102446 Research Effect of Chiranjeevi Yojana on institutional deliveries and neonatal and maternal outcomes in Gujarat, India: a difference-in-differences analysis Manoj Mohanan,a Sebastian Bauhoff,b Gerard La Forgia,c Kimberly Singer Babiarz,d Kultar Singhe & Grant Millerf Objective To evaluate the effect of the Chiranjeevi Yojana programme, a public–private partnership to improve maternal and neonatal health in Gujarat, India. Methods A household survey (n = 5597 households) was conducted in Gujarat to collect retrospective data on births within the preceding 5 years. In an observational study using a difference-in-differences design, the relationship between the Chiranjeevi Yojana programme and the probability of delivery in health-care institutions, the probability of obstetric complications and mean household expenditure for deliveries was subsequently examined. In multivariate regressions, individual and household characteristics as well as district and year fixed effects were controlled for. Data from the most recent District Level Household and Facility Survey (DLHS-3) wave conducted in Gujarat (n = 6484 households) were used in parallel analyses. Findings Between 2005 and 2010, the Chiranjeevi Yojana programme was not associated with a statistically significant change in the probability of institutional delivery (2.42 percentage points; 95% confidence interval, CI: −5.90 to 10.74) or of birth-related complications (6.16 percentage points; 95% CI: −2.63 to 14.95). Estimates using DLHS-3 data were similar. Analyses of household expenditures indicated that mean household expenditure for private-sector deliveries had either not fallen or had fallen very little under the Chiranjeevi Yojana programme. Conclusion The Chiranjeevi Yojana programme appears to have had no significant impact on institutional delivery rates or maternal health outcomes. The absence of estimated reductions in household spending for private-sector deliveries deserves further study. public–private partnership designed to increase institutional Introduction delivery rates.8 It was subsequently estimated that this pro- Each year, over 500 000 women in the world die from birth- gramme had led to a 90% reduction in maternal deaths and related complications1 and more than 5 million neonates die a 60% reduction in neonatal deaths among beneficiaries in before they reach 12 months of age.2 All but 2% of the neonatal Gujarat.8–12 The programme received the Asian Innovations deaths occur in developing countries.2 In the last decade, global Award in 2006,13 had covered almost 800  000 deliveries by efforts to reduce maternal and neonatal mortality have grown March 2012, and is generally perceived as a successful model rapidly. Between 2003 and 2008, global spending on maternal, that should be followed in other Indian states.14 neonatal and child health more than doubled – although it However, perceptions of the programme’s success are remained relatively constant as a share of official development based on the results of studies – simple cross-sectional inves- assistance.3,4 This allowed various new initiatives, including tigations or before-and-after comparisons – that had severe those focusing on skilled birth attendance and emergency limitations. These studies did not address the role of the self- obstetric care, to be supported.3,4 selection of institutional delivery by pregnant women and As no single intervention can address the range of causes took no account of the “background” increases in institutional of maternal death, facility-based intrapartum care – “insti- deliveries that probably occurred over each study period.10 tutional delivery” – is generally recommended as the best The Chiranjeevi Yojana programme covers the costs of option for improving maternal health.5 Facilities that provide deliveries – at designated private-sector hospitals – for women maternity care are likely to have the trained staff, infrastructure from “below-poverty-line” (BPL) households. BPL status – and standardized delivery protocols needed to manage most which is either determined by multidimensional means test- neonatal and obstetric complications. ing or designated by the relevant village authority – confers a In general, public hospitals in India lack the capacity and variety of other benefits, including public subsidies for food reach to serve many rural areas, which means that many poor grains, sugar, oil and fuel. The programme pays the designated women have no access to key health-care services.6,7 Recog- private-sector hospitals 1600 Indian rupees – approximately nizing this limitation, in January 2006 the state government 37 United States dollars (US$) – per delivery. In exchange, of Gujarat launched the Chiranjeevi Yojana programme, a the programme expects the hospitals both to offer vaginal a Sanford School of Public Policy, Duke University, 302 Towerview Drive, Durham NC 27708, United States of America (USA). b RAND Corporation, Arlington, USA. c The World Bank, Washington, USA. d Stanford Medical School, Stanford, California, USA. e Sambodhi Research