Utilization of the state led public private partnership program "Chiranjeevi Yojana" to promote facility births in Gujarat, India: a cross sectional community based study

Key recommendations to strengthen public-private partnership for adolescent health in resource constrained settings: Formative qualitative inquiry in Mongolia, Myanmar and the Philippines

Background

Public health services can be inaccessible for adolescents. The private sector provides many services, but often in parallel to the public sector. This study aimed to understand current private sector engagement in adolescent health service delivery and develop recommendations to strengthen partnerships.

Methods

The study focussed on Mongolia, Myanmar and the Philippines. An initial participatory workshop in each country was followed by semi-structured key-informant interviews (32 in total) with public and private sector actors and adolescents to explore: perceptions of the public and private sectors, strengths and challenges, existing models of partnership, and insights for successful public-private partnership (PPP). Interview transcripts were analysed thematically, with findings and recommendations verified through a second workshop in Mongolia and the Philippines.

Findings

The private sector already plays a significant role in adolescent health care, and stakeholders reported a genuine willingness for partnership. Strengthened PPP was identified as necessary to improve service accessibility and quality for adolescents, unburden the public sector and introduce new technologies, with advantages for the private sector including improved access to training and resources, and an enhanced public image. Recommendations for strengthened PPP included the need to establish the foundations for partnership, clearly define roles and co-ordinate stakeholders, ensure capacity and sustainability, and monitor and evaluate efforts.

Interpretation

This is the first comprehensive study of public-private partnership for adolescent health in the Asia Pacific region. It identifies stakeholders are willing for stronger partnerships and the benefits this partnership will bring. We define eight key recommendations to enable this partnership across sectors.

Sexual and reproductive health services in universal health coverage: a review of recent evidence from low- and middle-income countries

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.

Caesarean sections in the in the context of the Chiranjeevi Yojana public private partnership program to promote institutional birth in Gujarat, India; does the embedded disincentive for caesarean section work?

Background

The government of Gujarat, India runs a large public private partnership program to widen access to emergency obstetric care (EmOC). The program include a disincentive for Cesareans section (CS) which are capped at seven per 100 women. In this paper, we study if the disincentive works by comparing CS rates among similar groups of women who deliver within and outside the program.

Methods

Community-based panel study in three districts of Gujarat, India. Sample size: 2123 women. Data was analyzed using multivariable logistic regression.

Results

Overall seven point seven % (164/2123) of the all women in the study had a CS. After adjusting for confounding factors women within the program had 62% (AOR 0.38, 95% CI 0.22–0.44) lower odds of having a CS than to non-beneficiaries. In a separate model of predictors of CS among women giving birth only in program accredited hospitals, we found that CY program beneficiaries had lower odds of having a CS birth than non-beneficiary women (paying clients) (AOR 0.40, 95% CI 0.24–0.67).

Conclusions

The Gujarat government is trying to ensure access to EmOC (including CS) for its vulnerable population through CY. The embedded disincentive to prevent unnecessary cesareans by private obstetricians is a novel one, and appears to work, though one could argue it works ‘over-efficiently’ by depriving some women who need CS from receiving one under the program. The state needs to revisit and review what is happening in the program periodically, and have oversight over whether women who need CS under the program actually receive the care that they need.

Electronic supplementary material

The online version of this article (10.1186/s12939-019-0922-5) contains supplementary material, which is available to authorized users.

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

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.