Decentralisation of governance and maternal healthcare utilisation: Evidence from India

This paper examines the impact of a decentralisation program implemented in India's Schedule Five Areas - home to 100 million indigenous people (Scheduled Tribes, or STs) - on maternal healthcare utilisation. The program institutionalised local governance councils and introduced political reservations for STs, granting these councils formal authority over the provision of public goods and services. Using three rounds of a large-scale reproductive health data and a difference-in-differences strategy exploiting staggered program implementation, we find that the policy significantly increased the use of antenatal care services, particularly from government facilities. It also reduced delivery complications and increased reliance on public services for managing such complications. Evidence suggests that these improvements were driven by increased trust in the health system when political representatives belonged to the ST community. The findings highlight how decentralisation combined with political inclusion can improve public service utilisation and health outcomes among historically marginalised population.