Gujarat’s Chiranjeevi Yojana (CY) Programand the Promotion of Institutional Deliveries

in India

Grant MillerStanford University and NBER

(with Sebastian Bauhoff, Katherine Donato, Manoj Mohanan, Jerry La Forgia, Kim Singer Babiarz, and Kultar Singh)

Rationale for Presentation

An example of a program in India that could have improved quality of maternity care – but (we think) didn’t Doesn’t mean that the model can’t work But why it didn’t work is an important topic of discussion Would better integration of quality of care into contracting criteria

have improved performance?

Other candidates passed over (for discussion?) Performance incentives in China Micronutrient fortification of PDS rice in Tamil Nadu

The (many) perils, or limitations, of “health behavior change” GVK EMRI 108 Service

Preliminary results suggest an important success How/why? Open questions… [2]

Background

Policy efforts to reduce maternal and neonatal mortality emphasize promoting institutional deliveries Rationale: many complications can be better clinically

managed in hospitals

Broader question of whether or not this is the right policy target Effectiveness, allocative efficiency, etc

At the time of CY implementation, India’s institutional delivery rate was about 40% 13% among women in the lowest wealth quintile Poor maternal and neonatal health indicators Gujarat does better than average in India [3]

The Chiranjeevi Yojana (CY) Program

Motivation for Chiranjeevi (in the mind of Gujarat) Public sector providers

Located far from poor rural households, provide a minority share of services to them

Private sector providers Located in poor rural areas, but services may be too expensive

for the very poor

What is Chiranjeevi? A public-private partnership introduced in Gujarat in 2005 to

promote the use of private maternity hospitals among poor women Gujarat contracted with private maternity hospitals to deliver free

delivery services (for uncomplicated cases) to BPL women Government reimbursement of hospitals on a per-case basis

Contracting not linked to quality other than through selective empanelment

Many details I’m skipping…

The CY Program (Continued)

However, the Government of Gujarat did not know a variety of important things for the CY to succeed

How price-elastic is demand for institutional deliveries?

Are there important non-price reasons why demand for institutional deliveries might be low?

Poor quality, for example

What unintended behavioral responses on the supply-side might there be to an intervention aiming to lower private sector maternity hospital charges to patients?

[6]

Data Collection and Intended Study Design

Our project: A study of the impact of (and behavioral responses to) the CY program

Conduct a DHS-style survey in 2010 COHESIVE Chiranjeevi Yojana Survey Collect detailed birth histories for deliveries between

2005-2010

Given the discontinuous “Below Poverty Line” (BPL) eligibility threshold, we originally intended to use a “fuzzy” regression discontinuity (RD) design to evaluate the CY program

Sampled from the rural population in the vicinity of the eligibility threshold using our calculated BPL scores

[6]

Regression Discontinuity (RD) Design Example

[21]

What should an eligibility discontinuity look like?

…In the Presence of Eligibility Manipulation

[21]Source: Camacho and Conover

(2008)

BPL “Discontinuity” in Gujarat

[21]

What does our eligibility (dis)continuity look like?

“Plan B:” Difference-in-Difference Approach

Instead, use a difference-in-difference approach given staggered program implementation across Gujarat’s districts Confirm findings using District Level Household and

Facility Survey, Round 3 (DLHS 3) data

[6]

Results: Institutional Deliveries, CY Survey

Share of institutional deliveries in early and late implementation districts: COHESIVE Chiranjeevi Yojana Survey “Parallel trends” assumption tested using DLHS 2, appears

reasonable

[27]

Results: Institutional Deliveries, DLHS 3

Share of institutional deliveries in early and late implementation districts: District Level Household and Facility Survey 3 (DLHS 3)

[27]

Results: Primary Outcomes

Institutional and Attended Deliveries

[27]

COHESIVE Survey DLHS Data

Point estimates and 95% CI from OLS regression with full set of covariates

Results: Primary Outcomes (Continued)

Complications at birth and prenatal/antenatal care

[27]

COHESIVE Survey DLHS Data

Point estimates and 95% CI from OLS regression with full set of covariates

Puzzle: No Spending Reduction among Beneficiaries

Even if the CY program had no impact on institutional delivery rates or birth outcomes, it should have reduced delivery costs among BPL women delivering in private maternity hospitals (and who would have done so anyway)

We see no evidence of any reductions in spending Probability of any spending Spending conditional on any spending

No benefits even among BPL households For all results, triple difference analysis reveals no

differential program effect among BPL households (about half of households in Gujarat are classified BPL) [27]

Results: Probability of Any Spending

• Any spending

[27]

COHESIVE Survey DLHS Data

Point estimates and 95% CI from OLS regression with full set of covariates

Results: Spending (Conditional on Any Spending)

• Spending conditional on any spending

[27]

COHESIVE Survey DLHS Data

Point estimates and 95% CI from OLS regression with full set of covariates

Discussion: What Happened?

