The Chiranjeevi Yojana (CY) : a public-private-partnership to promote institutional births in Gujarat, India : studies of providers and users

Abstract: Introduction: National, regional and local governments, particularly in lower middleincome countries, are encouraged to pursue partnerships with the pool of private providers available to them, in order to achieve the Sustainable Development Goal for maternal health. The state of Gujarat in India (population 60 million) has been a pioneer in designing a large-scale Public-Private-Partnership (PPP), the Chiranjeevi Yojana (CY), for emergency obstetric care (EmOC) for vulnerable women through qualified obstetricians. The program was instituted in 2006-07 and 865 obstetricians partnered with the state at the time. Methodology: The papers in this thesis examine this CY program through three quantitative and one qualitative study. The studies were conducted in three districts of Gujarat state, Sabarkantha, Surendranagar and Dahod. The methods included two crosssectional surveys (i.e., a facility survey and a facility-based survey of women who gave birth) and in-depth interviews. These four studies elucidate characteristics of CY providers and CY beneficiaries, as well as outcomes in the health system environment and the population. In order to synthesise these results coherently, I adapted the Anderson’s theoretical model to synthesise, explain and discuss the findings in my studies. In the adapted model, I present my findings in three clear and linked domains – (1) Environment – Health system and population environment in which the CY program was implemented (2) Enabler – Characteristics of the health system and population that were enabled, i.e., made eligible, as per program criteria to participate in the CY program and (3) Outcomes – in the health system and population environment, examined through (a) Health system and provider behaviours (b) Users’ behaviours (c) Health status of the mothers and (d) Financial status of households with respect to using obstetric services. Results: The CY program influenced the health system’s environment towards increasing the availability of free CEmOC by 10 times, from 0.32 to 3.65 per 500,000 population, but actual performance of notionally free CEmOC functions was only 2 per 500,000 population (Study I). Providers’ behaviour was reflected in the en masse participation or non-participation of providers in ten out of seventeen urban centres. The facilities that participated in the CY program had a significantly higher likelihood, independently, of being general facilities (PR 1.9, 95% CI 1.3–2.9), or conducting lower proportion of caesarean 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) (Study II). The CY program criteria influenced the population environment by enabling mothers to become eligible for CY benefit. These mothers were significantly more likely to be vulnerable - rural, multiparous, scheduled tribe, and less educated. Users’ behaviours showed that eligible mothers had significantly less prevalence of ante-natal visits, as well as shorter hospital stay after birth. The evaluated health status showed low caesarean rates among eligible vulnerable mothers (6%) and high caesarean (40%) and episiotomy (63%) rates among ineligible mothers (Study III). The perceived health status of the population was reflected in the fact that most mothers and families were very happy with the care they had received and none reported any preferential treatment of paying mothers over CY beneficiary mothers. However, a few mothers who experienced instances of poor quality of care or rude behaviour, reflected back on their experience and still reported it as a “good (sari) delivery”. The financial status of the population showed only 15% of eligible mothers were CY beneficiaries, and only 4 % of them received a completely cashless birth. The median degree of subsidy for women in CY who birthed vaginally was 85% and by caesarean section was 71 % compared to out-of-pocket expenditure sustained by non-beneficiaries in the private health sector. Mothers without formal education were significantly less likely (OR 0.4, 95% CI 0.3–0.7) to receive CY benefit. Only having CY program knowledge (OR 4.7, 95% CI 2.6–8.4) and showing proof of poverty (OR 2.6, 95% CI 1.3–5.4) increased the likelihood of receiving the benefit. (Study III). Discussion: Although the CY program increased the availability of free emergency obstetric care to 10 times more than the UN standards, their actual performance increased by only twice. This indicated poor management mechanisms within the state authorities. Although the CY program criteria recognised vulnerable mothers adequately accurately, their behaviours, health status and financial status showed mixed outcomes. Vulnerable populations behaviours to ensure improved maternal health and access to the CY program were varied, despite the program being in effect for seven years before our study. The health status of the vulnerable population, in terms of low caesarean rates, were below established norms in the literature, and among the non-vulnerable populations was much higher. The financial status of the eligible population was not much eased by the program since 85% of them did not receive the CY benefit. However, the highest median expenditure in our study (INR 7224) was well below the mean cost in private facilities across the nation (INR 15000) thus indicating a possible partial protection from out-of-pocket cost due to the CY program activity in the region. Conclusion: The recently established Prime Minister’s People’s Health Program in India depends on PPPs for secondary and tertiary care all over the country. As revealed in this thesis, improved, adequate and effective health systems through PPPs requires better contract designing and managing capacities within in the state system. The health status and users’ behaviours could be assisted by the ongoing digitization of health systems such that (a) maternal health data is collected by both public and private sectors in enough detail to be able to categorise it by Robson’s criteria and thus monitor BEmOC and CEmOC performance, ante-natal visits, length of stay in hospital and other relevant variables (b) user feed-back is collected in a manner that captures actual experiences of women during birth, and that of their families during their interactions with the health system.