Tuition-free lower secondary education and women's healthcare decision-making in Sub-Saharan Africa

Autonomy in healthcare decision-making is not only critical for women's health, but also more broadly to gender equality, women's economic outcomes, and children's health. Moreover, the right to control over own's health is a fundamental human right recognized by international and regional frameworks. While education is widely recognized as a key pathway to enhancing women's autonomy, there is limited evidence on whether large-scale policy interventions can improve healthcare decision-making power. This study is the first to examine the impact of tuition-free primary and secondary education laws on women's control over their healthcare decisions across nine sub-Saharan African countries. Using a difference-in-differences approach, we exploit variation in the nature and timing of tuition-free education policy across countries. Drawing on harmonized household survey data and longitudinal policy data, we find that women exposed to both tuition-free primary and lower secondary education during childhood were 4.6 percentage points more likely to have at least joint say in healthcare decisions, and 4.0 percentage points more likely to have sole decision-making power. The latter represents a 23% increase from the mean and reflects a shift from having no say to full autonomy. These findings highlight the critical role of removing financial barriers to schooling in advancing women's health decision-making autonomy and underscore the value of investing in education—not only as a human right, but also as a strategic intervention for improving women's health and agency.