Universal Health Coverage and Fertility: Evaluating Pro-Fertility Versus Contraceptive Effects

Abstract Universal health coverage (UHC) serves two significant roles in fertility decisions: encouraging (pro-fertility effect) and discouraging/delaying fertility (contraceptive effect). I conducted an analysis to estimate the correlation and potential impact of UHC on the total fertility rate (TFR) across countries for the period 1990–2014. My analysis used data from the World Development Indicators, the World Health Organization, the European Values Study and the World Values Survey, and the United Nations Food and Agriculture Organization. To address potential endogeneity, I employed Lewbel’s heteroskedasticity-based instrumental variable (IV) approach. The results suggest a negative relationship between UHC and TFR, indicating the dominance of the contraceptive effect over the pro-fertility effect. Furthermore, enhancing UHC performance has the potential to lower TFR, leading to fewer children per woman with improved access to UHC services and financial protection. I relate these findings to the observed global fertility decline. Lastly, a decomposition analysis identifies the UHC program as a significant driver in closing the fertility gap between developed and developing countries, which indicates a convergence phenomenon.