A mixed methods study on evaluating the performance of a multi-strategy national health program to reduce maternal and child health disparities in Haryana, India

Several safe mother and childhood campaigns that are implemented in developing countries could not reduce maternal and child health (MCH) inequalities successfully, because of either lack of thorough analysis of existing data on inequalities or focus on contextual factors to deal with these inequalities [1]. The status of MCH impact indicators in India, have shown that there is still high infant mortality rate (IMR) of 40 deaths per 1000 live births [2], and maternal mortality ratio (MMR) of 167 per 100,000 live births [3]. Additionally, there is marked difference in the status of MCH outcomes topographically, like lower IMR in urban areas (27 per 1000 live births) as compared to rural regions (44 per 1000 live births) [2]. There is a need to review and evaluate how the current MCH programs are put into effect, so as to produce evidence on the effectiveness of these programs in improving the MCH outcomes and reducing MCH inequalities, as these consume majority of the health budget in developing nations like India. Since implementing a national health program at state and district level is a complex phenomenon, hence to report on its effectiveness the assessment needs to be done both from the health system perspective (supply side) as well as societal (demand side) perspective. Most of the health system assessments are quantitative in nature, and conducting qualitative studies more commonly assesses societal perspectives. Kaur (2016), suggested that mono-methods of assessments might not yield desired results as only quantitative methods may miss contextual information and only qualitative methods may miss to quantify the inequalities [4]. Hence, mixed methods study design is a better study design in such situations, which is being considered in this study for assessing the MCH program in India [5].

National Rural Health Mission (NRHM), a multi pronged community based strategy, was implemented to better MCH outcomes and reduce disparities in MCH than in the past in India, from 2005 to 06 to 2012–13. The aim of this mission was to improve the access to and availability of quality health services, mainly for the poor people so as to reduce inequalities between rich and poor people (socioeconomic disparities); for rural populations so as to reduce inequalities between urban and rural areas (geographical disparities); and for the women and children so as to reduce gender based disparities [6]. The plans of NRHM are described in detail in previously published study protocol [7]. In short, these comprised of health system strengthening by improving the health infrastructure, providing free essential medicines, free patient transport services and medical mobile units to increase the access of MCH services in hard to reach areas; specific MCH schemes included cash benefits to the pregnant women for institutional deliveries, free of cost delivery services in pregnancy and sick neonate’s treatment in public health facilities [8]; and recruiting local village woman known as accredited social health activists, so as to improve the access to domiciliary MCH care in the villages as part of communitization etc. [9, 10]. The goal of NRHM was to reduce the IMR to 30/1000 live births, and MMR to 100/100,000 live births. Most of the earlier evaluations of NRHM were mainly quantitative in nature that lack thorough exploration to identify context specific information regarding varied use of MCH care [11, 12].

The purpose of this study was to ascertain the extent to which MCH plans of NRHM were implemented, and resulted in reducing the MCH disparities and improving the outcomes by mixed methods study design so as to provide explanation for the findings of quantitative study, identify contextual factors for the improvement in MCH outcomes and reduction in MCH inequalities, and enhance or validate the findings of the quantitative study using qualitative study. Such explanations are paramount in understanding the complex implementation process of a national health program at the state and district level, which will guide the policy makers in the effective implementation of the program so as to reach the intended goal of improving the maternal and child survival and reducing inequalities, as second phase of NRHM (2013–2017) is continuing as part of the National Health Mission.

Since the results of the entire mixed methods study was too large to be presented in one paper, and these needed to be presented in detailed manner, hence separate quantitative and qualitative papers, which focused entirely on the quantitative and qualitative study findings, respectively, were published earlier [13‐15]. In this paper, findings regarding mixing of the results of quantitative and qualitative study that were not given in earlier papers are presented, after giving the brief reference about quantitative and qualitative studies. Hence, it provides the comprehensive and holistic view of the implementation and effectiveness status of NRHM in Haryana, which only quantitative and qualitative papers earlier failed to provide owing to use of mono-methods.

