Globally, nearly 40% of under-five deaths occur in the first 28 days after birth. Neonatal mortality is concentrated in sub-Saharan Africa and South Asia with an estimated 80% of all neonatal deaths occurring in the two regions. Low quality of care has been associated with poor health outcomes in low-and middle-income countries (LMICs). Low quality of intrapartum care has been shown to be strongly associated with poor newborn outcomes. Improving access to high-quality neonatal care for small and sick newborns is crucial to reducing preventable deaths in the immediate newborn period. Over the last two decades, significant advances have been made in measuring the coverage, quality and equity of maternal health services. However, few studies to-date have explored the quality of care for small and sick newborns in resource-constrained settings. Those studies conducted in low-and middle-income settings demonstrate that in-patient service readiness for small and sick newborns is low. While there have been increasing efforts to develop and standardize metrics for measuring facility readiness for this population, few studies to-date have explored the effective coverage – a term used to denote utilization adjusted for quality – of services for emergency newborn care in such settings. Recommendations for intervention packages for small and sick newborns have largely focused on secondary and tertiary levels of care, leaving the role of community and peripheral facilities under-explored. Central to the agenda of improving the coverage of high-quality services for small and sick newborns is also strengthening the capacity of health workforce that participate in their care. A plethora of training packages and supervision strategies have been tried and tested in LMICs for improving emergency obstetric care with the focus on emergency newborn limited to a few complications. These human resources initiatives have been criticized for being fragmented in implementation. Little is known about the quality of training and supervision for emergency newborn care competencies for the rural health workforce in under-resourced settings. This dissertation is presented in three papers to help evaluate specific components of quality and coverage for the small and sick newborn population in LMICs. Paper one identifies and describes the breadth of strategies used to successfully translate evidence-based community interventions for the management of newborns with possible serious bacterial infections (PSBI), enabling the generation of a common and consistent taxonomy for practitioners and researchers in this domain. Paper two uses quantitative methods to examine the service readiness and effective coverage of services for small and sick newborns at the sub-district and district levels in rural Ghana. Paper three, using a mixed-methods design, assesses health worker perceptions of the quality and gaps in training, supervision and tele-mentoring activities for emergency obstetric and newborn care in rural Ghana.

Mistreatment experienced by women delivering in healthcare institutions is a concerning pattern reproduced and normalized in health systems globally, causing widespread harm. Women’s reports and observations of childbirth practices in institutions have revealed that disturbing proportions of deliveries are characterized by indignity, humiliation, and neglect. The enormity of the problem constitutes a social catastrophe, as potentially hundreds of thousands are affected daily at a profoundly important moment of personal, family, and social life. Growing global concern has elicited research on mistreatment’s prevalence and characteristics, with limited attention to developing explanatory theory. The observed patterns indicate that mistreatment is systemic; therefore, social theory is required to understand why mistreatment persists, despite official norms that prohibit mistreatment and promulgate respectful care. Diane Vaughan’s normalization of organizational deviance theory from organizational sociology, emerged from studies of how things go wrong in organizations. The theory posits that organizational structures and processes are distorted due to resource scarcity combined with production pressures resulting in normalized organizational deviance in daily micro-level transactions. Furthermore, regulatory systems are unable to capture and mitigate the problem. Vaughan’s multi-level framework provided an opportunity for analogical cross-case comparison to elaborate theory on mistreatment as normalized organizational deviance.To elaborate the theory, the Tanzanian public health system in the period of 2010-2015 was selected as a case because it was the site of a seminal study to measure the prevalence of mistreatment, explore its causes, and develop and test interventions to reduce its occurrence. My participation in designing and conducting this study provided understanding of the phenomenon which formed the foundation of this dissertation. Novel theory was first elaborated through a systematic review of literature on maternal health care and the government health system in Tanzania. A broad Scopus search identified 4,068 articles published on the health system and maternal health in Tanzania of which 122 were selected. Data was extracted using a framework based on the theory and reviews of mistreatment in healthcare. Relationships and patterns emerged through comparative analysis across concepts