Topic: Reducing the cost of Institutional Delivery in Gujarat, India
Question: Is there a point where you should step away from evidence-based strategies and provide unique interventions? Why or why not?
Across India, maternal and infant mortality rates have varied significantly by socioeconomic status and by state. In Gujarat, a state in northwest India, the rate of loss of mothers and babies during childbirth was unacceptably high, in part because only 55 percent of births took place in a medical facility as of 2005. This was in sharp contrast to Kerala, in southwest India, where coverage of facility births had reached 99 percent.
In 2005, Gujarat’s government designed and introduced a new scheme to improve birth outcomes, called Chiranjeevi Yojana (CY) or the “Eternal Life” scheme. It aimed to tackle the state’s low rate of institutional delivery by removing one of the most important barriers for women with the highest risk of maternal mortality: the cost of the service. This was done primarily by incentivizing the private sector to serve below-the-poverty-line (BPL) and tribal women.
The case study describes the testing of a maternal and child health intervention in Gujarat, India, where the rate of mothers giving birth to children at health care facilities (also called institutional delivery) was only 55 percent in 2005. The program, called Chiranjeevi Yojana (CY), sought to incentivize private health care facilities to cater to low-income families. Despite strong political and private sector support, upon evaluation, the program was not found to increase the rate of institutional delivery or decrease maternal and child mortality to a worthwhile extent. This case is an example of a program that was tested and deemed not worth continuing.
The CY experience serves as a cautionary tale for programs that seek to improve maternal and infant health by increasing institutional delivery. Despite these impressive numbers, however, independent evaluations of CY found that the scheme did not significantly increase the likelihood of institutional delivery and did not reduce maternal or infant deaths. This is partly explained by changes in India’s overall health landscape: rates of institutional delivery were already rapidly increasing, and indicators of maternal and infant health were on the rise. These underlying trends reduced the relative impact of CY’s contribution. In addition, some of the features of CY’s design, such as a disincentive for unnecessary caesarian sections, turned out to be less valuable than its planners expected.
Improving maternal and infant health is a global health priority for which funding is at an all-time high. Gujarat’s experience reveals the importance of carefully considering many different components of program design, including financing, monitoring, entry criteria, and quality assurance, alongside the social determinants of health.