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George J, Jack S, Gauld R, Colbourn T, Stokes T. Impact of health system governance on healthcare quality in low-income and middle-income countries: a scoping review. BMJ Open 2023; 13:e073669. [PMID: 38081664 PMCID: PMC10729209 DOI: 10.1136/bmjopen-2023-073669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 11/24/2023] [Indexed: 12/18/2023] Open
Abstract
INTRODUCTION Improving healthcare quality in low-/middle-income countries (LMICs) is a critical step in the pathway to Universal Health Coverage and health-related sustainable development goals. This study aimed to map the available evidence on the impacts of health system governance interventions on the quality of healthcare services in LMICs. METHODS We conducted a scoping review of the literature. The search strategy used a combination of keywords and phrases relevant to health system governance, quality of healthcare and LMICs. Studies published in English until August 2023, with no start date limitation, were searched on PubMed, Cochrane Library, CINAHL, Web of Science, Scopus, Google Scholar and ProQuest. Additional publications were identified by snowballing. The effects reported by the studies on processes of care and quality impacts were reviewed. RESULTS The findings from 201 primary studies were grouped under (1) leadership, (2) system design, (3) accountability and transparency, (4) financing, (5) private sector partnerships, (6) information and monitoring; (7) participation and engagement and (8) regulation. CONCLUSIONS We identified a stronger evidence base linking improved quality of care with health financing, private sector partnerships and community participation and engagement strategies. The evidence related to leadership, system design, information and monitoring, and accountability and transparency is limited.
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Affiliation(s)
- Joby George
- Department of General Practice & Rural Health, University of Otago, Dunedin, New Zealand
| | - Susan Jack
- Te Whatu Ora - Southern, National Public Health Service, Dunedin, New Zealand
- Department of Preventive & Social Medicine, University of Otago, Dunedin, New Zealand
| | - Robin Gauld
- Department of Preventive & Social Medicine, University of Otago, Dunedin, New Zealand
- Otago Business School, University of Otago, Dunedin, New Zealand
| | | | - Tim Stokes
- Department of General Practice & Rural Health, University of Otago, Dunedin, New Zealand
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Shajarizadeh A, Grépin KA. The impact of institutional delivery on neonatal and maternal health outcomes: evidence from a road upgrade programme in India. BMJ Glob Health 2022; 7:bmjgh-2021-007926. [PMID: 35793838 PMCID: PMC9260806 DOI: 10.1136/bmjgh-2021-007926] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 05/14/2022] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Persistently high rates of neonatal and maternal mortality have been associated with home births in many low-income and middle-income countries (LMICs). However, causal evidence of the effect of institutional deliveries on neonatal and maternal health outcomes is limited in these settings. METHODS We investigate the effect of institutional deliveries on neonatal mortality and maternal postpartum complications in rural India using data from the 2015-2016 Indian Demographic and Health Survey and an instrumental variable methodology to overcome selection bias issues inherent in observational studies. Specifically, we exploit plausibly exogenous variation in exposure to a road upgrade programme that quasi-randomly upgraded roads to villages across India. RESULTS We find large effects of the road construction programme on the probability that a woman delivered in a health facility: moving from an unconnected village to a connected village increased the probability of an institutional delivery by 13 percentage points, with the biggest increases in institutional delivery observed in public hospitals and among women with lower levels of education and from poorer households. However, we find no evidence that increased institutional delivery rates improved rates of neonatal mortality or postpartum complications, regardless of whether the delivery occurred in a public or private facility, or if it was with a skilled birth attendant. CONCLUSION Policies that encourage institutional delivery do not always translate into increased health outcomes and should thus be complemented with efforts to improve the quality of care to improve neonatal and maternal health outcomes in LMICs.
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Affiliation(s)
| | - Karen Ann Grépin
- School of Public Health, University of Hong Kong Li Ka Shing Faculty of Medicine, Hong Kong, China
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Shah S, Desai S, Desai T, Szkwarko D, Desai G. Trends and risk factors in tribal vs nontribal preterm deliveries in Gujarat, India. AJOG GLOBAL REPORTS 2021; 1:100026. [PMID: 36277462 PMCID: PMC9563542 DOI: 10.1016/j.xagr.2021.100026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Although risk factors of preterm deliveries across the world have been extensively studied, the trends and risk factors of preterm deliveries for the population of rural India, and specifically tribal women, remain unexplored. OBJECTIVE The aim of this study was to assess and compare the preterm delivery rates among women from a rural area in Gujarat, India, based on socioeconomic and clinical factors. The second aim of the study was to assess and identify predictors or risk factors for preterm deliveries. STUDY DESIGN This was a retrospective medical record review study investigating deliveries that took place at the Kasturba Maternity Hospital in Jhagadia, Gujarat, from January 2012 to June 2019 (N=32,557). We performed odds ratio and adjusted odds ratio analyses of preterm delivery risk factors. Lastly, we also considered the neonatal outcomes of preterm deliveries, both overall and comparing tribal and nontribal mothers. RESULTS For the study period, the tribal preterm delivery rate was 19.7% and the nontribal preterm delivery rate was 13.9%; the rate remained consistent for both groups over the 7-year study period. Adjusted odds ratios indicated that tribal status (adjusted odds ratio, 1.16; 95% confidence interval, 1.08–1.24), maternal illiteracy ((adjusted odds ratio, 1.29, 95% confidence interval, 1.18–1.42), paternal illiteracy (adjusted odds ratio, 1.27; 95% confidence interval, 1.15–1.410), hemoglobin <10 g/dL (adjusted odds ratio, 1.41; 95% confidence interval, 1.32–1.51), and a lack of antenatal care (adjusted odds ratio, 2.15; 95% confidence interval, 1.94–2.37) are significantly associated with higher odds of preterm delivery. The overall stillbirth rate among tribal women was 3.06% and 1.73% among nontribal women; among preterm deliveries, tribal women have a higher proportion of stillbirth outcomes (11.77%) than nontribal women (8.86%). CONCLUSION Consistent with existing literature, risk factors for preterm deliveries in rural India include clinical factors such as a lack of antenatal care and low hemoglobin. In addition, sociodemographic factors, such as tribal status, are independently associated with higher odds of delivering preterm. The higher rates of preterm deliveries among tribal women need to be studied further to detail the underlying reasons of how it can influence a woman's delivery outcome.