and Communications Pvt Ltd, New Delhi, India. f School of Medicine and Freeman Spogli Institute for International Studies, Stanford University, Stanford, California, USA. Correspondence to Manoj Mohanan (e-mail: manoj.mohanan@duke.edu). (Submitted: 15 May 2013 – Revised version received: 14 October 2013 – Accepted: 30 October 2013 – Published online: 9 December 2013 ) Bull World Health Organ 2014;92:187–194 | doi: http://dx.doi.org/10.2471/BLT.13.124644 187 Research Effect of Chiranjeevi Yojana in India Manoj Mohanan et al. deliveries or caesarean sections to poor (Appendix A, available at: http://www. to identify households that had below- women free of charge and to reimburse cohesiveindia.org/IMATCHINE/CY- poverty-line status. However, the demo- at least some of the women’s travel BWHO2013Appendix.pdf ). Within graphic characteristics of the DLHS-3 costs. The hospitals can offer additional each study village we conducted a brief sample were reasonably comparable to hospital services to beneficiaries for a census of all households. We then ran- those of our own survey (Table 1), and separate fee. By 2010, the programme domly selected 10 households that had both measured similar delivery-related covered more than 800 private-sector reported at least one delivery since Janu- outcomes. hospitals and had helped finance more ary 2005. We selected households with Data analysis than 400 000 deliveries.15 BPL index scores between 16 and 25 in The aim of the present study was to the year 2002 based on original plans to A multivariate difference-in-differences estimate the relationship between the use a “fuzzy” regression discontinuity ordinary least-squares regression analy- Chiranjeevi Yojana programme and the design.16,17 Unfortunately, widespread sis was used to determine if changes in probability of institutional delivery, the inconsistencies in classification of the our primary outcomes were associated use of maternal and neonatal services BPL status of households prevented such with the staggered introduction of the provided by trained health workers, analyses. Of the 6002 sampled house- Chiranjeevi Yojana programme across birth-related maternal complications holds, 5663 (94.4%) agreed to provide Gujarat’s districts. We use the timing of and household spending for delivery. data and 5597 (93.3%) provided full data births – as reported by mothers in the We used population-based samples and were included in the final analysis. two surveys – together with mother’s and adjusted for time-invariant differ- Through household surveys mod- district of residence to determine if the ences across the districts of Gujarat, elled after the well-known Demographic Chiranjeevi Yojana programme had changes in outcomes over time that and Health Surveys, we recorded ma- been implemented when a delivery were common across the state, and a ternal and household demographic and occurred. range of household-level characteris- socioeconomic characteristics as well Specifically, using birth-level ob- tics. By matching information about as detailed retrospective information servations, we regress our primary out- programme placement and timing to about antenatal and postnatal care and comes on an indicator variable denoting population-level data – rather than data deliveries for all births since 2005. Our whether or not the Chiranjeevi Yojana from participating hospitals – we were primary outcomes were: the place of programme was active. In all regres- also able to minimize the influence of delivery – public facility, private facility sions we control for district and year self-selection into institutional delivery or home; who assisted with the deliv- fixed effects to account for unobserved among pregnant women. ery – a trained health professional or a interdistrict differences that did not vary relative; the type of delivery – vaginal over time and changes over time that or caesarean; whether the mother had were common to all districts;19 as well Methods received antenatal care, postnatal care as maternal characteristics (mother’s age The Chiranjeevi Yojana programme was or both and, if so, whether such care at marriage, age at delivery and level of launched in five northern districts of had been provided by a trained health education); and household characteris- Gujarat in January 2006 and then ex- professional; whether the mother suf- tics (caste, religion, and wealth – BPL panded to the rest of the state between fered birth-related maternal complica- score, monthly household income in December 2006 and January 2007. We tions such as premature labour, exces- our data and a composite wealth index use a multivariate difference-in-differ- sive bleeding or loss of consciousness; in the DLHS-3 data). We calculated ences regression framework to identify whether the neonate had been admitted robust standard errors that are clustered changes in primary outcomes associated to a neonatal intensive-care unit; and by block (the primary sampling unit) with the spread of the programme across how much the household had spent on to relax the assumption