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Islam MA, Nahar MT, Siddiquee T, Toma AS, Hoque F, Hossain MZ. Prevalence and determinants of utilizing skilled birth attendance during home delivery of pregnant women in India: Evidence from the Indian Demographic and Health Survey 2015-16. PLoS One 2024; 19:e0295389. [PMID: 38452023 PMCID: PMC10919655 DOI: 10.1371/journal.pone.0295389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 11/21/2023] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND Utilization of skilled birth attendance during home delivery of pregnant women is proven to reduce complications during and after childbirth. Though the utilization of skilled birth attendance (SBA) during home delivery has increased significantly in recent times, the rate of utilizing skilled birth attendance is still low in several regions across India. The objective of this study is to analyze the prevalence and to identify the determinants of the utilization of skilled birth attendance during home delivery of pregnant women in India. METHODS To conduct this study, data and information from the Indian Demographic and Health Survey 2015-16 have been utilized. The sample size for this study is a weighted sample of 41,171 women. The sample consisted of women who had given a live birth in the three years preceding the survey. For women with more than one child, only the first live birth was considered. The binary logistic regression model and the log-binary logistic regression analysis have been applied as the adjusted odds ratios (AORs) with 95% confidence intervals for identifying the determinants of home-based skilled birth attendance during delivery. That allows us to select the most appropriate model for our study objective by ensuring that the determinants of skilled birth attendance for home delivery are accurately assessed based on the characteristics of the data. RESULTS The analyses show that only 18.8% of women had utilized skilled birth attendance during delivery. Women residing in urban areas are more likely to utilize skilled birth attendance during home delivery (AOR: 1.14; 95% CI: 1.08-1.20). Women having higher education levels are associated with increased use of SBA during home delivery (AOR: 1.15; 95% CI: 1.04-1.28). Exposure to media is associated with increased utilization of SBA (AOR: 1.17; 95% CI: 1.11-1.23). Overweight women are also more likely to avail the SBA during home delivery (AOR: 1.11; 95% CI: 1.03-1.19). Women belonging to affluent households have higher odds of utilizing skilled birth attendance (AOR: 1.41; 95% CI: 1.33-1.49). Having 3+ tetanus injections is associated with the utilization of SBA (AOR: 1.56; 95% CI: 1.43-1.69). Women having 4+ antenatal care visits were more likely to utilize SBA (AOR: 1.81; 95% CI: 1.71-1.92). Women belonging to the Hindu religion were 1.12 times more likely to utilize SBA (AOR: 1.12; 95% CI: 1.07-1.18). Women with 1 to 3 birth orders were 1.40 times more likely to utilize skilled birth attendance during home delivery (AOR: 1.40; 95% CI: 1.30-1.51). CONCLUSION The percentage of women utilizing skilled birth attendance during home delivery is still very low which is a matter of serious concern. Several factors have been found to be associated with the utilization of SBA during home delivery in India. As skilled birth attendance has significant positive health outcomes for pregnant women and newborns, efforts to increase the rate of SBA utilization during home delivery should be undertaken.
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Affiliation(s)
- Md. Akhtarul Islam
- Statistics Discipline, Science, Engineering & Technology School, Khulna University, Khulna, Bangladesh
| | - Mst. Tanmin Nahar
- Statistics Discipline, Science, Engineering & Technology School, Khulna University, Khulna, Bangladesh
| | - Tanjim Siddiquee
- Statistics Discipline, Science, Engineering & Technology School, Khulna University, Khulna, Bangladesh
| | - Afrina Sultana Toma
- Statistics Discipline, Science, Engineering & Technology School, Khulna University, Khulna, Bangladesh
| | - Farhana Hoque
- Development Studies Discipline, Social Science School, Khulna University, Khulna, Bangladesh
| | - Md. Zobayer Hossain
- Development Studies Discipline, Social Science School, Khulna University, Khulna, Bangladesh
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Mishra PS, Sinha D, Kumar P, Srivastava S. Spatial inequalities in skilled birth attendance in India: a spatial-regional model approach. BMC Public Health 2022; 22:79. [PMID: 35022008 PMCID: PMC8756682 DOI: 10.1186/s12889-021-12436-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 12/17/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Despite a significant increase in the skilled birth assisted (SBA) deliveries in India, there are huge gaps in availing maternity care services across social gradients - particularly across states and regions. Therefore, this study applies the spatial-regression model to examine the spatial distribution of SBA across districts of India. Furthermore, the study tries to understand the spatially associated population characteristics that influence the low coverage of SBA across districts of India and its regions. METHODS The study used national representative cross-sectional survey data obtained from the fourth round of National Family Health Survey, conducted in 2015-16. The effective sample size was 259,469 for the analysis. Moran's I statistics and bivariate Local Indicator for Spatial Association maps were used to understand spatial dependence and clustering of deliveries conducted by SBA coverage in districts of India. Ordinary least square, spatial lag and spatial error models were used to examine the correlates of deliveries conducted by SBA. RESULTS Moran's I value for SBA among women was 0.54, which represents a high spatial auto-correlation of deliveries conducted by SBA over 640 districts of India. There were 145 hotspots for deliveries conducted by SBA among women in India, which includes almost the entire southern part of India. The spatial error model revealed that with a 10% increase in exposure to mass media in a particular district, the deliveries conducted by SBA increased significantly by 2.5%. Interestingly, also with the 10% increase in the four or more antenatal care (ANC) in a particular district, the deliveries conducted by SBA increased significantly by 2.5%. Again, if there was a 10% increase of women with first birth order in a particular district, then the deliveries conducted by SBA significantly increased by 6.1%. If the district experienced an increase of 10% household as female-headed, then the deliveries conducted by SBA significantly increased by 1.4%. CONCLUSION The present study highlights the important role of ANC visits, mass media exposure, education, female household headship that augment the use of an SBA for delivery. Attention should be given in promoting regular ANC visits and strengthening women's education.
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Affiliation(s)
- Prem Shankar Mishra
- Research Scholar, Population Research Centre, Institute for Social and Economic Change, Bengaluru, Karnataka 560072 India
| | - Debashree Sinha
- Research Scholar, Department of Development Studies, International Institute for Population Sciences, Mumbai, Maharashtra 400088 India
| | - Pradeep Kumar
- Research Scholar, Department of Survey Research & Data Analytics, International Institute for Population Sciences, Mumbai, Maharashtra 400088 India
| | - Shobhit Srivastava
- Research Scholar, Department of Survey Research & Data Analytics, International Institute for Population Sciences, Mumbai, Maharashtra 400088 India
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Agarwal N, Jain V, Bagga R, Sikka P, Chopra S, Jain K. Near miss: determinants of maternal near miss and perinatal outcomes: a prospective case control study from a tertiary care center of India. J Matern Fetal Neonatal Med 2021; 35:5909-5916. [PMID: 33749485 DOI: 10.1080/14767058.2021.1902497] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND/PURPOSE To study the causes of maternal near miss and compared maternal and perinatal outcome of maternal near miss cases with controls (women with potential life-threatening complication [PLTC]) and maternal death. METHODS Mothers (n = 100) who fulfilled the WHO criteria for maternal near miss (MNM) were identified and enrolled in the study. Two controls for each near miss case were taken. This included the women who had same PLTC but did not reach near miss within one week of enrollment. The comparison of maternal and fetal outcome was done between the two groups and with the maternal death (MD) group, who presented initially as near miss. RESULTS Obstetric hemorrhage was the most common potential life-threatening complication in MNM and MD group. On multiple logistic regression analysis, we found that the presence of organ dysfunction was the independent predictor of near miss and need of mechanical ventilation and coagulation dysfunction as an independent predictor of maternal death. A mother in the near miss group or death group had a higher chance of giving birth to a still-born child (p = < 0.001). Risk of neonatal death after NICU admission was numerically more among near miss and death group than controls, although statistically insignificant (p > .05). CONCLUSION Despite making tremendous progress in obstetric care facilities at a tertiary level, developing countries need to strengthen primary care infrastructure and referral system. To improve maternal care, there should be the provision of health education for all pregnant women and antenatal services should be improved.