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Affiliation(s)
- Shital Shah
- Warren Alpert Medical School of Brown University, Providence, RI (Ms Shah)
- Corresponding author: Shital Shah, MPA.
| | - Shrey Desai
- Society for Education Welfare and Action (SEWA) Rural, Jhagadia, Gujarat, India (Drs S Desai, T Desai, and G Desai)
| | - Tushar Desai
- Society for Education Welfare and Action (SEWA) Rural, Jhagadia, Gujarat, India (Drs S Desai, T Desai, and G Desai)
| | - Daria Szkwarko
- Department of Family Medicine, Warren Alpert Medical School of Brown University, Providence, RI (Dr Szkwarko)
| | - Gayatri Desai
- Society for Education Welfare and Action (SEWA) Rural, Jhagadia, Gujarat, India (Drs S Desai, T Desai, and G Desai)
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Gardiner E, Lai JF, Khanna D, Meza G, de Wildt G, Taylor B. Exploring women's decisions of where to give birth in the Peruvian Amazon; why do women continue to give birth at home? A qualitative study. PLoS One 2021; 16:e0257135. [PMID: 34506573 PMCID: PMC8432815 DOI: 10.1371/journal.pone.0257135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 08/24/2021] [Indexed: 11/18/2022] Open
Abstract
Background Despite improvements in maternal mortality globally, hundreds of women continue to die daily. The World Health Organisation therefore advises all women in low-and-middle income countries to give birth in healthcare facilities. Barriers to seeking intrapartum care have been described in Thaddeus and Maine’s Three Delays Model, however these decisions are complex and often unique to different settings. Loreto, a rural province in Peru has one of the highest homebirth rates in the country at 31.8%. The aim of this study was to explore facilitators and barriers to facility births and explore women’s experiences of intrapartum care in Amazonian Peru. Methods Through purposive sampling, postnatal women were recruited for semi-structured interviews (n = 25). Interviews were transcribed verbatim and thematically analysed. A combination of deductive and inductive coding was used. Analytical triangulation was undertaken, and data saturation was used to determine when no further interviews were necessary. Results Five themes were generated from the data: 1) Financial barriers; 2) Accessing care; 3) Fear of healthcare facilities; 4) Importance of seeking care and 5) Comfort and traditions of home. Generally, participants realised the importance of seeking skilled care however barriers persisted, across all areas of the Three Delays Model. Barriers identified included fear of healthcare facilities and interventions, direct and indirect costs, continuation of daily activities, distance and availability of transport. Women who delivered in healthcare facilities had mixed experiences, many reporting good attention, however a selection experienced poor treatment including abusive behaviour. Conclusion Despite free care, women continue to face barriers seeking obstetric care in Amazonian Peru, including fear of hospitals, cost and availability of transport. However, women accessing care do not always receive positive care experiences highlighting implications for changes in accessibility and provision of care. Minimising these barriers is critical to improve maternal and neonatal outcomes in rural Peru.
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Affiliation(s)
- Esme Gardiner
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- * E-mail:
| | - Jo Freda Lai
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Divya Khanna
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Graciella Meza
- Facultad de Medicina Human, Universidad Nacional de la Amazonía Peruana, Iquitos, Peru
| | - Gilles de Wildt
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Beck Taylor
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
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Singh A, Vellakkal S. Impact of public health programs on maternal and child health services and health outcomes in India: A systematic review. Soc Sci Med 2021; 274:113795. [PMID: 33667744 DOI: 10.1016/j.socscimed.2021.113795] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 01/18/2021] [Accepted: 02/19/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND In the last two decades, India's central and many state governments launched several public health programs with the goal of improving maternal and child health outcomes. Many individual studies assessed the impact of these programs; however, they focused on select health programs and few specific outcomes. OBJECTIVES AND METHODS This paper summarizes the literature, published during 2000-2019, investigating the impacts of public health programs on both the uptake of maternal and child health services and the related-health outcomes in India. We followed PRISMA guidelines of systematic review, and carried out a narrative synthesis of the study findings. FINDINGS AND CONCLUSION We found 66 relevant studies covering 11 health programs across India. Most studies had applied non-experimental study designs (n = 50), with few applying experimental (n = 1) and quasi-experimental (n = 15) designs. Most studies (n = 64) assessed the impact on the intermediate outcomes of the uptake of various health services rather on the long-term outcomes of improvement in health. Overall we found studies reporting positive impacts, however, we could not find any strong consensus emerging from these studies about the impact, partly due to differences in: outcome indicators; study designs; study population; data sets. Several studies also reported considerable beneficial impacts among low socioeconomic population groups. However, given that the outreach of the public health programs have been low across the country and population groups, we found that broader objectives of health programs remained unassessed: most studies assessed the impact on who actually participated in the program (average treatment effect on-the-treated) rather on the target population (intent-to-treat effect). Furthermore, there was dearth of research on the impacts of the state-level programs. Future research need to assess the impact of the programs on health outcomes, and on quality adjusted measures of maternal and child health services and its continuum of care.