of independent the state. The 21 “late-implementing” the delivery – both the hospital fees and and identically distributed errors within districts served as a control for the total costs including transportation and districts. five “early-implementing” districts of other expenses. Given our available data using a Banaskantha, Dahod, Kachchh, Panch We conducted parallel analyses us- baseline of 0.56 (proportion of institu- Mahal and Sabarkantha in 2006 and vice ing publicly available data from the third tional deliveries), the minimum detect- versa in 2007. wave of the District Level Household able effect size for test of proportions and Facility Survey (DLHS-3). Such sur- is 5 percentage points or more in the Data sources and outcome veys have been routinely commissioned probability of institutional delivery (a measures – by the Indian Ministry of Health and change from 0.56 to 0.61). The summary We relied on two sources of data for Family Welfare – to monitor reproduc- statistics for all outcomes are shown in our study: our own household survey in tive and child health throughout India. Table 2. 2010 and analogous data from the third In Gujarat, DLHS-3 was conducted in wave of the District Level Household 2007 and 2008 across each of the state’s and Facility Survey (DLHS-3). 26 districts. We restricted our DLHS-3 Results In our survey – conducted in Au- sample to women whose last delivery – Programme impact gust to September 2010 – we collected at the time of the survey – had been in retrospective information from a state- or after 2005, yielding a final sample of Fig. 1 shows the unadjusted mean insti- wide sample of women who had had 6484 households. Because the sample tutional delivery rates (and confidence deliveries since January 2005. We used was designed to be representative at intervals, CIs) in the early- and late-im- stratified three-stage cluster sampling the district level, no attempt was made plementation districts – separately using 188 Bull World Health Organ 2014;92:187–194 | doi: http://dx.doi.org/10.2471/BLT.13.124644 Research Manoj Mohanan et al. Effect of Chiranjeevi Yojana in India data from our 2010 survey and DLHS-3 Yojana programme. Both panels also that coincide with the introduction of from 2007–2008. Both panels show show modest changes in institutional the Chiranjeevi Yojana programme. background increases in institutional delivery rates over time, but there are The divergence between early- and late- delivery rates over time across Gujarat otherwise no relative changes in either implementation districts in 2008 shown that are unrelated to the Chiranjeevi early- or late-implementation districts using DLHS-3 data (left-hand panel of Fig. 1) is not present in 2008 (right-hand Table 1. Summary statistics from two household surveys, Gujarat, India panel of Fig. 1) and disappears when the DLHS-3 data are weighted to compen- sate for between-survey differences in Characteristic Present studya DLHS-3b key BPL scoring components, such as Mother’s age at marriage, years (SD) 18.39 (2.12) 18.08 (2.95) household assets, sanitation and literacy. Mother’s age at delivery, years (SD) 24.52 (4.24) 25.06 (4.73) (The results with reweighted DLHS-3 Hindu households, % (SD) 94 (23) 91 (29) data are available from the correspond- Mothers who had attended school, % (SD) 57 (ND) 58 (49) ing author on request). Wealth index, SDc ND 0.15 (0.94) The relationship between the Chi- Mother’s education, % ranjeevi Yojana programme and each of     Illiterate 43 ND the primary outcomes we investigated is     Primary 27 ND reported in Table 2. In Appendix A we     Middle or higher 30 ND also report odds ratios obtained using Monthly household income in Indian rupees,d % of logistic regressions rather than linear households probability models and note that the two     < 250 1 ND approaches yield comparable inferences     250–499 3 ND throughout. The data collected through     500–1499 27 ND our study indicated that implementation of the programme was not associated     1500–2500 42 ND with a statistically significant change in     > 2500 27 ND the probability of institutional delivery Caste,e % (2.42 percentage points; 95% CI: −5.90     General or other 18 19 to 10.74). The CIs also imply that any     “Scheduled” caste 22 13 association with institutional delivery     “Scheduled” tribe 21 30 too small to be detected in our samples     Other “backward” caste 39 0 could be no larger than an increase of     No designated caste or tribe 0 38 10.7 percentage points. The analysis DLHS-3, District Level Household and Facility Survey for 2007–2008; ND, not determined; SD, standard using data from the DLHS-3 also con- deviation. firms our findings that the programme’s a 5597 households. implementation was not associated b 6484 households. c Calculated using the method of Filmer and Pritchett.18 with a statistically significant change in d Approximately 43 Indian rupees to one United States dollar. institutional deliveries (−3.08 percent- e Different caste designations were used in the two surveys. age points; 95% CI: –9.12 to 