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Affiliation(s)
- Neha Agarwal
- Department of Obstetrics and Gynecology, Lok Nayak Jai Prakash Narayan Hospital, New Delhi, India
| | - Vanita Jain
- Department of Obstetrics and Gynecology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rashmi Bagga
- Department of Obstetrics and Gynecology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Pooja Sikka
- Department of Obstetrics and Gynecology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Seema Chopra
- Department of Obstetrics and Gynecology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Kajal Jain
- Department of Anaesthesiology, Post Graduate Institute of Medical Education and Research, Chandigar, India
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Joudyian N, Doshmangir L, Mahdavi M, Tabrizi JS, Gordeev VS. Public-private partnerships in primary health care: a scoping review. BMC Health Serv Res 2021; 21:4. [PMID: 33397388 PMCID: PMC7780612 DOI: 10.1186/s12913-020-05979-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 11/26/2020] [Indexed: 01/21/2023] Open
Abstract
Background The Astana Declaration on Primary Health Care reiterated that PHC is a cornerstone of a sustainable health system for universal health coverage (UHC) and health-related Sustainable Development Goals. It called for governments to give high priority to PHC in partnership with their public and private sector organisations and other stakeholders. Each country has a unique path towards UHC, and different models for public-private partnerships (PPPs) are possible. The goal of this paper is to examine evidence on the use of PPPs in the provision of PHC services, reported challenges and recommendations. Methods We systematically reviewed peer-reviewed studies in six databases (ScienceDirect, Ovid Medline, PubMed, Web of Science, Embase, and Scopus) and supplemented it by the search of grey literature. PRISMA reporting guidelines were followed. Results Sixty-one studies were included in the final review. Results showed that most PPPs projects were conducted to increase access and to facilitate the provision of prevention and treatment services (i.e., tuberculosis, education and health promotion, malaria, and HIV/AIDS services) for certain target groups. Most projects reported challenges of providing PHC via PPPs in the starting and implementation phases. The reported challenges and recommendations on how to overcome them related to education, management, human resources, financial resources, information, and technology systems aspects. Conclusion Despite various challenges, PPPs in PHC can facilitate access to health care services, especially in remote areas. Governments should consider long-term plans and sustainable policies to start PPPs in PHC and should not ignore local needs and context.
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Affiliation(s)
- Nasrin Joudyian
- Tabriz Health Services Management Research Center, Iranian Center of Excellence in Health Management, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Leila Doshmangir
- Tabriz Health Services Management Research Center, Iranian Center of Excellence in Health Management, Tabriz University of Medical Sciences, Tabriz, Iran. .,Social Determinants of Health Research Center, Health Management and Safety Promotion Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran. .,Department of Health Policy& Management, School of Management & Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran.
| | - Mahdi Mahdavi
- National Institute of Health Research (NIHR), Tehran University of Medical Sciences, Tehran, Iran.,Erasmus School of Health Policy and Management (ESHPM), Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Jafar Sadegh Tabrizi
- Tabriz Health Services Management Research Center, Iranian Center of Excellence in Health Management, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Vladimir Sergeevich Gordeev
- Institute of Population Health Sciences, Queen Mary University of London, London, UK.,Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
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Carmone AE, Kalaris K, Leydon N, Sirivansanti N, Smith JM, Storey A, Malata A. Developing a Common Understanding of Networks of Care through a Scoping Study. Health Syst Reform 2020; 6:e1810921. [PMID: 33021881 DOI: 10.1080/23288604.2020.1810921] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
The phrase "Networks of Care" seems familiar but remains poorly defined. A health system that exemplifies effective Networks of Care (NOC) purposefully and effectively interconnects service delivery touch points within a catchment area to fill critical service gaps and create continuity in patient care. To more fully elaborate the concept of Networks of Care, we conducted a multi-method scoping study that included a literature review, stakeholder interviews, and descriptive case studies from five low- and middle-income countries. Our extended definition of a Network of Care features four overlapping and interdependent domains of activity at multiple levels of health systems, characterized by: 1) Agreement and Enabling Environment, 2) Operational Standards, 3) Quality, Efficiency and Responsibility, and 4) Learning and Adaptation. There are a series of key interrelated themes within each domain. Creating a common understanding of what characterizes and fosters an effective Network of Care can drive the evolution and strengthening of national health programs, especially those incorporating universal health coverage and promoting comprehensive care and integrated services. An understanding of the Networks of Care model can help guide efforts to move health service delivery toward goals that can benefit a diversity of stakeholders, including a variety of health system actors, such as health care workers, users of health systems, and the wider community at large. It can also contribute to improving poor health outcomes and reducing waste originating from fragmented services and lack of access.
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Affiliation(s)
- Andy E Carmone
- Clinical Sciences, Clinton Health Access Initiative , Boston, Massachusetts, USA
| | - Katherine Kalaris
- Maternal and Neonatal Health, Clinton Health Access Initiative , Boston, Massachusetts, USA
| | - Nicholas Leydon
- Global Delivery Programs, Bill & Melinda Gates Foundation , Seattle, Washington, USA
| | - Nicole Sirivansanti
- Maternal, Newborn & Child Health, Bill & Melinda Gates Foundation , Seattle, Washington, USA
| | - Jeffrey M Smith
- Maternal, Newborn & Child Health, Bill & Melinda Gates Foundation , Seattle, Washington, USA
| | - Andrew Storey
- Maternal and Neonatal Health, Clinton Health Access Initiative , Boston, Massachusetts, USA
| | - Address Malata
- Office of the Chancellor, Vice Chancellor, Malawi University of Science and Technology , Limbe, Malawi
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Does choice of health care facility matter? Assessing out-of-pocket expenditure and catastrophic spending on emergency obstetric care in India. J Biosoc Sci 2020; 53:481-496. [PMID: 32583761 DOI: 10.1017/s0021932020000310] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The key recommendation of the Child Survival and Safe Motherhood programme was the provision of Emergency Obstetric Care (EmOC) for the prevention of maternal mortality, especially in developing countries like India. The objectives of this paper were three-fold: to examine the socioeconomic differentials in mean out-of-pocket expenditure on EmOC in public and private health care facilities in India; to evaluate the catastrophic health expenditure of households at the threshold levels of 5% and 10%; and finally, to assess the effects of various socioeconomic and demographic covariates on the levels of catastrophic health expenditure on EmOC. Data were extracted from the 71st round of the National Sample Survey Office (NSSO) survey conducted in India between January and June 2014. A stratified multi-stage sampling design was followed to conduct the survey. The information was collected from 65,932 households (rural: 36,480; urban: 29,452) and 33,104 individuals across various states and union territories in India. However, the present study had taken only 1653 sample women who availed EmOC care during the last one year preceding the survey date. Binary logistic regression was applied. Large differences in out-of-pocket expenditure on EmOC were found between private and public health care facilities. Mean annual out-of-pocket expenditure by women in private hospitals was INR 23,309 (US$367), which was about 6 times higher than in public hospitals, where mean spending was INR 3651 (US$58). Furthermore, logistic regression analysis showed a significant association between household socioeconomic status and level of catastrophic health expenditure on EmOC. The odds of catastrophic health expenditure in public health facilities among women from the North region were higher than among those from the Central, South and West regions. Age and level of education significantly influenced the mean level of catastrophic health expenditure. Access to good-quality obstetric care is key to reducing the maternal mortality rate and child deaths, and thus achieving Sustainable Development Goal 3. There is an urgent need for policy interventions to reduce the financial burden of households in accessing obstetric care in India.
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Iyer V, Sidney K, Mehta R, Mavalankar D, De Costa A. Characteristics of private partners in Chiranjeevi Yojana, a public-private-partnership to promote institutional births in Gujarat, India - Lessons for universal health coverage. PLoS One 2017; 12:e0185739. [PMID: 29040336 PMCID: PMC5644975 DOI: 10.1371/journal.pone.0185739] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 09/15/2017] [Indexed: 02/05/2023] Open
Abstract
Background The Chiranjeevi Yojana (CY) is a Public-Private-Partnership between the state and private obstetricians in Gujarat, India, since 2007. The state pays for institutional births of the most vulnerable households (below-poverty-line and tribal) in private hospitals. An innovative remuneration package has been designed to disincentivise unnecessary cesareans. This study examines characteristics of private facilities which participated in the program. Methods We conducted a cross-sectional survey of all facilities which had conducted any births between June 2012 and April 2013 in three districts. We identified 111 private and 47 public facilities. Ninety of the 111 private facilities did caesarean sections in the last three months and were eligible to participate in the CY program. Of these, 40 (44%) participated in the CY program. We conducted descriptive and bivariate analyses followed by a Poisson regression model to estimate prevalence ratios of facility characteristics that predicted participation. Results We found that facilities participating in the CY program had a significantly higher likelihood of being general facilities (PR 1.9, 95% CI 1.3–2.9), or conducting lower proportion of cesarean births (PR 2.1, 95% CI 1.2–3.5) or having obstetricians new in private practice (PR 1.9, 95% CI 1.2–3.1) or being less expensive (PR 1.8, 95% CI 1.1–3.0). But none of these factors retained significance in a multi variable model. Conclusion Private obstetricians who participate in the CY program tend to be new to private practice, provide general services, conduct fewer caesareans and are also less expensive. This is advantageous to the PPP and widens the target beneficiary groups that can be serviced by the PPP. The state should design remuneration packages with the aim of attracting relatively new obstetricians to set up practices in more remote areas. It is possible that the CY remuneration package design is effective in keeping caesarean rates in check, and needs to be studied further.
