Education and health in developing countries - s FCUBE

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ContentslistsavailableatScienceDirect

World Development Sustainability

journalhomepage:www.elsevier.com/locate/wds

Education and health in developing countries: Evidence from Ghana’s FCUBE

Gabriel Aboyadana

^∗

Department of Economics, University of Strathclyde, Glasgow, United Kingdom

1. Introduction

Foralongtime,ithasbeenobservedthatpeoplewhohavemoreedu- cationtendtobehealthier[5,7–9].Somesuggestthatthereasonforthis isbecausebetter-educatedpeoplehavebetterlabourmarketoutcomes whichprovidethemwithhigherincomewithwhichtheyareabletoac- cessqualityhealthcare[5,28].Othershavealsosuggestedthatschool- ingdevelopscognitiveskillswhichenhancehealthdecision-makingand theadoptionofpositivehealthbehaviour[38,44].Atthenationallevel, theUNDPhealthindex[51]andnationalliteracyrates[11]revealthat onaverage,themoreliteratecountriesalsohavehigherhealthindices.

Thereis,however,noconclusiveevidencethatsuggeststhatthisrela- tionshipiscausalinnature[28,55].Whileafewstudieshavepursued thepathofﬁndingcausalrelationshipsindevelopedcountries,partic- ularlyintheUSandUKinthelastdecade,thesamecannotbesaidfor developingcountries[18,22,23,25].Thispaperextendsthefrontiersof thisstrandof researchbyexaminingdatafromanaturalexperiment originatingfromanearlychildhoodpolicyinGhana,adevelopingcoun- try.

Thisstudycontributestoourunderstandingoftheeducation-health nexus by examining the causal relationship between education and health.Therearerelativelymorestudiesthathaveshownthatthereis acorrelationbetweeneducationandhealth.Studiesconcernedwiththe causalityofthisrelationshiparehoweverlimited.Thesmall(butfast- growing)literatureinthisarea,however,presentsmixedresults[5,28]. Forinstance,[14]and[34]exploredcompulsoryschoolinglaws,asa sourceof exogeneityin Britainandconcluded thatwhilethose poli- ciesincreasedaverageyearsofschooling,therewasnocausaleffecton healthoutcomes.Albarranetal.[5]obtainasimilarconclusionusing cross-countrydataforEurope.Oneexplanationsuggestedforthosere- sultsisthatthegeneralqualityof,andaccesstohealthcarein those countriesarehighsothatthereislittlevariationbasedoneducational attainment.Otherstudiessuchas[15]however,usingdataforBritain andexploitingthesamecompulsoryschooling laws,findverystrong causaleffectsofeducationonhealth.Thispapercontributestothisdis- cussionbyprovidingnewevidence.

The evidence supporting both sides of the discussion above has mostlybeenfromEuropeancountriesandtheUS.Theevidencefrom developingcountriesislimited.Thisisnotedinrecentreviewsofthe

∗Correspondingauthor.

E-mailaddress:[email protected]

literaturebyHamadetal.[28]andArcayaandSaiz[8].Asearchofthe literature showsthatthefewstudiesondeveloping countrycontexts mostlyexaminethefertilityeﬀectsofeducation.ThereviewbyHamad et al.[28]forinstance,foundone publishedin Africa(fromKenya) whichexaminedsexualhealth.Also,Iﬁnd[46],forNigeria,[10]for Ghanaand[35]forUganda,allofwhichexaminedfemalefertilityef- fectsofschooling.Thisstudyexaminesotheroutcomesinadditionto fertility. Iamnot awareof anyotherstudyon Africathatexamines other outcomesbesides fertility.Moststudiesexaminedfemale data.

Thepresentstudyhoweverincludesdataformenforsomevariables.

Thispaperalsoexaminestheeffectofauniversalschoolfeewaiverat thebasiceducationlevel.Universalprimaryeducation(UPE)hasbeen implemented inotherAfricancountries.Thisincluded6years offree primaryeducation.However,Ghana’sversionofthepolicyincluded3 yearsofjuniorsecondaryschool;atotalof9years.Uganda’sUPEhas beenexploitedusingasimilarmethodologybyKeats[35].Thepolicies examined in developedcountrieshave beenat thesecondary school level. It hashowever beenshown thatearlyeducation interventions areimportantforlong-termoutcomes.Thispaperexaminesthelong- termhealtheffectsofanearlychildhoodeducationpolicy.Thefactthat schoolfeepolicieshavenotbeenpreviouslystudiedmakesthefindings ofthispaperrelevantforpoorcountriesandfordevelopedcountriesthat experiencehealthinequalitiesresultingfrominter-generationalpoverty.

Theidentificationstrategyreliesonthediscontinuityinschoolat- tainmentasaresultoftheFCUBE¹policyin1996andtheassumption thatobservationsclosetotheeligibilitythresholdareasgoodasran- domized.Pupilsenrollinginprimaryoneatdifferenttimesaroundthe policyimplementationyearreceiveddifferenttreatments.Ianalyzethis asanaturalexperimentinaregressiondiscontinuityframeworksuch that thoseclosetotheimplementationboundaryreceivedeither full treatmentoratleastoneyearlessoftreatment.Theunitsofanalysis inthisstudyaretheresidentsofGhana,asmallemergingeconomyin WestAfrica.Ghana’sethnicdiversityislikeotherAfricancountries.Its politicalstabilityoverseveraldecades,andtheECOWAS²policyoffree movementwithinthesub-regionhasmadeithometomillionsofpeo- plefromotherWestAfricancountries.Thisregionalcharactermeansthe

1FreeCompulsoryUniversalBasicEducation.

2EconomicCommunityofWestAfricaStates.

https://doi.org/10.1016/j.wds.2022.100041

Received4June2022;Receivedinrevisedform3December2022;Accepted22December2022

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studyﬁndingsarerelevantforotherwest-Africanscountriesassomeof thesecountriesplantoimplementsimilarpolicies[41].