Potential explanations

No increase in institutional deliveries Quality of services is low, so demand is low, even when

services are free (Relationship between price elasticity and quality unclear) …And survey respondents remember delivery costs poorly

No increase in institutional deliveries – and no reduction in HH spending

Provider responses to CY Version 1: Providers increased service intensity (and are allowed

to charge for “extras” on top of standard delivery care) Version 2: Providers are expropriating financial benefits rather

than passing them on to intended beneficiaries (ie, still charging for deliveries – and also collecting government reimbursement)[34]

Discussion (Continued)

Strategies to improve quality of care should presumably differ in stronger vs. weaker institutional environments

Would more explicit contracting criteria (or empanelment renewal) related to quality of care have mattered?

[34]

[37]

Thank You

[37]

Extra Slides

Empirical Strategy

Parallel trends assumption for institutional delivery rates (DLHS2)

[38]

Eligibility: “Below Poverty Line” (BPL) status Poverty-targeting index comprised of 13 indicators:

Land ownershipType of houseAmount of clothing per personFood security (less than 1 meal per day)Sanitation (latrine type)Ownership of consumer durablesLiteracy of the household headLabor force participation of household membersOccupation of household headStatus of children (in school or working)IndebtednessMigration household membersReceipt of other public assistance

Local authorities can independently judge a household to be BPL

BPL status confers eligibility for many public programs (hence location and timing of CY program is important)

[10]

Chiranjeevi Yojana Overview

Chiranjeevi Yojana Overview (Continued)

Benefits Free delivery at empanelled private facility; no condition

exclusions Some travel cost reimbursement Lost wage support for accompanying person

Reimbursement to empanelled providers Empanelled doctors receive Rs. 160,000 (~ USD 3,000) per

100 deliveries (reimbursement rate allows for added cost of up to 15% cesarean deliveries)

Providers must verify eligibility and file for reimbursements monthly

Little incentive to do anything beyond basics (fixed reimbursement) Purposeful decision not to pay much more for Cesarean

deliveries, etc.[11]

Data

COHESIVE Chiranjeevi Yojana Survey

Random sample of 600 villages (weighted by population) from all districts of Gujarat

In each village, enumerators performed a census of households Identify households with births since 2005 Collect data on 13 BPL components (2002 and present)

Calculate BPL score for each household

Among households +/- 5 points of the official BPL threshold having births since 2005, population-weighted random sample of 6,000 households

Response rate of 94.4% => 5,663 households Collected DHS-style fertility histories

[14]

Data (Continued)

[14]

District Level Household and Facility Survey III : 2007-2008

Sample of households drawn to be representative of each district

Restricting the sample to households reporting births since January 2005, 6,927 women from 6,554 households

Similar retrospective fertility histories collected for each birth since 2005

No data on BPL components Key difference with COHESIVE survey – sampling across the

entire range of BPL scores, not just +/- 5 points of the eligibility threshold

Data (Continued)

[14]

Key Primary Outcomes Institutional delivery Use of maternal and neonatal services provided by trained

providers Maternal/perinatal health complications Costs of delivery (by type of cost)

Other variables Maternal characteristics (age at marriage, age at delivery,

education) Household characteristics

Wealth (BPL status/score, wealth index, monthly income) Caste Religion

Empirical Strategy

Difference-in-difference strategy Look for changes in primary outcomes that vary in the

same spatial and temporal pattern as the staggered introduction of the CY program – for births b, districts d, and years t:

outcomebdt=βCYdt + Σλmatcharbdt + δd + δt + εbdt

(Maternal characteristics: age at delivery, age at marriage, wealth index, religion, and caste)

Use a linear probability model with standard errors clustered at the district level Same basic results with non-linear maximum likelihood

models[21]