title: Evaluation of publicly financed and privately delivered model of emergency referral services for maternal and child health care in India.
abstract: BACKGROUND
  Emergency referral services (ERS) are being strengthened in India to improve access for institutional delivery. We evaluated a publicly financed and privately delivered model of ERS in Punjab state, India, to assess its extent and pattern of utilization, impact on institutional delivery, quality and unit cost.
  
  
  METHODS
  Data for almost 0.4 million calls received from April 2012 to March 2013 was analysed to assess the extent and pattern of utilization. Segmented linear regression was used to analyse month-wise data on number of institutional deliveries in public sector health facilities from 2008 to 2013. We inspected ambulances in 2 districts against the Basic Life Support (BLS) standards. Timeliness of ERS was assessed for determining quality. Finally, we computed economic cost of implementing ERS from a health system perspective.
  
  
  RESULTS
  On an average, an ambulance transported 3-4 patients per day. Poor and those farther away from the health facility had a higher likelihood of using the ambulance. Although the ERS had an abrupt positive effect on increasing the institutional deliveries in the unadjusted model, there was no effect on institutional delivery after adjustment for autocorrelation. Cost of operating the ambulance service was INR 1361 (USD 22.7) per patient transported or INR 21 (USD 0.35) per km travelled.
  
  
  CONCLUSIONS
  Emergency referral services in Punjab did not result in a significant change in public sector institutional deliveries. This could be due to high baseline coverage of institutional delivery and low barriers to physical access. Choice of interventions for reduction in Maternal Mortality Ratio (MMR) should be context-specific to have high value for resources spent. The ERS in Punjab needs improvement in terms of quality and reduction of cost to health system.
authors.affiliation: School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
authors.forename: Shankar
authors.initials: S
authors.lastname: Prinja
authors.affiliation: School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
authors.forename: Pankaj
authors.initials: P
authors.lastname: Bahuguna
authors.affiliation: School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
authors.forename: P V M
authors.initials: PV
authors.lastname: Lakshmi
authors.affiliation: National Health Systems Resource Centre, Ministry of Health and Family Welfare, New Delhi, India.
authors.forename: Tushar
authors.initials: T
authors.lastname: Mokashi
authors.affiliation: School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
authors.forename: Arun Kumar
authors.initials: AK
authors.lastname: Aggarwal
authors.affiliation: School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
authors.forename: Manmeet
authors.initials: M
authors.lastname: Kaur
authors.affiliation: National Health Systems Resource Centre, Ministry of Health and Family Welfare, New Delhi, India.
authors.forename: K Rahul
authors.initials: KR
authors.lastname: Reddy
authors.affiliation: School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
authors.forename: Rajesh
authors.initials: R
authors.lastname: Kumar
mesh_terms: D000552:Ambulances / Q000706:statistics & numerical data; D003365:Costs and Cost Analysis; D036861:Delivery, Obstetric / Q000191:economics* / Q000706:statistics & numerical data; D004632:Emergency Medical Services / Q000191:economics*; D005260:Female; D006297:Health Services Accessibility / Q000191:economics; D006801:Humans; D007194:India; D008427:Maternal Health Services / Q000191:economics; D008428:Maternal Mortality; D011247:Pregnancy; D017149:Private Sector; D017150:Public Sector; D011787:Quality of Health Care; D012017:Referral and Consultation / Q000191:economics / Q000706:statistics & numerical data*