Improving maternal and child health programmes in India
Context
In response to this crisis, the national and state governments have introduced a range of programmes, many of which include incentives to encourage pregnant women to deliver children at accredited health facilities rather than at home. Two such initiatives by the Indian state governments of Gujarat and Karnataka enabled pregnant women from poor households to access free maternity care at public or private hospitals.
The Gujarat government’s Chiranjeevi Yojana (the long life scheme), implemented in 800 hospitals in all of the state’s districts since 2005, enabled free hospital access for delivery to tribal women and those from households below the poverty line. The hospitals were reimbursed at a fixed rate for each delivery under the scheme. Although previous studies of the scheme indicated that it dramatically increased institutional deliveries and reduced maternal and infant deaths, they were subject to critical limitations and officials noted that nearly half of the eligible households were not accessing free deliveries under the scheme. Even so, the scheme grew in political influence and multiple other state governments were keen to start similar programmes.
The Gujarat government was keen to understand how best to structure incentive contracts with private health providers. Policy dialogue between the researchers of the 3ie-supported study and the state’s officials laid the foundation for an evaluation in 2010.
The Karnataka government, too, planned to launch an initiative similar to the Chiranjeevi Yojana in design as part of its existing Thayi Bhagya Yojana (or mothers’ fortune scheme). The World Bank suggested the evaluation include this initiative, which had been piloted in seven districts of Karnataka since 2009, because the state government wanted to decide whether and how to expand it.
Researchers from Duke University, the National Bureau of Economic Research, the World Bank and Sambodhi Research evaluated the effectiveness of the two government initiatives, provider behaviour and maternal and child health outcomes. They also studied different performance incentive structures that could be used to motivate private health care providers.
The evaluation project began with significant buy-in from both state governments and other influential stakeholders. A senior Gujarat government official served as a policy advisor on the study team. In Karnataka, the government funded the baseline survey and the World Bank funded implementation of the performance incentives component.
Evidence
The researchers found that neither Chiranjeevi Yojana in Gujarat nor the new Thayi Bhagya Yojana in Karnataka had a significant effect on institutional delivery rates or maternal and child health outcomes.
Previous evaluations in Gujarat that found large programme impacts did not account for self-selection of women into hospitals for delivery or for secular increases in institutional delivery over time, leading to upward biases in estimates.
The evaluation found that input incentive contracts, where payment depended on whether providers met quality of care standards, reduced the rates of post-partum haemorrhage – a leading cause of maternal mortality in India – by 28 per cent. Output-based or performance-based incentives had no such effects. The findings suggest that providers responded less to performance contracts, which carried a greater risk of efforts not being rewarded.
Evidence impacts
Type of impact: Inform discussions of policies and programmes
When subsequent phases of the evaluated programme or policy draw from the findings of the evaluation or review, and/or the study team participates in informing the design of a subsequent phase.
This is one of 3ie’s seven types of evidence use. Impact types are based on what we find in the monitoring data for an evaluation or review. Due to the nature of evidence-informed decision-making and action, 3ie looks for verifiable contributions that our evidence makes, not attribution.
Read our complete evidence impact typology and verification approach here.
Close windowThe Chiranjeevi Yojana evaluation findings received significant media attention as their release coincided with elections in Gujarat. Following this, the research team’s work had more exposure and they were able to use evaluation findings to convince the Karnataka government not to scale the new Thayi Bhagya initiative.
Type of impact: Inform global guidelines and policy discussions
When findings from an evaluation or review can be traced to discussions or actions. Examples include governments or multilateral or bilateral donors’ mentioning the findings to inform policy or programming. To date, we have only one case of an individual impact evaluation informing global health guidelines. WHO guidelines require that the guidance is based on randomised evaluation evidence.
This is one of 3ie’s seven types of evidence use. Impact types are based on what we find in the monitoring data for an evaluation or review. Due to the nature of evidence-informed decision-making and action, 3ie looks for verifiable contributions that our evidence makes, not attribution.
Read our complete evidence impact typology and verification approach here.
Close windowA report commissioned by the USAID’s Bureau for Global Health cited findings from the study to highlight the potential cost of not embedding impact evaluations in large-scale health programmes and scaling up ineffective programmes in the absence of rigorous evidence. The 2014 report, Investing in global health systems: sustaining gains, transforming lives, was produced by the Institute of Medicine. It sought to inform the US Congress and other government authorities on the value of investments in health systems in low- and middle-income countries.
Type of impact: Inform global guidelines and policy discussions
When findings from an evaluation or review can be traced to discussions or actions. Examples include governments or multilateral or bilateral donors’ mentioning the findings to inform policy or programming. To date, we have only one case of an individual impact evaluation informing global health guidelines. WHO guidelines require that the guidance is based on randomised evaluation evidence.
This is one of 3ie’s seven types of evidence use. Impact types are based on what we find in the monitoring data for an evaluation or review. Due to the nature of evidence-informed decision-making and action, 3ie looks for verifiable contributions that our evidence makes, not attribution.
Read our complete evidence impact typology and verification approach here.
Close windowThe 2014 volume of the highly ranked health journal, Bulletin of the World Health Organization, carried a summary of the evaluation findings that was cited and featured in the third edition of the Center for Global Development’s book, Millions saved, in 2016. The book mentions the programme in the foreword by global health philanthropist Bill Gates.
Millions Saved also has a website that features case studies of large-scale interventions to improve health in low- and middle-income countries. It cites the Chiranjeevi Yojana evaluation findings to emphasise the need for ‘carefully considering many different components of program design, including financing, monitoring, entry criteria, and quality assurance, alongside the social determinants of health’.
Suggested citation
International Initiative for Impact Evaluation (3ie), 2020. Improving maternal and child health programmes in India [online summary], Evidence Impact Summaries. New Delhi: 3ie.
Evidence impact summaries aim to demonstrate and encourage the use of evidence to inform programming and policymaking. These reflect the information available to 3ie at the time of posting. Since several factors influence policymaking, the summaries highlight contributions of evidence rather than endorsing a policy or decision or claiming that it can be attributed solely to evidence. If you have any suggestions or updates to improve this summary, please write to influence@3ieimpact.org
Last updated on 11th November 2020