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Affiliation(s)
- Veena Iyer
- Indian Institute of Public Health, Gandhinagar, Gujarat, India.,Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Kristi Sidney
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Rajesh Mehta
- Department of Preventive and Social Medicine, Valsad Medical College, Valsad, Gujarat, India
| | | | - Ayesha De Costa
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
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Abstract
BACKGROUND Effective basic newborn resuscitation is an important strategy to reduce the incidence of birth asphyxia and associated newborn outcomes. Outcomes for newborns can be markedly improved if health providers have appropriate newborn resuscitation skills. PURPOSE To evaluate the skills of midwives in newborn resuscitation in delivery rooms in Jordan. METHODS Data were collected from observation of 118 midwives from National Health Service hospitals in the north of Jordan who performed basic newborn resuscitation for full-term neonates. A structured checklist of 14 items of basic skills of resuscitation was used. Descriptive statistics were used to analyze the data. RESULTS The results highlighted the lack of appropriate performance of the 8 necessary skills at birth by midwives. About 17.8% of midwives had performed the core competencies at birth (ie, assessing breathing pattern/crying, cleaning airways) appropriately and met the standard sequence. Less than half of midwives assessed skin color (40.7%) and breathing pattern or crying (41.5%) appropriately with or without minor deviations from standard sequences. Of the 6 skills that had to be performed by midwives at 30 seconds up to 5 minutes after birth, 4 skills were not performed by about one-quarter of midwives. IMPLICATIONS FOR PRACTICE AND RESEARCH The midwives' practices at the 2 hospitals of this study were not supported by best practice international guidelines. The study showed that a high proportion of midwives had imperfect basic newborn resuscitation skills despite a mean experience of 8 years. This highlights the critical need for continuing medical education in the area of basic newborn resuscitation. The results highlight the need for formal assessment of midwives' competence in basic newborn resuscitation. National evidence-based policies and quality assurance are needed to reflect contemporary practice.
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Tripathy JP, Shewade HD, Mishra S, Kumar AMV, Harries AD. Cost of hospitalization for childbirth in India: how equitable it is in the post-NRHM era? BMC Res Notes 2017; 10:409. [PMID: 28810897 PMCID: PMC5556367 DOI: 10.1186/s13104-017-2729-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 08/06/2017] [Indexed: 11/24/2022] Open
Abstract
Background and objective Information on out-of-pocket (OOP) expenditure during childbirth in public and private health facilities in India is needed to make rational decisions for improving affordability to maternal care services. We undertook this study to evaluate the OOP expenditure due to hospitalization from childbirth and its impact on households. Methods This is a secondary data analysis of a nationwide household survey by the National Sample Survey Organization in 2014. The survey reported health service utilization and health care related expenditure by income quintiles and type of health facility. The recall period for hospitalization expenditure was 365 days. OOP expenditure amounting to more than 10% of annual consumption expenditure was termed as catastrophic. Results Median expenditure per episode of hospitalisation due to childbirth was US$54. The expenditure incurred was about six times higher among the richest quintile compared to the poorest quintile. Median private sector OOP hospitalization expenditure was nearly nine times higher than in the public sector. Hospitalization in a private sector facility leads to a significantly higher prevalence of catastrophic expenditure than hospitalization in a public sector (60% vs. 7%). Indirect cost (43%) constituted the largest share in the total expenditure in public sector hospitalizations. Urban residence, poor wealth quintile, residing in eastern and southern regions of India and delivery in private hospital were significantly associated with catastrophic expenditure. Conclusions We strongly recommend cash transfer schemes with effective pro-poor targeting to reduce the impact of catastrophic expenditure. Strengthening of public health facilities is required along with private sector regulation.
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Affiliation(s)
- Jaya Prasad Tripathy
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Regional Office, C-6, Qutub Institutional Area, New Delhi, 110016, India.
| | - Hemant D Shewade
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Regional Office, C-6, Qutub Institutional Area, New Delhi, 110016, India
| | | | - A M V Kumar
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Regional Office, C-6, Qutub Institutional Area, New Delhi, 110016, India
| | - A D Harries
- International Union Against Tuberculosis and Lung Disease (The Union), Paris, France.,London School of Hygiene and Tropical Medicine, London, UK
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Yadav V, Kumar S, Balasubramaniam S, Srivastava A, Pallipamula S, Memon P, Singh D, Bhargava S, Sunil GA, Sood B. Facilitators and barriers to participation of private sector health facilities in government-led schemes for maternity services in India: a qualitative study. BMJ Open 2017; 7:e017092. [PMID: 28645984 PMCID: PMC5541501 DOI: 10.1136/bmjopen-2017-017092] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 04/12/2017] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Despite provision of accreditation of private sector health providers in government-led schemes for maternity services in India, their participation has been low. This has led to an underutilisation of their presence, resources and expertise for providing quality maternal and newborn health services. This study explores the perception of various stakeholders on expectations, benefits, barriers and facilitators to private sector participation in government-led schemes-specifically Janani Suraksha Yojana (JSY)-for maternity service delivery. DESIGN Narrative-based qualitative study. Face-to-face in-depth interviews were conducted with study participants. The interviews were transcribed, translated and analysed using a reflexive and inductive approach to allow codes, categories and themes to emerge from within the data. SETTING Private obstetricians, government health officials and FOGSI (Federation of Obstetrics and Gynaecological Societies of India) members, Jharkhand and Uttar Pradesh, India. PARTICIPANTS Eighteen purposefully selected private obstetricians from 9 cities across states of Uttar Pradesh and Jharkhand, 11 government health officials and 2 FOGSI members. RESULTS The major factors serving as barriers to participation of private practitioners in JSY-which emerged on thematic analysis-were low reimbursement amounts, delayed reimbursements, process of interaction with the government and administrative issues, previous experiences and trust deficit, lack of clarity on the accreditation process and patient-level barriers. On the other hand, factors which were facilitators to participation of private practitioners were ease of process, better communication, branding, motivation of increasing clientele as well as satisfaction of doing social service. CONCLUSION Factors such as financial processes and administrative delays, mistrust between the stakeholders, ambiguity in processes, lack of transparency and lack of ease in the process of empanelment of private sector are hindering effective public-private partnerships under JSY. Simplifying and strengthening the processes, communication strategies and branding can help revitalise it.
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Affiliation(s)
- Vikas Yadav
- Jhpiego - an affiliate of Johns Hopkins University, New Delhi, India
| | - Somesh Kumar
- Jhpiego - an affiliate of Johns Hopkins University, New Delhi, India
| | | | - Ashish Srivastava
- Jhpiego - an affiliate of Johns Hopkins University, New Delhi, India
| | | | - Parvez Memon
- Jhpiego - an affiliate of Johns Hopkins University, Lucknow, UP
| | - Dinesh Singh
- Jhpiego - an affiliate of Johns Hopkins University, Ranchi, Jharkhand
| | - Saurabh Bhargava
- Jhpiego - an affiliate of Johns Hopkins University, New Delhi, India
| | | | - Bulbul Sood
- Jhpiego - an affiliate of Johns Hopkins University, New Delhi, India
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11
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Sharma G, Powell-Jackson T, Haldar K, Bradley J, Filippi V. Quality of routine essential care during childbirth: clinical observations of uncomplicated births in Uttar Pradesh, India. Bull World Health Organ 2017; 95:419-429. [PMID: 28603308 PMCID: PMC5463813 DOI: 10.2471/blt.16.179291] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 12/30/2016] [Accepted: 01/03/2017] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To evaluate the quality of essential care during normal labour and childbirth in maternity facilities in Uttar Pradesh, India. METHODS Between 26 May and 8 July 2015, we used clinical observations to assess care provision for 275 mother-neonate pairs at 26 hospitals. Data on 42 items of care were collected, summarized into 17 clinical practices and three aggregate scores and then weighted to obtain population-based estimates. We examined unadjusted differences in quality between the public and private facilities. Multilevel linear mixed-effects models were used to adjust for birth attendant, facility and maternal characteristics. FINDINGS The quality of care we observed was generally poor in both private and public facilities; the mean percentage of essential clinical care practices completed for each woman was 35.7%. Weighted estimates indicate that unqualified personnel provided care for 73.0% and 27.0% of the mother-neonate pairs in public and private facilities, respectively. Obstetric, neonatal and overall care at birth appeared better in the private facilities than in the public ones. In the adjusted analysis, the score for overall quality of care in private facilities was found to be six percentage points higher than the corresponding score for public facilities. CONCLUSION In 2015, the personnel providing labour and childbirth care in maternity facilities were often unqualified and adherence to care protocols was generally poor. Initiatives to measure and improve the quality of care during labour and childbirth need to be developed in the private and public facilities in Uttar Pradesh.
