The payoff from paying off

Photograph: STR/AFP

The Lancet featured a paper a few days ago on the effectiveness of China’s facility-based birth strategy in lowering neonatal mortality rates. The paper finds that rising rates of professional delivery in institutional settings have reduced the death rates among mothers and babies by almost two thirds in twelve years — considerably more than the rate reported for community-based interventions.

The program examined in the study focused on increasing both the quality of facility-based care and the demand for professional delivery services. On the supply side, the program aimed to strengthen facilities, train providers, and improve infrastructure and procurement. On the demand side, it offered more than 22 million women money (500 yuan) for delivering in hospitals, in line with the concept behind programs like Oportunidades, which provided cash payments to families in Mexico in exchange for regular school attendance, health clinic visits, and nutritional support. Similar programs, based on conditional cash transfers, have been successful in Brazil and over 40 other countries, according to the World Bank.

The study finds that more than 96% of mothers in rural areas gave birth in hospitals last year. Deaths fell from 24.7 per 1,000 live births in 1996 to 9.3 in 2008, according to data from 37 urban districts and 79 rural counties collected by China’s National Maternal and Child Mortality Surveillance System. Facility-based, professionally assisted delivery has considerable impact not only on maternal and neonatal health, but also on the child’s health outcomes in the first five years of life (the impact of professional delivery care on child health outcomes is a personal research interest of mine – in a research project using DHS data, I found that the use of professional delivery care in Kenya had significant impacts on growth outcomes and rates of vaccination, immunization, diarrhea, and malaria among children, up to 5 years of age).

Although the study’s results have received considerable attention already, it is hard to be entirely convinced of the extent of the reported “substantial progress” achieved by the program, especially since children born in the least developed rural counties were found to be four more times likely to die than children in urban hospitals.

Nevertheless, UN figures report that China has met its goal of reducing child mortality rates by two thirds by 2015, and is on course to reduce the maternal mortality rate by three quarters. The study highlighted by The Lancet is one of several on the impact of similar health financing programs implemented by the Chinese Ministry of Health, such as the New Cooperative Medical Scheme, a rural health insurance program introduced in 2003. This suite of policies has driven a substantial increase in the proportion of women with health insurance, reduced financial burdens on households, and increased rates of facility-based delivery – which has long-term effects on maternal and child health. It is an interesting case study of a successful program that addresses both the “push” (improved facilities, provider training, etc) and “pull” (increased demand for services) drivers of the uptake of facility-based care.