Political Decentralization, Women’s Reservation and Child Health Outcomes: A Case Study of Rural Bihar

Project summary:
This working paper studies how political decentralization and gender quotas in local governance affect maternal and child health in rural Bihar. Using multiple rounds of the District Level Household Survey (DLHS-1 and DLHS-3) for Bihar and the neighbouring state of Jharkhand, the authors apply a differences-in-differences strategy that compares changes in health outcomes before and after Bihar implemented the 73rd Constitutional Amendment and later reserved 50 percent of panchayat seats for women. The analysis shows that decentralization is associated with higher probabilities of institutional births, safe deliveries, and births in government health facilities, indicating better use of maternal health services. While the overall effect on child mortality is not statistically significant, survival improves for children from richer households, suggesting heterogeneous benefits by socio-economic status.

Study setting and data:
The research focuses on rural districts in Bihar and Jharkhand, using DLHS waves 1 (1998–99) and 3 (2007–08), which provide district-representative data on fertility, antenatal care, delivery care, immunization and child health outcomes. Jharkhand, carved out of southern Bihar in 2000, serves as a comparison state because it implemented panchayat elections and gender quotas later than Bihar.

Methodology:
The empirical strategy is a differences-in-differences design that contrasts changes in health outcomes between Bihar (treatment) and Jharkhand (control) from the pre-decentralization period (1998–99) to the post-decentralization period (2007–08). The main outcomes include institutional delivery, safe delivery, use of government vs. private facilities, child immunization, and under-five mortality. The models control for child and household characteristics and district fixed effects. Additional cohort-based analysis uses variation in exposure to the 2006 introduction of 50 percent women’s reservation in Bihar’s panchayat seats to examine effects on child survival.

Key findings:

• Institutional and safe delivery: Political decentralization increases the likelihood that births occur in health facilities and that deliveries are classified as safe (institutional or attended by skilled personnel). The probability of institutional delivery rises by about 6.5 percentage points from a baseline of roughly 23 percent, implying nearly a 28 percent increase.
• Public vs. private facilities: The policy shift raises births in government health facilities while reducing reliance on private facilities, indicating that strengthened local governance improves use of public-sector maternity services.
• Immunization and maternal care: Coverage of key vaccines (BCG, DPT3, Polio3, measles) and full child immunization improves more in Bihar than in Jharkhand between 1998–99 and 2007–08, although levels in Bihar remain below the national average. Antenatal care indicators also improve, but full ANC coverage stays low.
• Child mortality: On average, the reforms do not produce a statistically significant reduction in under‑five mortality. However, disaggregated results show significant survival gains for children from the top two wealth quintiles, while no clear effects are observed for poorer households.
• Equity and policy implications: The findings suggest that decentralization and women’s political representation can improve service utilization but may initially benefit better-off households more. Complementary policies are needed to ensure that poorer households gain equally from local governance reforms.

Implications:
The study highlights that empowering local governments and reserving seats for women can expand access to maternal and child health services, particularly institutional and safe deliveries, but targeted efforts are required to translate these improvements into broad-based reductions in child mortality. Strengthening public health infrastructure, increasing frontline staff, and addressing socio-economic barriers remain crucial for achieving inclusive health gains in Bihar and similar settings.

Citation:
Kumar, Santosh and Nishith Prakash (2012). Political Decentralization, Women’s Reservation and Child Health Outcomes: A Case Study of Rural Bihar. Working Paper, International Growth Centre (IGC), London School of Economics.