Ambulance Service Associated With Reduced Probabilities Of Neonatal And Infant Mortality In Two Indian States.

India had no large-scale, centralized emergency medical system or ambulance service until 2005. Since then, the GVK Emergency Management and Research Institute (GVK EMRI) has emerged as India's largest ambulance service provider, covering more than 630 million people. This study provides the first quantitative evidence of GVK EMRI's early impact on population-level infant and maternal health outcomes in Andhra Pradesh and Gujarat, two Indian states with a combined population of about 145 million people. We found that GVK EMRI coverage is associated with reductions in the probability of neonatal and infant mortality as well as delivery complications (statewide in Andhra Pradesh and in high-mortality districts in Gujarat). However, we found little change in the probability of institutional delivery or skilled birth attendance. Taken together, our findings suggest that population-level health gains were achieved through improvements in the quality (rather than quantity) of maternal and neonatal health services-an interpretation consistent with qualitative reports. More research on this topic is needed.

Effect Of A Large-Scale Social Franchising And Telemedicine Program On Childhood Diarrhea And Pneumonia Outcomes In India.

Despite the rapid growth of social franchising, there is little evidence on its population impact in the health sector. Similar in many ways to private-sector commercial franchising, social franchising can be found in sectors with a social objective, such as health care. This article evaluates the World Health Partners (WHP) Sky program, a large-scale social franchising and telemedicine program in Bihar, India. We studied appropriate treatment for childhood diarrhea and pneumonia and associated health care outcomes. We used multivariate difference-in-differences models to analyze data on 67,950 children ages five and under in 2011 and 2014. We found that the WHP-Sky program did not improve rates of appropriate treatment or disease prevalence. Both provider participation and service use among target populations were low. Our results do not imply that social franchising cannot succeed; instead, they underscore the importance of understanding factors that explain variation in the performance of social franchises. Our findings also highlight, for donors and governments in particular, the importance of conducting rigorous impact evaluations of new and potentially innovative health care delivery programs before investing in scaling them up.

Tuberculosis treatment discontinuation and symptom persistence: an observational study of Bihar, India's public care system covering >100,000,000 inhabitants.

BACKGROUND: The effectiveness of India's TB control programs depend critically on patients completing appropriate treatment. Discontinuing treatment prior to completion can leave patients infectious and symptomatic. Developing strategies to reduce early discontinuation requires characterizing its patterns and their link to symptom persistence. METHODS: The 2011 BEST-TB survey (360 clusters, 11 districts) sampled patients (n = 1007) from Bihar's public healthcare system who had initiated treatment >6 months prior to being interviewed, administering questionnaires to patients about TB treatment duration and symptoms, prior treatment, and sociodemographic characteristics. Multivariate logistic regression models estimated the risk of treatment discontinuation for these characteristics. Similar models estimated probabilities of symptom persistence to 25 weeks post-treatment initiation adjusting for the same predictors and treatment duration. All models included district fixed effects, robust standard errors, and adjustments for the survey sampling design. Treatment default timing and symptom persistence relied solely on self-report. RESULTS: 24% of patients discontinued treatment prior to 25 weeks. Higher likelihood of discontinuation occurred in those who had failed to complete previous TB treatment episodes (aOR: 4.77 [95% CI: 1.98-11.53]) and those seeing multiple providers (3.67 per provider [1.94-6.95]). Symptoms persisted in 42% of patients discontinuing treatment within 5 weeks versus 28% for completing 25 weeks of treatment. Symptom persistence was more likely for those with prior TB treatment (aOR: 5.05 [1.90-13.38]); poorer patients (2.94 [1.51-5.72]); and women (1.79 [1.07-2.99]). Predictors for treatment discontinuation prior to 16 weeks were similar. CONCLUSIONS: Premature TB treatment discontinuation and symptom persistence is particularly high among individuals who have failed to complete treatment for a prior episode. Strategies to identify and promote treatment completion in this group appear promising. Likewise, effective TB regimens of shortened duration currently in trials may eventually help to achieve higher treatment completion rates.

Explaining variations in state foster care maintenance rates and the implications for implementing new evidence-based programs.

BACKGROUND: U.S. Child Welfare systems are involved in the lives of millions of children, and total spending exceeds $26 billion annually. Out-of-home foster care is a critical and expensive Child Welfare service, a major component of which is the maintenance rate paid to support housing and caring for a foster child. Maintenance rates vary widely across states and over time, but reasons for this variation are not well understood. As evidence-based programs are disseminated to state Child Welfare systems, it is important to understand what may be the important drivers in the uptake of these practices including state spending on core system areas. DATA AND METHODS: We assembled a unique, longitudinal, state-level panel dataset (1990-2008) for all 50 states with annual data on foster care maintenance rates and measures of child population in need, poverty, employment, urbanicity, proportion minority, political party control of the state legislature and governorship, federal funding, and lawsuits involving state foster care systems. All monetary values were expressed in per-capita terms and inflation adjusted to 2008 dollars. We used longitudinal panel regressions with robust standard errors and state and year fixed effects to estimate the relationship between state foster care maintenance rates and the other factors in our dataset, lagging all factors by one year to mitigate the possibility that maintenance rates influenced their predictors. Exploratory analyses related maintenance rates to Child Welfare outcomes. FINDINGS: State foster care maintenance rates have increased in nominal terms, but in many states, have not kept pace with inflation, leading to lower real rates in 2008 compared to those in 1991 for 54% of states for 2 year-olds, 58% for 9 year-olds, and 65% for 16 year-olds. In multivariate analyses including socioeconomic, demographic, and political factors, monthly foster care maintenance rates declined $15 for each 1% increase in state unemployment and declined $40 if a state's governorship and legislature became Republican, though significance was marginal. In analyses also examining state revenue, federal funding, and legal challenges, maintenance rates increased as the federal share of maximum TANF payments increased. However, >50% of variation in foster care maintenance rates was explained by unobserved state-level factors as measured by state fixed effects. These factors did not appear to be strongly related to 2008 Child Welfare outcomes like foster care placement stability and maltreatment which were also not correlated with foster care maintenance rates. CONCLUSIONS: Despite being part of a social safety net, foster care maintenance rates have declined in real terms since 1991 in many states, and there is no strong evidence that they increase in response to harsher economic climates or to federal programs or legal reviews. State variation in maintenance rates was not related to Child Welfare outcomes, though further analysis of this important relationship is needed. Variability in state foster care maintenance rates appears highly idiosyncratic, an important contextual factor to consider when designing and disseminating evidence-based services.

China's new cooperative medical scheme improved finances of township health centers but not the number of patients served.

China's New Cooperative Medical Scheme, launched in 2003, was designed to protect rural households from the financial risk posed by health care costs and to increase the use of health care services. This article reports on findings from a longitudinal study of how the program affected the use of health care services, out-of-pocket spending on medical care, and the operations and financial viability of China's township health centers, which constitute a middle tier of care in between village clinics and county hospitals. We found that between 2005 and 2008 the program provided some risk protection and increased the intensity of inpatient care at township health centers. Importantly, the program appears to have improved the centers' financial status. At the same time, the program did not increase the overall number of patients served or the likelihood that a sick person would seek care at a township center. These findings serve as a benchmark of the program's early impact. The results also suggest that the composition of health care use in China has changed, with people increasingly seeking outpatient care at village clinics and inpatient care at township health centers.