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Affiliation(s)
- Abinash Singh
- Department of Economics, BITS Pilani K. K. Birla Goa Campus, Birla Institute of Technology and Science, Pilani, India
| | - Sukumar Vellakkal
- Department of Economics, BITS Pilani K. K. Birla Goa Campus, Birla Institute of Technology and Science, Pilani, India; Department of Economic Sciences, Indian Institute of Technology Kanpur, Uttar Pradesh, 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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Ravindran TKS, Govender V. Sexual and reproductive health services in universal health coverage: a review of recent evidence from low- and middle-income countries. Sex Reprod Health Matters 2020; 28:1779632. [PMID: 32530387 PMCID: PMC7887992 DOI: 10.1080/26410397.2020.1779632] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
If universal health coverage (UHC) cannot be achieved without the sexual and reproductive health (SRH) needs of the population being met, what then is the current situation vis-à-vis universal coverage of SRH services, and the extent to which SRH services have been prioritised in national UHC plans and processes? This was the central question that guided this critical review of more than 200 publications between 2010 and 2019. The findings are the following. The Essential Package of Healthcare Services (EPHS) across many countries excludes several critical SRH services (e.g. safe abortion services, reproductive cancers) that are already poorly available. Inadequate international and domestic public funding of SRH services contributes to a sustained burden of out-of-pocket expenditure (OOPE) and inequities in access to SRH services. Policy and legal barriers, restrictive gender norms and gender-based inequalities challenge the delivery and access to quality SRH services. The evidence is mixed as to whether an expanded role and scope of the private sector improves availability and access to services of underserved populations. As momentum gathers towards SRH and UHC, the following actions are necessary and urgent. Advocacy for greater priority for SRH in government EPHS and health budgets aligned with SRH and UHC goals is needed. Implementation of stable and sustained financing mechanisms that would reduce the proportion of SRH-financing from OOPE is a priority. Evidence, moving from descriptive towards explanatory studies which provide insights into the "hows" and "whys" of processes and pathways are essential for guiding policy and programme actions.
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Affiliation(s)
- T. K. Sundari Ravindran
- Principal Visiting Fellow, United Nations University, International Institute for Global Health, Kuala Lumpur, Malaysia
| | - Veloshnee Govender
- Scientist, Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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8
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Maisonneuve JJ, Semrau KEA, Maji P, Pratap Singh V, Miller KA, Solsky I, Dixit N, Sharma J, Lagoo J, Panariello N, Neal BJ, Kalita T, Kara N, Kumar V, Hirschhorn LR. Effectiveness of a WHO Safe Childbirth Checklist Coaching-based intervention on the availability of Essential Birth Supplies in Uttar Pradesh, India. Int J Qual Health Care 2019; 30:769-777. [PMID: 29718354 PMCID: PMC6340347 DOI: 10.1093/intqhc/mzy086] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 04/09/2018] [Indexed: 12/20/2022] Open
Abstract
Objective Evaluate the impact of a World Health Organization Safe Childbirth Checklist coaching-based intervention (BetterBirth Program) on availability and procurement of essential childbirth-related supplies. Design Matched pair, cluster-randomized controlled trial. Setting Uttar Pradesh, India. Participants 120 government-sector health facilities (60 interventions, 60 controls). Supply-availability surveys were conducted quarterly in all sites. Coaches collected supply procurement sources from intervention sites. Interventions Coaching targeting implementation of Checklist with data feedback and action planning. Main Outcome Measures Mean supply availability by study arm; change in procurement sources for intervention sites. Results At baseline, 6 and 12 months, the intervention sites had a mean of 20.9 (95% confidence interval (CI): 20.2–21.5); 22.4 (95% CI: 21.8–22.9) and 22.1 (95% CI:21.4–22.8) items, respectively. Control sites had 20.8 (95% CI: 20.3–21.3); 20.9 (95% CI: 20.3–21.5) and 21.7 (95% CI: 20.8–22.6) items at the same time-points. There was a small but statistically significant higher availability in intervention sites at 6 months (difference-in-difference (DID) = 1.43, P < 0.001), which was not seen by 12 months (DID = 0.37, P = 0.53). Greater difference between intervention and control sites starting in the bottom quartile of supply availability was seen at 6 months (DID = 4.0, P = 0.0002), with no significant difference by 12 months (DID = 1.5, P = 0.154). No change was seen in procurement sources with ~5% procured by patients with some rates as high as 29% (oxytocin). Conclusions Implementation of the BetterBirth Program, incorporating supply availability, resulted in modest improvements with catch-up by control facilities by 12 months. Supply-chain coaching may be most beneficial in sites starting with lower supply availability. Efforts are needed to reduce reliance on patient-funding for some critical medications. Trial Registration ClinicalTrials.gov #NCT02148952; Universal Trial Number: U1111-1131–5647
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Affiliation(s)
- Jenny J Maisonneuve
- Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Katherine E A Semrau
- Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Pinki Maji
- Population Services International, Lucknow, Uttar Pradesh, India
| | | | - Kate A Miller
- Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ian Solsky
- Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Neeraj Dixit
- Population Services International, Lucknow, Uttar Pradesh, India
| | - Jigyasa Sharma
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Janaka Lagoo
- Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Natalie Panariello
- Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Brandon J Neal
- Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Tapan Kalita
- Population Services International, Lucknow, Uttar Pradesh, India
| | - Nabihah Kara
- Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | - Lisa R Hirschhorn
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Kuwawenaruwa A, Ramsey K, Binyaruka P, Baraka J, Manzi F, Borghi J. Implementation and effectiveness of free health insurance for the poor pregnant women in Tanzania: A mixed methods evaluation. Soc Sci Med 2019; 225:17-25. [DOI: 10.1016/j.socscimed.2019.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 01/24/2019] [Accepted: 02/03/2019] [Indexed: 11/25/2022]
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Lamichhane P, Sharma A, Mahal A. Impact evaluation of free delivery care on maternal health service utilisation and neonatal health in Nepal. Health Policy Plan 2018; 32:1427-1436. [PMID: 29029159 DOI: 10.1093/heapol/czx124] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2017] [Indexed: 11/12/2022] Open
Abstract
Nepal introduced free delivery services for births in public facilities in 2005 in 25 districts with the intervention initially restricted to women with less than two living children and/or women with obstetric complications. After November 2007, eligibility conditions were relaxed to include all women, and the programme was later expanded to cover an additional 50 districts in December 2008. We exploit the phased expansion of the free birth delivery programme to identify its impact on place of delivery, the presence of skilled birth attendants (SBAs) and neonatal mortality using difference-in-difference methods, on data for 4457 live-births reported between 2001 and 2008 from Nepal Demographic and Health Surveys for 2006 and 2011. Programme impacts were estimated for: (1) initial implementation until the relaxation of eligibility criteria to include all women in November 2007 (early phase); and (2) initial implementation until the programme was expanded nationwide in December 2008 (longer phase). Early implementing districts were treatment districts, while late implementing hill districts were control districts. In the early phase, the likelihood of delivery by SBAs was 5.6 percentage points higher (95%CI 0.002, 0.111) and the likelihood of delivery in a public facility was 5.1 percentage points higher (95%CI -0.003, 0.106) in treatment districts compared with control districts. The programme lowered the likelihood of neonatal mortality by 4.0 (-0.072, -0.009) percentage points for women with less than two living children and by 6.9 percentage points (95%CI -0.104, -0.035) for women from lower castes and indigenous groups in treatment districts compared with women in control districts, during the early phase. Programme effects on use of public facilities for births and deliveries attended by SBAs were not sustained over a longer exposure period. The results on neonatal mortality persisted with longer programme exposure, although the effects were smaller in magnitude.
