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Essays on Health Financing for the Poor
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Kusuma, Dian. 2015. Essays on Health Financing for the Poor. Doctoral dissertation, Harvard
T.H. Chan School of Public Health.
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ESSAYS ON HEALTH FINANCING FOR THE POOR

DIAN KUSUMA

A Dissertation Submitted to the Faculty of
The Harvard T.H. Chan School of Public Health
in Partial Fulfillment of the Requirements
for the Degree of Doctor of Science
in the Department of Global Health and Population
Harvard University

Boston, Massachusetts
May 2015
Dissertation Advisor: Dr. Jessica Cohen Dian Kusuma

Essays on Health Financing for the Poor

ABSTRACT

Health systems aim to improve population health. Despite global efforts, millions of
children still die every year from vaccine preventable diseases and undernutrition attributed
deaths. Moreover, about 293,000 maternal deaths occurred in 2013. The sources  of  these  deaths  
include  various  inequalities  such  as  vaccine  coverage,  nutritional  status,  and   health  services  
utilization.  In  order  to  make  progress  toward  mortality  reduction,  we  need  to  address  the  sources  
that  are  most  likely  to  affect  the  poorest.  One  strategy  is  conditional  cash  transfers  (CCTs),  which  
provides  cash  payments  in  exchange  for  compliance  with  health-related  conditionality. This
dissertation explores evidence from two large randomized experiments in Indonesia, PKH  (a  
large-scale  household  CCT)  and  Generasi  (a  large-scale  incentivized  community  block  grant).
Chapter two investigates whether PKH improves vaccination coverage among poor
children. After  two  years  of  implementation,  the  results show that PKH leads to significant
increase in vaccination coverage for all vaccine types among children younger than 12 months
old. The evidence also suggests that PKH is equity enhancing by reducing the differences in
vaccination coverage between children living in more and less supply-ready areas and children
of more and less educated mothers.
Chapter three investigates the impact of PKH and Generasi on child food intake. The
results show that both  programs  increase  child  food  intake  particularly  for  protein-rich  items.  
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They  increase  milk  and  fish  intake  up  to  19%  and  14%  compared  to  the  control  group  means,  
respectively.  Improving  child  nutrition  outcomes,  PKH  reduces  wasting  and  severe  wasting  up  to  
41%  and  Generasi  reduces  the  prevalence  of  severely  underweight  children  up  to  47%,  compared  
to  the  control  areas.  
Chapter four explores how PKH and Generasi help improve determinants of maternal
mortality among poor women. Evidence shows different results between the two programs with
Generasi   produces   more   positive   impact   in   many   aspects   of   determinants.   Both   programs,  
however,  are  unlikely  to  have  a  large  effect  on  maternal  mortality  due  to  factors  that  might  
significantly  reduce  the  program’s  effectiveness.  For  instance,  while  the  programs  improved  
utilization,  they  did  so  at  community-based  facilities,  which  are  not  appropriate  for  delivery  
services  in  the  case  of  obstetric  emergency.

Keywords:  Conditional  cash  transfers,  Household,  Community,  Child  vaccination,  Child  food  
intake,  Determinants  of  maternal  health,  Indonesia.

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TABLE OF CONTENTS

ABSTRACT .................................................................................................................................... ii
TABLE OF CONTENTS ............................................................................................................... iv
LIST OF FIGURES ...................................................................................................................... vii
LIST OF TABLES ....................................................................................................................... viii
LIST OF ABBREVIATIONS ..........................................................................................................x
ACKNOWLEDGEMENTS ........................................................................................................... xi

CHAPTER  1.  Introduction ...........................................................................................................1

1.1 GOAL AND STRUCTURE OF DISSERTATION .............................................................4
1.2 BIBLIOGRAPHY ................................................................................................................5

CHAPTER  2.  The  effects  of  conditional  cash  transfers  on  child  vaccination  rates:  New  
evidence  from  a  large-scale  cluster-randomized  trial  in  Indonesia ...........................................7