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Affiliation(s)
- Gaurav Sharma
- London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, England
| | | | - Kaveri Haldar
- Sambodhi Research and Communications, New Delhi, India
| | - John Bradley
- London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, England
| | - Véronique Filippi
- London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, England
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Sharma J, Osrin D, Patil B, Neogi SB, Chauhan M, Khanna R, Kumar R, Paul VK, Zodpey S. Newborn healthcare in urban India. J Perinatol 2016; 36:S24-S31. [PMID: 27924107 PMCID: PMC5144125 DOI: 10.1038/jp.2016.187] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The rapid population growth in urban India has outpaced the municipal capacity to build essential infrastructures that make life in cities safe and healthy. Local and national governments alike are grappling with the challenges of urbanization with thousands migrating from villages to cities. Thus, urbanization in India has been accompanied by a concentration of poverty and urban public healthcare has emerged as one of the most pressing priorities facing our country. Newborn mortality rates in urban settings are lower than rural areas, early neonatal deaths account for greater proportion than late neonatal deaths. The available evidence suggests that socio-economic inequalities and poor environment pose major challenges for newborn health. Moreover, fragmented and weak public health system, multiplicity of actors and limited capacity of public health planning further constrain the delivery of quality and affordable health care service. Though healthcare is concentrated in urban areas, delay in deciding to seek health care, reaching a source of it and receiving appropriate care affects the health outcomes disproportionately. However, a few city initiatives and innovations piloted in different states and cities have brought forth the evidences of effectiveness of different strategies. Recently launched National Urban Health Mission (NUHM) provides an opportunity for strategic thinking and actions to improve newborn health outcomes in India. There is also an opportunity for coalescence of activities around National Health Mission (NHM) and Reproductive, Maternal, Newborn and Child Health+Adolescent (RMNCH+A) strategy to develop feasible and workable models in different urban settings. Concomitant operational research needs to be carried out so that the obstacles, approaches and response to the program can be understood.
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Affiliation(s)
- J Sharma
- Indian Institute of Public Health (Delhi), Public Health Foundation of India, New Delhi, India
| | - D Osrin
- UCL Institute for Global Health, University College London, London, UK
| | - B Patil
- Saving Newborn Lives, Save the Children, India
| | - S B Neogi
- Indian Institute of Public Health (Delhi), Public Health Foundation of India, New Delhi, India
| | - M Chauhan
- Indian Institute of Public Health (Delhi), Public Health Foundation of India, New Delhi, India
| | - R Khanna
- Saving Newborn Lives, Save the Children, India
| | - R Kumar
- Ministry of Health and Family Welfare, Govt. of India, New Delhi, India
| | - V K Paul
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - S Zodpey
- Indian Institute of Public Health (Delhi), Public Health Foundation of India, New Delhi, India,Indian Institute of Public Health Delhi, Public Health Foundation of India, Plot No. 47, Sector-44 Institutional Area, Gurgaon 122002, New Delhi, India. E-mail:
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Yasobant S, Vora KS, Shewade HD, Annerstedt KS, Isaakidis P, Mavalankar DV, Dholakia NB, De Costa A. Utilization of the state led public private partnership program "Chiranjeevi Yojana" to promote facility births in Gujarat, India: a cross sectional community based study. BMC Health Serv Res 2016; 16:266. [PMID: 27421254 PMCID: PMC4946109 DOI: 10.1186/s12913-016-1510-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 07/05/2016] [Indexed: 11/10/2022] Open
Abstract
Background “Chiranjeevi Yojana (CY)”, a state-led large-scale demand-side financing scheme (DSF) under public-private partnership to increase institutional delivery, has been implemented across Gujarat state, India since 2005. The scheme aims to provide free institutional childbirth services in accredited private health facilities to women from socially disadvantaged groups (eligible women). These services are paid for by the state to the private facility with the intention of service being free to the user. This community-based study estimates CY uptake among eligible women and explores factors associated with non-utilization of the CY program. Methods This was a community-based cross sectional survey of eligible women who gave birth between January and July 2013 in 142 selected villages of three districts in Gujarat. A structured questionnaire was administered by trained research assistant to collect information on socio-demographic details, pregnancy details, details of childbirth and out-of-pocket (OOP) expenses incurred. A multivariable inferential analysis was done to explore the factors associated with non-utilization of the CY program. Results Out of 2,143 eligible women, 559 (26 %) gave birth under the CY program. A further 436(20 %) delivered at free public facilities, 713(33 %) at private facilities (OOP payment) and 435(20 %) at home. Eligible women who belonged to either scheduled tribe or poor [aOR = 3.1, 95 % CI:2.4 - 3.8] or having no formal education [aOR = 1.6, 95 % CI:1.1, 2.2] and who delivered by C-section [aOR = 2.1,95 % CI: 1.2, 3.8] had higher odds of not utilizing CY program. Of births at CY accredited facilities (n = 924), non-utilization was 40 % (n = 365) mostly because of lack of required official documentation that proved eligibility (72 % of eligible non-users). Women who utilized the CY program overall paid more than women who delivered in the free public facilities. Conclusion Uptake of the CY among eligible women was low after almost a decade of implementation. Community level awareness programs are needed to increase participation among eligible women. OOP expense was incurred among who utilized CY program; this may be a factor associated with non-utilization in next pregnancy which needs to be studied. There is also a need to ensure financial protection of women who have C-section.
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Affiliation(s)
- Sandul Yasobant
- Indian Institute of Public Health-Gandhinagar, Sardar Patel Institute Campus, Drive-in-Road, Ahmedabad, Gujarat, 380054, India.
| | - Kranti Suresh Vora
- Indian Institute of Public Health-Gandhinagar, Sardar Patel Institute Campus, Drive-in-Road, Ahmedabad, Gujarat, 380054, India
| | - Hemant Deepak Shewade
- International Union Against Tuberculosis and Lung Disease (The Union), South East Asia Office, New Delhi, India
| | | | - Petros Isaakidis
- Médecins Sans Frontières (MSF)/Doctors Without Borders, Mumbai, India
| | - Dileep V Mavalankar
- Indian Institute of Public Health-Gandhinagar, Sardar Patel Institute Campus, Drive-in-Road, Ahmedabad, Gujarat, 380054, India
| | - Nishith B Dholakia
- Department of Health & Family Welfare, Government of Gujarat, Gandhinagar, India
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Sidney K, Iyer V, Vora K, Mavalankar D, De Costa A. Statewide program to promote institutional delivery in Gujarat, India: who participates and the degree of financial subsidy provided by the Chiranjeevi Yojana program. JOURNAL OF HEALTH, POPULATION, AND NUTRITION 2016; 35:2. [PMID: 26825366 PMCID: PMC5026006 DOI: 10.1186/s41043-016-0039-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 01/19/2016] [Indexed: 06/05/2023]
Abstract
BACKGROUND The Chiranjeevi Yojana (CY) is a large public-private partnership program in Gujarat, India, under which the state pays private sector obstetricians to provide childbirth services to poor and tribal women. The CY was initiated statewide in 2007 because of the limited ability of the public health sector to provide emergency obstetric care and high out-of-pocket expenditures in the private sector (where most qualified obstetricians work), creating financial access barriers for poor women. Despite a million beneficiaries, there have been few reports studying CY, particularly the proportion of vulnerable women being covered, the expenditures they incur in connection with childbirth, and the level of subsidy provided to beneficiaries by the program. METHODS Cross-sectional facility based the survey of participants in three districts of Gujarat in 2012-2013. Women were interviewed to elicit sociodemographic characteristics, out-of-pocket expenditures, and CY program details. Descriptive statistics, chi square, and a multivariable logistic regression were performed. RESULTS Of the 901 women surveyed in 129 facilities, 150 (16 %) were CY beneficiaries; 336 and 415 delivered in government and private facilities, respectively. Only 36 (24 %) of the 150 CY beneficiaries received a completely cashless delivery. Median out-of-pocket for vaginal/cesarean delivery among CY beneficiaries was $7/$71. The median degree of subsidy for women in CY who delivered vaginally/cesarean was 85/71 % compared to out-of-pocket expenditure of $44/$208 for vaginal/cesarean delivery paid by non-program beneficiaries in the private health sector. CONCLUSIONS CY beneficiaries experienced a substantially subsidized childbirth compared to women who delivered in non-accredited private facilities. However, despite the government's efforts at increasing access to delivery services for poor women in the private sector, uptake was low and very few women experienced a cashless delivery. While the long-term focus remains on strengthening the public sector's ability to provide emergency obstetric care, the CY program is a potential means by which the state can ensure its poor mothers have access to necessary care if uptake is increased.