This mixed method study has presented the holistic and in-depth review of the extent and effectiveness of NRHM’s MCH plans i.e., health system strengthening, communitization, maternal and child health care strategies in Haryana, by conducting both quantitative and qualitative study. Both quantitative and qualitative studies reported overall partial implementation of NRHM’s MCH plans in Haryana. Quantitative results of improved MCH outcomes and reduction in geographical and socioeconomic MCH inequality were enhanced and validated by the qualitative study [23]. However, the qualitative explanation for improved immunization status among girls than boys as observed in quantitative study was quite a revelation. It was perceived that immunization was unsafe, and hence care-givers would rather let the girl children get it than the boys (especially in district Mewat). The results of the qualitative study also proffered the explanation for the improved MCH outcomes and reduction in inequalities through the construction of pathways of change, and how these could not work in district Mewat, as all the preconditions were not met [23]. It is earlier reported that the mixed methods study design could be especially illustrative, and it could assimilate multiple theoretical frameworks [29], as was done in this study.

Various circumstantial and contextual factors were identified in this mixed methods study regarding degree of implementation of NRHM’s schemes, especially in district Mewat, like acute shortage of human resources in all the health facilities from primary to secondary care level, cultural barriers in accepting immunization/injection etc. Barriers that were reported to prevent the availability of health care providers in this study pointed towards the fact that policies regarding human resource management needed a revamping in the state. The interested local residents from the respective districts should be promoted to acquire the requisite qualification so as to get the job in the health sector in their respective districts. Alternatively, health care providers should be offered the place of posting of their native area. Inequality in distribution of the human resources at the grass root level in the health care delivery system is also reported by Pallikadavath et al. (2013) in India [30]. Availability of primary schools in the villages and good roads were some of the contextual factors that were reported as a determinant factor for the availability of health care providers in their study. Mukherjee et al. (2010) also reported similar inefficiencies in terms of infrastructure and human resource provisions in the states of Jharkhand, Assam, Chhattisgarh and Orissa [10].

The equity issues might be addressed by the program due to better implementation of the schemes like accredited social health activists, free referral transport, financial incentive schemes for institutional delivery or cashless delivery in the public hospital in rural areas, which especially benefitted the poor. The role of accredited social health activists as a catalyst in improving the institutional delivery rate, immunization rate and utilization of various MCH schemes in rural areas was also observed in Uttar Pradesh [31] and Manipur in India [32]. Such role of indigenous community health workers in improving MCH is also reported in other developing countries like Bangladesh [33], and developed countries like Canada among vulnerable groups [34]. Increase in utilization of antenatal care and delivery by skilled birth attendants following implementation of financial incentive scheme (Janani Suraksha Yojna) is also reported by Kingkaew et al. (2016) in Myanmar [35]. However, similar barriers in utilizing funds under financial incentive scheme for institutional delivery like the need for having identity documents by pregnant women are also reported by Chaturvedi et al. (2015) in Madhya Pradesh [36]. Overall utilization of certain services, like institutional deliveries, may be improved by cash incentives programs, which are linked to performance of the health workers, if the utilization of these services is evenly low, as reported by Priedman et al. (2013) [37]. However, if the disparities are severe, then such programs without targets will have small effect on reducing disparities. Low performance of village health nutrition and sanitation committees, as observed in this study, is also reported from Maharashtra in India. [38]. At the ground level, NRHM schemes were sometimes considered poorly visible indicating an information gap between service providers and users. Perhaps lessons can be learnt from Taleb et al. (2015) study in Bangladesh, where the maternal and newborn health improved by a focused and dedicated bridging of the information gap through community-based programs that influenced knowledge levels and practices of women [39]. Qualitative findings had also pointed towards the overall socio-political context of a district, especially in district Mewat, in improving MCH. There was less political will to develop district Mewat, probably because of increased allocation of funds to this district due to its underdeveloped status [40, 27].

During 2009–10, NRHM’s plans were reviewed in Jharkhand, Orissa, Assam, Jammu and Kashmir, Uttar Pradesh, Madhya Pradesh, and Tamil Nadu stated using quantitative and qualitative methods by planning commission. MCH services utilization and availability was reported to be improved in rural areas to some extent in that evaluation, and further strengthening of health facilities was suggested [9]. Several limitations of that evaluation were overcome by this study by providing information on the extent of implementation of MCH plans of NRHM, comparing the results with the MCH status before and after the implementation of the NRHM, specifically estimating the MCH inequalities, and assimilating the qualitative and quantitative data by a mixed-methods research.