and system levels and then were compared with Vaughan’s theory and additional organizational theories, resulting in a nascent theory. A qualitative theory-driven approach was then applied to verify and expand the nascent theory using qualitative exploratory data from the study in Tanzania described above. The data included eight focus group discussions and 37 in-depth interviews involving 91 individuals representing community and health system stakeholders. Data were analyzed deductively and inductively using the theory’s framework while allowing for emergent constructs. Analysis based on the literature review revealed that normalized scarcity at the macro-level combined with production pressures that emphasized biomedical care and imbalanced power-dependence on limited financial sources altered values, structures, and processes in the health system. Meso-level actors strove to achieve production goals with limited autonomy and insufficient resources, resulting in workarounds and informal rationing. Biomedical care was prioritized, and emotion work was rationed in provider interactions with women, which many women experienced as disrespect. The nascent theory developed through literature review was largely supported by the qualitative data, while providing further nuance and elucidating new components. Moral distress, which occurs when one knows the right thing to do but is prevented from taking the right action due to institutional constraints, emerged as an important systems effect of organizational dysfunction. In addition, the qualitative data revealed that managers coped with dual roles as both managers and providers and that the service interaction includes families, not solely providers, women, and newborns. The challenges in the regulatory environment also were clarified, highlighting that monitoring and observing mistreatment was hindered due to structural secrecy and the nature of mistreatment. The nascent theory revealed the importance of emotional labor and emotion work in understanding mistreatment. Emotional labor has been widely acknowledged as an important aspect of healthcare provision, especially for a positive patient experience; yet there has been limited attention to emotion work as the underlying effort required to provide respectful maternity care and prevent mistreatment. Qualitative data from the exploratory formative research were further analyzed to explore the characteristics of emotion work. 22 interviews and 3 focus groups with 44 maternity providers from different levels of care provision in two districts were analyzed using thematic analysis combined with affinity diagramming. Six key themes were identified that provide a deeper understanding of the emotion work required of maternity providers, including 1) expected to love and care for patients; 2) controlling emotions; 3) managing patient expectations in the face of system shortages; 4) providers are human beings too; 5) nurses are perceived as harsh; and 6) limited system support for emotion work. The themes and corresponding sub-themes highlight that the nature of childbirth care, the context, and gender norms influence the ability to exert emotion work and thus provide respectful care. Emotion work was expected but good performance was unacknowledged by the system. Additional resources are required, not only to ensure the most basic of resources to provide quality of care, but to ensure sufficient organizational support to address the emotional demands of providers. Systems need to acknowledge the extra effort required for emotion work and support and train providers to provide this care, as well as help them to manage difficult emotions that they experience due to the nature of their work. Analogical comparison with another case of organizational deviance enabled a novel approach to elaborate theory. Normalization of organizational deviance proved useful for understanding mistreatment. This theory and others from organizational sociology that explore why things go wrong in organizations may be relevant for other areas of persistent systems failure and underperformance. Further theory testing in different contexts and types of health systems is needed to understand the generalizability of the nascent theory and advance its development. In addition, many of the constructs, such as emotional labor and moral distress, have not been widely applied in low- and middle-income settings and require deeper study. This theory reveals the systemic factors driving mistreatment and can guide the identification of system leverage points to transform health systems towards ensuring a respectful experience during childbirth for women and their newborns. Ensuring that adequate resources are provided to achieve targets is essential, but organizational support to address the emotional demands of providers must also be provided. These changes will ease the burden among providers and managers struggling to provide care in under-resourced health systems. The extra effort required for emotion work should be acknowledged and appropriate training provided, as well as support for providers to manage the difficult emotions that they experience due to the nature of their work. The findings may also have implications beyond childbirth, as the theory highlights the conditions that may lead to burnout and poor mental health among providers, an ongoing problem worldwide that was exacerbated by the COVID-19 pandemic.