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Affiliation(s)
- Kristi Sidney
- Public Health Sciences, Karolinska Institutet, Widerströmska, Tomtebodavägen 18A, plan 4, SE-171 77, Stockholm, Sweden.
| | - Veena Iyer
- Indian Institute of Public Health Gandhinagar, Public Health Foundation of India, Ahmedabad, Gujarat, India.
| | - Kranti Vora
- Indian Institute of Public Health Gandhinagar, Public Health Foundation of India, Ahmedabad, Gujarat, India.
| | - Dileep Mavalankar
- Indian Institute of Public Health Gandhinagar, Public Health Foundation of India, Ahmedabad, Gujarat, India.
| | - Ayesha De Costa
- Public Health Sciences, Karolinska Institutet, Widerströmska, Tomtebodavägen 18A, plan 4, SE-171 77, Stockholm, Sweden.
- Indian Institute of Public Health Gandhinagar, Public Health Foundation of India, Ahmedabad, Gujarat, India.
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Vora KS, Annerstedt KS, Mavalankar DV, Dholakia NB, Yasobant S, Saiyed S, Upadhyay A, De Costa A. Community Based Survey Methodology for Maternal Healthcare Utilization: Gujarat, India. Health (London) 2016. [DOI: 10.4236/health.2016.814152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Vora KS, Yasobant S, Patel A, Upadhyay A, Mavalankar DV. Has Chiranjeevi Yojana changed the geographic availability of free comprehensive emergency obstetric care services in Gujarat, India? Glob Health Action 2015; 8:28977. [PMID: 26446287 PMCID: PMC4596889 DOI: 10.3402/gha.v8.28977] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Revised: 08/26/2015] [Accepted: 09/11/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The high rate of maternal mortality in India is of grave concern. Poor rural Indian women are most vulnerable to preventable maternal deaths primarily because they have limited availability of affordable emergency obstetric care (EmOC) within reasonable geographic proximity. Scarcity of obstetricians in the public sector combined with financial barriers to accessing private sector obstetrician services preclude this underserved population from availing lifesaving functions of comprehensive EmOC such as C-section. In order to overcome this limitation, Government of Gujarat initiated a unique public-private partnership program called Chiranjeevi Yojana (CY) in 2005. The program envisaged leveraging private sector providers to increase availability and thereby accessibility of EmOC care for vulnerable sections of society. Under CY, private sector providers render obstetric care services to poor women at no cost to patients. This paper examines the CY's effectiveness in improving availability of CEmOC services between 2006 and 2012 in three districts of Gujarat, India. METHODS Primary data on facility locations, EmOC functionality, and obstetric bed availability were collected in the years 2012 and 2013 in three study districts. Secondary data from Census 2001 and 2011 were used along with required geographic information from Topo sheets and Google Earth maps. ArcGIS version 10 was used to analyze the availability of services using two-step floating catchment area (2SFCA) method. RESULTS Our analysis suggests that the availability of CEmOC services within reasonable travel distance has greatly improved in all three study districts as a result of CY. We also show that the declining participation of the private sector did not result in an increase in distance to the nearest facility, but the extent of availability of providers for several villages was reduced. Spatial and temporal analyses in this paper provide a comprehensive understanding of trends in the availability of EmOC services within reasonable travel distance. CONCLUSIONS This paper demonstrates how GIS could be useful for evaluating programs especially those focusing on improving availability and geographic accessibility. The study also shows usefulness of GIS for programmatic planning, particularly for optimizing resource allocation.
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Affiliation(s)
| | - Sandul Yasobant
- Indian Institute of Public Health - Gandhinagar, Ahmedabad, India
| | - Amit Patel
- School of Policy, Government, and International Affairs, George Mason University, Fairfax, VA, USA
| | - Ashish Upadhyay
- Indian Institute of Public Health - Gandhinagar, Ahmedabad, India
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Sharma G, Mathai M, Dickson KE, Weeks A, Hofmeyr GJ, Lavender T, Day LT, Mathews JE, Fawcus S, Simen-Kapeu A, de Bernis L. Quality care during labour and birth: a multi-country analysis of health system bottlenecks and potential solutions. BMC Pregnancy Childbirth 2015; 15 Suppl 2:S2. [PMID: 26390886 PMCID: PMC4577867 DOI: 10.1186/1471-2393-15-s2-s2] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Good outcomes during pregnancy and childbirth are related to availability, utilisation and effective implementation of essential interventions for labour and childbirth. The majority of the estimated 289,000 maternal deaths, 2.8 million neonatal deaths and 2.6 million stillbirths every year could be prevented by improving access to and scaling up quality care during labour and birth. METHODS The bottleneck analysis tool was applied in 12 countries in Africa and Asia as part of the Every Newborn Action Plan process. Country workshops engaged technical experts to complete the survey tool, which is designed to synthesise and grade health system "bottlenecks", factors that hinder the scale up, of maternal-newborn intervention packages. We used quantitative and qualitative methods to analyse the bottleneck data, combined with literature review, to present priority bottlenecks and actions relevant to different health system building blocks for skilled birth attendance and basic and comprehensive emergency obstetric care. RESULTS Across 12 countries the most critical bottlenecks identified by workshop participants for skilled birth attendance were health financing (10 out of 12 countries) and health workforce (9 out of 12 countries). Health service delivery bottlenecks were found to be the most critical for both basic and comprehensive emergency obstetric care (9 out of 12 countries); health financing was identified as having critical bottlenecks for comprehensive emergency obstetric care (9 out of 12 countries). Solutions to address health financing bottlenecks included strengthening national financing mechanisms and removing financial barriers to care seeking. For addressing health workforce bottlenecks, improved human resource planning is needed, including task shifting and improving training quality. For health service delivery, proposed solutions included improving quality of care and establishing public private partnerships. CONCLUSIONS Progress towards the 2030 targets for ending preventable maternal and newborn deaths is dependent on improving quality of care during birth and the immediate postnatal period. Strengthening national health systems to improve maternal and newborn health, as a cornerstone of universal health coverage, will only be possible by addressing specific health system bottlenecks during labour and birth, including those within health workforce, health financing and health service delivery.
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Affiliation(s)
- Gaurav Sharma
- Maternal, Adolescent, Reproductive and Child Health (MARCH) Centre, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, United Kingdom
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Matthews Mathai
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland
| | - Kim E Dickson
- Health Section, Programme Division, UNICEF Headquarters, 3 United Nations Plaza, New York, 10017, USA
| | - Andrew Weeks
- Sanyu Research Unit, University of Liverpool, c/o Liverpool Women's Hospital, Crown Street, Liverpool, L8 7SS, UK
| | - G Justus Hofmeyr
- Department of Obstetrics and Gynaecology, East London Hospital Complex, University of the Witwatersrand, University of Fort Hare, Eastern Cape Department of Health, East London, South Africa
| | - Tina Lavender
- University of Manchester School of Nursing, Midwifery & Social Work, Jean McFarlane Building University Place, Oxford Road, Manchester, M13 9PL, UK
| | - Louise Tina Day
- LAMB, Integrated Rural Health & Development, Dinajpur, 5250, Bangladesh
| | - Jiji Elizabeth Mathews
- Department of Obstetrics and Gynaecology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Sue Fawcus
- Department of Obstetrics & Gynaecology, University of Cape Town, Observatory 7925, Cape Town, South Africa
| | - Aline Simen-Kapeu
- Health Section, Programme Division, UNICEF Headquarters, 3 United Nations Plaza, New York, 10017, USA
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Options for Optimal Coverage of Free C-Section Services for Poor Mothers in Indian State of Gujarat: Location Allocation Analysis Using GIS. PLoS One 2015; 10:e0137122. [PMID: 26332207 PMCID: PMC4558015 DOI: 10.1371/journal.pone.0137122] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 08/12/2015] [Indexed: 11/25/2022] Open
Abstract
Background Gujarat, a western state of India, has seen a steep rise in the proportion of institutional deliveries over the last decade. However, there has been a limited access to cesarean section (C-Section) deliveries for complicated obstetric cases especially for poor rural women. C-section is a lifesaving intervention that can prevent both maternal and perinatal mortality. Poor women bear a disproportionate burden of maternal mortality, and lack of access to C-section, especially for these women, is an important contributor for high maternal and perinatal mortality in resource limited settings. To improve access for this underserved population in the context of inadequate public provision of emergency obstetric services, the state government of Gujarat initiated a public private partnership program called “Chiranjeevi Yojana” (CY) in 2005 to increase the number of facilities providing free C-section services. This study aimed to analyze the current availability of these services in three districts of Gujarat and to identify the best locations for additional service centres to optimize access to free C-section services using Geographic Information System technology. Methodology Supply and demand for obstetric care were calculated using secondary data from sources such as Census and primary data from cross-sectional facility survey. The study is unique in using primary data from facilities, which was collected in 2012–13. Information on obstetric beds and functionality of facilities to calculate supply was collected using pretested questionnaire by trained researchers after obtaining written consent from the participating facilities. Census data of population and birth rates for the study districts was used for demand calculations. Location-allocation model of ArcGIS 10 was used for analyses. Results Currently, about 50 to 84% of populations in all three study districts have access to free C-section facilities within a 20km radius. The model suggests that about 80–96% of the population can be covered for free C-section services with addition of 4–6 centres in critical but underserved regions. It was also suggested that upgrading of public sector facilities with minimal investment can improve the services. Conclusion This study highlights utility of Geographic Information System technology for planning service centres to optimize access to vital lifesaving procedure such as C-section. Although the location allocation methodology has been available for decades, it has been used sparsely by public health professionals. This paper makes an important contribution to the literature for use of the method for planning in resource limited settings.