Thisstudyissimilarto[10]inthatthetwostudiesarethefirstto haveexaminedtheimpactoftheGhanaFCUBEonhealthoutcomesand bothuseidenticalestimationstrategies.However,[10]pooldifferent wavesofthesurvey,usetheyearofbirthascohorts,andselect1989as thecut-off year.Thisapproachassumesthatallchildrenborninagiven yearstartschoolinthesameyear.However,becausetheschoolyear startsinAugustorearlySeptember,childrenbornin thelastquarter arerequiredtoenrolinthefollowingschoolyear.Thisalsomeansthat childrenareexposedtotheFCUBEpolicyinone-yearincrements.The approachItakeinthispaperistodefineanannualcohortaschildren borninorafterAugustuptoJulyofthefollowingyear.Thatis,Idefine acohortaspeoplestartingschoolinthesameacademicyearinsteadof peopleborninthesamecalendaryear.Thisapproachallowsthecut-off pointintheregressiondiscontinuitytobepreciselydetermined.Thisre- flectsthefactthatchildrenborninJanuaryandDecemberofthesame yearwillstartschoolindifferentyears.Thatis,allthingsbeingequal, thoughtheyareborninthesameyear,theywouldstartschoolindiffer- entyearsandreceivedifferenttreatments.Thusthecohortstotheright ofthecutoff serveasplacebochecks.Beingbornclosertotheofficial schoolstartmonth(mostlylateAugustuptomid-September)increases theprobabilityofreceivingthefulltreatment.Usingtheyearofbirth masksthis.Nonetheless,Icheckfortheexistenceofdiscontinuityusing adefinitionsimilarto[10]andanalternativedatasettoverifythatthe approachusedhereisrobust(seeFig.A.7).

I give an overview of the study context in Section 2 and de- scribethedataandmethodsinSection3.Theresultsarediscussedin Sections4and5concludes.

2. Thestudycontext 2.1. Theeducationsystem

Ghana’scurrenteducationsystem,introducedin1987, includes2 yearsofnon-compulsorykindergartenfromage4to6;6yearsofpri- mary school from ages6 to12; 3 yearsof junior secondary school from ages 12 to 15; 3 years of senior secondary school (or voca- tional/technical school) fromages 15 to18;qualifyingstudentscan thenenrolfortertiary education. Basiceducationin Ghanais classi- fiedtoincludeprimaryschoolandjuniorsecondaryschoolandpupils arerequiredtotakeaschool-leavingexamcalledtheBasicEducation CertificateExam(BECE)inthefinalyearofjuniorsecondaryschool.

TheBECEexaminesthesyllabusofthejuniorsecondaryschool,which comprises8compulsorysubjectsand2optionalsubjects(aGhanaian languageandFrench).Pupilsmustobtainatleast6passes,whichmust includeEnglish,Maths,andIntegratedScience,tobeabletoprogressto seniorsecondaryschool.Theytake8subjectsinsecondaryschooland mustpassatleast6ofthem(includingEnglish,Maths,andGeneralSci- ence)intheWestAfricaSecondarySchoolCertiﬁcateExam(WASSCE) toqualifyforadmissionintotheuniversityandotherpost-secondary educationalinstitutions.Studentsrequireatleast50%topassasubject [53].

Until1987,theeducationalsystemconsistedof6yearsofprimary school,4yearsof middleschool,5yearsofsecondary school,and2 yearsofsixthform;atotalof17years.Thepoliticalandeconomicevents prior,togetherwithdeterioratingeducationalinfrastructureledtoade- creaseinschoolenrolmentbymorethan100,000andstagnateduntil 1986/1987.Governmentspendingoneducationalsoreducedfrom6.4 to1.5%ofamuchlowerGDPby1984[42].Theseeventsledtothe deepeningofinequalityinschoolenrolment[4].Byreducingtheyears ofpre-tertiaryschoolto12years,thesavingswerechannelledtoexpand theinfrastructureandreversethedeclineinenrolment.Theseinterven- tions,however,didnotleadtoarapidincreaseinenrolmentuntilafter theimplementationofFCUBEin1996.

2.2. Thepolicy

The1992constitutionmandatedthegovernmenttomakebasiced- ucation fee-freeandcompulsory,hencetheFCUBEpolicywasimple- mented intheschoolyearstartinginAugust1996[4].Priortothis, the1961EducationAct(Act87)hadmadeeducationtuition-freebut pupilswererequiredtobuybooksandpayforothercosts.Thispolicy wasdiscontinuedafterthecountry’sﬁrstpresidentwasoverthrownina coupd’étatin1966(see[21]and[4]foradetailedhistoryofeducation inGhana).Variousformsofadditionalcostwereintroducedandenrol- mentdeclineduntiltheFCUBEpolicywasimplementedin1996.Besides eliminatingfeesandlevies,theFCUBEpolicyrequiredthegovernment toprovidebooksandotherlearningmaterialspupilsneededforschool.

Intheyearsfollowing,thegovernmentintroducedfreeschoolmealsand freeschooluniforms[49].Thus,theFCUBEpolicysoughttoeliminate allformsofdirectmoneycost.Toimprovequality,thegovernmentalso embarkedonalarge-scaleexpansionofeducationinfrastructureacross thecountryandtrainedmoreteacherstoteachatthebasicschoollevel andreducedthenumberofuntrainedteachersitemployed.

Unlikeotheruniversalprimaryeducationpoliciesthathavebeenim- plementedinotherAfricancountries,Ghana’sFCUBEeliminatedfeesfor allpupilsatthebasiclevel,notjustforthosewhoenteredprimaryschool aftertheimplementationofthepolicy.Thismeansthatallchildrenen- rolledinprimaryandjuniorsecondaryschoolfrom1996beneﬁtedfrom thepolicyregardlessofthegradetheywereat.

3. Empiricalstrategy 3.1. Studydesign

ChildreninGhana arerequiredtoenrolin primaryschoolin the academicyearstartingaftertheir6thbirthday.Thepolicyimplementa- tiondatewastheacademicyearstartinginAugust1996.Thus,children bornafterAugust1989uptoAugust1990werethefirstcohortthepol- icytargetedforfulltreatment.Asaresult,August1989ischosenasthe cut-off foreligibility.Thisallowsforanalysingtheimplementationof theFCUBEwithintheframeworkofaregressiondiscontinuitydesign (RDD).TheFCUBEpolicywashowevernotimplementedstrictly.This generatesnon-complianceoneithersideofthecut-off point.Thisnon- complianceimpliesafuzzyRDDandcapturesanintent-to-treateffect.