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Affiliation(s)
- Prabhat Lamichhane
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, 553 St. Kilda Road, VIC 3004, Australia.,School of Medicine, Faculty of Health, Deakin University, Geelong 3216, Australia
| | - Anurag Sharma
- School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW 2052, Australia
| | - Ajay Mahal
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, 553 St. Kilda Road, VIC 3004, Australia.,The Nossal Institute for Global Health, The University of Melbourne, 333 Exhibition Street, Melbourne 3004, Australia
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Das J, Woskie L, Rajbhandari R, Abbasi K, Jha A. Rethinking assumptions about delivery of healthcare: implications for universal health coverage. BMJ 2018; 361:k1716. [PMID: 29784870 PMCID: PMC5961312 DOI: 10.1136/bmj.k1716] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Simply providing more resources for universal coverage is not enough to improve health, argue Jishnu Das and colleagues. We also need to ensure good quality of care
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Affiliation(s)
| | - Liana Woskie
- Harvard Initiative on Global Health Quality, Cambridge, MA 02138, USA
| | | | | | - Ashish Jha
- Department of Health Policy and Management, Harvard T H Chan School of Public Health, Harvard Global Health Institute, Boston
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12
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Odendaal WA, Ward K, Uneke J, Uro‐Chukwu H, Chitama D, Balakrishna Y, Kredo T. Contracting out to improve the use of clinical health services and health outcomes in low- and middle-income countries. Cochrane Database Syst Rev 2018; 4:CD008133. [PMID: 29611869 PMCID: PMC6494528 DOI: 10.1002/14651858.cd008133.pub2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Contracting out of governmental health services is a financing strategy that governs the way in which public sector funds are used to have services delivered by non-governmental health service providers (NGPs). It represents a contract between the government and an NGP, detailing the mechanisms and conditions by which the latter should provide health care on behalf of the government. Contracting out is intended to improve the delivery and use of healthcare services. This Review updates a Cochrane Review first published in 2009. OBJECTIVES To assess effects of contracting out governmental clinical health services to non-governmental service provider/s, on (i) utilisation of clinical health services; (ii) improvement in population health outcomes; (iii) improvement in equity of utilisation of these services; (iv) costs and cost-effectiveness of delivering the services; and (v) improvement in health systems performance. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, NHS Economic Evaluation Database, EconLit, ProQuest, and Global Health on 07 April 2017, along with two trials registers - ClinicalTrials.gov and the International Clinical Trials Registry Platform - on 17 November 2017. SELECTION CRITERIA Individually randomised and cluster-randomised trials, controlled before-after studies, interrupted time series, and repeated measures studies, comparing government-delivered clinical health services versus those contracted out to NGPs, or comparing different models of non-governmental-delivered clinical health services. DATA COLLECTION AND ANALYSIS Two authors independently screened all records, extracted data from the included studies and assessed the risk of bias. We calculated the net effect for all outcomes. A positive value favours the intervention whilst a negative value favours the control. Effect estimates are presented with 95% confidence intervals. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of the evidence and we prepared a Summary of Findings table. MAIN RESULTS We included two studies, a cluster-randomised trial conducted in Cambodia, and a controlled before-after study conducted in Guatemala. Both studies reported that contracting out over 12 months probably makes little or no difference in (i) immunisation uptake of children 12 to 24 months old (moderate-certainty evidence), (ii) the number of women who had more than two antenatal care visits (moderate-certainty evidence), and (iii) female use of contraceptives (moderate-certainty evidence).The Cambodia trial reported that contracting out may make little or no difference in the mortality over 12 months of children younger than one year of age (net effect = -4.3%, intervention effect P = 0.36, clustered standard error (SE) = 3.0%; low-certainty evidence), nor to the incidence of childhood diarrhoea (net effect = -16.2%, intervention effect P = 0.07, clustered SE = 19.0%; low-certainty evidence). The Cambodia study found that contracting out probably reduces individual out-of-pocket spending over 12 months on curative care (net effect = $ -19.25 (2003 USD), intervention effect P = 0.01, clustered SE = $ 5.12; moderate-certainty evidence). The included studies did not report equity in the use of clinical health services and in adverse effects. AUTHORS' CONCLUSIONS This update confirms the findings of the original review. Contracting out probably reduces individual out-of-pocket spending on curative care (moderate-certainty evidence), but probably makes little or no difference in other health utilisation or service delivery outcomes (moderate- to low-certainty evidence). Therefore, contracting out programmes may be no better or worse than government-provided services, although additional rigorously designed studies may change this result. The literature provides many examples of contracting out programmes, which implies that this is a feasible response when governments fail to provide good clinical health care. Future contracting out programmes should be framed within a rigorous study design to allow valid and reliable measures of their effects. Such studies should include qualitative research that assesses the views of programme implementers and beneficiaries, and records implementation mechanisms. This approach may reveal enablers for, and barriers to, successful implementation of such programmes.