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Vora KS, Koblinsky SA, Koblinsky MA. Predictors of maternal health services utilization by poor, rural women: a comparative study in Indian States of Gujarat and Tamil Nadu. JOURNAL OF HEALTH, POPULATION, AND NUTRITION 2015; 33:9. [PMID: 26825416 PMCID: PMC5026000 DOI: 10.1186/s41043-015-0025-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 07/23/2015] [Indexed: 05/25/2023]
Abstract
BACKGROUND India leads all nations in numbers of maternal deaths, with poor, rural women contributing disproportionately to the high maternal mortality ratio. In 2005, India launched the world's largest conditional cash transfer scheme, Janani Suraksha Yojana (JSY), to increase poor women's access to institutional delivery, anticipating that facility-based birthing would decrease deaths. Indian states have taken different approaches to implementing JSY. Tamil Nadu adopted JSY with a reorganization of its public health system, and Gujarat augmented JSY with the state-funded Chiranjeevi Yojana (CY) scheme, contracting with private physicians for delivery services. Given scarce evidence of the outcomes of these approaches, especially in states with more optimal health indicators, this cross-sectional study examined the role of JSY/CY and other healthcare system and social factors in predicting poor, rural women's use of maternal health services in Gujarat and Tamil Nadu. METHODS Using the District Level Household Survey (DLHS)-3, the sample included 1584 Gujarati and 601 Tamil rural women in the lowest two wealth quintiles. Multivariate logistic regression analyses examined associations between JSY/CY and other salient health system, socio-demographic, and obstetric factors with three outcomes: adequate antenatal care, institutional delivery, and Cesarean-section. RESULTS Tamil women reported greater use of maternal healthcare services than Gujarati women. JSY/CY participation predicted institutional delivery in Gujarat (AOR = 3.9), but JSY assistance failed to predict institutional delivery in Tamil Nadu, where mothers received some cash for home births under another scheme. JSY/CY assistance failed to predict adequate antenatal care, which was not incentivized. All-weather road access predicted institutional delivery in both Tamil Nadu (AOR = 3.4) and Gujarat (AOR = 1.4). Women's education predicted institutional delivery and Cesarean-section in Tamil Nadu, while husbands' education predicted institutional delivery in Gujarat. CONCLUSIONS Overall, assistance from health financing schemes, good road access to health facilities, and socio-demographic and obstetric factors were associated with differential use of maternity health services by poor, rural women in the two states. Policymakers and practitioners should promote financing schemes to increase access, including consideration of incentives for antenatal care, and address health system and social factors in designing state-level interventions to promote safe motherhood.
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Affiliation(s)
- Kranti Suresh Vora
- Indian Institute of Public Health Gandhinagar, Drive-in-Road, Ahmedabad, Gujarat, 380054, India.
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Ganguly P, Jehan K, de Costa A, Mavalankar D, Smith H. Considerations of private sector obstetricians on participation in the state led "Chiranjeevi Yojana" scheme to promote institutional delivery in Gujarat, India: a qualitative study. BMC Pregnancy Childbirth 2014; 14:352. [PMID: 25374099 PMCID: PMC4289232 DOI: 10.1186/1471-2393-14-352] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 08/17/2014] [Indexed: 11/24/2022] Open
Abstract
Background In India a lack of access to emergency obstetric care contributes to maternal deaths. In 2005 Gujarat state launched a public-private partnership (PPP) programme, Chiranjeevi Yojana (CY), under which the state pays accredited private obstetricians a fixed fee for providing free intrapartum care to poor and tribal women. A million women have delivered under CY so far. The participation of private obstetricians in the partnership is central to the programme’s effectiveness. We explored with private obstetricians the reasons and experiences that influenced their decisions to participate in the CY programme. Method In this qualitative study we interviewed 24 purposefully selected private obstetricians in Gujarat. We explored their views on the scheme, the reasons and experiences leading up to decisions to participate, not participate or withdraw from the CY, as well as their opinions about the scheme’s impact. We analysed data using the Framework approach. Results Participants expressed a tension between doing public good and making a profit. Bureaucratic procedures and perceptions of programme misuse seemed to influence providers to withdraw from the programme or not participate at all. Providers feared that participating in CY would lower the status of their practices and some were deterred by the likelihood of more clinically difficult cases among eligible CY beneficiaries. Some providers resented taking on what they saw as a state responsibility to provide safe maternity services to poor women. Younger obstetricians in the process of establishing private practices, and those in more remote, ‘less competitive’ areas, were more willing to participate in CY. Some doctors had reservations over the quality of care that doctors could provide given the financial constraints of the scheme. Conclusions While some private obstetricians willingly participate in CY and are satisfied with its functioning, a larger number shared concerns about participation. Operational difficulties and a trust deficit between the public and private health sectors affect retention of private providers in the scheme. Further refinement of the scheme, in consultation with private partners, and trust building initiatives could strengthen the programme. These findings offer lessons to those developing public-private partnerships to widen access to health services for underprivileged groups.
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De Costa A, Vora KS, Ryan K, Sankara Raman P, Santacatterina M, Mavalankar D. The state-led large scale public private partnership 'Chiranjeevi Program' to increase access to institutional delivery among poor women in Gujarat, India: How has it done? What can we learn? PLoS One 2014; 9:e95704. [PMID: 24787692 PMCID: PMC4006779 DOI: 10.1371/journal.pone.0095704] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2013] [Accepted: 03/28/2014] [Indexed: 11/23/2022] Open
Abstract
Background Many low-middle income countries have focused on improving access to and quality of obstetric care, as part of promoting a facility based intra-partum care strategy to reduce maternal mortality. The state of Gujarat in India, implements a facility based intra-partum care program through its large for-profit private obstetric sector, under a state-led public-private-partnership, the Chiranjeevi Yojana (CY), under which the state pays accredited private obstetricians to perform deliveries for poor/tribal women. We examine CY performance, its contribution to overall trends in institutional deliveries in Gujarat over the last decade and its effect on private and public sector deliveries there. Methods District level institutional delivery data (public, private, CY), national surveys, poverty estimates, census data were used. Institutional delivery trends in Gujarat 2000–2010 are presented; including contributions of different sectors and CY. Piece-wise regression was used to study the influence of the CY program on public and private sector institutional delivery. Results Institutional delivery rose from 40.7% (2001) to 89.3% (2010), driven by sharp increases in private sector deliveries. Public sector and CY contributed 25–29% and 13–16% respectively of all deliveries each year. In 2007, 860 of 2000 private obstetricians participated in CY. Since 2007, >600,000 CY deliveries occurred i.e. one-third of births in the target population. Caesareans under CY were 6%, higher than the 2% reported among poor women by the DLHS survey just before CY. CY did not influence the already rising proportion of private sector deliveries in Gujarat. Conclusion This paper reports a state-led, fully state-funded, large-scale public-private partnership to improve poor women’s access to institutional delivery - there have been >600,000 beneficiaries. While caesarean proportions are higher under CY than before, it is uncertain if all beneficiaries who require sections receive these. Other issues to explore include quality of care, provider attrition and the relatively low coverage.