2.96). The Fig. 1. Meana institutional delivery rates in Gujarat, India, 2005–2010 100 100 (% of deliveries): DLHS-3 [2007–2008] Early-implementing districts Early-implementing districts Mean institutional delivery rate Mean institutional delivery rate 90 Late-implementing districts 90 Late-implementing districts (% of deliveries): 2010 survey 80 80 70 70 60 60 50 50 40 40 Early rollout Late rollout Early rollout Late rollout 30 30 2005 2006 2007 2008 2009 2010 2005 2006 2007 2008 2009 2010 Year of delivery Year of delivery a Unadjusted mean. Note: the data were collected specifically for the present study (left-hand panel) or in the District Level Household and Facility Survey for 2007–2008 (right-hand panel). They are plotted separately for the “early-implementing” districts – i.e. Banaskantha, Dahod, Kachchh, Panch Mahal and Sabarkantha, which implemented the Chiranjeevi Yojana programme in January 2006 – and the “late-implementing” districts – i.e. the other 21 districts of Gujarat, which implemented the same programme in December 2006 or January 2007. Error bars indicate 95% confidence intervals, adjusted for survey design. Bull World Health Organ 2014;92:187–194 | doi: http://dx.doi.org/10.2471/BLT.13.124644 189 190 Table 2. Primary outcomes of the Chiranjeevi Yojana programme recorded for 2005, before the programme was launched, and for 2008, after the programme’s state-wide implementation, Gujarat, India Research Outcome Unadjusted mean value (SD) Difference-in-differences estimatea (95% CI) Present studya DLHS-3b Present studya DLHS-3b 2005 2008 2005 2008 Percentage of deliveries in year In health facility 56.0 (49.7) 68.0 (46.7) 52.8 (49.9) 60.3 (49.0) 2.42 (−5.90 to 10.74) –3.08 (−9.12 to 2.96) In private health facilityc 58.1 (49.4) 58.2 (49.4) 63.4 (48.2) 60.4 (48.9) –2.47 (−8.30 to 3.36) –4.39 (−12.17 to 3.39) Effect of Chiranjeevi Yojana in India Assisted by physician or nurse 61.6 (48.7) 72.1 (44.9) 59.4 (49.1) 65.5 (47.6) 3.13 (−5.31 to 11.58) –2.51 (−8.27 to 3.25) Vaginal 94.2 (23.4) 92.7 (25.9) 90.7 (29.0) 91.6 (27.8) 1.61 (−1.35 to 4.58) 0.12 (−3.37 to 3.60) With complications 57.1 (49.6) 53.8 (49.9) 46.5 (49.9) 44.0 (49.7) 6.16 (−2.63 to 14.95) 2.45 (−3.34 to 8.24) With mother becoming unconscious 8.8 (28.4) 9.0 (28.7) ND ND –1.82 (−6.83 to 3.19) ND With neonate admitted to NICU 5.4 (22.6) 5.1 (21.9) ND ND 2.12 (−3.32 to 7.55) ND With excessive maternal bleeding ND ND 6.8 (25.1) 6.2 (24.1) ND 1.99 (−1.28 to 5.26) With maternal convulsions ND ND 3.8 (19.0) 3.3 (17.8) ND –2.17 (−4.49 to 0.14) With AN check-up 85.2 (35.6) 89.5 (30.6) 68.3 (46.6) 75.0 (43.3) 3.18 (−1.69 to 8.06) –2.09 (−8.07 to 3.90) With AN check-up by physician or nursed 87.4 (33.2) 87.2 (33.4) 97.7 (15.1) 97.9 (14.5) –3.76 (−11.75 to 4.24) 0.12 (−2.89 to 3.13) With AN testing ND ND 95.6 (20.5) 97.2 (16.4) ND 0.80 (−3.61 to 5.20) With PN check-up 74.4 (43.7) 82.3 (38.2) 60.4 (48.9) 62.9 (48.3) 4.99 (−2.15 to 12.13) 2.23 (−3.50 to 7.96) With PN check-up by physician or nursee 84.3 (36.4) 85.3 (35.4) ND ND 0.77 (−9.79 to 11.33) ND With any household costs 85.8 (34.9) 86.9 (33.7) 81.3 (39.0) 80.5 (39.6) 2.69 (−1.10 to 6.48) –3.06 (−8.81 to 2.70) Household costs associated with delivery, US$f Total 55.57 (86.44) 55.82 (82.82) 47.15 (94.72) 44.97 (86.52) 0.42 (−0.23 to 1.08) −0.49 (−0.87 to −0.11) Health facility 49.18 (84.24) 49.38 (79.54) ND ND 0.33 (−0.40 to 1.02) ND Non-facility 6.37 (9.00) 6.44 (11.13) ND ND 0.03 (−0.47 to 0.52) ND Transportation ND ND 5.81 (10.04) 7.00 (10.97) ND 0.22 (−0.40 to 0.80) AN, antenatal; CI, confidence interval; DLHS-3, District Level Household and Facility Survey for 2007–2008; ND, not determined; NICU, neonatal intensive-care unit; PN, postnatal; SD, standard deviation; US$, United States dollars. a  5597 households. b 6484 households. c Estimates for difference in change between 2005 and 2008, calculated using ordinary least-squares regression and with adjustment for the survey design. Difference-in-differences estimates for variables that are binary (such as the ones listed as a percentage of deliveries) are percentage point changes, while for last four rows, where the outcome (household costs) is a continuous variable, the difference-in-differences estimate of programme impact is interpreted as a percentage change. d Percentages shown are of the deliveries that occurred in a health facility. e Percentages shown are of the mothers that received such a check-up. f Based on an exchange rate of approximately 43 Indian rupees to one United States dollar. Bull World Health Organ 2014;92:187–194 | doi: http://dx.doi.org/10.2471/BLT.13.124644 Manoj Mohanan et al. Research Manoj Mohanan et al. Effect of Chiranjeevi Yojana in India DLHS-3 estimates are also more precise, not to have changed significantly under services provided by private maternity which suggests that any programme the programme. hospitals is poor or, at least, is perceived impact too small to detect in our analy- to be poor by the local population. As sis could have been no larger than an a result, demand for institutional de- increase of 2.9 