2.1 INTRODUCTION ...............................................................................................................7
2.2 BACKGROUND AND LITERATURE REVIEW ...........................................................10
2.2.1 Government vaccination programs in Indonesia ..................................................10
2.2.2 Program Keluarga Harapan (PKH) ......................................................................11
2.2.3 Theory: conditionality and behavior to vaccinate .................................................14
2.3 EVALUATION DESIGN AND DATA ............................................................................16
2.3.1 Evaluation design...................................................................................................16
2.3.2 Data........................................................................................................................17
2.3.3 Dependent variables ..............................................................................................18
2.3.4 Equity enhancing hypothesis..................................................................................19
2.4 METHODS AND EMPIRICAL MODEL .........................................................................20
2.4.1 Outcome of randomization .....................................................................................21
2.4.2 Empirical specification .........................................................................................24
2.5 EFFECTS OF PKH ON VACCINATION ........................................................................25
2.5.1 PKH effects ............................................................................................................25
2.5.2 Heterogeneity analysis ...........................................................................................26
2.6 DISCUSSION ....................................................................................................................30
2.6.1 Explaining the increase in both control and treatment areas................................31
2.6.2 Explaining the variation of the effects of PKH by age and vaccine type ...............33
2.6.3 Explaining the effects of PKH: Implementation issues ..........................................34
2.7 CONCLUSION ..................................................................................................................37
2.8 BIBLIOGRAPHY ..............................................................................................................38

CHAPTER  3.  The  effects  of  household  and  community  cash  transfers  on  child  food  intake:  
Evidence  from  two  large  field  experiments  in  Indonesia .........................................................41

3.1 INTRODUCTION .............................................................................................................41
3.2 BACKGROUND AND LITERATURE REVIEW ...........................................................46
3.2.1 Child nutrition in Indonesia ...................................................................................46
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3.2.2 Review: child food intake and nutrition outcomes .................................................48
3.2.3 PKH and Generasi .................................................................................................50
3.2.4 Review: causal mechanisms ...................................................................................56
3.3 EVALUATION DESIGN AND DATA ............................................................................58
3.3.1 Evaluation Design ..................................................................................................58
3.3.2 Data........................................................................................................................61
3.3.3 Dependent variables ..............................................................................................62
3.4 METHODS AND EMPIRICAL MODELS.......................................................................63
3.4.1 Outcome of randomization .....................................................................................63
3.4.2 Empirical specifications ........................................................................................66
3.5 EFFECTS OF CASH TRANSFERS .................................................................................71
3.5.1 Effects on child food intake ....................................................................................71
3.5.2 Evidence on causal mechanisms ............................................................................72
3.5.3 Child nutrition outcomes........................................................................................73
3.6 DISCUSSION AND CONCLUDING REMARKS...........................................................73
3.7 BIBLIOGRAPHY ..............................................................................................................78

CHAPTER  4.  Cash  transfers  and  determinants  of  maternal  mortality:  Evidence  from  
household  and  community  cash  transfers  in  Indonesia............................................................84

4.1 INTRODUCTION .............................................................................................................84
4.2 BACKGROUND AND LITERATURE REVIEW ...........................................................88
4.2.1 Maternal health in Indonesia .................................................................................88
4.2.2 Determinants of maternal mortality.......................................................................91
4.2.3 Cash transfers: PKH and Generasi .......................................................................92
4.2.4 Causal mechanism framework on how PKH and Generasi might improve
maternal health ......................................................................................................96
4.2.5 Generasi: The MIS data .........................................................................................99
4.3 EVALUATION DESIGN AND DATA ..........................................................................103
4.3.1 Evaluation Design ................................................................................................103
4.3.2 Data......................................................................................................................106
4.3.3 Dependent variables ............................................................................................107
4.3.4 Equity hypothesis .................................................................................................109
4.4 METHODS AND EMPIRICAL MODELS.....................................................................110
4.4.1 Outcome of randomization ...................................................................................110
4.4.2 Empirical specifications.......................................................................................113
4.5 EFFECTS OF CASH TRANSFERS ...............................................................................115
4.5.1 Effects on determinants of maternal mortality.....................................................115
4.5.2 Effects on equity and maternal outcomes ............................................................119
4.6 DISCUSSION AND CONCLUDING REMARKS.........................................................130
4.6.1 Cash transfers and determinants of maternal mortality ......................................130
4.6.2 Increased utilization at community-based facilities and provider quality...........131
4.6.3 Explaining the impact of cash transfers, or lack thereof .....................................133
4.7 BIBLIOGRAPHY ............................................................................................................136