The analysisproceedsasfollows. First, Iselectanoptimalband- width³[12,31,32]fromthefullsampleofadultsfromtheDHSdataset andIestimatetheimpactofthepolicyonattainment.Secondly,Ies- timatetheeﬀectsofschoolingonvarioushealthvariables.Thisstudy seekstoisolatethecausaleﬀectofschoolingonhealth.Icomparethe averagehealth(𝐻)outcomesforthebirthcohorts(𝑐)whowereexposed tofulltreatment(𝐷=1)andthosewhowerenot(𝐷=0).Thatis:

𝐸[𝐻1𝑐|𝐷_𝑖=1]−𝐸[𝐻0𝑐|𝐷_𝑖=0]=𝐸[𝐻1𝑐−𝐻0𝑐|𝐷_𝑖=1] (1) Iestimatetheeﬀectofassignmenttofulltreatmentatthetimeof enrolmentonschoolingusingspeciﬁcation2:

𝑆_𝑖𝑐=Υ₀+Υ₁𝐷_𝑖𝑐+𝑓(𝑅_𝑖𝑐)+𝕏^′_𝑖𝑐Υ₂+𝜀_𝑖𝑐 (2) WhereSistheyearsofschoolingcompleted,Disthedummyforwhether anindividualwasassignedtoreceive9yearsoffeewaiver.Ris the centredrunningvariable(measuresage),centredat0.Thus,months priortoAugust1989takenegativevalues,andthosebornafterAugust 1989takepositivevalues,ineachcase,atincrementsof1.August1989 takesavalueof0.𝕏isavectorofcontrols.Itsinclusionintheﬁrststage reducesthevariationintheresidualandsoimprovestheeﬃciencyof theestimates.Thefunction𝑓(⋅)estimatestherelationshipbetweenthe outcomeandbirthcohort.Theerrorterm,𝜀capturesotherfactorsthat

3Theoptimalbandwidthisarangeofobservationsselectedcloseenoughto thecut-oﬀ pointtominimizebiasintheestimation.see[12,31,32]fordetailed discussions.

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mayaffectschoolingbesidesthecontrols.Theparameterofinterestis Υ₁.ItcapturestheeffectofFCUBEonschooling.Thesubscriptsiandc areindividualandcohort,respectively.Aninteractiontermisincluded tocapturetheeffectofdifferencesinslopeoneithersideofthecut-off.

IestimateEq.(3)inthesecondstageoftwostageleastsquare(2SLS) withEq.(2)asinstrument.

𝐻𝑖𝑐=𝛽0+𝛽1𝑆𝑖𝑐+ℎ(𝑅𝑖𝑐)+𝑋_𝑖𝑐^′𝛽2+𝜐𝑖𝑐 (3) Where𝐻_𝑖𝑐ishealthforindividualiincohortc.Othervariableshavethe samedescriptionasbefore.Thefunctionℎ(⋅)capturestherelationship betweenbirthcohortandhealth.𝛽1capturestheeffectofanadditional yearoffeewaiverand𝑋^′isavectorofothercontrolsandaninteraction tocapturedifferencesinslopeoneithersideofthecut-off.Iestimate 𝛽1via2-stageleastsquareusing𝐷_𝑖𝑐astheexcludedinstrumenttoob- tainanestimateofthehealthreturntoadditionalschoolinginducedby assignmenttoanextrayearoffeewaiver.

3.2. Internalvalidity

Theliteraturesuggeststwowaystoimplementregressiondiscon- tinuityanalysis[31–33]. Theparametricestimationcharacterisesthe treatmentasadiscontinuityatthecut-off andfindsanoptimalspeci- fication(functionalform)tofitthedata.Thenonparametricapproach, ontheotherhand,characterisesthetreatmenteffectaslocalrandomi- sationandfindstheminimumdatathatfitsalinearspecification.While theparametricapproachproducesmoreefficientestimates,biasismore likely.Thereverseistrueforthenonparametricapproach.However,a trade-off infavouroflessbiasispreferred(see[32]fordetaileddiscus- sion).Consequently,Ifollowthenonparametricapproachwhichisalso themorepreferredintheliterature.Thisapproachisunderpinnedby theassumptionthattheconditionalexpectationof outcomesbybirth cohortsissmooththroughthecut-off point(R=0).Hence,anydiscon- tinuitycanbeattributedtothecausalimpactsofthepolicy.Theop- timalbandwidthallowsforacomparisonofthosewhowerebornlate enoughtobeexposedto9yearsoffee-freeschoolingandthoseborn earlyenoughtoreceive8yearsoffee-freeschooling[27].

Threeimportantconcernsmayberaisedregardingtheabilityofthe FCUBEasanaturalexperimenttorecoverthepolicyeffect[37].The firstisthatparentsofchildrenfrompoorhouseholdsarelikelytodelay enrollingtheirchildreniftheyknowthepolicyimplementationdateto benefitfromthepolicy.This ishowevernotlikelytohavehappened becauseallchildrenin schoolweregoingtobenefitfrom thepolicy regardlessofthegradetheywereinasofAugust1996.Sincethepol- icywasannouncedin 1995,ifthisconcernholds,there wouldhave beenasignificantdeclineingrossenrolmentin1995.Datapresented byAkyeampong[4]howevershowsthatgrossenrolmentin1994was comparableto1995.Theyobserveasharpincreaseonlyfrom1996(see Fig.2).Moreover,theannouncementwasmadewhentheschoolyear hadalreadystarted.

Asecondconcerniswhethertheexclusioncriterionislikelytohold.

Apotentialproblemisthatothergovernmentpoliciesarelikelytohave occurredatthesamecut-off.Tothebestofmyknowledge,nootherpol- icywasimplementedwhoseeligibilitycriteriafortreatmentissimilar totheFCUBEorwhichonlyaffectedaportionoftheobservationsinthe optimalbandwidth.Furthermore,ifanyprivateeducationalinvestment createdadiscontinuityatthecut-off,thiswouldaffecttheinternalva- lidityoftheresults.Itwillimplythattheestimatesareacombinedeffect ofboththeprivateinvestmentsandthepolicy;hencetheeffectswillbe overestimated.Theexclusioncriterionistestedbyexaminingpretreat- mentvariables[33]. Thebestpretreatmentvariablesinthedataare ethnicityandreligion.Iconductatwo-samplet-testtocheckforthis.

Theresultisasshownintheappendix.Togetherwithotherformaltests inFig.3,thereisnoevidenceofmanipulation.