percentage points. We Discussion livery may be low even if such delivery find similar null estimates both for prob- Our findings indicate that the Chiran- is provided free of charge. Another is ability of delivery in private maternity jeevi Yojana programme was not associ- that – despite the support of the pro- hospitals and for birth attendance by ated with changes in the probability of gramme – institutional deliveries in physicians or nurses. institutional delivery (including delivery Gujarat remain associated with large The programme was also not asso- at private institutions), maternal mor- transportation costs, informal payments ciated with changes in the incidence of bidity or delivery-related household or other expenses that make programme birth-related maternal complications, the expenditure. These findings differ from benefits small relative to the full cost of use of antenatal and postnatal services or those reported by previous evaluations institutional delivery.21 the use of neonatal intensive care. Our suggesting substantial benefits of the Our finding of little or no asso- survey data suggests that 54% of the Chiranjeevi Yojana programme, in- ciation between the Chiranjeevi Yojana mothers in our sample suffered complica- cluding a 27% increase in institutional programme and the out-of-pocket costs tions, including premature delivery, pro- deliveries, a 90% reduction in maternal of deliveries is more puzzling. Even if the longed and obstructed labour, excessive deaths and a 60% reduction in neonatal programme failed to make institutional bleeding, breech presentation, convul- deaths.8,9,12 These earlier studies did not delivery more attractive for any women, sions, hypertension, fever, incontinence address self-selection of women into it should have reduced the household or other birth-related problems after the institutional delivery, reporting inac- expenses for the many poor women programme had been implemented – and curacies by hospitals, or any increases who still chose institutional delivery. that the probability of these complica- in institutional deliveries over time that Although we cannot fully explain this tions did not significantly change under were unrelated to the programme. The finding, we note media reports of poor the Chiranjeevi Yojana programme. programme was rolled out in a period women still being asked to pay fees for The reimbursement offered to when the economy of Gujarat was grow- deliveries in health facilities that were designated health facilities by the Chi- ing by over 10% per year, for example. participating in the programme.22,23 It ranjeevi Yojana programme is intended Our study also has important limi- seems possible that some providers are to cover the costs of delivery for poor tations. One is that because it was not providing extra, chargeable services – or women who choose to give birth in a a randomized, controlled evaluation, simply increasing side charges. If charg- health facility. Even if the programme we cannot rule out the possibility of es are being made for extra services, has not increased institutional delivery confounding. However, we note that those services do not appear to have rates, we would expect to see lower our results are robust to the inclusion any discernible health benefits. Further mean household expenditures on de- of a wide variety of control variables research on this issue is needed. ■ liveries, given that the programme had and that the staggered introduction of paid providers over US$ 32 million as the Chiranjeevi Yojana programme does Acknowledgements of 2012. However, analysis of our survey not appear correlated with pre-existing We thank the Department of Health data indicated that implementation trend differences in institutional deliv- and Family Welfare, Government of of the programme had no significant ery rates (see analysis of DLHS-2 data Gujarat, for its support. We are grate- relationship either with the probability in Appendix A). Analyses using two ful to Manveen Kohli, Pragya Pranjali, that households reported any delivery- independent sources of data (our survey Razdan Rahman, Harshad Vaidya and related spending (2.69 percentage and DLHS-3) also yielded very similar the Sambodhi team for their support. points; 95% CI: −1.10 to 6.48) or with results. Another limitation of our study mean hospital spending for delivery is that it relied on respondents’ recall of Funding: Research discussed in this pub- conditional on any spending (18.22% primary outcomes for a period of up to lication has been financed with funds change; 95% CI: –9.91 to 46.34). 