbirth, and neonatal and infant mortality. Methods and findings We used information on pregnancies and live births between 2000 to 2016 reported by women 15 to 49 years of age surveyed as part of the Bangladesh Demographic and Health Surveys. Our analytic sample included 23,275 pregnancies lasting at least 7 months for analyses of stillbirth and between 15,125 and 21,668 live births for analyses of health services use, neonatal, and infant mortality. With respect to live births occurring prior to the introduction of the MHVS, 31.3%, 14.1%, and 18.0% of women, respectively, reported receiving at least 3 antenatal care visits, delivering in a health institution, and having a skilled birth attendant at delivery. Rates of neonatal and infant mortality during this period were 40 and 63 per 1,000 live births, respectively, and there were 32 stillbirths per 1,000 pregnancies lasting at least 7 months. We applied a difference-in-differences design to estimate the effect of providing subdistrict-level access to the MHVS program, with inverse probability of treatment weights to address selection into the program. The introduction of the MHVS program was associated with a lagged improvement in the probability of delivering in a health facility, one of the primary targets of the program, although associations with other health services were less evident. After 6 years of access to the MHVS, the probabilities of reporting at least 3 antenatal care visits, delivering in a health facility, and having a skilled birth attendant present increased by 3.0 [95% confidence interval (95% CI) = −4.8, 10.7], 6.5 (95% CI = −0.6, 13.6), and 5.8 (95% CI = −1.8, 13.3) percentage points, respectively. We did not observe evidence consistent with the program improving health outcomes, with probabilities of stillbirth, neonatal mortality, and infant mortality decreasing by 0.7 (95% CI = −1.3, 2.6), 0.8 (95% CI = −1.7, 3.4), and 1.3 (95% CI = −2.5, 5.1) percentage points, respectively, after 6 years of access to the MHVS. The sample size was insufficient to detect smaller associations with adequate precision. Additionally, we cannot rule out the possibility of measurement error, although it was likely nondifferential by treatment group, or unmeasured confounding by concomitant interventions that were implemented differentially in treated and control areas. Conclusions In this study, we found that the introduction of the MHVS was positively associated with the probability of delivering in a health facility, but despite a longer period of follow-up than most extant evaluations, we did not observe attendant reductions in stillbirth, neonatal mortality, or infant mortality. Further work and engagement with stakeholders is needed to assess if the MHVS has affected the quality of care and health inequalities and whether the design and eligibility of the program should be modified to improve maternal and neonatal health outcomes.

Although the positive developmental effects of infrastructure provisioning are well documented, research on the potential role of governance in the improvement of infrastructure performance and individual-level service utilization is lacking. I explore the effect of infrastructure provisioning on individual-level health service utilization, paying close attention to whether governance at different levels shapes people's access to health care. The different geographical levels of infrastructure provisioning, governance, and health service utilization require a multilevel analysis, which I perform using Afrobarometer Round 5 survey data on 34 African countries in a three-stage mixed-effects modeling. Results show that the presence of health infrastructure is crucial for enhancing people's health service utilization. However, people encounter certain problems when receiving services at their local health clinics or hospitals, and these problems are directly linked with governance in the health sector as well as overall governance at the country level. Improvements in people's health service utilization therefore require both better infrastructure provisioning and better governance at different levels, as the former does not guarantee the latter. Development scholars need to widen their focus beyond national-level governance and help policy makers identify at which level state interventions are most needed for removing barriers to development.

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