Finally,becausesurveydatawasused,concernsmayberaisedre- garding social desirability bias and recall bias, particularly for self- reportedvariables.Inthecaseoftheformer,peoplemayanswerques-

tionsinawaythattheyconsidertocast themin agoodlight inthe eyeofsociety.Forinstance,ifsmokingcarriesasocialstigma,aperson whosmokesmayfailtodisclosethetruthabouttheirsmokingstatus or thesubstancetheysmoke.While thisislikely,itis notavoidable insurveys.However,itseffectsarenotlikelytobesignificant.Inany case,thesummarystatisticsforthevariablesthatcouldpossiblycarry astigma(example:SmokingandSexualInfections)areconsistentwith officialestimatesinotherdatasets.Inaddition,becauserespondentsare interviewedindividually,andbyastrangerwhovisitsinanofficialca- pacity,respondentsarelikelytofeelmoreconfidenttodiscloseaccurate information.Recallbias,ontheotherhand,islikelytobeminimalsince informationonthevariablesusedinthisstudyisusuallyaboutrecent events.Inthecaseofothereventsthatmayhaveoccurredinthedistant past,theseareoftenmajoreventsthatareunlikelytobeforgotten.For instance,apersonisunlikelytoforgetthattheyendedtheirschooling atthesecondaryschoollevel.

3.3. Otherestimationissues

Itiswellestablishedintherelatedliteraturethateducationisen- dogenouspartlybecauseschoolingisachoicevariable.Thisendogeneity hasbeenshowntheoreticallytoarisefromomittedabilitywhichcorre- lateswiththechoiceofyearsofschoolingandhealthoutcomes.That said,[25]and[39]foundfromusingtwinsdatathatunobservedability mightbeuncorrelatedwithschoolinglevel.Measurementerrorsinyears ofschoolingcouldalsoaccountforendogeneity.Measurementerrorsare likelytobesmallbecausetheschoolingdataisreliable.Iconﬁrmthat yearsofschoolingisendogenousinthedatausingWooldridge’stest.

Theendogeneityproblemisaddressedbyusingassignment-to-full- treatmentstatusasaninstrumentinthesecondstageestimates.Icon- firmthevalidityandstrengthoftheinstrumentusingtheKleibergen- Paap Rank LM (F) test, Cragg-Donald Wald test, Stock-Yogo, and Hansen’sJ-testinallspecifications.Usingalargesampleprovidesad- ditionalefficiencygains,whichisimportantinanonparametricestima- tion[26].Reversecausalityisalsoaconcerninempiricalstudies.For instance,pupilsmaydropoutofschoolduetoillhealth[17,30,40].The GhanaLivingStandardsSurvey(GLSS7)showsthatillhealthaccounted forasmallpartofthereasonsfornotattendingschool.Instead,itshows thatthemostimportantreasonwasfinancialandthisisaddressedby thepolicy.Besides,thisconcernismitigatedbytheresearchdesign.

Following the recommendations by Abadie et al. [1] and Nunn [43]standarderrorsareclusteredatthelevelofsurveyclusters.This approachtoclusteringyieldsstandarderrorsthatarerobustagainstar- bitrarypatternsofwithin-clustervariationandcovariation[13].Clus- teringatsurveyclustersisusefulbecausewhilerespondentsareidentical acrosscohorts,theircharacteristicsmaydiﬀerbylocation;inthecon- textofthisstudy,socialandeconomicstatuscanvarymuchwithinand betweenclusters.Asectionoftheliteraturealsoclustersatthelevelof runningvariables.Thepointestimatesremainrobusttoclusteringatthe leveloftherunningvariable.Thestrengthoftheinstrument,however, becomessensitivetoalternativebandwidthsinthisapproach.Ireport resultsfortheformeronly.Asexpected,thepointestimatesandcon- clusionsremainrobusttonotclustering.Forbrevity,onlytherelevant mainresultsarereported.

3.4. Data

The Dataset: This study analyses data from round sevenof the GhanastandardDHSconductedfromSeptembertoDecember2014by theUSAID⁴fundedDHS⁵Program.RoundsevenoftheGhanaDHSsur- veyincludesadultfemalesinallsampledhouseholdsbetweenages15 and49yearsandmalesinselectedhouseholdsbetweenages15and59

4UnitedStatesAgencyforInternationalDevelopment.

5DemographicandHealthSurveys.

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Table1

Summarystatistics.

Variable Mean (SD)

Smokes 0.0172 (0.1512)

Antenatal Visits 6.1668 (2.75)

Fertility Intention 3.979(1.2121)

Healthy Eating 3.6156 (2.4127)

Weight for Height 0.0067 (0.1131)

Body Mass Index 23.9794 (4.0553)

Notes:Dataisfromthe2014GhanaDemographicandHealthSur- veys.Meansarepresentedfortheoptimalbandwidth.Standardde- viationsareinparentheses

years.Theoptimalbandwidthforthisstudyincludesrespondentswho werebetween22and28yearsonthesurveydate.Summarystatistics arepresentedinTable1anddiscussedbelowforrespondentsintheop- timalbandwidth.Dataforsomevariablesareavailableforonlymales oronlyfemales.Wherethisisthecase,thediscussionhighlightsit.

Table1reportsthesummarystatisticsfortheoutcomevariablesin this study.ThevariableSmokesis anindicatorvariableforwhether anindividualsmokesanysubstances.FertilityIntentionismeasured asthetotalnumberofchildrenonewantstohaveortheiridealnum- ber of children.Healthy Eating is deﬁned as howmany days in a weekarespondentatevegetables.AntenatalVisitsisthetotalnum- ber oftimes a womanvisitedthehospitalor healthcentrefor ante- natalcareduringherlastpregnancy.RiskofObesityismeasuredus- ingBodyMassIndexandStandarddeviationofWeightforHeight.The DHS surveymeasuresrespondents’ heightandweightandcalculates bodymassindex(BMI)fromit.Highervaluessignalahighriskofvar- iousdiseases.HighBMIisassociatedwithhealthconditionsincluding type2diabetes,highmortality,andobesity.ThemeanBMIof24puts theaveragepersonintheoverweightcategory.Weightforheightin- dexmeasuresthebodymassofindividualsrelativetotheirheightand isanindicatorofcurrentnutritionalstatus[45].Theindexexpressed asastandarddeviationshowswhetherapersonismalnourished (in- cludingbeingoverweight).Itisacomparisonofweightsofindividuals

Fig.1. DiscontinuityinSchoolingNotes:ThisﬁgureshowstheincreaseinschoolattainmentasaresultoftheintroductionofFCUBEusingdiﬀerentmeasuresof schoolattainment.TotalYearsofSchoolingismeasuredinsingleyears.Highestlevelofeducationattendedismeasuredfrom0to3;where0isnoeducation(person hasneverbeenenrolledinschool),1is“attendedprimaryschool(includingJuniorSecondarySchool)”,2is“attendedsecondaryschool” and3isattendedhigher education”.Allothermeasuresofschoolingareindicatorvariables.