5 years. Poor recall quality in the house- provided by the UK Department For In general, the DLHS-3 data also hold surveys is a potential concern, International Financing (DFID) to the indicated that the programme was not although we followed the methods of the International Initiative for Impact Evalu- associated with significant changes in well regarded Demographic and Health ation, Inc. (3ie) and managed through the household spending for institutional Surveys’ “fertility roster” to collect these Global Development Network (GDN), as deliveries. The single exception is a retrospective data.20 The degree of recall well as support from the World Bank. The 21.2% reduction in mean spending (95% error is also unlikely to be related to findings, interpretations, and conclusions CI: 4.71 to 37.69) among households the implementation of the Chiranjeevi expressed here are those of the authors reporting any expenditure, but this loses Yojana programme. and do not necessarily reflect the views statistical significance after adjustment There are several possible explana- of any of the funders, the Board of Execu- for the multiple comparisons (data not tions for observing no increase in the tive Directors of the World Bank or the shown). Even among the households of probability of institutional delivery governments they represent. women who delivered in private hospi- associated with the Chiranjeevi Yojana tals, spending on the deliveries appeared programme. One is that the quality of Competing interests: None declared. Bull World Health Organ 2014;92:187–194 | doi: http://dx.doi.org/10.2471/BLT.13.124644 191 Research Effect of Chiranjeevi Yojana in India Manoj Mohanan et al. ‫ملخص‬ ‫تأثري برنامج شريانجيفي يوجانا عىل الوالدات التي تتم يف املؤسسات وحصائل الولدان واألمهات يف منطقة غوجارات‬ ‫ حتليل الفرق يف االختالفات‬:‫باهلند‬ .‫أرسة) يف حتليالت موازية‬ ‫ إحدى الرشاكات‬،‫الغرض تقييم تأثري برنامج شريانجيفي يوجانا‬ ‫ مل يرتبط برنامج شريانجيفي‬،2010 ‫ إىل‬2005 ‫النتائج يف الفرتة من‬ ‫بني القطاع العام واخلاص لتحسني صحة األمهات والولدان يف‬ ‫يوجانا بتغري كبري من الناحية اإلحصائية يف احتاملية الوالدة التي‬ .‫منطقة غوجارات باهلند‬ ‫ فاصل‬،% 95 ‫ يف املائة نقطة؛ فاصل الثقة‬2.42( ‫تتم يف املؤسسات‬ ‫ أرسة) يف منطقة‬5597 = ‫الطريقة تم إجراء مسح أرسي (العدد‬ ‫) أو التعقيدات املرتبطة بالوالدة‬10.74 ‫ إىل‬-5.90 ‫ من‬:‫الثقة‬ ‫غوجارات بغية مجع البيانات االسرتجاعية بشأن حاالت الوالدة‬ -2.63 ‫ من‬:‫ فاصل الثقة‬،95% ‫ يف املائة نقطة؛ فاصل الثقة‬6.16( ‫ ويف دراسة قائمة عىل املالحظة‬.‫خالل اخلمسة أعوام السابقة‬ DLHS-3 ‫ وكانت التقديرات باستخدام بيانات‬.)14.95 ‫إىل‬ ‫ تم يف مرحلة الحقة‬،‫باستخدام تصميم الفرق يف االختالفات‬ ‫ وأشارت حتليالت نفقات األرس إما إىل عدم انخفاض‬.‫متشاهبة‬ ‫دراسة العالقة بني برنامج شريانجيفي يوجانا واحتاملية الوالدة‬ ‫متوسط إنفاق األرس عىل الوالدات يف القطاع اخلاص أو انخفاضه‬ ‫يف مؤسسات الرعاية الصحية واحتاملية حدوث مضاعفات‬ .‫عىل نحو طفيف جد ًا يف ظل برنامج شريانجيفي يوجانا‬ ‫ ويف االرتدادات‬.‫الوالدة ومتوسط إنفاق األرس عىل الوالدات‬ ‫االستنتاج يبدو أن برنامج شريانجيفي يوجانا مل يكن له تأثري كبري‬ ‫ تم ضبط اخلصائص الفردية واألرسية باإلضافة‬،‫متعددة املتغريات‬ .‫عىل معدالت الوالدة يف املؤسسات أو حصائل صحة األمهات‬ ‫ وتم استخدام البيانات‬.‫إىل التأثريات الثابتة للمنطقة والسنة‬ ‫ويستوجب غياب االنخفاضات املقدرة يف إنفاق األرس عىل‬ ‫املستمدة من أحدث موجة مسح لألرس واملرافق عىل صعيد املنطقة‬ .‫الوالدات يف القطاع اخلاص مزيد ًا من الدراسة‬ 6484 = ‫) أجريت يف منطقة غوجارات (العدد‬DLHS-3( 摘要 目的 评估赤拉尼维由旬计划的效果,这是一个改善印 结果 在 2005 和 2010 年之间,赤拉尼维由旬计划与机 度古吉拉特邦母亲和新生儿健康的公私合作项目。 构分娩的可能性(2.42 百分点 ; 95% 置信区间,CI : 方法 对古吉拉特邦之前 5 年内回顾性出生数据进行家 -5.90 至 10.74)或出生相关并发症(6.16 百分点 ; 95% 庭调查(n = 5597 个家庭)。随后在使用双重差分设计 CI : -2.63 至 14.95)统计数据的显著变化没有相关性。 的观察性研究中,调查赤拉尼维由旬计划和医疗机构 使用 DLHS-3 数据的估算结果相似。家庭支出分析表 分娩可能性、产科并发症可能性以及分娩的平均家庭 明,私营机构分娩的平均家庭开支在赤拉尼维由旬计 费用之间的关系。在多元回归中,将个人和家庭特征 划中没有降低或降低非常少。 以及地区和年固定影响作为控制变量。在平行分析中 结论 赤拉尼维由旬计划似乎对机构分娩率或母亲健康 使用最近在古吉拉特邦(n = 6484 个家庭)执行的地区 结局没有显著影响。私人机构分娩的家庭估计开支没 级家庭和设施调查(DLHS-3)中的数据。 有减少,这一点需要进一步的研究。 Résumé Effets du programme Chiranjeevi Yojana sur les accouchements en institutions et les résultats néonatals et maternels au Gujarat, en Inde: une analyse de l’écart des différences Objectif Évaluer le programme Chiranjeevi Yojana, un partenariat Résultats Entre 2005 et 2010, le programme Chiranjeevi Yojana n’était public-privé établi pour améliorer la santé maternelle et néonatale au pas associé à un changement statistiquement significatif pour la Gujarat, en Inde. probabilité d’accouchement en institutions (2,42 points de pourcentage; Méthodes Une enquête sur les ménages (n = 5597 ménages) a intervalle de confiance à 95%, IC: −5,90–10,74) ou pour les complications été menée à Gujarat pour collecter les données rétrospectives sur liées à l’accouchement (6,16 points de pourcentage; IC à 95%: −2,63– les naissances ayant eu lieu au cours des 5 années précédentes. 14,95). Les estimations utilisant les données DLHS-3 étaient semblables La relation entre le programme Chiranjeevi Yojana et la probabilité à ces résultats. Les analyses des dépenses des ménages ont indiqué que d’accouchement dans des établissements de soins de santé, la les dépenses moyennes des ménages pour les accouchements dans probabilité de complications obstétriques et les dépenses moyennes des le secteur privé n’ont pas baissé ou très peu pendant le programme ménages pour les accouchements a ensuite été examinée par une étude Chiranjeevi Yojana. d’observation utilisant une approche de l’écart dans les différences. Les Conclusion Le programme Chiranjeevi Yojana semble n’avoir eu aucun caractéristiques des individus et des ménages ainsi que les effets fixes impact significatif sur le taux d’accouchement en institution ou dans les des districts et de l’année ont été contrôlés en utilisant des régressions résultats de santé maternelle. L’absence de diminution estimée dans les multivariées. Les données issues des dernières vagues d’enquêtes sur les dépenses des ménages pour les accouchements dans le secteur privé installations et le niveau des ménages des districts (DLHS-3) menées au mérite une étude plus approfondie. Gujarat (n = 6484 ménages) ont été utilisées dans des analyses parallèles. 