Impact of referral transport system on institutional deliveries in Haryana, India.

Background & objectives: Creation of a strong referral transport network across the country is necessary for improving physical access to public sector health facilities. In this study we evaluated the referral transport services in Haryana, i.e. Haryana Swasthya Vaahan Sewa (HSVS), now known as National Ambulance Service (NAS), to assess the extent and pattern of utilization, and to ascertain its effect on public sector institutional deliveries. Methods: Secondary data on 116,562 patients transported during April to July 2011 in Haryana state were analysed to assess extent and pattern of NAS utilization. Exit interviews were conducted with 270 consecutively selected users and non- users of referral services respectively in Ambala (High NAS utilization), Hisar (medium utilization) and Narnaul (low utilization) districts. Month-wise data on institutional deliveries in public facilities during 2005-2012 were collected in these three districts, and analysed using interrupted time series analysis to assess the impact of NAS on institutional deliveries. Results: Female gender (OR = 77.7), rural place of residence (OR = 5.96) and poor socio-economic status (poorest wealth quintile OR = 2.64) were significantly associated with NAS ambulance service usage. Institutional deliveries in Haryana rose significantly after the introduction of NAS service in Ambala (OR=137.4, 95% CI=22.4-252.4) and Hisar (OR=215, 95% CI=88.5-341.3) districts. No significant increase was observed in Narnaul (OR=4.5, 95% CI= -137.4 to 146.4) district. Interpretation & conclusions: The findings of the present study showed a positive effect of referral transport service on increasing institutional deliveries. However, this needs to be backed up with adequate supply of basic and emergency obstetric care at hospitals and health centres.

Cost & efficiency evaluation of a publicly financed & publicly delivered referral transport service model in three districts of Haryana State, India.

Background & objectives: Various models of referral transport services have been introduced in different States in India with an aim to reduce maternal and infant mortality. Most of the research on referral transport has focussed on coverage, quality and timeliness of the service with not much information on cost and efficiency. This study was undertaken to analyze the cost of a publicly financed and managed referral transport service model in three districts of Haryana State, and to assess its cost and technical efficiency. Methods: Data on all resources spent for delivering referral transport service, during 2010, were collected from three districts of Haryana State. Costs incurred at State level were apportioned using appropriate methods. Data Envelopment Analysis (DEA) technique was used to assess the technical efficiency of ambulances. To estimate the efficient scale of operation for ambulance service, the average cost was regressed on kilometres travelled for each ambulance station using a quadratic regression equation. Results: The cost of referral transport per year varied from `5.2 million in Narnaul to `9.8 million in Ambala. Salaries (36-50%) constituted the major cost. Referral transport was found to be operating at an average efficiency level of 76.8 per cent. Operating an ambulance with a patient load of 137 per month was found to reduce unit costs from an average ` 15.5 per km to ` 9.57 per km. Interpretation & conclusions: Our results showed that the publicly delivered referral transport services in Haryana were operating at an efficient level. Increasing the demand for referral transport services among the target population represents an opportunity for further improving the efficiency of the underutilized ambulances.

Cost of Neonatal Intensive Care Delivered through District Level Public Hospitals in India.

Objective: To assess the unit cost of level II neonatal intensive care treatment delivered through public hospitals and its fiscal implications in India. Design: Cost analysis study. Setting: Four Special Care Newborn Units (SCNUs) in public sector district hospitals in three Indian states, i.e. Bihar, Madhya Pradesh and Orissa, for the period 2010. Methods: Bottom-up economic costing methodology was adopted. Health system resources, i.e. capital, equipment, drugs and consumables, non-consumables, referral and overheads, utilized to treat all neonates during 2010 were elicited. Additionally, 360 randomly selected treatment files of neonates were screened to estimate direct out-of-pocket (OOP) expenditure borne by the patients. In order to account for variability in prices and other parameters, we undertook a univariate sensitivity analysis. Main Outcome Measures: Unit cost was computed as INR (Indian national rupees) per neonate treated and INR per bed-day treatment in SCNU. Standardized costs per neonate treatment and per bed day were estimated to incorporate the variation in bed occupancy rates across the sites. Results: Overall, SCNU neonatal treatment costs the Government INR 4581 (USD 101.8) and INR 818 (USD 18.2) per neonate treatment and per bed-day treatment, respectively. Standardized treatment costs were estimated to be INR 5090 (USD 113.1) per neonate and INR 909 (USD 20.2) per bed-day treatment. In the event of entire direct medical expenditure being borne by the health system, we found cost of SCNU treatment as INR 4976 (USD 110.6) per neonate and INR 889 (USD 19.8) per bed-day. Conclusions: Level II neonatal intensive care at SCNUs is cost intensive. Rational use of SCNU services by targeting its utilization for the very low birth weight neonates and maintenance of community based home-based newborn care is required. Further research is required on cost-effectiveness of level II neonatal intensive care against routine pediatric ward care.