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Table2

Firststageestimateswithdiﬀerentbandwidths.

32 months (Optimal bandwidth) 12 months 24 months 36 months

(1) (2) (3) (4) (5) (6) (7) (8)

Dependent variable = Total number of years of education

Assigned 1.4697 ^∗^∗^∗ 1.2797 ^∗^∗^∗ 2.4484 ^∗^∗^∗ 2.2248 ^∗^∗^∗ 1.8572 ^∗^∗^∗ 1.7021 ^∗^∗^∗ 1.3709 1.1717 ^∗^∗^∗ (0.4064) (0.3638) (0.6334) (0.5607) (0.4533) (0.3973) (0.3807) (0.3485)

Observations 2,333 2,332 959 959 1,774 1,773 2,626

F-stat 13.08 12.37 14.94 15.74 16.78 18.35 6.79 41.65

Controls No Yes No Yes No Yes No Yes

Notes:Thistableshowstheﬁrststageresults.Columns(1),(3),(5)and(7)donotincludecontrolsandcolumns(2),(4), (6)and(8)includecontrolsforethnicityandreligion.ItshowstheaverageeﬀectoftheFCUBEpolicyonthetotalnumber ofyearsineducation.Thepolicywasintendedtogetpupilsintoschoolandtokeepthemenrolledforatleast9years.

Usingtheoptimalbandwidth,theresultsshowthattheadditionalyearoffeewaiverincreasedthetotalyearsofschooling completedbyabout1.5years.Thissuggeststhatthepolicywaseﬀective.Standarderrorsareclusteredatthesurveyclusters andreportedinparentheses∗∗∗𝑝<0.01,∗∗𝑝<0.05,∗𝑝<0.1.

Fig.2. GrossEnrolmentRateThisgraphisfrom[4].Itshowsgrossannualpri- maryschoolenrolmentforGhana.Thegrossenrolmentratewasstablearound 80%andwithadownwardtrendupto1995butrisescontinuallyfrom1996, theyeartheFCUBEwasimplemented.

withidenticalheightsgloballyusingaWHObenchmarkweightfortheir height.

4. Resultsanddiscussion

4.1. Schoolfeewaiversincreasedattainment

TheFCUBEpolicyhadaspartofitsobjectivestoincreaseenrolment, reducedropout,andconsequentlyincreasetheaveragetotalyearsof schoolingcompleted.Thefirststageresultssuggestthatthepolicywas effectiveinachievingtheseobjectives.Fig.1showsthelocalaverage effectoftheFCUBEpolicyontheyearsofschoolingcompletedusing thecohortsclosesttotheassignmentthreshold.Anoptimalbandwidth of32monthswasselectedusingthe[12]localpolynomialbandwidth selectionmethod.ThecorrespondingregressioninTable2showsthat theaverageeffectofthepolicywasupto1.5yearsmoreforthecohorts whowereassignedto9yearsoffeewaiver comparedtothosewho wereassignedtoreceivefeweryearsoffeewaivers.Thissizeiscloseto 1.4yearsfrom[44]’sfirststage;sheusedNigeria’s1976UPE.

Thesizeof theeffectsgetslargerwith narrowerbandwidthsand smallerwithwiderbandwidths,asexpected(seeFig.A.9).Backofthe envelopeestimatesusingalladultsinthesurveyshowadifferenceof 1.7years,similar towhat[44]findsfor Nigeria.Icheck forthero- bustnessofthepolicyeffectestimatestofunctionalforms.Theresults aresummarisedin Fig.A.8. Itshowsthatthepolicy effectsarewell withinidenticalrangesregardlessofthefunctionalformselected.Using

theInformationCriteria(BIC,AIC),thelinearinteractionformisimple- mented.Thisisalsoappropriategiventhediﬀerencesinslopeonboth sidesofthecutoﬀ[33].

4.2. Educationimproveshealth

HavingestablishedthattheFCUBEpolicyhasapositiveimpacton yearsofschoolingcompleted,Inowdiscussitsimpactonhealth.The healthoutcomevariablesincludedinthisstudyalsoreﬂecthealthbe- haviours.Theexpectationisthatpeoplewhohavehighereducational attainmentwillhavebetterhealthbehaviourbecausetheycanaccess informationonhealthylivingandareabletoprocesssuchinformation better.Also,theyhavebetterlabourmarketoutcomes.

ThefirstsetofresultsispresentedinTable3.Thesecondsetofre- sultsispresentedinTableA.5.Themaindifferencebetweenthetwo setsisthatthealgorithmofthesecondselectsadifferentoptimalband- widthforeachoutcomevariable.Thesebandwidthsarereportedinthe resultstableforinformation.Ontheotherhand,thefirstsetusesasingle bandwidth,whichwasdiscussedearlier.

OLSestimatesmaybebiasedupwardsduetounobservedfactorssuch asinnateabilityorbiaseddownwardsduetomeasurementerrors.These areamelioratedbytheinstrumentusedintheIVestimatesgiventhat theeligibilitycriteriaforassignmenttofulltreatmentforFCUBEarenot manipulatedandalsogiventheplacebo.TheIVresultsareinterpreted astheeﬀectof1yearofschoolingcompleted.Thereducedform(RF) resultsareinterpretedastheeﬀectofthefeewaiverpolicy.Thecon- clusionsarestableacrossIVandRFestimates.Eitherofthetwolatter resultsisinterestingbutwithinaregressiondiscontinuityframework, theRFestimatesaremoreinformativehencethediscussionthatfollows isbasedonthereducedformestimates.Nonetheless,OLS,IVandRF estimatesareallpresentedinallcases.

WhencomparingtheIVandRFestimates,onemustkeepinmind that thepolicyeffectis 1.5yearswhereastheIV resultsmeasure the effectofeachyearofschooling.Comparedthisway,thepointestimates areintuitivelyidentical.Ontheotherhand,theresultsinTableA.5are interpretedastheeffectsofthepolicyonthosewhoweresufficiently close tobetreated oruntreated. Thatis thelocalaverage treatment effect(LATE).Innearlyallcases,theresultsshowapositiveimpactof thefeewaiveronhealth.