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Affiliation(s)
- Ayesha De Costa
- Dept of Public Health Sciences, Karolinska Insitutet, Stockholm, Sweden
- * E-mail:
| | - Kranti S. Vora
- Indian Institute of Public Health, Gandhinagar, Gujarat, India
| | - Kayleigh Ryan
- Dept of Public Health Sciences, Karolinska Insitutet, Stockholm, Sweden
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Van de Poel E, Flores G, Ir P, O'Donnell O, Van Doorslaer E. Can vouchers deliver? An evaluation of subsidies for maternal health care in Cambodia. Bull World Health Organ 2014; 92:331-9. [PMID: 24839322 DOI: 10.2471/blt.13.129122] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Revised: 11/05/2013] [Accepted: 11/28/2013] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To evaluate the effect of vouchers for maternity care in public health-care facilities on the utilization of maternal health-care services in Cambodia. METHODS The study involved data from the 2010 Cambodian Demographic and Health Survey, which covered births between 2005 and 2010. The effect of voucher schemes, first implemented in 2007, on the utilization of maternal health-care services was quantified using a difference-in-differences method that compared changes in utilization in districts with voucher schemes with changes in districts without them. FINDINGS Overall, voucher schemes were associated with an increase of 10.1 percentage points (pp) in the probability of delivery in a public health-care facility; among women from the poorest 40% of households, the increase was 15.6 pp. Vouchers were responsible for about one fifth of the increase observed in institutional deliveries in districts with schemes. Universal voucher schemes had a larger effect on the probability of delivery in a public facility than schemes targeting the poorest women. Both types of schemes increased the probability of receiving postnatal care, but the increase was significant only for non-poor women. Universal, but not targeted, voucher schemes significantly increased the probability of receiving antenatal care. CONCLUSION Voucher schemes increased deliveries in health centres and, to a lesser extent, improved antenatal and postnatal care. However, schemes that targeted poorer women did not appear to be efficient since these women were more likely than less poor women to be encouraged to give birth in a public health-care facility, even with universal voucher schemes.
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Affiliation(s)
- Ellen Van de Poel
- Institute of Health Policy and Management, Erasmus University Rotterdam, PO Box 1738, 3000 DR Rotterdam, Netherlands
| | - Gabriela Flores
- Institute of Health Economics and Management, University of Lausanne, Lausanne, Switzerland
| | - Por Ir
- Institute of Tropical Medicine, Antwerp, Belgium
| | | | - Eddy Van Doorslaer
- Institute of Health Policy and Management, Erasmus University Rotterdam, PO Box 1738, 3000 DR Rotterdam, Netherlands
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Mohanan M, Bauhoff S, La Forgia G, Babiarz KS, Singh K, Miller G. Effect of Chiranjeevi Yojana on institutional deliveries and neonatal and maternal outcomes in Gujarat, India: a difference-in-differences analysis. Bull World Health Organ 2014; 92:187-94. [PMID: 24700978 PMCID: PMC3949592 DOI: 10.2471/blt.13.124644] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Revised: 10/14/2013] [Accepted: 10/30/2013] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To evaluate the effect of the Chiranjeevi Yojana programme, a public-private partnership to improve maternal and neonatal health in Gujarat, India. METHODS A household survey (n = 5597 households) was conducted in Gujarat to collect retrospective data on births within the preceding 5 years. In an observational study using a difference-in-differences design, the relationship between the Chiranjeevi Yojana programme and the probability of delivery in health-care institutions, the probability of obstetric complications and mean household expenditure for deliveries was subsequently examined. In multivariate regressions, individual and household characteristics as well as district and year fixed effects were controlled for. Data from the most recent District Level Household and Facility Survey (DLHS-3) wave conducted in Gujarat (n = 6484 households) were used in parallel analyses. FINDINGS Between 2005 and 2010, the Chiranjeevi Yojana programme was not associated with a statistically significant change in the probability of institutional delivery (2.42 percentage points; 95% confidence interval, CI: -5.90 to 10.74) or of birth-related complications (6.16 percentage points; 95% CI: -2.63 to 14.95). Estimates using DLHS-3 data were similar. Analyses of household expenditures indicated that mean household expenditure for private-sector deliveries had either not fallen or had fallen very little under the Chiranjeevi Yojana programme. CONCLUSION The Chiranjeevi Yojana programme appears to have had no significant impact on institutional delivery rates or maternal health outcomes. The absence of estimated reductions in household spending for private-sector deliveries deserves further study.
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Affiliation(s)
- Manoj Mohanan
- Sanford School of Public Policy, Duke University, 302 Towerview Drive, Durham NC 27708, United States of America (USA)
| | | | | | | | - Kultar Singh
- Sambodhi Research and Communications Pvt Ltd, New Delhi, India
| | - Grant Miller
- School of Medicine and Freeman Spogli Institute for International Studies, Stanford University, Stanford, California, USA
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Dangoria D, Pampallona S, Lata NS, Bollini P. A retrospective observational study of obstetric care in rural Andhra Pradesh by Dangoria Charitable Trust (1979 to 2009). Indian J Med Res 2013; 138:928-34. [PMID: 24521638 PMCID: PMC3978984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND & OBJECTIVES In India several models of health care delivery have been explored to increase access to skilled obstetric care in rural areas, where there is a lack of specialists and appropriate facilities. We present here an innovative and affordable approach to the delivery of antenatal and obstetric care provided by the Dangoria Charitable Trust (DCT) since 1979, twinning a not-for-profit hospital in rural Andhra Pradesh with a for-profit one in the capital Hyderabad. METHODS A retrospective observational study of a random sample of the deliveries performed from 1979 to 2009 by the Dangoria Charitable Trust, based on the maternity hospital birth register, was conducted. The profile of mothers, such as their age, parity and previous miscarriages, as well as type of delivery, gender and birth weight of the newborn, and frequency of stillbirths and in hospital deaths as they evolved over time were presented using simple descriptive methods. The risk of stillbirth and in hospital death over time was explored by logistic regression after allowance for selected factors. RESULTS From 1979 to 2009 the cumulative number of deliveries at the Narsapur maternity hospital was 9333, from a few dozens per year in the early 1980s to over 1000 in 2009. The number of primiparae significantly increased over time, while the percentage of low birth weight babies (less than 2.5 kg) did not change appreciably. Caesarean section increased significantly over time, from 8.6 per cent in the first decade to 20.3 per cent in the last. The risk of death (stillbirths and in hospital death) consistently decreased over time, reaching 15 per thousand in the last decade. The results of a logistic regression adjusted for potential confounders showed that low birth weight babies had 4 times the risk of dying as compared to those weighing 2.5 kg or above. CONCLUSIONS Over the 30 year period the percentage of babies discharged alive from DCT improved considerably. Caesarean sections increased significantly from the first decade to the third decade. The model adopted by the DCT to improve maternal and child health in rural areas could be replicated in other rural parts of the country.
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Affiliation(s)
| | | | | | - Paola Bollini
- Services for Medical Research, Evolene, Switzerland,Reprint requests: Dr Paola Bollini, Services for Medical Research, 1983 Evolene, Switzerland e-mail:
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Mony PK, Krishnamurthy J, Thomas A, Sankar K, Ramesh BM, Moses S, Blanchard J, Avery L. Availability and distribution of emergency obstetric care services in Karnataka State, South India: access and equity considerations. PLoS One 2013; 8:e64126. [PMID: 23717547 PMCID: PMC3661461 DOI: 10.1371/journal.pone.0064126] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Accepted: 04/10/2013] [Indexed: 12/02/2022] Open
Abstract
Background As part of efforts to reduce maternal deaths in Karnataka state, India, there has been a concerted effort to increase institutional deliveries. However, little is known about the quality of care in these healthcare facilities. We investigated the availability and distribution of emergency obstetric care (EmOC) services in eight northern districts of Karnataka state in south India. Methods & Findings We undertook a cross-sectional study of 444 government and 422 private health facilities, functional 24-hours-a-day 7-days-a-week. EmOC availability and distribution were evaluated for 8 districts and 42 taluks (sub-districts) during the year 2010, based on a combination of self-reporting, record review and direct observation. Overall, the availability of EmOC services at the sub-state level [EmOC = 5.9/500,000; comprehensive EmOC (CEmOC) = 4.5/500,000 and basic EmOC (BEmOC) = 1.4/500,000] was seen to meet the benchmark. These services however were largely located in the private sector (90% of CEmOC and 70% of BemOC facilities). Thirty six percent of private facilities and six percent of government facilities were EmOC centres. Although half of eight districts had a sufficient number of EmOC facilities and all eight districts had a sufficient number of CEmOC facilities, only two-fifths of the 42 taluks had a sufficient number of EmOC facilities. With the private facilities being largely located in select towns only, the ‘non-headquarter’ taluks and ‘backward’ taluks suffered from a marked lack of coverage of these services. Spatial mapping further helped identify the clustering of a large number of contiguous taluks without adequate government EmOC facilities in northeastern Karnataka. Conclusions In conclusion, disaggregating information on emergency obstetric care service availability at district and subdistrict levels is critical for health policy and planning in the Indian setting. Reducing maternal deaths will require greater attention by the government in addressing inequities in the distribution of emergency obstetric care services.
