title: Statewide program to promote institutional delivery in Gujarat, India: who participates and the degree of financial subsidy provided by the Chiranjeevi Yojana program.
abstract: BACKGROUND
  The Chiranjeevi Yojana (CY) is a large public-private partnership program in Gujarat, India, under which the state pays private sector obstetricians to provide childbirth services to poor and tribal women. The CY was initiated statewide in 2007 because of the limited ability of the public health sector to provide emergency obstetric care and high out-of-pocket expenditures in the private sector (where most qualified obstetricians work), creating financial access barriers for poor women. Despite a million beneficiaries, there have been few reports studying CY, particularly the proportion of vulnerable women being covered, the expenditures they incur in connection with childbirth, and the level of subsidy provided to beneficiaries by the program.
  
  
  METHODS
  Cross-sectional facility based the survey of participants in three districts of Gujarat in 2012-2013. Women were interviewed to elicit sociodemographic characteristics, out-of-pocket expenditures, and CY program details. Descriptive statistics, chi square, and a multivariable logistic regression were performed.
  
  
  RESULTS
  Of the 901 women surveyed in 129 facilities, 150 (16 %) were CY beneficiaries; 336 and 415 delivered in government and private facilities, respectively. Only 36 (24 %) of the 150 CY beneficiaries received a completely cashless delivery. Median out-of-pocket for vaginal/cesarean delivery among CY beneficiaries was $7/$71. The median degree of subsidy for women in CY who delivered vaginally/cesarean was 85/71 % compared to out-of-pocket expenditure of $44/$208 for vaginal/cesarean delivery paid by non-program beneficiaries in the private health sector.
  
  
  CONCLUSIONS
  CY beneficiaries experienced a substantially subsidized childbirth compared to women who delivered in non-accredited private facilities. However, despite the government's efforts at increasing access to delivery services for poor women in the private sector, uptake was low and very few women experienced a cashless delivery. While the long-term focus remains on strengthening the public sector's ability to provide emergency obstetric care, the CY program is a potential means by which the state can ensure its poor mothers have access to necessary care if uptake is increased.
authors.affiliation: Public Health Sciences, Karolinska Institutet, Widerströmska, Tomtebodavägen 18A, plan 4, SE-171 77, Stockholm, Sweden. kristi.sidney@ki.se.
authors.forename: Kristi
authors.initials: K
authors.lastname: Sidney
authors.affiliation: Indian Institute of Public Health Gandhinagar, Public Health Foundation of India, Ahmedabad, Gujarat, India. veenaiyer@iiphg.org.
authors.forename: Veena
authors.initials: V
authors.lastname: Iyer
authors.affiliation: Indian Institute of Public Health Gandhinagar, Public Health Foundation of India, Ahmedabad, Gujarat, India. kvora@iiphg.org.
authors.forename: Kranti
authors.initials: K
authors.lastname: Vora
authors.affiliation: Indian Institute of Public Health Gandhinagar, Public Health Foundation of India, Ahmedabad, Gujarat, India. dmavalankar@iiphg.org.
authors.forename: Dileep
authors.initials: D
authors.lastname: Mavalankar
authors.affiliation: Public Health Sciences, Karolinska Institutet, Widerströmska, Tomtebodavägen 18A, plan 4, SE-171 77, Stockholm, Sweden. ayesha.de.costa@ki.se.|Indian Institute of Public Health Gandhinagar, Public Health Foundation of India, Ahmedabad, Gujarat, India. ayesha.de.costa@ki.se.
authors.forename: Ayesha
authors.initials: A
authors.lastname: De Costa
mesh_terms: D000328:Adult; D044466:Asian People; D002585:Cesarean Section / Q000009:adverse effects / Q000193:education; D015331:Cohort Studies; D003430:Cross-Sectional Studies; D036861:Delivery, Obstetric / Q000009:adverse effects* / Q000191:economics; D005260:Female; D006078:Government Programs; D019538:Health Care Surveys; D005102:Health Expenditures; D006269:Health Facilities, Proprietary / Q000191:economics; D006297:Health Services Accessibility / Q000191:economics; D006700:Home Childbirth / Q000009:adverse effects* / Q000191:economics; D006801:Humans; D007194:India; D008483:Medical Assistance; D010342:Patient Acceptance of Health Care / Q000208:ethnology; D011203:Poverty / Q000208:ethnology; D011247:Pregnancy; D013221:State Health Plans; D035862:Vulnerable Populations / Q000208:ethnology
references.citation: Lancet. 2006 Oct 7;368(9543):1284-99
references.pmid: 17027735
references.citation: Lancet. 2004 Jan 3;363(9402):23-7
references.pmid: 14723990
references.citation: Bull World Health Organ. 2009 Dec;87(12):960-4
references.pmid: 20454488
references.citation: J Health Popul Nutr. 2009 Apr;27(2):184-201
references.pmid: 19489415
references.citation: Health Policy Plan. 2009 Nov;24(6):445-56
references.pmid: 19687135
references.citation: Bull World Health Organ. 2014 Mar 1;92(3):187-94
references.pmid: 24700978
references.citation: BMC Public Health. 2011 Mar 08;11:150
references.pmid: 21385404
references.citation: PLoS One. 2014 May 01;9(5):e95704
references.pmid: 24787692
references.citation: Bull World Health Organ. 2015 Jun 1;93(6):436
references.pmid: 26240467
references.citation: Bull World Health Organ. 2009 Mar;87(3):238-44, 244A-244D
references.pmid: 19377721
references.citation: Stud Fam Plann. 1992 Jan-Feb;23(1):23-33
references.pmid: 1557792
references.citation: J Health Popul Nutr. 2013 Dec;31(4 Suppl 2):106-28
references.pmid: 24992806
references.citation: Health Policy. 2009 Aug;91(3):297-305
references.pmid: 19217184
references.citation: J Health Popul Nutr. 2009 Apr;27(2):249-58
references.pmid: 19489419
references.citation: J Health Popul Nutr. 2013 Dec;31(4 Suppl 2):8-22
references.pmid: 24992800
references.citation: Int J Gynaecol Obstet. 2006 Jun;93(3):300-7
references.pmid: 16682039
references.citation: Lancet. 2006 Sep 30;368(9542):1189-200
references.pmid: 17011946
references.citation: BMC Pregnancy Childbirth. 2014 Nov 05;14:352
references.pmid: 25374099
references.citation: Glob Health Action. 2013 Mar 06;6:1-9
references.pmid: 23469890
references.citation: Int J Gynaecol Obstet. 2009 Dec;107(3):271-6
references.pmid: 19846090