4.2.1. Educationreducesthelikelihoodofsmoking

Resultsin Table3show thatbeing inthecohorts assignedtoan extrayearoffeewaiverreducesthelikelihoodthatanindividualwill beasmokerbyabout2.6%.TheestimatesinTableA.5areclose.This eﬀectissigniﬁcantrelativetothesamplemean.Thatmeansthatthe cohortswhowereassignedtoreceivethefulltreatmentweretwiceas likelynottobesmokersatthetimeofthesurveycomparedtothosewho wereassignedtoreceiveoneyearlessoftreatment[17].makesacom-

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Fig.3. ManipulationNotes:[12]methodisused.Therunningvariableisthecentredmonthofbirthusingthecenturymonthcode.Centredatzero,months increase(decrease)atintervalsofone.Monthstotheleft(right)arethosebefore(after)August1989.August1989iszero,thecut-off point.Thisdefinitionofacohort ismorerepresentativeoftheactualdefinitionofaschoolcohortbuthasnotbeenusedinpreviousstudies.Forrobustness,Iusethecommonmeasureandapreviously useddatasetinFig.A.7toconfirmthatthereisnomanipulation.

Table3

FeeWaiver,SchoolingandHealth.

OLS IV RF OLS IV RF

Panel A

Smokes Healthy Eating

Schooling -0.001 ^∗^∗ -0.023 ^∗ -0.026 ^∗^∗ 0.005 0.311 ^∗ 0.359 ^∗^∗ (0.001) (0.012) (0.012) (0.012) (0.177) (0.176)

Observations 2,625 2,624

Panel B

Body Mass Index Weight for Height Schooling 0.064 ^∗^∗ 0.852 0.826 ^∗ 0.002 ^∗^∗^∗ 0.049 ^∗ 0.048 ^∗^∗^∗

(0.028) (0.666) (0.482) (0.001) (0.028) (0.013)

Observations 992 990

Panel C

Antenatal Visits Fertility Intention Schooling 0.115 ^∗^∗^∗ 1.464 0.8280 ^∗^∗^∗ -0.072 ^∗^∗^∗ -0.289 ^∗^∗^∗ -0.333 ^∗^∗^∗

(0.020) (1.225) (0.288) (0.006) (0.096) (0.085)

Observations 1,161 2,626

Notes:Thistablepresentsestimatesoftheaverageeffectofanadditionalyearofschool- ingonhealthoutcomesandbehaviours.Threeestimatesarepresentedforeachvariable, OLS,IVandReducedForm.InthecaseoftheRFresults,thecoefficientofSchoolingis thedifferencebetweenthoseassignedtoreceivefulltreatmentvrspartialtreatment.

Allestimatesincludecontrolsforethnicityandreligionandthefunctionalformused islinearinteraction.Errorsareclusteredatthesurveyclusterlevelandpresentedin parentheses∗∗∗𝑝<0.01,∗∗𝑝<0.05,∗𝑝<0.1.

pellingcaseforwhyeducationandsmokinghabitsmaybeassociated citingargumentsby[24].Back-of-the-envelopecalculationsshowthat withintheoptimalbandwidth,individualswhohadneverenrolledin schoolwere2.8timesmorelikelytobesmokers.Similarly,individuals whoenrolledbutdidnotcompleteJSSwere3.2timesmorelikelytobe smokersthanthosewhocompletedJSS.Thiscomparesto4timesinthe fullsample.Thisrevealsapossiblespillovereﬀectonthelargercommu- nity.Thatis,thereisapositivepeereﬀect.Smokingcanbefashionable ifone’speerssmoke.Thefewerpeerswhosmokeonehas,thelesslikely theyaretobesmokers.

ThemagnitudeofeffectsIfindforGhanaissmallerthan[52]finds fortheUS.HestudiedtheeffectofeducationintheUSusingtheyears ofschoolingabovecollegeasameasureofeducation.Hefindsthatcom-

pleting1yearabovecollegereducesthelikelihoodofsmokingbyabout 5%.ThisisnotsurprisingbecausesmokingismorecommonintheUS thaninGhanaandthemeasureofschoolingissetmuchhigher.Thus, beingeducatedincollege(equivalenttoabachelor’sdegree)meansa personinGhanaisgoingtobemuchlesslikelytosmokethanoneinthe US.However,[29]findseffectstorangefor2.6to3.3%and[17]finds 2.7%,bothforhighschoolgraduationintheUSandUKrespectively.

InanAfricancontext,[16]ﬁndthatinSouthAfrica,peoplewhohad droppedoutofschoolbeforeturning20yearsweremuchmorelikelyto besmokers.Currently,about6milliondeathsannuallyareattributable tosmoking[16].Thisisexpectedtoriseto10millionin2030anditis projectedthat70%ofthesedeathswilloccurindevelopingcountries [47].Globally,smokingprevalenceisabout21%forpeople15+.The

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rateisevenhigherinsomedevelopingcountries.Forinstance,[16]re- portsa prevalence of 31%in South Africa. The datasetused in the presentstudyplacestheprevalencerateat3.7%forGhana,similarto estimatesby[47]of3.8%.Thismeansthatsmokingisnotabigproblem inGhanaasinotherdevelopingcountries.Nonetheless,[47]ﬁnds,as inthisstudy,thatthefewwhosmoketendtobethosewithlowerlevels ofeducation.

4.2.2. Educationimproveshealthyeating

Ideﬁnehealthyeatingasonethatregularlyincludesvegetables.A healthierdietreducesthelikelihoodofillnessandmayacceleratethe healingprocessifoneisill.Respondentsprovidedinformationonhow manydaysintheweektheyincludedvegetablesintheirdiet.Theresults showthatcohortsassignedtoreceiveanextrayearoffeewaiverate healthilymoreoften. Theyate healthilyatleast0.36daysmore per weekthancohortswhoreceivedayearlessoffeewaiver.Thisisabout 10%oftheaveragedaysofhealthyeatingintheweek.

Therecommendedhealthydietisonethathasallnutrientsavail- able.Thehighcostofvegetables,resultingfromhighercostsofproduc- tion,isconsideredanobstacletotheirinclusionindietsregularly[45]. Well-educatedpeoplearemorelikelytounderstandtheimportanceof abalanceddietandsochoosetoeatthemoften.Havingmoreschooling alsoimprovesearningsandmakeshealthyeatingmoreaﬀordable.

4.2.3. Educatedwomenuseantenatalservicesmore

Maternalmortalityishighindevelopingcountries[54].Healthper- sonnelareabletodetectanypotentialdangerstomaternalhealthor dangerstothebabyinthewombifthemotherattendsregularmedi- calcheckups[2].Thus,antenatalcareisimportantforthehealthofthe motherandforthebaby.Modernantenatalcarepracticescoexistwith traditionalpracticesindevelopingcountries.Itaketheviewthatwomen whohaveattendedmoreschoolingarelikelytohaveamorefavourable dispositiontomodernpracticesandsowouldattendtheclinicwhen pregnant[20].Thisviewissupportedbytheﬁndingsofthisstudy.