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Affiliation(s)
- Willem A Odendaal
- South African Medical Research CouncilHealth Systems Research UnitCape TownWestern CapeSouth Africa
- Stellenbosch UniversityDepartment of PsychiatryStellenboschSouth Africa
| | - Kim Ward
- University of the Western CapeSchool of PharmacyCape TownSouth Africa
| | - Jesse Uneke
- Ebonyi State UniversityAfrican Institute for Health Policy and Health SystemsAbakalikiNigeria
| | - Henry Uro‐Chukwu
- National Obstetrics Fistula CentreSocial Mobilization and Disease ControlAbakalikiNigeria
| | - Dereck Chitama
- Muhimbili University of Health and Allied SciencesSchool of Public Health and Social SciencesDar es SalaamTanzania
| | - Yusentha Balakrishna
- South African Medical Research CouncilBiostatistics Unit491 Ridge Road, OverportDurbanKwazulu‐NatalSouth Africa4001
| | - Tamara Kredo
- South African Medical Research CouncilCochrane South AfricaPO Box 19070TygerbergCape TownWestern CapeSouth Africa7505
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Mohanan M, Hay K, Mor N. Quality Of Health Care In India: Challenges, Priorities, And The Road Ahead. Health Aff (Millwood) 2018; 35:1753-1758. [PMID: 27702945 DOI: 10.1377/hlthaff.2016.0676] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
India's health care sector provides a wide range of quality of care, from globally acclaimed hospitals to facilities that deliver care of unacceptably low quality. Efforts to improve the quality of care are particularly challenged by the lack of reliable data on quality and by technical difficulties in measuring quality. Ongoing efforts in the public and private sectors aim to improve the quality of data, develop better measures and understanding of the quality of care, and develop innovative solutions to long-standing challenges. We summarize priorities and the challenges faced by efforts to improve the quality of care. We also highlight lessons learned from recent efforts to measure and improve that quality, based on the articles on quality of care in India that are published in this issue of Health Affairs The rapidly changing profile of diseases in India and rising chronic disease burden make it urgent for state and central governments to collaborate with researchers and agencies that implement programs to improve health care to further the quality agenda.
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Affiliation(s)
- Manoj Mohanan
- Manoj Mohanan is an assistant professor of public policy and economics in the Sanford School of Public Policy at Duke University, an assistant research professor at the Duke Global Health Institute, and faculty research scholar at the Duke Population Research Institute, all in Durham, North Carolina
| | - Katherine Hay
- Katherine Hay is deputy director of the Bill & Melinda Gates Foundation India, in New Delhi
| | - Nachiket Mor
- Nachiket Mor is director of the Bill & Melinda Gates Foundation India
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Babiarz KS, Mahadevan SV, Divi N, Miller G. Ambulance Service Associated With Reduced Probabilities Of Neonatal And Infant Mortality In Two Indian States. Health Aff (Millwood) 2018; 35:1774-1782. [PMID: 27702948 DOI: 10.1377/hlthaff.2016.0564] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
India had no large-scale, centralized emergency medical system or ambulance service until 2005. Since then, the GVK Emergency Management and Research Institute (GVK EMRI) has emerged as India's largest ambulance service provider, covering more than 630 million people. This study provides the first quantitative evidence of GVK EMRI's early impact on population-level infant and maternal health outcomes in Andhra Pradesh and Gujarat, two Indian states with a combined population of about 145 million people. We found that GVK EMRI coverage is associated with reductions in the probability of neonatal and infant mortality as well as delivery complications (statewide in Andhra Pradesh and in high-mortality districts in Gujarat). However, we found little change in the probability of institutional delivery or skilled birth attendance. Taken together, our findings suggest that population-level health gains were achieved through improvements in the quality (rather than quantity) of maternal and neonatal health services-an interpretation consistent with qualitative reports. More research on this topic is needed.
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Affiliation(s)
- Kimberly S Babiarz
- Kimberly S. Babiarz is a research associate at the Center for Primary Care and Outcomes Research at Stanford University, in California
| | - Swaminatha V Mahadevan
- Swaminatha V. Mahadevan is an associate professor of surgery in the Department of Emergency Medicine at Stanford University
| | - Nomita Divi
- Nomita Divi is a program officer at the Skoll Global Threats Fund, in Palo Alto, California
| | - Grant Miller
- Grant Miller is an associate professor of medicine at Stanford University School of Medicine; director of the Stanford Center for International Development; senior fellow, Freeman Spogli Institute for International Studies, Stanford University; senior fellow, Stanford Institute for Economic Policy Research; and a research associate at the National Bureau of Economic Research, in Cambridge, Massachusetts
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Lépine A, Lagarde M, Le Nestour A. How effective and fair is user fee removal? Evidence from Zambia using a pooled synthetic control. HEALTH ECONOMICS 2018; 27:493-508. [PMID: 29034537 PMCID: PMC5900920 DOI: 10.1002/hec.3589] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 07/24/2017] [Accepted: 08/11/2017] [Indexed: 06/02/2023]
Abstract
Despite its high political interest, the impact of removing user charges for health care in low-income settings remains a debatable issue. We try to clear up this contentious issue by estimating the short-term effects of a policy change that occurred in 2006 in Zambia, when 54 of 72 districts removed fees. We use a pooled synthetic control method in order to estimate the causal impact of the policy on health care use, the provider chosen, and out-of-pocket medical expenses. We find no evidence that user fee removal increased health care utilisation, even among the poorest group. However, we find that the policy is likely to have led to a substitution away from the private sector for those using care and that it virtually eliminated medical expenditures, thereby providing financial protection to service users. We estimate that the policy was equivalent to a transfer of US$3.2 per health visit for the 50% richest but of only US$1.1 for the 50% poorest.