Research objectives: This study examined research, media, and public opinion related to maternal health in order to understand some of the social and structural factors that influence the passage of comprehensive maternal health policies in the United States. This study also examined the messaging of race and racism in media and health communication. Research objectives were: 1.) To summarize the perinatal care experiences of Black birthing people through a scoping review of the literature, 2.) To explore media depictions of maternal mortality in terms of the groups, causes, and solutions discussed in coverage, and 3.) To test the effects of two different approaches to communicating maternal health on public beliefs about the causes of racial health disparities and public support for structural policies. Methods: The review of the literature followed a scoping review protocol and developed tailored search strings to retrieve relevant articles in three databases. The review protocol included developing selection criteria, screening articles retrieved from three databases, charting the data, and identifying themes across articles using an ecological health model as a conceptual guide. For the second paper – a content analysis of news media coverage of maternal mortality – relevant news articles were retrieved using NexisUni, an online database of newspaper articles. A codebook was developed deductively using previous research and grey literature on maternal health, and articles were subsequently coded for the presence or absence of codes that assessed how articles framed causes, solutions, and social groups in their coverage of maternal mortality in the United States. The third paper tested the effects of articles that communicated the maternal health issues faced by Black birthing people using a web-based survey experiment. Participants in this study were recruited using Qualtrics’ panel services, and were randomly assigned to read either a narrative or nonnarrative article communicating the relationship between race and adverse maternal health outcomes. Participants were then asked to respond to the questions that assessed their agreement with structural causes for racial health disparities and their support for policies to improve maternal health. Findings: The scoping review found that Black birthing people described factors at the interpersonal, organizational, community, and policy level in their accounts of their perinatal care experiences. This included their interactions with their providers, the dominant models of care in healthcare settings, institutional representation, and the limitations of care covered through existing Medicaid policies. The content analysis of media found that newspaper coverage of maternal health reflected the factors described in research. Media predominantly focused on structural causes and solutions for maternal health (e.g., access to services and care, social determinants of health, structural racism) and described racial disparities in maternal mortality. The final study built on the findings of the media analysis by testing the effects of news articles that described the role of social and structural factors on the maternal health outcomes of Black birthing people. Data from the experiment showed that participants who read a narrative article about the issue had greater support for structural policies than participants who read a nonnarrative article. The difference in agreement with structural causes for racial health disparities between participants in the narrative and nonnarrative groups was not statistically significant. Additionally, data showed significant differences in treatment effects and policy support across groups distinguished by race and gender.

This thesis comprises three chapters on topics in development economics. The first chapter studies access to maternal healthcare in markets with vertically differentiated public and private providers. The second chapter studies the efficacy of induction stoves in reducing indoor air pollution in rural households when faced with erratic power supply. Finally, the third chapter studies the role of financial incentives in correcting disparities in sex ratios. All three chapters study the context of India but are representative of important development issues in low-income countries. The first chapter titled "Equilibrium Effects of Subsidizing Public Services" studies one of India's largest welfare schemes Janani Suraksha Yojana (JSY) that incentivized pregnant women in India to access institutional maternal care at public hospitals. We argue that governments can make complementary investments to improve welfare gains from large scale policies. JSY did not improve health outcomes despite a substantial increase in the take-up of institutional care. We document three equilibrium responses that explain this policy failure. First, JSY led to a mismatch of risk across health facilities -- high-risk mothers sorted out of highest quality care at private facilities. Second, in line with the literature, public sector quality deteriorated as a result of congestion. This resulted in lower quality care for both marginal as well as infra-marginal patients at public hospitals. We show that only mothers with high socio-economic status adapted to the worsening quality of care at public hospitals by sorting into more expensive private hospitals. Third, despite increased competition, private hospitals maintained high prices, crowding out riskier and poorer mothers. We do not find evidence that private hospitals improved healthcare quality to justify higher prices. The second chapter titled "Electric Stoves as a Solution for Household Air Pollution" is an interdisciplinary field-based research study that studies the role of reliable electricity in inducing rural Indian households to switch away from dirty cooking fuels towards a clean cooking technology, induction cookstoves, thereby reducing the exposure to high levels of indoor air pollution. We collected minute-by-minute data on electricity availability, electric induction stove use, and kitchen and outdoor particulate pollution in a sample of rural Indian households for one year. Using within household-month variation generated by unpredictable outages, we estimate the effects of electricity availability and electric induction stove use on kitchen PM2.5 concentration at each hour of the day. Electricity availability reduces kitchen PM2.5 by up to 50 ??/?3, which is between 10 and 20 percent of peak concentrations during cooking hours. Induction stove use instrumented by electricity availability reduces PM2.5 in kitchens by 200-450 ??/?3 during cooking hours. The final chapter titled "Can Large-Scale Conditional Cash Transfers Resolve the Fertility-Sex Ratio Trade-off? Evidence from India" studies a large-scale conditional cash transfer (CCT) scheme Ladli Laxmi Yojana that offered cash incentives to households upon the birth of girl children. The policy also offered substantial incentive for investing in girls' education. In my evaluation of the Ladli Laxmi Yojana in Madhya Pradesh, India. I find that financial incentives aimed at the girl child increased average fertility by about 0.15 children per household (on baseline average of 0.93 children) children per household and improved sex-ratio by 3%. This points to the well known fertility-sex ratio trade-off. Moreover, these effects are quite opposite to a similar CCT scheme in Haryana (Anukriti, 2018) suggesting context dependence of such policies.

