title: Utilization of the state led public private partnership program "Chiranjeevi Yojana" to promote facility births in Gujarat, India: a cross sectional community based study.
abstract: "Chiranjeevi Yojana (CY)", a state-led large-scale demand-side financing scheme (DSF) under public-private partnership to increase institutional delivery, has been implemented across Gujarat state, India since 2005. The scheme aims to provide free institutional childbirth services in accredited private health facilities to women from socially disadvantaged groups (eligible women). These services are paid for by the state to the private facility with the intention of service being free to the user. This community-based study estimates CY uptake among eligible women and explores factors associated with non-utilization of the CY program.
  
  
  
  This was a community-based cross sectional survey of eligible women who gave birth between January and July 2013 in 142 selected villages of three districts in Gujarat. A structured questionnaire was administered by trained research assistant to collect information on socio-demographic details, pregnancy details, details of childbirth and out-of-pocket (OOP) expenses incurred. A multivariable inferential analysis was done to explore the factors associated with non-utilization of the CY program.
  
  
  
  Out of 2,143 eligible women, 559 (26 %) gave birth under the CY program. A further 436(20 %) delivered at free public facilities, 713(33 %) at private facilities (OOP payment) and 435(20 %) at home. Eligible women who belonged to either scheduled tribe or poor [aOR = 3.1, 95 % CI:2.4 - 3.8] or having no formal education [aOR = 1.6, 95 % CI:1.1, 2.2] and who delivered by C-section [aOR = 2.1,95 % CI: 1.2, 3.8] had higher odds of not utilizing CY program. Of births at CY accredited facilities (n = 924), non-utilization was 40 % (n = 365) mostly because of lack of required official documentation that proved eligibility (72 % of eligible non-users). Women who utilized the CY program overall paid more than women who delivered in the free public facilities.
  
  
  
  Uptake of the CY among eligible women was low after almost a decade of implementation. Community level awareness programs are needed to increase participation among eligible women. OOP expense was incurred among who utilized CY program; this may be a factor associated with non-utilization in next pregnancy which needs to be studied. There is also a need to ensure financial protection of women who have C-section.
authors.affiliation: Indian Institute of Public Health-Gandhinagar, Sardar Patel Institute Campus, Drive-in-Road, Ahmedabad, Gujarat, 380054, India. dryasobant@gmail.com.
authors.forename: Sandul
authors.identifier: 0000-0003-1770-8745
authors.initials: S
authors.lastname: Yasobant
authors.affiliation: Indian Institute of Public Health-Gandhinagar, Sardar Patel Institute Campus, Drive-in-Road, Ahmedabad, Gujarat, 380054, India.
authors.forename: Kranti Suresh
authors.initials: KS
authors.lastname: Vora
authors.affiliation: International Union Against Tuberculosis and Lung Disease (The Union), South East Asia Office, New Delhi, India.
authors.forename: Hemant Deepak
authors.initials: HD
authors.lastname: Shewade
authors.affiliation: Karolinska Institutet, Solna, Sweden.
authors.forename: Kristi Sidney
authors.initials: KS
authors.lastname: Annerstedt
authors.affiliation: Médecins Sans Frontières (MSF)/Doctors Without Borders, Mumbai, India.
authors.forename: Petros
authors.initials: P
authors.lastname: Isaakidis
authors.affiliation: Indian Institute of Public Health-Gandhinagar, Sardar Patel Institute Campus, Drive-in-Road, Ahmedabad, Gujarat, 380054, India.
authors.forename: Dileep V
authors.initials: DV
authors.lastname: Mavalankar
authors.affiliation: Department of Health & Family Welfare, Government of Gujarat, Gandhinagar, India.
authors.forename: Nishith B
authors.initials: NB
authors.lastname: Dholakia
authors.affiliation: Karolinska Institutet, Solna, Sweden.
authors.forename: Ayesha
authors.initials: A
authors.lastname: De Costa
mesh_terms: D000293:Adolescent; D000328:Adult; D002585:Cesarean Section / Q000191:economics; D003430:Cross-Sectional Studies; D036861:Delivery, Obstetric / Q000191:economics / Q000706:statistics & numerical data*; D005260:Female; D017048:Health Care Costs / Q000706:statistics & numerical data; D006268:Health Facilities / Q000191:economics / Q000706:statistics & numerical data*; D006297:Health Services Accessibility / Q000191:economics; D006801:Humans; D007194:India; D008427:Maternal Health Services / Q000706:statistics & numerical data*; D015999:Multivariate Analysis; D011247:Pregnancy; D055818:Public-Private Sector Partnerships; D012959:Socioeconomic Factors; D011795:Surveys and Questionnaires; D035862:Vulnerable Populations; D055815:Young Adult
keywords: Chiranjeevi Yojana; Demand side financing; India; Institutional delivery; Maternal mortality; Utilization