192 Bull World Health Organ 2014;92:187–194 | doi: http://dx.doi.org/10.2471/BLT.13.124644 Research Manoj Mohanan et al. Effect of Chiranjeevi Yojana in India Резюме Влияние программы Чирандживи Йоджана на принятие родов в учреждениях здравоохранения и влияние на здоровье новорожденных и матерей в штате Гуджарат, Индия: анализ типа «разница-в- различиях» Цель Оценить влияние программы Чирандживи Йоджана — в Гуджарате (n = 6484 домохозяйств). государственно-частного партнерства, целью которого Результаты В период 2005-2010 годов осуществление программы является улучшение медицинского обслуживания матерей и Чирандживи Йоджана не привело к статистически значимому новорожденных в штате Гуджарат в Индии. изменению вероятности родов в учреждениях здравоохранения Методы В штате Гуджарат было проведено обследование (2,42 процентных пункта; 95%-ный доверительный интервал, домохозяйств (n = 5597 домохозяйств) для сбора ретроспективных ДИ: –5, 90–10,74) или количества осложнений из-за родов данных о рождаемости за последние 5 лет. В обсервационном (6,16 процентных пункта; 95%-ный ДИ: –2,63-14,95). Оценки с исследовании с использованием модели «разница-в-различиях» использованием данных DLHS-3 оказались схожими. Анализ были последовательно исследованы взаимосвязи между расходов домохозяйств показал, что в результате осуществления программой Чирандживи Йоджана и вероятностью родов в программы Чирандживи Йоджана средние расходы домохозяйств учреждениях здравоохранения, вероятностью осложнений во на роды в частных учреждениях либо не снизились вовсе, либо время родов и средним уровнем расходов домохозяйств на роды. снизились незначительно. В рамках многопараметрических регрессий была выполнена Вывод Похоже, что программа Чирандживи Йоджана не оказала проверка характеристик отдельных лиц и домохозяйств, а также существенного влияния на количество родов, принимаемых зафиксированных результатов по районам и годичным периодам. в учреждениях здравоохранения, или на их последствия В ходе параллельного анализа также использовались данные для материнского здоровья. Отсутствие предполагаемого самой последней кампании обследования домохозяйств и сокращения расходов домохозяйств на роды в частных учреждений на уровне районов (DLHS-3), которая проводилась учреждениях здравоохранения требует дальнейшего изучения. Resumen El efecto de Chiranjeevi Yojana en los partos atendidos en instituciones y los resultados neonatales y maternos en Gujarat, India: un análisis de diferencias en diferencias Objetivo Evaluar el efecto del programa Chiranjeevi Yojana, una Resultados Entre 2005 y 2010, el programa Chiranjeevi Yojana no se asociación público-privada destinada a mejorar la salud materna y asoció con un cambio importante desde el punto de vista estadístico neonatal en Gujarat, India. en la probabilidad de partos en instituciones (2,42 puntos porcentuales; Métodos Se llevó a cabo una encuesta doméstica (n = 5597 hogares) intervalo de confianza del 95 %, IC −5,90 a 10,74) o de complicaciones en Gujarat para recabar datos retrospectivos sobre los nacimientos en relacionadas con el parto (6,16 puntos porcentuales; IC del 95 %: − 2,63 los últimos 5 años. En un estudio observacional, se examinó la relación a 14,95). Las estimaciones que emplearon los datos DLHS-3 fueron entre el programa Chiranjeevi Yojana y la probabilidad de parto en similares. Los análisis de los gastos domésticos revelaron que el gasto instituciones de atención sanitaria, la probabilidad de complicaciones doméstico en partos en el sector privado no había disminuido en obstétricas y la media de gasto doméstico en partos, empleando un absoluto o muy poco bajo el programa Chiranjeevi Yojana. diseño de diferencia en las diferencias. En las regresiones multivariantes, Conclusión El programa Chiranjeevi Yojana no parece haber tenido se controlaron las características individuales y domésticas, así como los un impacto significativo en las tasas de parto en instituciones ni en los efectos fijos anuales y del distrito. Se emplearon los datos de la última resultados de salud materna. La ausencia de las reducciones previstas en ronda de encuestas domésticas y de las instalaciones a nivel de distrito el gasto doméstico por partos en el sector privado merece un estudio (DLHS-3) realizadas en Gujarat (n = 6484 hogares) en análisis paralelos. más profundo. References 1. Hill K, Thomas K, AbouZahr C, Walker N, Say L, Inoue M et al.; Maternal 5. Campbell OMR, Graham WJ; Lancet Maternal Survival Series steering Mortality Working Group. Estimates of maternal mortality worldwide group. Strategies for reducing maternal mortality: getting on with what between 1990 and 2005: an assessment of available data. Lancet works. Lancet 2006;368:1284–99. doi: http://dx.doi.org/10.1016/S0140- 2007;370:1311–9. doi: http://dx.doi.org/10.1016/S0140-6736(07)61572-4 6736(06)69381-1 PMID:17027735 PMID:17933645 6. Lim SS, Dandona L, Hoisington JA, James SL, Hogan MC, Gakidou E. India’s 2. Hyder AA, Wali SA, McGuckin J. The burden of disease from neonatal Janani Suraksha Yojana, a conditional cash transfer programme to increase mortality: a review of South Asia and sub-Saharan Africa. BJOG births in health facilities: an impact evaluation. Lancet 2010;375:2009–23. 