Inefficiency, heterogeneity and spillover effects in maternal care in India: a spatial stochastic frontier analysis

Abstract

BackgroundInstitutional delivery is one of the key and proven strategies to reduce maternal deaths. Since the 1990s, the government of India has made substantial investment on maternal care to reduce the huge burden of maternal deaths in the country. However, despite the effort access to institutional delivery in India remains below the global average. In addition, even in places where health investments have been comparable, inter- and intra-state difference in access to maternal care services remain wide and substantial. This raises a fundamental question on whether the sub-national units themselves differ in terms of the efficiency with which they use available resources, and if so, why?MethodsData obtained from round 3 of the country’s District Level Health and Facility Survey was analyzed to measure the level and determinants of inefficiency of institutional delivery in the country. Analysis was conducted using spatial stochastic frontier models that correct for heterogeneity and spatial interactions between sub-national units.ResultsInefficiency differences in maternal care services between and within states are substantial. The top one third of districts in the country has a mean efficiency score of 90 per cent or more, while the bottom 10 per cent of districts exhibit mean inefficiency score of as high as over 75 per cent or more. Overall mean inefficiency is about 30 per cent. The result also reveals the existence of both heterogeneity and spatial correlation in institutional delivery in the country.ConclusionsGiven the high level of inefficiency in the system, further progress in improving coverage of institutional delivery in the country should focus both on improving the efficiency of resource utilization—especially where inefficiency levels are extremely high—and on bringing new resources in to the system. The additional investment should specifically focus on those parts of the country where coverage rates are still low but efficiency levels are already at a high level. In addition, given that inefficiency was also associated inversely with literacy and urbanization and positively related with proportion of households belonging to poor households, investment in these areas can also improve coverage of institutional delivery in the country.

Challenges to generating evidence-informed policy and the role of systematic reviews and (perceived) conflicts of interest

“…Consistent with research on policymakers, 8–13 our findings suggest caution about attempting to train consumer advocates to understand and use scientific evidence. Such educational interventions have been popular for policymakers, but evidence on their effectiveness is mixed.…”

“…8–14 Researchers may find it most effective to focus on easily-understandable concerns about scientific evidence when addressing advocacy groups and policymakers, which will help them make sense of competing research findings and identify potential conflicts of interest. While existing research suggests the value of personal communications and targeted recommendations in communicating evidence, our results suggest that these strategies may be even more effective if discussions with advocacy groups and policymakers specifically emphasize the value of systematic reviews and the problems inherent in research when funders support research in the hope or expectation that it will lead to a desired conclusion.…”

“…1–5 To date they have most often relied on communication strategies more appropriate to scientific discourse than political constraints. 6,7 However, policymakers rely on personal communication with intermediaries rather than written reports, 8,9 demand customized information, 10–12 and will rarely report the use of research findings in their decisions. 13 Political actors are generalists with limited engagement with research, 14,15 more interested in questions of presenter credibility than in research methodology.…”

“…24–26 In situations such as these and more generally, although policymakers see scientific evidence as having a more limited role in decision making than clinical researchers do, they are increasingly interested in enacting evidence-informed health policy. 2,3,8,11,12,27 …”

The efficiency of the local health systems: investigating the roles of health administrations and health care providers

“…Add refs Efficiency in healthcare has been analysed as the difference between the observed and optimal productivity mostly of providers, including hospitals, but also individual practitioners, primary healthcare units, clinics, nursing homes, public health teams and primary healthcare facilities (Hollingsworth and Wildman 2003, Hollingsworth 2008, Hollingsworth and Peacock 2008, Hussey, de Vries et al 2009, Kirigia, Sambo et al 2011, Au, Hollingsworth et al 2014. The efficiency of health systems has also been addressed, mostly at national level through cross-countries comparisons (Gravelle, Jacobs et al 2003, Hollingsworth and Wildman 2003, Greene 2004, Retzlaff-Roberts, Chang et al 2004, but also at sub-national level, by comparing states (Kathuria and Sankar 2005, Prachitha and Shanmugam 2012), districts (Kinfu 2013, Kinfu andSawhney 2015) or lower level health authorities (Giuffrida 1999, Giuffrida, Gravelle et al 2000, Giuffrida and Gravelle 2001, PuigJunoy and Ortún 2004, Varela, Martins et al 2010). …”