Declining fertility and increasing use of traditional methods of family planning: a paradox in Uttar Pradesh, India?

Uttar Pradesh (UP), with more than 220 million people, is the most populous state in India. Despite a high unmet need for modern family planning methods, the state has experienced a substantial decline in fertility. India has also seen a decline during this period which can be attributed to the increased prevalence of modern methods of family planning, particularly female sterilisation, but in UP, the corresponding increase was marginal. At the same time, Traditional Family Planning Methods (TMs) increased significantly in UP in contrast to India, where it was marginal. The trends in UP raise questions about the drivers in fertility decline and question the conventional wisdom that fertility declines are driven by modern methods, and the paper aims to understand this paradox. Fertility trends and family planning practices in UP were analysed using data from different rounds of National Family Health Surveys (NFHS) and the two UP Family Planning Surveys conducted by the UP Technical Support Unit to understand whether the use of TMs played a role in the fertility decline. As per NFHS-4, the prevalence of TM in India (6%) was less than half that of UP (13%). The UP Family Planning Survey in 25 High Priority Districts estimated that 22% of women used TMs. The analysis also suggested that availability and accessibiility of modern contraceptives might have played a role in the increased use of TMs in UP. If there are still couples who make a choice in favour of TMs, they should be well informed about the risks associated with the use of traditional methods as higher failure rate is observed among TMs users.

Establishing evidence-based decision-making mechanism in a health eco-system and its linkages with health service coverage in 25 high-priority districts of Uttar Pradesh, India.

BACKGROUND: Achievement of successful health outcomes depends on evidence-based programming and implementation of effective health interventions. Routine Health Management Information System is one of the most valuable data sets to support evidence-based programming, however, evidence on systemic use of routine monitoring data for problem-solving and improving health outcomes remain negligible. We attempt to understand the effects of systematic evidence-based review mechanism on improving health outcomes in Uttar Pradesh, India. METHODS: Data comes from decision-tracking system and routine health management information system for period Nov-2017 to Mar-2019 covering 6963 health facilities across 25 high-priority districts of the state. Decision-tracking data captured pattern of decisions taken, actions planned and completed, while the latter one provided information on service coverage outcomes over time. Three service coverage indicators, namely, pregnant women receiving 4 or more times ANC and haemoglobin testing during pregnancy, delivered at the health facility, and receive post-partum care within 48 h of delivery were used as outcomes. Univariate and bivariate analyses were conducted. RESULTS: Total 412 decisions were taken during the study reference period and a majority were related to ante-natal care services (31%) followed by delivery (16%) and post-natal services (16%). About 21% decisions-taken were focused on improving data quality. By 1 year, 67% of actions planned based on these decisions were completed, 26% were in progress, and the remaining 7% were not completed. We found that, over a year, districts witnessing > 20 percentage-point increase in outcomes were also the districts with significantly higher action completion rates (> 80%) compared to the districts with < 10 percentage-point increase in outcomes having completion of action plans around 50-70%. CONCLUSIONS: Findings revealed a significantly higher improvement in coverage outcomes among the districts which used routine health management data to conduct monthly review meetings and had high actions completion rates. A data-based review-mechanisms could specifically identify programmatic gaps in service delivery leading to strategic decision making by district authorities to bridge the programmatic gaps. Going forward, establishing systematic evidence-based review platforms can be an important strategy to improve health outcomes and promote the use of routine health monitoring system data in any setting.

Impact of droughts on industrial emissions into surface waters.

In this paper, we examine the impact of droughts on industrial emissions into surface waters and transfers to publicly owned treatment works (POTWs). We use industrial discharges into surface waters data from the US Environmental Protection Agency's Toxics Release Inventory (TRI) database. We employ runoffs normalized using previous 61-year average runoffs as a proxy for drought. We match both the discharges into surface waters and the runoffs at the 8-digit hydrologic unit code (HUC) level. Our analysis indicates that normalized runoffs of the current and previous years positively influence industrial emissions into surface waters. We also find that the impact of uneven availability of water on emissions is higher on larger facilities. Normalized runoffs of the current and previous years do not have a statistically significant influence on transfers to publicly owned treatment works. However, normalized runoffs of the previous year do affect transfers of larger facilities. Businesses are dependent on water not only for their operations but to discharge their pollutants as well. Climate change will increase the frequency and intensity of droughts and floods. Therefore, every business that requires significant quantities of water must plan to cope with uneven availability of water.

Institutional arrangements and efficiency of health care delivery systems.

This study examined the efficiency of health care delivery systems in 24 OECD countries. Practicing physicians, practicing nurses, inpatient beds, and pharmaceuticals were considered as inputs to treat populations of various age groups. Data envelopment analysis (DEA) was utilized to calculate efficiency. We also calculated input efficiency that should be helpful in determining excess number of physicians, nurses, inpatient beds, and pharmaceuticals consumed. Institutional arrangements affect efficiency: public-contract and public-integrated countries are more efficient than public-reimbursement countries. Countries in which physicians are paid in wages and salaries and countries with capitation have higher efficiency than fee-for-service countries. Countries in which a primary care physician acts as a gatekeeper are also more efficient than countries without gatekeepers.

Health systems performance: a statewide analysis.

In this study, we examine the statewide consumption of health care resources. We assume that the physicians, hospital beds, nurses, and pharmaceuticals represent inputs to the health care delivery system required to treat the population of each state. Since health care resources needed by the various age groups of the population are different, we categorize the population into under 18 years of age, 18 to under 65 years of age, and 65 years of age and older. We develop efficient production frontiers and estimate the overall efficiency of individual states, and also the efficiencies of four inputs. In addition, we estimate the excess number of physicians, nurses, hospital beds, and pharmaceuticals consumed. This study should be useful for the states to help identify appropriate policy measures to make their health delivery systems more efficient.