This dissertation is motivated by the study of economic development and inequality within and across nations. Spanning topics in labor and public economics, this collection of papers speaks to two overarching themes: (i) how the distribution of power affects economic outcomes, and (ii) how governments can mobilize resources and spend them effectively. In Chapter 1, I study how the allocation of ownership and control rights within firms affect responses to economic shocks. To shed light on this issue, I study the heterogeneous effects of a pro-competitive reform on cooperative manufacturing firms and their non-cooperative counterparts in India. The reform removed firm-size restrictions on the production of “reserved” items, increasing competition for incumbents in “de-reserved” product markets. Using a difference-in-differences approach, I find that supplier cooperatives (SCs), owned and controlled by producer-members who supply material inputs, are resilient to the shock in terms of total revenue and move away from the production of de-reserved items. SCs increase their share of income spent on materials relative to similarly sized non-cooperatives in the same industry and location, with some evidence of downward adjustments in labor spending. These cooperatives are able to withstand competitive pressure from entrants while broadly catering to the interests of their membership. On the other hand, worker cooperatives (WCs), owned and controlled by worker-members employed at the firm, face a sharp decline in revenue due to de-reservation, unlike their non-cooperative counterparts. A potential channel behind these results is that WCs are less likely to respond by picking up items that are not directly affected by the reform. Spending on labor does not fall as much as revenue for WCs, which is in line with the immediate interests of membership, but adjustments to labor inputs vary sigificantly across employment categories. In the following chapter, my co-author, Utkarsh Kumar, and I study the equilibrium effects of subsidizing public services in the presence of vertically differentiated public and private suppliers. We evaluate one of India’s largest welfare schemes, Janani Suraksha Yojana (JSY), which subsidized childbirth at public health institutions. JSY did not improve health outcomes despite a substantial increase in take-up of institutional care. We document three equilibrium responses that explain this policy failure. First, JSY led to a mismatch in patient risk across health facilities. High-risk mothers sorted out of the highest-quality care at private facilities and into lower-quality public facilities. Second, in response to congestion and deterioration of care at public hospitals, only mothers with high socio-economic status sorted out of congested public facilities into more expensive private facilities. Third, private hospitals increased prices without improvements in healthcare quality in a specific subset of states, further crowding out high-risk and poor mothers. These findings point to the need for complementary public policies in addition to JSY. In Chapter 3, I, along with my co-authors, Alexander Klemm and Li Liu, explore the increasingly prominent position of services in international trade and their potential to facilitate tax-driven reporting and reallocation of economic activity. Given their potential in countering this form of base erosion, withholding taxes (WHTs) on payments for services have featured extensively in ongoing reforms of the international tax architecture. The rationale behind WHTs is to preserve some taxation rights in the source country given their straightforward application, which is particularly important for low-income countries in the absence of more effective rules. We build a simple model of reporting decisions when firms have economic activities in one country and affiliates in others. We then test the predictions of this model using newly compiled data on treaty and non-treaty rates for 120+ countries over 2009-2021. Our findings indicate that while there is no significant relationship between WHTs and services trade in general, these taxes do have a strong negative impact on services imports from known low-tax jurisdictions, when base erosion is a particular concern.