Infant Mortality and Desired Fertility: The Case of the Free Health Care Initiative in Sierra Leone

Sierra Leone launched the Free Health Care Initiative, which abolished health user fees for pregnant and breastfeeding women and children under five years of age, in 2010. Combining data from the Demographic and Health Survey and a geocoded dataset for the distribution of public health facilities, I design a difference-in-differences study involving birth timing and transportation cost to investigate its impact on infant mortality and desired fertility. I find that the program does not achieve its goal of reducing infant mortality, with the lack of vaccination being a major problem. Notwithstanding the lack of reduction in infant mortality, the program leads to a significant decline in desired fertility, implying that parents may overestimate the program's benefits and change their expectations of infant mortality accordingly. Heterogeneous effects by household wealth suggest that poor households are more adversely affected by the program than wealthy ones.