2003;110:894–901. doi: http://dx.doi.org/10.1111/j.1471-0528.2003.02446.x doi: http://dx.doi.org/10.1016/S0140-6736(10)60744-1 PMID:20569841 PMID:14550358 7. Mazumdar S, Mills A, Powell-Jackson T. Financial incentives in health: new 3. Pitt C, Greco G, Powell-Jackson T, Mills A. Countdown to 2015: assessment evidence from India’s Janani Suraksha Yojana. Oxford: Health Economics Research of official development assistance to maternal, newborn, and child health, Centre; 2011. Available from: http://www.herc.ox.ac.uk/people/tpowelljackson/ 2003–08. Lancet 2010;376:1485–96. doi: http://dx.doi.org/10.1016/S0140- financial%20incentives%20in%20health [accessed 7 November 2013]. 6736(10)61302-5 PMID:20850869 8. Singh A, Mavalankar DV, Bhat R, Desai A, Patel SR, Singh PV et al. Providing 4. Bhutta ZA, Chopra M, Axelson H, Berman P, Boerma T, Bryce J et al. skilled birth attendants and emergency obstetric care to the poor through Countdown to 2015 decade report (2000–10): taking stock of maternal, partnership with private sector obstetricians in Gujarat, India. Bull World newborn, and child survival. Lancet 2010;375:2032–44. doi: http://dx.doi. Health Organ 2009;87:960–4. doi: http://dx.doi.org/10.2471/BLT.08.060228 org/10.1016/S0140-6736(10)60678-2 PMID:20569843 PMID:20454488 Bull World Health Organ 2014;92:187–194 | doi: http://dx.doi.org/10.2471/BLT.13.124644 193 Research Effect of Chiranjeevi Yojana in India Manoj Mohanan et al. 9. Mavalankar D, Singh A, Patel SR, Desai A, Singh PV. Saving mothers 17. Jinyong H, Todd P, Van der Klaauw W. Identification and estimation of and newborns through an innovative partnership with private sector treatment effects with a regression-discontinuity design. Econometrica obstetricians: Chiranjeevi scheme of Gujarat, India. Int J Gynaecol Obstet 2001;69:201–9. 2009;107:271–6. 18. Filmer D, Pritchett L. Estimating wealth effects without expenditure 10. Acharya A, McNamee P. Assessing Gujarat’s ‘Chiranjeevi’ scheme. Econ Polit data – or tears: an application to educational enrollments in states of India. Wkly 2009;44:13–5. Demography 2001;38:115–32. 11. Krupp K, Madhivanan P. Leveraging human capital to reduce maternal 19. Neyman J, Scott EL. Consistent estimates based on partially consistent mortality in India: enhanced public health system or public-private observations. Econometrica 1948;16:1–32. doi: http://dx.doi. partnership? Hum Resour Health 2009;7:18. doi: http://dx.doi. org/10.2307/1914288 org/10.1186/1478-4491-7-18 PMID:19250542 20. Das J, Hammer J, Sánchez-Paramo C. The impact of recall periods on 12. Bhat R, Mavalankar DV, Singh PV, Singh N. Maternal healthcare financing: reported morbidity and health seeking behavior . J Dev Econ 2012;98:76–88. Gujarat’s Chiranjeevi scheme and its beneficiaries. J Health Popul doi: http://dx.doi.org/10.1016/j.jdeveco.2011.07.001 Nutr 2009;27:249–58. doi: http://dx.doi.org/10.3329/jhpn.v27i2.3367 21. Krishna A, Ananthpur K. Globalization, distance and disease: spatial health PMID:19489419 disparities in rural India. Millennial Asia 2013;4:3–25. doi: http://dx.doi.org/ 13. Ramesh M. Innovation award for Gujarat. The Hindu Business Line. 6 November http://dx.10.1177/0976399613480879 2006. Available from: http://www.thehindubusinessline.in/bline/2006/11/06/ 22. Chiranjeevi scheme failed to deliver: CAG report. Indian Express. 31 March stories/2006110600801500.htm [accessed 7 November 2013]. 2011. Available from: http://www.indianexpress.com/news/chiranjeevi- 14. Outcome of Chiranjeevi scheme. Gandhinagar: Gujarat Government scheme-failed-to-deliver-cag-report/769645/ [accessed 7 November 2013]. Department of Health and Family Welfare; 2013. 23. Govt scheme to arrest infant mortality fails to deliver. Times of India. 15. Health statistics, Gujarat 2009–2010. Gandhinagar: Gujarat Government 31 March 2011. Available from: http://articles.timesofindia.indiatimes. Vital Statistics Division; 2011. Available from: http://www.gujhealth.gov.in/ com/2011-03-31/ahmedabad/29365735_1_mortality-rate-infant- images/pdf/Health-review-09-10.pdf [accessed 7 November 2003]. mortality-govt-scheme [accessed 7 November 2013]. 16. Sundaram K. On identification of households below the poverty line in the BPL Census 2002: some comments on the proposed methodology. Econ Polit Wkly 2003;38:896–901. 194 Bull World Health Organ 2014;92:187–194 | doi: http://dx.doi.org/10.2471/BLT.13.124644