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CHAPTER  5.  Conclusion ..........................................................................................................140

5.1 LIMITATIONS OF RESEARCH AND AREAS OF FUTURE RESEARCH ...............142
5.2 POLICY IMPLICATIONS AND LESSONS LEARNED ..............................................144
5.3 BIBLIOGRAPHY ............................................................................................................148

APPENDIX .................................................................................................................................149

A. APPENDIX TO CHAPTER 2 .........................................................................................149
B. APPENDIX TO CHAPTER 3 .........................................................................................154
C. APPENDIX TO CHAPTER 4 .........................................................................................162

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LIST OF FIGURES

CHAPTER 4 Figures

Figure 4.1: Causal Mechanism Framework on How PKH and Generasi Improve Maternal Health
..................................................................................................................................101
Figure 4.2: Heterogeneous Effects of PKH and Generasi on Prenatal Visits and Facility Delivery
by Prenatal Quality Index .........................................................................................128
Figure 4.3: Heterogeneous Effects of PKH and Generasi on Prenatal Visits and Facility Delivery
by Pregnancy Risk ....................................................................................................129

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LIST OF TABLES

CHAPTER 2 Tables

Table 2.1: PKH Conditionality ..................................................................................................12
Table 2.2: Basic Vaccination Schedule for Up-to-Date Vaccinations in Indonesia ..................19
Table 2.3: Baseline Test for Balance of Dependent Variables in PKH .....................................22
Table 2.4: Baseline Characteristics and Tests for Balance in PKH ...........................................23
Table 2.5: Difference-in-Differences Estimates of the Effects of PKH on Vaccination by
Cohort and by Vaccine Types ...................................................................................28
Table 2.6: Heterogeneous  Effects  of  PKH  by  Locations  (on/off  Java  Island)  and  Mother’s  
education ...................................................................................................................29

CHAPTER 3 Tables

Table 3.1: Conditionality and Target Indicators for PKH and Generasi....................................50
Table 3.2: Generasi MIS Data on Health Beneficiaries, Funds, and Village Activity 2007/2008
...................................................................................................................................55
Table 3.3: Baseline Characteristics and Tests for Balance in PKH and Generasi .....................65
Table 3.4: Difference-in-Differences Estimates of the Impact of PKH and Generasi on Child
Food Intake ...............................................................................................................68
Table 3.5: Difference-in-Differences Estimates of the Impact of PKH and Generasi on
Household Food Spending and Posyandu Activities ................................................69
Table 3.6: Difference-in-Differences Estimates of the Impact of PKH and Generasi on
Nutrition Outcomes ...................................................................................................70

CHAPTER 4 Tables

Table 4.1: Conditionality and Target Indicators for PKH and Generasi....................................93
Table 4.2: Generasi MIS data on Health Beneficiaries, Fund, Village Activity 2007/2008....102
Table 4.3: Baseline Characteristics and Tests for Balance in PKH and Generasi ...................112
Table 4.4: Difference-in-Differences Estimates of the Effects of PKH and Generasi on BCC
and Health Knowledge ............................................................................................120
Table 4.5: Difference-in-Differences Estimates of the Effects of PKH and Generasi on
Delivery Preference ................................................................................................121
Table 4.6: Difference-in-Differences Estimates of the Effects of PKH and Generasi on
Financial Barriers ....................................................................................................122
Table 4.7: Difference-in-Differences Estimates of the Effects of PKH and Generasi on Health
Services Utilization .................................................................................................123
Table 4.8: Difference-in-Differences Estimates of the Effects of PKH and Generasi on Health
Services Utilization by Types of Facilities .............................................................124
Table 4.9: Difference-in-Differences Estimates of the Effects of PKH and Generasi on
Provider Quality ......................................................................................................125
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Table 4.10: Difference-in-Differences Estimates of the Effects of PKH and Generasi on Health
Status and Nutrition ................................................................................................126
Table 4.11: Difference-in-Differences Estimates of the Effects of PKH and Generasi on
Maternal Outcomes .................................................................................................127
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