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Keya KT, Bellows B, Rob U, Warren C. Improving Access to Delivery Care and Reducing the Equity Gap Through Voucher Program in Bangladesh: Evidence From Difference-in-Differences Analysis. INTERNATIONAL QUARTERLY OF COMMUNITY HEALTH EDUCATION 2018; 38:137-145. [PMID: 29298635 DOI: 10.1177/0272684x17749568] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
To test a statistically significant change in delivery by medically trained providers following introduction of a demand-side financing voucher, a population-based quasi-experimental study was undertaken, with 3,300 mothers in 2010 and 3,334 mothers at follow-up in 2012 in government-implemented voucher program and control areas. Results found that voucher program was significantly associated with increased public health facility use (difference-in-differences (DID) 13.9) and significantly increased delivery complication management care (DID 13.2) at facility although a null effect was found in facility-based delivery increase. A subset analysis of the five well-functioning facilities showed that facility deliveries increased DID 5.3 percentage points. Quintile-based analysis of all facilities showed that facility delivery increased more than threefold in lower quintile households comparing to twofold in control sites. The program needs better targeting to the beneficiaries, ensuring available gynecologist-anesthetist pair and midwives, effective monitoring, and timely fund reimbursements to facilities.
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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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Gosain M, Goel AD, Kharya P, Agarwal R, Amarchand R, Rai SK, Kapoor S, Paul VK, Krishnan A. Reduction of Neonatal Mortality Requires Strengthening of the Health System: A Situational Analysis of Neonatal Care Services in Ballabgarh. J Trop Pediatr 2017; 63:365-373. [PMID: 28122945 DOI: 10.1093/tropej/fmw098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Planning a comprehensive program addressing neonatal mortality will require a detailed situational analysis of available neonatal-specific health infrastructure. METHODS We identified facilities providing essential and sick neonatal care (ENC, SNC) by a snowballing technique in Ballabgarh Block. These were assessed for infrastructure, human resource and equipment along with self-rated competency of the staff and compared with facility-based or population-based norms. RESULTS A total of 35 facilities providing ENC and 10 facilities for SNC were identified. ENC services were largely in the public-sector domain (68.5% of births) and were well distributed in the block. SNC burden was largely being borne by the private sector (66% of admissions), which was urban-based. The private sector and nurses reported lower competency especially for SNC. Only 53.9% of government facilities and 17.5% of private facilities had a fully equipped newborn care corner. CONCLUSIONS Serious efforts to reduce neonatal mortality would require major capacity strengthening of the health system, including that of the private sector.
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Affiliation(s)
- Mudita Gosain
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Akhil D Goel
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Pradeep Kharya
- Department of Community Medicine, Government Medical College, Kannauj, Uttar Pradesh 209732, India
| | - Ramesh Agarwal
- Division of Neonatology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Ritvik Amarchand
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Sanjay K Rai
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Suresh Kapoor
- Centre for Chronic Disease Control, Gurugram, Haryana 122002, India
| | - Vinod K Paul
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Anand Krishnan
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi 110029, India
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Hunter BM, Murray SF. Demand-side financing for maternal and newborn health: what do we know about factors that affect implementation of cash transfers and voucher programmes? BMC Pregnancy Childbirth 2017; 17:262. [PMID: 28854877 PMCID: PMC5577737 DOI: 10.1186/s12884-017-1445-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 08/04/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Demand-side financing (DSF) interventions, including cash transfers and vouchers, have been introduced to promote maternal and newborn health in a range of low- and middle-income countries. These interventions vary in design but have typically been used to increase health service utilisation by offsetting some financial costs for users, or increasing household income and incentivising 'healthy behaviours'. This article documents experiences and implementation factors associated with use of DSF in maternal and newborn health. METHODS A secondary analysis (using an adapted Supporting the Use of Research Evidence framework - SURE) was performed on studies that had previously been identified in a systematic review of evidence on DSF interventions in maternal and newborn health. RESULTS The article draws on findings from 49 quantitative and 49 qualitative studies. The studies give insights on difficulties with exclusion of migrants, young and multiparous women, with demands for informal fees at facilities, and with challenges maintaining quality of care under increasing demand. Schemes experienced difficulties if communities faced long distances to reach participating facilities and poor access to transport, and where there was inadequate health infrastructure and human resources, shortages of medicines and problems with corruption. Studies that documented improved care-seeking indicated the importance of adequate programme scope (in terms of programme eligibility, size and timing of payments and voucher entitlements) to address the issue of concern, concurrent investments in supply-side capacity to sustain and/or improve quality of care, and awareness generation using community-based workers, leaders and women's groups. CONCLUSIONS Evaluations spanning more than 15 years of implementation of DSF programmes reveal a complex picture of experiences that reflect the importance of financial and other social, geographical and health systems factors as barriers to accessing care. Careful design of DSF programmes as part of broader maternal and newborn health initiatives would need to take into account these barriers, the behaviours of staff and the quality of care in health facilities. Research is still needed on the policy context for DSF schemes in order to understand how they become sustainable and where they fit, or do not fit, with plans to achieve equitable universal health coverage.
