Academic journal article Journal of Health Population and Nutrition

Statewide Program to Promote Institutional Delivery in Gujarat, India: Who Participates and the Degree of Financial Subsidy Provided by the Chiranjeevi Yojana Program

Academic journal article Journal of Health Population and Nutrition

Statewide Program to Promote Institutional Delivery in Gujarat, India: Who Participates and the Degree of Financial Subsidy Provided by the Chiranjeevi Yojana Program

Article excerpt

Electronic supplementary material

The online version of this article (doi:10.?1186/?s41043-016-0039-z) contains supplementary material, which is available to authorized users.

Background

Despite the global maternal mortality ratio (MMR) declining from 380 maternal deaths per 100,000 live births in 1990 to 210 deaths in 2013 [1], maternal deaths still remain high in some countries such as India. Almost a fifth of the 287,000 annual maternal deaths occur in India [2-5].

It is known that skilled birth attendance and access to quality emergency obstetric care (EmOC) are critical to the reduction of maternal mortality [6, 7]. Institutional childbirth has been advocated and adopted by governments all over the world, including India, as a strategy to reduce maternal mortality. Considering the unpredictable occurrence of life-threatening obstetric complications, the assumption is that a facility birth will provide a woman access to skilled birth attendance and EmOC, facilitating the management of complications that could ultimately lead to a reduction in mortality [8].

Although governments in many low middle income countries actively encourage facility-based childbirth for this reason, the capacity of public health facilities to provide life-saving EmOC is limited because of structural weaknesses in the health system including a lack of qualified human resources and shortages of infrastructure and supplies [9]. Such a situation exists in the public health system in many parts of India and in the Western Indian state of Gujarat. The public health sector has an extreme shortage of qualified obstetricians [10] and hence little capacity to provide EmOC. However, in comparison, there are over 1500 qualified obstetricians [11] practicing in the for-profit private health sector. This sector operates largely on the basis of out-of-pocket (OOP) payments from users.

The relationship between poverty and maternal death is well known [12]. Recent studies in South Asia [13, 14] have highlighted OOP expenditures for poor women as a barrier to seeking childbirth services in a health facility. In 2005-2006, only 13 % of India's poorest women gave birth in a health facility providing EmOC, while the corresponding figure for the wealthiest women was 84 % [15]. Poor/tribal women (who bear the brunt of maternal morbidity and mortality) face financial barriers to accessing functional EmOC services in the country as these services are largely concentrated in the for-profit private sector [16, 17]. This inequity emphasizes the importance of developing strategies that remove financial barriers to maternal delivery services and enable poor women to receive proper care where it is available.

In order to minimize financial barriers and provide poor/tribal women access to the available EmOC in the private sector, the Government of Gujarat initiated a voucher-like program, Chiranjeevi Yojana (CY, a scheme for long life). Under this public-private partnership, qualified private obstetricians are paid by the state government to provide a cashless delivery for poor/tribal women within the state [18].

Most voucher-like programs worldwide are small and managed by non-governmental organizations or donors [19]. CY in comparison is a large statewide voucher-like program run and financed entirely by the government. Despite nearly a million beneficiaries [20], there have been few reports critically studying the CY public-private partnership [21-27]. While a small pilot evaluation was performed in 2006 [21], only three studies were implemented since the program was rolled out statewide. Two studies examined the impact of CY on increasing institutional delivery [23, 24], and the third was a qualitative study focusing on the perception and experience of private providers with regard to the CY program [27].

This paper aims to advance the state of knowledge on the CY program particularly by establishing the degree of uptake and the level of financial subsidy obtained by beneficiaries by (i) studying the proportion of eligible women who become CY beneficiaries and (ii) ascertaining OOP expenditures and the extent the CY program subsidized childbirth. …

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