Gujarat govt's programme to reduce maternal deaths, infant mortality failed to deliver, says WHO study

By Our Representative

A high-profile study, carried out by half-a-dozen scholars associated with the Duke University, Rand Corporation, World Bank, Stanford University and Stanford Medical School (all from US), and Sambodhi Research and Communications Pvt Ltd (New Delhi), has come to the drastic conclusion that the Chiranjeevi yojna of the Gujarat government, launched to reduce infant and maternal deaths in rural areas, has been largely unsuccessful. Published in the Bulletin of the World Health Organization (WHO), it suggests that the samples collected by the scholars have put a question mark on the project’s aim of encouraging mothers to deliver in private hospitals, with the government subsidizing the costs.

“The project”, the study says, “aimed to provide free childbirth care at participating private-sector hospitals to women who are below the poverty line. The hospitals are paid 1600 Indian rupees per delivery, approximately $30 to $40. The hospitals may offer additional services to patients and charge separate fees for them. By 2012, approximately 800 private-sector hospitals were participating and the program had helped pay for more than 800,000 deliveries”.

Titled “Effect of Chiranjeevi Yojana on institutional deliveries and neonatal and maternal outcomes in Gujarat, India: a difference-in-differences analysis”, its authors, Manoj Mohanan, Sebastian Bauhoff, Gerard La Forgia, Kimberly Singer Babiarz, Kultar Singh and Grant Miller, say, there was an “increase in institutional delivery rates over time across Gujarat”, but this was “unrelated to the Chiranjeevi yojana.”

The study says, “The data collected through our study indicated that implementation of the programme was not associated with a statistically significant change in the probability of institutional delivery (2.42 percentage points).” In fact, it underlines, “The programme was also not associated with changes in the incidence of birth-related maternal complications, the use of antenatal and postnatal services or the use of neonatal intensive care.”

It underlines, “Our survey data suggests that 54% of the mothers in our sample suffered complications, including premature delivery, prolonged and obstructed labour, excessive bleeding, breech presentation, convulsions, hypertension, fever, incontinence or other birth-related problems after the programme had been implemented – and that the probability of these complications did not significantly change under the Chiranjeevi yojana.”

“Even if the programme has not increased institutional delivery rates, we would expect to see lower mean household expenditures on deliveries, given that the programme had paid providers over US$ 32 million as of 2012. However, analysis of our survey data indicated that implementation of the programme had no significant relationship either with the probability that households reported any delivery-related spending, or with mean hospital spending for delivery conditional on any spending”, it says.

The study underlines, “Our findings indicate that the Chiranjeevi yojana was not associated with changes in the probability of institutional delivery (including delivery at private institutions), maternal morbidity or delivery-related household expenditure. These findings differ from those reported by previous evaluations suggesting substantial benefits of the Chiranjeevi yojana, including a 27 per cent increase in institutional deliveries, a 90 per cent reduction in maternal deaths and a 60 per cent reduction in neonatal deaths.”

It insists, “These earlier studies did not address self-selection of women into institutional delivery, reporting inaccuracies by hospitals, or any increases in institutional deliveries over time that were unrelated to the programme. The programme was rolled out in a period when the economy of Gujarat was growing by over 10 per cent per year.”

Claiming that the results of the study are “robust to the inclusion of a wide variety of control variables”, and that “the staggered introduction of the Chiranjeevi yojana does not appear correlated with pre-existing trend differences in institutional delivery rates”, it notes, “There are several possible explanations for observing no increase in the probability of institutional delivery associated with the Chiranjeevi yojana. One is that the quality of services provided by private maternity hospitals is poor or, at least, is perceived to be poor by the local population. As a result, demand for institutional delivery may be low even if such delivery is provided free of charge.”

The study also points out that – despite the support of the programme – “institutional deliveries in Gujarat remain associated with large transportation costs, informal payments or other expenses that make programme benefits small relative to the full cost of institutional delivery.” The study emphasizes, “The finding of little or no association between the Chiranjeevi yojana and the out-of-pocket costs of deliveries is more puzzling. Even if the programme failed to make institutional delivery more attractive for any women, it should have reduced the household expenses for the many poor women who still chose institutional delivery.”

In fact, the poor women were found to be “asked to pay fees for deliveries in health facilities that were participating in the programme… It seems possible that some providers are providing extra, chargeable services – or simply increasing side charges. If charges are being made for extra services, those services do not appear to have any discernible health benefits.”

Interestingly, the study comes against the backdrop of the fact that the Chiranjeevi yojana received Wall Street Journal Asian Innovation Award in 2006 and has been hailed by some as a model for wide adoption throughout India. It was launched to help address the shortage of obstetricians at public hospitals accessible to low-income women in rural areas.