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Affiliation(s)
- Benjamin M. Hunter
- King’s College London, Department of International Development, The Strand, London, WC2R 2LS UK
| | - Susan F. Murray
- King’s College London, Department of International Development, The Strand, London, WC2R 2LS 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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Yasobant S, Shewade HD, Vora KS, Annerstedt KS, Isaakidis P, Dholakia NB, Mavalankar DV. Effect of previous utilization and out-of-pocket expenditure on subsequent utilization of a state led public-private partnership scheme "Chiranjeevi Yojana" to promote facility births in Gujarat, India. BMC Health Serv Res 2017; 17:302. [PMID: 28441941 PMCID: PMC5405527 DOI: 10.1186/s12913-017-2256-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 04/21/2017] [Indexed: 11/10/2022] Open
Abstract
Background In Gujarat, India, a state led public private partnership scheme to promote facility birth named Chiranjeevi Yojana (CY) was implemented in 2005. Institutional birth is provided free of cost at accredited private health facilities to women from socially disadvantaged groups (eligible women). CY has contributed in increasing facility birth and providing substantially subsidized (but not totally free) birth care; however, the retention of mothers in this scheme in subsequent child birth is unknown. Therefore, we conducted a study aimed to determine the effect of previous utilization of the scheme and previous out of pocket expenditure on subsequent child birth among multiparous eligible women in Gujarat. Methods This was a retrospective cohort study of multiparous eligible women (after excluding abortions and births at public facility). A structured questionnaire was administered by trained research assistant to those with recent delivery between Jan and Jul 2013. Outcome of interest was CY utilization in subsequent child birth (Jan–Jul 2013). Explanatory variables included socio-demographic characteristics (including category of eligibility), pregnancy related characteristics in previous child birth, before Jan 2013, (including CY utilization, out of pocket expenditure) and type of child birth in subsequent birth. A poisson regression model was used to assess the association of factors with CY utilization in subsequent child birth. Results Of 997 multiparous eligible women, 289 (29%) utilized and 708 (71%) did not utilize CY in their previous child birth. Of those who utilized CY (n = 289), 182 (63%) subsequently utilized CY and 33 (11%) gave birth at home; whereas those who did not utilize CY (n = 708) had four times higher risk (40% vs. 11%) of subsequent child birth at home. In multivariable models, previous utilization of the scheme was significantly associated with subsequent utilization (adjusted Relative Risk (aRR): 2.7; 95% CI: 2.2–3.3), however previous out of pocket expenditure was not found to be associated with retention in the CY scheme. Conclusion Women with previous CY utilization were largely retained; therefore, steps to increase uptake of CY are expected to increase retention of mothers within CY in their subsequent child birth. To understand the reasons for subsequent child birth at home despite previous CY utilization and previous zero/minimal out of pocket expenditure, future research in the form of systematic qualitative enquiry is recommended.
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Affiliation(s)
- Sandul Yasobant
- Indian Institute of Public Health Gandhinagar (IIPHG), Gandhinagar, India.
| | - Hemant Deepak Shewade
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
| | - Kranti Suresh Vora
- Indian Institute of Public Health Gandhinagar (IIPHG), Gandhinagar, India
| | | | - Petros Isaakidis
- Médecins Sans Frontières (MSF)/Doctors Without Borders, Mumbai, India
| | - Nishith B Dholakia
- Department of Health & Family Welfare, Government of Gujarat, Gandhinagar, India
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Hunter BM, Harrison S, Portela A, Bick D. The effects of cash transfers and vouchers on the use and quality of maternity care services: A systematic review. PLoS One 2017; 12:e0173068. [PMID: 28328940 PMCID: PMC5362260 DOI: 10.1371/journal.pone.0173068] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 02/14/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Cash transfers and vouchers are forms of 'demand-side financing' that have been widely used to promote maternal and newborn health in low- and middle-income countries during the last 15 years. METHODS This systematic review consolidates evidence from seven published systematic reviews on the effects of different types of cash transfers and vouchers on the use and quality of maternity care services, and updates the systematic searches to June 2015 using the Joanna Briggs Institute approach for systematic reviewing. The review protocol for this update was registered with PROSPERO (CRD42015020637). RESULTS Data from 51 studies (15 more than previous reviews) and 22 cash transfer and voucher programmes suggest that approaches tied to service use (either via payment conditionalities or vouchers for selected services) can increase use of antenatal care, use of a skilled attendant at birth and in the case of vouchers, postnatal care too. The strongest evidence of positive effect was for conditional cash transfers and uptake of antenatal care, and for vouchers for maternity care services and birth with a skilled birth attendant. However, effects appear to be shaped by a complex set of social and healthcare system barriers and facilitators. Studies have typically focused on an initial programme period, usually two or three years after initiation, and many lack a counterfactual comparison with supply-side investment. There are few studies to indicate that programmes have led to improvements in quality of maternity care or maternal and newborn health outcomes. CONCLUSION Future research should use multiple intervention arms to compare cost-effectiveness with similar investment in public services, and should look beyond short- to medium-term service utilisation by examining programme costs, longer-term effects on service utilisation and health outcomes, and the equity of those effects.
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Affiliation(s)
- Benjamin M. Hunter
- Department of International Development, King’s College London, London, United Kingdom
| | - Sean Harrison
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Anayda Portela
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Debra Bick
- Florence Nightingale Faculty of Nursing and Midwifery, King’s College London, London, United Kingdom
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Das J, Chowdhury A, Hussam R, Banerjee AV. The impact of training informal health care providers in India: A randomized controlled trial. Science 2016; 354:354/6308/aaf7384. [DOI: 10.1126/science.aaf7384] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 08/25/2016] [Indexed: 11/02/2022]
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Das S, Alcock G, Azad K, Kuddus A, Manandhar DS, Shrestha BP, Nair N, Rath S, More NS, Saville N, Houweling TAJ, Osrin D. Institutional delivery in public and private sectors in South Asia: a comparative analysis of prospective data from four demographic surveillance sites. BMC Pregnancy Childbirth 2016; 16:273. [PMID: 27649897 PMCID: PMC5029035 DOI: 10.1186/s12884-016-1069-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 09/13/2016] [Indexed: 11/29/2022] Open
Abstract
Background Maternity care in South Asia is available in both public and private sectors. Using data from demographic surveillance sites in Bangladesh, Nepal and rural and urban India, we aimed to compare institutional delivery rates and public-private share. Methods We used records of maternity care collected in socio-economically disadvantaged communities between 2005 and 2011. Institutional delivery was summarized by four potential determinants: household asset index, maternal schooling, maternal age, and parity. We developed logistic regression models for private sector institutional delivery with these as independent covariates. Results The data described 52 750 deliveries. Institutional delivery proportion varied and there were differences in public-private split. In Bangladesh and urban India, the proportion of deliveries in the private sector increased with wealth, maternal education, and age. The opposite was observed in rural India and Nepal. Conclusions The proportion of institutional delivery increased with economic status and education. The choice of sector is more complex and provision and perceived quality of public sector services is likely to play a role. Choices for safe maternity are influenced by accessibility, quantity and perceived quality of care. Along with data linkage between private and public sectors, increased regulation should be part of the development of the pluralistic healthcare systems that characterize south Asia. Electronic supplementary material The online version of this article (doi:10.1186/s12884-016-1069-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sushmita Das
- SNEHA (Society for Nutrition, Education and Health Action), 310, Urban Health Centre, 60 Feet Road, Dharavi, Mumbai, 400 017, Maharashtra, India
| | - Glyn Alcock
- UCL Institute for Global Health, 30 Guilford Street, London, WC1N 1EH, UK
| | - Kishwar Azad
- Perinatal Care Project, Diabetic Association of Bangladesh, 122 Kazi Nazrul Islam Avenue, Dhaka, 1000, Bangladesh
| | - Abdul Kuddus
- Perinatal Care Project, Diabetic Association of Bangladesh, 122 Kazi Nazrul Islam Avenue, Dhaka, 1000, Bangladesh
| | - Dharma S Manandhar
- Mother and Infant Research Activities (MIRA), YB Bhavan, Thapathali, GPO Box 921, Kathmandu, Nepal
| | - Bhim Prasad Shrestha
- Mother and Infant Research Activities (MIRA), YB Bhavan, Thapathali, GPO Box 921, Kathmandu, Nepal
| | - Nirmala Nair
- Ekjut, Plot 556B, Potka, Chakradharpur, West Singhbhum, Jharkhand, India
| | - Shibanand Rath
- Ekjut, Plot 556B, Potka, Chakradharpur, West Singhbhum, Jharkhand, India
| | - Neena Shah More
- SNEHA (Society for Nutrition, Education and Health Action), 310, Urban Health Centre, 60 Feet Road, Dharavi, Mumbai, 400 017, Maharashtra, India
| | - Naomi Saville
- UCL Institute for Global Health, 30 Guilford Street, London, WC1N 1EH, UK
| | - Tanja A J Houweling
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - David Osrin
- UCL Institute for Global Health, 30 Guilford Street, London, WC1N 1EH, UK.