Theresultsshowthatthecohortsthatwereassignedanextrayearof feewaiverattendedantenatalcaresessionsabout0.8moretimesthan others.Thisrepresentsabout13%morevisitsthanthemean.Antenatal careisfreeinGhanaatallhealthfacilities.Coupledwiththerangeofac- cessoptions,attendanceisnotconstrainedbycosts.Apossibleexplana- tionisthatbetter-educatedwomenunderstandthebeneﬁtsofantenatal careandsochoosetoattendmoreofit[2].

4.2.4. Educationreducesfertilityintention

Thisﬁndingisnotsurprisingandinfactnotnew.Manystudiesdocu- mentthisacrossnearlyallcontexts[10,35,36,48,50].Bydesign,respon- dentsareyoungerthan30,sothisvariablesoughttomeasurehowmany childrentheywantedintheiridealfamily.Thatistheirdesirednumber ofchildren.TheresultsinTable3includesbothmalesandfemales.

Theresultsshowthatonemoreyearofschoolingreducesthisap- petiteby about0.33children(8%of themean).The meanappetite intheestimationdatais4childrencomparedto4.8forwomenover 40 intheDHS data.Women over40 areusuallyconsideredtohave completedchildbearingorareveryclosetofinishing.Italsoconfirmsa trendofdecliningfertilityandidealsaroundthefamilysizeinGhana whichhasbeenattributedinparttoanincreasingrateofhighereduca- tion,changinglabourmarketsforwomenandaccesstocontraception options.Thisfindingandinterpretationareconsistentwithaprevious studyonGhana’sneighbour,Nigeria,whereitwasfoundthatanaddi- tionalyearofschoolingreducedfertilityby0.26[46].Bothestimates alsocompareto[6]whoexaminesseveralbirthcohorts,foundeffects rangingfrom0.09and0.36;andsuggeststhattheeffectsofeducation onfertilityvarybycohort.

4.2.5. Educationincreasestheriskofobesityforwomen

Apersonwhosebodymassistoohighfortheirheightisconsidered tobeoverweight orobese.Obesityisafunctionofweightforheight

andhasbeenlinkedtothecausesofseverallife-threateningdiseases.

Theresultsshowthatoneextrayearofschoolingincreasesafemale’s weightforheightby0.05ofastandarddeviation.Bodymassindexalso increasesbyabout0.8forthecohortswhowereassignedtoreceivethe fulltreatment.Whiletheseestimatessuggestanincreasedriskofobesity themeansofthesemeasurementsreportedinTable1isjustunderthe thresholdforobesity.Thiscouldbeexplainedpartiallytobeasaresult ofthesedentarynatureoftheemploymentthathighly-educatedpeople areinvolvedin[3,19]andthefactthatthesepeoplemayalsobeableto aﬀordmorefood.Secondly,thereisasub-culturewherefemaleobesity isassociatedwithbeautyandhavingagoodlife[19].

5. Conclusion

Thispaperexaminedwhetheracausallinkexistsbetweeneducation andhealthbyexploitingtheFCUBEpolicyinGhanaasasourceofex- ogeneityinaFuzzyRDD.Thepapermakesimportantcontributionsto theliteratureasbeingoneofscarcelyanystudiesonthecausaleffect ofeducationonhealthinAfrica,andtohaveexaminedothervariables besidesfertilityandoneofscarcelyanytohaveincludedmen.Beyond Africa,existingevidenceinEuropeismixedandsplitalmostevenlyon eitherside.StudiesontheUSmostlyshowfindingsconsistentwiththe findingsinthispaper.Thisstudyalsoincludesvariablessuchasantena- talvisitsandfertilityintention.Onthewhole,thequestionofcausality hasonlybeguntobeaddressedinempiricalstudiesinthelastdecade.

TableA1

Twosampletestofdiﬀerencesinpre-assignmentvariables.

Ethnicity Religion

t 0.9971 -0.8360

𝑃 𝑟 ( |𝑇 |> |𝑡 |) 0.3188 0.4033

Notes:Thistableteststhehypothesisthatpretreatmentvariables donotdifferforrespondentsoneithersideofthecut-off.Itisgen- erallydifficulttogetsuitablevariablesinsurveydataforthistype ofhypothesistest.EthnicityandReligionarethebesttwovariables availableinthedatasetthatcanbeusedtotestthis.Ethnicityis fixedandreligionisusuallysticky;thatis,itdoesnotchangeoften andmostpeopletendtofollowthereligionoftheirfamilies.The assumptionhereisthatiftreatmentwasrandomlyassigned,then respondentsshouldnotdifferonpretreatmentvariables.Theresults presentedinthistablesuggestthistobethecase.Indeed,inGhana, severalsocioeconomicfactorsdiffersystematicallyacrossethnicities andreligionsandsowecanbeconfidentthatthisresultisindicative thatindeedthesampleselectionandtreatmentassignmentarenot biased.

TableA2

FeeWaiver,SchoolingandHealth.

Coeﬃcient BW Left,Right Weight for Height SD 0.0532 ^∗^∗^∗ 51,29

(0.0187)

Body Mass Index 1.1181 ^∗^∗ 62,44 (0.5653)

Healthy Eating 0.4560 ^∗^∗ 111,37 (0.2106)

Smokes -0.0388 ^∗ 32,32

(0.0208)

Fertility Intention -0.1539 ^∗ 10,452 (0.8898)

Antenatal Visits 1.1714 ^∗^∗ 50,33 (0.5026)

Notes:Thistableshowstheeﬀectofthepolicyonhealth outcomesandhealthbehaviour.Adiﬀerentbandwidthis selectedforeachoutcomeusingthemethodrecommended by[12].Itincludescontrolsforethnicityandreligion.Ro- buststandarderrorsarereportedinparentheses∗∗∗𝑝<0.01,

∗∗𝑝<0.05,∗𝑝<0.1.

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Fig.A1. Discontinuityatnon-discontinuitypoint1Notes:Figuretestsfordiscontinuityatpointsotherthanthecut-off pointforrobustness.Itakeallrespondents whosecohortswereassignedtoreceiveatleastoneyearoftreatment.Thedataissplitintotwohalvesoneithersideofthecutoff.Forthoseontheleft,thosefurther leftofthefakecut-off wereassignedtoreceiveoneyearlessoftreatmentbutarealsoolder.Forthoseontheright,everyonewasassignedtoreceivefulltreatment.