Review of earlier studies on MCH disparities in India indicated marked MCH inequalities during antenatal, natal or postnatal period to the disadvantage of the poor [41‐48]. However, most of these studies reported the status before NRHM implementation period, as observed in this study as well during that period (2002–04). Since this study compared the MCH status and inequalities over NRHM implementation period, hence it provides information on the status of MCH disparities and outcomes during and after NRHM period in Haryana, North India, as well. It also provides tailor-made solutions to further bridge the MCH related gaps, in Haryana (especially in district Mewat). This is pertinent in the context of considering state as unique entity having its own sociocultural background and issues. However, this does not limit the lessons learnt from this study to Haryana, as these may also be exchangeable to other states in India because of having similar health care delivery systems with in the states.

Using a mixed methods study design is the strength of this study, as quantitative assessment of community’s needs and status as per the providers’ perspective was complimented by assessing the felt needs of the health service users by conducting qualitatively study. Thus a mixed methods approach brought the users’ perspective to the fore [4, 5, 49]. Joint display of quantitative and qualitative data helped us in understanding how mixed methods design provided new insight into the implementation process of NRHM’s MCH plans [50, 51]. Investigation for community health research by using mixed methods research design is not only an effective way of research, but is also a foundation for primary care research [52, 53]. This is probably the first study that has evaluated the national program using mixed methods approach in Indian settings, and has provided useful insight and explanations for the findings of the quantitative study.

Having said so, there is definitely a scope for improvement in future for carrying out such studies. In-depth review of how funds are being spent on implementing the NRHM’s scheme in the district, right to the village level, can give us better understanding of the process of budget expenditure on implementing programs at various health care delivery levels. This information will bring further clarification on barriers and facilitating factors to improve the implementation. We also acknowledge that the budget left unspent may not indicate true implementation status of a given NRHM plan, because the reasons why it could not be spent fully might be due to more efficient use of funds or too high estimation on the forehand, hence this aspect was investigated qualitatively as well so as to have better insight of how spending of the money is appreciated and judged by the key persons involved.

The causal association between NRHM implementation and MCH outcomes and inequalities however, cannot be established, as there was no control region (without NRHM). There might have been other (confounding) developments in the same time period (e.g. improving socioeconomic conditions in general) that brought up the positive changes.

The results of this study has an implication for policy makers on the way the program is implemented during the second phase of NRHM as part of National Health Mission. Appreciable achievements were observed for schemes (patient ambulance services, cashless hospital delivery, cash payments for deliveries in the health facilities, and village health activists) that had intended to raise the rate of deliveries by skilled birth attendants among the poor and rural women during the first phase of NRHM implementation. Hence, it is recommended that these schemes should be further strengthened by effectively tackling the reported bottle necks for the implementation of these schemes like increasing the number of ambulances per district especially in district Mewat, placing a maintenance mechanisms for the ambulances, improving the availability of human resources like doctors, nurses, auxiliary nurse midwives, and social health activists, and preventing administrative delays in providing incentives to the pregnant women; and strengthening the supportive supervision of child health plans including integrated management of neonatal and childhood illness.

Another challenge that needs to be addressed is of the long-term sustainability of financial incentive schemes or free MCH services in the government hospitals under NRHM. If these schemes are no longer remain sustainable or government feels burdened then is there a possibility that MCH status or inequalities worsens. However, there is less likelihood of such situation in India, as Indian economy is on the rise [54], and it has committed to increase health expenditure on health from the current gross domestic product (GDP) of 1.15% to 2.5% GDP by 2025, as per National Health Policy 2017 [55].

In future, a structured mixed methods approach may also be used in the planning phase of a rigorous community-based participatory research program so as to develop acceptable, community need based MCH interventions for vulnerable populations (especially for districts like Mewat) to meet the desired MCH goals [56].

It can be concluded that NRHM’s plans might have succeeded in improving the MCH outcomes, and in reducing geographical and socioeconomic inequalities in Haryana by successfully implementing accredited social health activists scheme, free referral transport scheme, free medicines and providing maternal and child health schemes for the poor and rural women. However, the decline did not reach the intended goal (which was a decrease to a maternal mortality ratio of less than 1 per 1000 live births and a decrease of infant mortality rate to 30/1000 live births) may be due to partial implementation of NRHM’s schemes. Gender-based inequalities are linked to increased education level and adoption of small family norms. Underlying socio-economic development of the district was observed to be an important determinant of MCH (from district Mewat’s experience). Health policy makers should take this aspect into account while framing future policies related to MCH. Overall it can be said that Haryana is on the right track for achieving the sustainable development goals of reducing MCH inequalities.