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Agha S, Williams E. Quality of antenatal care and household wealth as determinants of institutional delivery in Pakistan: Results of a cross-sectional household survey. Reprod Health 2016; 13:84. [PMID: 27430518 PMCID: PMC4950643 DOI: 10.1186/s12978-016-0201-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Accepted: 07/04/2016] [Indexed: 11/10/2022] Open
Abstract
Background Pakistan has a high burden of maternal and newborn mortality, which would be largely preventable through appropriate antenatal and delivery care. While the influence of socio-economic status on institutional delivery is well established in the literature, relatively little is known about the relationship between the quality of antenatal care and institutional delivery. Methods A household survey of 4,000 currently married women who had given birth in the two years before the survey was conducted in Sindh province in 2013. The survey collected data on socio-economic and demographic variables, the quality of antenatal care provided during a woman’s last pregnancy and whether she delivered at a health facility. Logistic regression was used to estimate adjusted odds ratios and 95 % confidence intervals around independent variables for institutional delivery. Results In the multivariate analysis, a variable measuring quality of antenatal care showed the strongest association with institutional delivery. Moreover, there was a dose-response relationship between the number of elements of quality provided and the odds of institutional delivery: receiving one element of quality increased the odds of institutional delivery 1.7 times, receiving three elements increased the odds 3.8 times and receiving seven elements increased the odds 10.6 times. Household wealth had a statistically significant relationship with institutional delivery but the effect was weaker than that of quality of care. Urban-rural differentials in institutional delivery did not remain significant after adjusting for household wealth and education. Conclusions The quality of antenatal care provided to a woman during her pregnancy is more strongly associated with institutional delivery than household wealth. Improving the quality of care at health facilities in Sindh should be the foremost priority. Improving the quality of antenatal care services is likely to contribute to rapid increases in skilled birth attendance and better health outcomes for women and children.
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Affiliation(s)
- Sohail Agha
- The Bill and Melinda Gates Foundation, Seattle, USA
| | - Emma Williams
- Jhpiego, 1615 Thames St., Baltimore, MD, 21231, USA.
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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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Godlonton S, Okeke EN. Does a ban on informal health providers save lives? Evidence from Malawi. JOURNAL OF DEVELOPMENT ECONOMICS 2016; 118:112-132. [PMID: 26681821 PMCID: PMC4677333 DOI: 10.1016/j.jdeveco.2015.09.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Informal health providers ranging from drug vendors to traditional healers account for a large fraction of health care provision in developing countries. They are, however, largely unlicensed and unregulated leading to concern that they provide ineffective and, in some cases, even harmful care. A new and controversial policy tool that has been proposed to alter household health seeking behavior is an outright ban on these informal providers. The theoretical effects of such a ban are ambiguous. In this paper, we study the effect of a ban on informal (traditional) birth attendants imposed by the Malawi government in 2007. To measure the effect of the ban, we use a difference-in-difference strategy exploiting variation across time and space in the intensity of exposure to the ban. Our most conservative estimates suggest that the ban decreased use of traditional attendants by about 15 percentage points. Approximately three quarters of this decline can be attributed to an increase in use of the formal sector and the remainder is accounted for by an increase in relative/friend-attended births. Despite the rather large shift from the informal to the formal sector, we do not find any evidence of a statistically significant reduction in newborn mortality on average. The results are robust to a triple difference specification using young children as a control group. We examine several explanations for this result and find evidence consistent with quality of formal care acting as a constraint on improvements in newborn health.
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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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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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de Costa A, Vora K, Schneider E, Mavalankar D. Gujarat's Chiranjeevi Yojana - a difficult assessment in retrospect. Bull World Health Organ 2015; 93:436. [PMID: 26240467 PMCID: PMC4450700 DOI: 10.2471/blt.14.137745] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2014] [Revised: 11/01/2014] [Accepted: 11/02/2014] [Indexed: 11/29/2022] Open
Affiliation(s)
- Ayesha de Costa
- Public Health Sciences, Karolinska Institutet, Tömtebodavägen 18A, 17177 Stockholm, Sweden
| | - Kranti Vora
- Indian Institute of Public Health, Ahmedabad, India
| | - Eric Schneider
- Johns Hopkins Bloomberg School of Public Health, Baltimore, United States of America
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