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Affiliation(s)
- Prem K Mony
- Division of Epidemiology & Population Health, St John's Research Institute, Bangalore, India.
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Jehan K, Sidney K, Smith H, de Costa A. Improving access to maternity services: an overview of cash transfer and voucher schemes in South Asia. REPRODUCTIVE HEALTH MATTERS 2012; 20:142-54. [PMID: 22789092 DOI: 10.1016/s0968-8080(12)39609-2] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
In Nepal, India, Bangladesh and Pakistan, policy focused on improving access to maternity services has led to measures to reduce cost barriers impeding women's access to care. Specifically, these include cash transfer or voucher schemes designed to stimulate demand for services, including antenatal, delivery and post-partum care. In spite of their popularity, however, little is known about the impact or effectiveness of these schemes. This paper provides an overview of five major interventions: the Aama (Mothers') Programme (cash transfer element) in Nepal; the Janani Suraksha Yojana (Safe Motherhood Scheme) in India; the Chiranjeevi Yojana (Scheme for Long Life) in India; the Maternal Health Voucher Scheme in Bangladesh and the Sehat (Health) Voucher Scheme in Pakistan. It reviews the aims, rationale, implementation challenges, known outcomes, potential and limitations of each scheme based on current available data. Increased use of maternal health services has been reported since the schemes began, though evidence of improvements in maternal health outcomes has not been established due to a lack of controlled studies. Areas for improvement in these schemes, identified in this review, include the need for more efficient operational management, clear guidelines, financial transparency, plans for sustainability, evidence of equity and, above all, proven impact on quality of care and maternal mortality and morbidity.
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Affiliation(s)
- Kate Jehan
- International Health Group, Liverpool School of Tropical Medicine, Liverpool, UK.
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Upadhyay RP, Chinnakali P, Odukoya O, Yadav K, Sinha S, Rizwan SA, Daral S, Chellaiyan VG, Silan V. High neonatal mortality rates in rural India: what options to explore? ISRN PEDIATRICS 2012; 2012:968921. [PMID: 23213561 PMCID: PMC3506889 DOI: 10.5402/2012/968921] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Accepted: 09/16/2012] [Indexed: 11/27/2022]
Abstract
The neonatal mortality rate in India is amongst the highest in the world and skewed towards rural areas. Nonavailability of trained manpower along with poor healthcare infrastructure is one of the major hurdles in ensuring quality neonatal care. We reviewed case studies and relevant literature from low and middle income countries and documented alternative strategies that have proved to be favourable in improving neonatal health. The authors reiterate the fact that recruiting and retaining trained manpower in rural areas by all means is essential to improve the quality of neonatal care services. Besides this, other strategies such as training of local rural healthcare providers and traditional midwives, promoting home-based newborn care, and creating community awareness and mobilization also hold enough potential to influence the neonatal health positively and efforts should be made to implement them on a larger scale. More research is demanded for innovations such as “m-health” and public-private partnerships as they have been shown to offer potential in terms of improving the standards of care. The above proposed strategy is likely to reduce morbidity among neonatal survivors as well.
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Affiliation(s)
- Ravi Prakash Upadhyay
- Department of Community Medicine, Vardhman Mahavir Medical College and Safdarjang Hospital, New Delhi 110049, India
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Basu S, Andrews J, Kishore S, Panjabi R, Stuckler D. Comparative performance of private and public healthcare systems in low- and middle-income countries: a systematic review. PLoS Med 2012; 9:e1001244. [PMID: 22723748 PMCID: PMC3378609 DOI: 10.1371/journal.pmed.1001244] [Citation(s) in RCA: 354] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Accepted: 05/08/2012] [Indexed: 11/01/2022] Open
Abstract
INTRODUCTION Private sector healthcare delivery in low- and middle-income countries is sometimes argued to be more efficient, accountable, and sustainable than public sector delivery. Conversely, the public sector is often regarded as providing more equitable and evidence-based care. We performed a systematic review of research studies investigating the performance of private and public sector delivery in low- and middle-income countries. METHODS AND FINDINGS Peer-reviewed studies including case studies, meta-analyses, reviews, and case-control analyses, as well as reports published by non-governmental organizations and international agencies, were systematically collected through large database searches, filtered through methodological inclusion criteria, and organized into six World Health Organization health system themes: accessibility and responsiveness; quality; outcomes; accountability, transparency, and regulation; fairness and equity; and efficiency. Of 1,178 potentially relevant unique citations, data were obtained from 102 articles describing studies conducted in low- and middle-income countries. Comparative cohort and cross-sectional studies suggested that providers in the private sector more frequently violated medical standards of practice and had poorer patient outcomes, but had greater reported timeliness and hospitality to patients. Reported efficiency tended to be lower in the private than in the public sector, resulting in part from perverse incentives for unnecessary testing and treatment. Public sector services experienced more limited availability of equipment, medications, and trained healthcare workers. When the definition of "private sector" included unlicensed and uncertified providers such as drug shop owners, most patients appeared to access care in the private sector; however, when unlicensed healthcare providers were excluded from the analysis, the majority of people accessed public sector care. "Competitive dynamics" for funding appeared between the two sectors, such that public funds and personnel were redirected to private sector development, followed by reductions in public sector service budgets and staff. CONCLUSIONS Studies evaluated in this systematic review do not support the claim that the private sector is usually more efficient, accountable, or medically effective than the public sector; however, the public sector appears frequently to lack timeliness and hospitality towards patients.
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Affiliation(s)
- Sanjay Basu
- Department of Medicine, University of California, San Francisco, California, United States of America.
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Pathak PK, Singh A, Subramanian SV. Economic inequalities in maternal health care: prenatal care and skilled birth attendance in India, 1992-2006. PLoS One 2010; 5:e13593. [PMID: 21048964 PMCID: PMC2965095 DOI: 10.1371/journal.pone.0013593] [Citation(s) in RCA: 130] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2010] [Accepted: 09/15/2010] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The use of maternal health care is limited in India despite several programmatic efforts for its improvement since the late 1980's. The use of maternal health care is typically patterned on socioeconomic and cultural contours. However, there is no clear perspective about how socioeconomic differences over time have contributed towards the use of maternal health care in India. METHODOLOGY/PRINCIPAL FINDINGS Using data from three rounds of National Family Health Survey (NFHS) conducted during 1992-2006, we analyse the trends and patterns in utilization of prenatal care (PNC) in first trimester with four or more antenatal care visits and skilled birth attendance (SBA) among poor and nonpoor mothers, disaggregated by area of residence in India and three contrasting provinces, namely, Uttar Pradesh, Maharashtra and Tamil Nadu. In addition, we investigate the relative contribution of public and private health facilities in meeting the demand for SBA, especially among poor mothers. We also examine the role of salient socioeconomic, demographic and cultural factors in influencing aforementioned outcomes. Bivariate analyses, concentration curve and concentration index, logistic regression and multinomial logistic regression models are used to understand the trends, patterns and predictors of the two outcome variables. Results indicate sluggish progress in utilization of PNC and SBA in India and selected provinces during 1992-2006. Enormous inequalities in utilization of PNC and SBA were observed largely to the disadvantage of the poor. Multivariate analysis suggests growing inequalities in utilization of the two outcomes across different economic groups. CONCLUSIONS The use of PNC and SBA remains disproportionately lower among poor mothers in India irrespective of area of residence and province. Despite several governmental efforts to increase access and coverage of delivery services to poor, it is clear that the poor (a) do not use SBA and (b) even if they had SBA, they were more likely to use the private providers.
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Anderson I, Axelson H, Tan BK. The other crisis: the economics and financing of maternal, newborn and child health in Asia. Health Policy Plan 2010; 26:288-97. [DOI: 10.1093/heapol/czq067] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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