Asaconsequence,somejumpisexpectedonthelefthalfbutlesssignificantthanattherealcut-off whereasnosignificantjumpisexpectedontherighthalf.Thisis asshown.

Fig.A2. Discontinuityatnon-discontinuitypoint2Notes:Thisfiguretestsforrobustnessofdiscontinuityatcut-off pointsbyusingfakecut-offsfortheoptimal bandwidth.Ichooseonecut-off twoyearsleftwardsandanothertwoyearsrightwardsbothwithintheoptimalbandwidths.Thesecut-off pointsdonotshow significantjumps.

Fig.A3. DiscontinuityatrandomAugustNotes:Theliteratureshowsthatmonthofbirthpotentiallyaffectstheageofenrolment,performanceinschoolandthe totalnumberofyearsofschooling.Thisistestedbycheckingforamonthofbirtheffectinthedata.Ifthereisajumpinthemonthofthestartoftheschoolyear,then theeffectsreportedintheresultswouldcaptureboththemonthofbirtheffectandtheFCUBEeffect.Theresultsintheplotsaboveareconsistentwiththeliterature inthatthosebornafterthestartoftheschoolyearhavemoreschoolingforobservationsoneithersideofthecut-off butthereisnodiscontinuityatAugust.

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Fig.A4. AdditionalgraphsusingtheLivingStandardsSurveyNotes:Irepeatthegraphsformanipulationandpolicyeffectontotalyearsofschoolingusingthe Ghanalivingstandardssurveyround7(GLSS7)tocheckforrobustnessacrossdatatypes.TheGLSS7isamorerecentdataanditincludesamoreevendistribution onmalesandfemales[10].usedanearlierroundofthissurveytoshowadiscontinuity.Thisisthusnotanexactreplicationoftheirresultsbutthepolicyeffects estimatesareclose.Imaintaintheirdefinitionofacohortinthepolicyeffectgraphbutusethestandarddefinitionadoptedinthisstudyforthemanipulationtests.

Theseconﬁrmtherobustnessofearlierconclusions.

Fig.A5. PolicyeffectusingdifferentfunctionalformsNotes:Icheckforro- bustnessoftheresultsforpolicyeffectstofunctionalform.Ishowthefirststage resultsforvariousfunctionalformsinthisfigure.Theresultspresentedhere showthatpolicyeffectsoverlapforallfunctionalforms.

Thecontributionsofthispaperarethusimportantbothforthedevelop- ingcountrycontextandthegeneralliterature.

Thefindings of thisstudyhave economicsignificance.Consistent withglobaltrends,lifeexpectancyandoverallwell-beingareincreas- inginGhanaasaresultofmedicaladvances.Theresultspresentedhere show thattheincreasesin educationaloutcomes arepartly responsi- bleforthesepositivehealthoutcomes.Bydesign,thefindingsofthis studyapplyspecificallytotherespondentsintheoptimalbandwidth.

Nonetheless,theresultscanbeextrapolatedtothewholepopulationes- peciallybecausetheunder-30sconstitutethelargershareoftheGhana- ianpopulation.Ghanaextendedthetuition feewaivertoseniorsec- ondaryschoolsin2017.Theeﬀectofthefeewaiversinducedbythe FCUBEisestimatedtobeatleast1.5years.Themeanyearsofschooling ofthesampleintheoptimalbandwidthwere8years.Thismeansthat theindividualsincludedinthisstudydidnotcompletejuniorsecondary school,onaverage.Thedurationofseniorsecondaryschoolis3years.

Thismeansthatthefeewaiverforseniorsecondaryschoolcanadduce morethantwicethehealthbenefitsestimatedinthisstudy.Thisisnot asmalleffect.Withtheexceptionoftheriskofobesity(andarguably fertility),theseeffectscangenerallyberegardedaspositive.

Outsideof Ghana’scontext, theresults provide usefullessonsfor countrieswhosetuitionfeewaiverpolicieshavenotbeenextensively evaluated.Italsoprovideslessonsforthosecountriesthathaveplans

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Fig.A6. PolicyeffectusingdifferentbandwidthsNotes:Icheckforrobustness oftheresultsforpolicyeffectstodifferentbandwidths.Iusethestandardhalf bandwidthanddoublebandwidthsuggestedintheliterature.Additionally,I checkfordifferentbandwidths.Smallerbandwidthsyieldlargereffectsthan largerbandwidthsandallarewithinidenticalrangesoftheoptimalbandwidth.

Asisexpected,widerbandwidthshavesmallereﬀectsbecausefullytreatedre- spondentsfurthestleftwereyoungandstillinschoolwhereaspartiallytreated anduntreatedrespondentswereolderyethadcompletedfeweryearsofschool- ing.Also,asthebandwidthgetslargerandapproachesthebandwidthusedby [10],theeﬀectbecomesidenticaltotheirs.

toadoptasimilarpolicy.Itmayalsobeinformativeinthatitprovides a counterfactualforcountriesthat havenotimplemented tuition fee waiverpolicies.Althoughsuchacomparisonmustconsideranydiﬀer- encesinnationalcircumstances.

Consideringthatthehealthvariablesexaminedherearemostlybe- haviour, increasing educationalattainmentcould meanlowerpublic healthexpenditureinthelongrun.Theresultsalsosuggestthathealth knowledge andemploymentareplausiblechannels forat leastsome healthoutcomes.Intermsofthepracticalimpactofthefindingsofthis study.Itisnoteworthythatobesityisonitswaytobeingendemicglob- ally,malnutritionandsmokingarealreadyglobalcrises.Thefindingsof thispapercontributetoeffortstounderstandthesocialandeconomic factorsthatcauseormitigatethesehealthchallenges.Thusacontribu- tiontothesolution

DeclarationofCompetingInterest

Theauthorsdeclarethattheyhavenoknowncompetingﬁnancial interestsorpersonalrelationshipsthatcouldhaveappearedtoinﬂuence theworkreportedinthispaper.

Fig.A7. Discontinuitiesinhealthoutcomesatcut-off pointNotes:ThegraphspresentedhereshowtheexistenceofdiscontinuitiesattheFCUBEintent-to-treat cut-off point.Thesecanbetakenasagraphicalillustrationofthetreatmenteffectforeachoftheoutcomesoftheresultspresentedinthetables.Keepinmind howeverthatthegraphsdonotincludecontrolsbutthetablesdo.Thepresenceofsignificantjumpsinthegraphsconfirmsthepointestimatesinthetables.