Involving Private Healthcare Providers to Reduce Maternal Mortality in India: A Simulation Study to Understand Implications on Provider Incentives

Gujarat State has implemented the “Chiranjeevi Yojana” to improve access to institutional delivery with an objective to reduce maternal mortality and at the same time providing financial protection to poor families. The scheme involves private providers in provision of maternity services through contracting-out and use of voucher type of mechanism. Five districts covered by this scheme have population of about 10.5 million of which 43 per cent are below poverty line having about 110,000 deliveries per annum. The scheme during first year of its implementation has covered 31,641 deliveries. Of the total 217 providers in these districts 133 (61 per cent) have been empanelled in this scheme. This paper mainly examines two things, one, the revenue distribution a private provider would have experienced if the provider was not part of the Chiranjeevi Scheme and second, does the financial package provided in the scheme provides adequate incentives to the private provider to join the scheme. Further, given the number of providers empanelled in each district, does number of providers contracted-out in the scheme make any difference in revenue distribution of private provider? We use Monte Carlo simulation method to examine these issues. The simulation results suggest that the average revenue is Rs. 1416 per delivery. This is less than what the provider is being reimbursed by the government on capitation fee basis, which is Rs. 1445 (Rs. 1795 less Rs. 350 towards reimbursement for food, transport and Dai). By joining this scheme, the provider’s additional margin on an average is 2 per cent. This is over and above the profits included in the average revenue earned if the provider was not part of the scheme. The results further suggest that revenue distribution is scattered asymmetrically indicating significant risk in revenues to the provider. By joining in the Chiranjeevi Scheme, the provider is able to reduce the overall risk in revenue. In addition to this, the increased volume of services will spread the fixed cost of the provider and increase overall profitability further. Since the provider is paid up-front advance for delivering services under the scheme, there is no transaction cost of bureaucratic delays in payments. The provider in the absence of this scheme can maximise the revenue by doing more cesarean cases. The scheme has embedded incentive to minimise the cesarian cases to maximise the revenue and this produces larger indirect benefits from health systems point of view. The study identifies other issues that need further investigation.

Evaluation of Penalty and Enforcement Strategies to Combat Speeding Offences among Professional Drivers: A Hong Kong Stated Preference Experiment

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A New Generalized Heterogeneous Data Model (GHDM) to Jointly Model Mixed Types of Dependent Variables

This paper formulates a generalized heterogeneous data model (GHDM) that jointly handles mixed types of dependent variables—including multiple nominal outcomes, multiple ordinal variables, and multiple count variables, as well as multiple continuous variables—by representing the covariance relationships among them through a reduced number of latent factors. Sufficiency conditions for identification of the GHDM parameters are presented. The maximum approximate composite marginal likelihood (MACML) method is proposed to estimate this jointly mixed model system. This estimation method provides computational time advantages since the dimensionality of integration in the likelihood function is independent of the number of latent factors. The study undertakes a simulation experiment within the virtual context of integrating residential location choice and travel behavior to evaluate the ability of the MACML approach to recover parameters. The simulation results show that the MACML approach effectively recovers underlying parameters, and also that ignoring the multidimensional nature of the relationship among mixed types of dependent variables can lead not only to inconsistent parameter estimation, but also have important implications for policy analysis.Civil, Architectural, and Environmental Engineerin

A study of factors delaying hospital arrival and predictors of mortality in patients presenting to emergency department with stroke: A developing state scenario

Background: Thrombolytic therapy for acute ischemic stroke has recently become available in India but its success depends on initiating the treatment in the narrow therapeutic time window. There is commonly a delay of several hours before patients with acute stroke seek medical attention. Materials and Methods: A prospective study was conducted to assess the factors influencing this delay in admission of acute stroke cases. 134cases (101 males, 33 females) of acute stroke that arrived within 72 hours at our hospital casualty were recruited. A standardized structured questionnaire was given to patients or their attendants. Results: The median time to casualty arrival was 9 hours with 13.4% cases arriving within 3 hours and 36.5 % cases within 6 hours. Distances from hospital, referral, belief in myths and alternate medicine and low threat perception of symptoms of stroke were independent factors associated with delay in arrival. Living in city, day time onset, urgency shown by attendant, availability of transport and presence of family history were associated with early arrival. There was no correlation with patients' or attendants' sex, educational status, history of previous stroke or transient ischemic attack, subtype or severity of stroke, time of stroke and availability of transport. 134 patients (65.7% were from rural population, 55.22%-smokers, 46.76%-alcoholics) with mean (SD) age of 53.83+/-18.02years [significantly lower in females (mean difference=9.73years p=0.002)], were admitted and diagnosed to have stroke. 87.3% had first episode of stroke and 12.7 had more than one episode of stroke. ICF rate was 26.1%. ICF rate has no relation with age (p=0.516), sex (p=0.460), number of episodes (0.795), underlying hypertension (p=0.905). Odds of diabetics dying were 12 times higher than non-diabetics. Inpatient mortality was also significantly higher in smokers compared with non-smokers (p=0.004), in patients with right-sided compared with left-sided hemiplegic (p=0.029) and who couldn’t afford computed tomography (CT) scan (p=0.007). Kaplan Meier curve in Image-1 shows the survival following admission to emergency ward. Conclusion: Adequate measures need to be taken to improve the public awareness of stroke and the role of local doctors. Our study has shown that active smokers, involvement of the right side and non performance of CT were independent predictors of mortality which have not been shown earlier. Also, we found that diabetes mellitus is independent predictor of mortality in stroke, which has been seen in earlier studies too

A Copula-Based Joint Model of Commute Mode Choice and Number of Non-Work Stops during the Commute

At the time of publication A. Portoghese, E. Spissu, and I. Meloni were at University of Cagliari, and C.R. Bhat and N. Eluru were at the University of Texas at Austin.In this paper, in the spirit of a tour-based frame of analysis, we examine the commute mode choice and the number of non-work stops during the commute. Understanding the mode and activity stop dimensions of weekday commute travel is important since the highest level of weekday traffic congestion in urban areas occurs during the commute periods. The paper employs a copula-based joint multinomial logit – ordered modeling framework in which commute mode choice is modeled using a multinomial logit formulation and the number of commute stops is modeled using an ordered response formulation. The data used in this study are drawn from the “Time use” multipurpose survey conducted between 2002 and 2003 by the Turin Town Council and the Italian National Institute of Statistics (ISTAT) in the Greater Turin metropolitan area of Italy. The results highlight the importance of accommodating the inter-relationship between commute mode choice and commute stops behavior. The results also point to the stronger effect of household responsibilities and demographic characteristics in the Italian context compared to the US context.Civil, Architectural, and Environmental Engineerin

Incorporating a multiple discrete-continuous outcome in the generalized heterogeneous data model: Application to residential self-selection effects analysis in an activity time-use behavior model

This paper makes both a methodological contribution as well as an empirical contribution. From a methodological perspective, we propose a new econometric approach for the estimation of joint mixed models that include a multiple discrete choice outcome and a nominal discrete outcome, in addition to the count, binary/ordinal outcomes, and continuous outcomes considered in traditional structural equation models. These outcomes are modeled together by specifying latent underlying unobserved individual lifestyle, personality, and attitudinal factors that impact the many outcomes, and generate the jointness among the outcomes. From an empirical perspective, we analyze residential location choice, household vehicle ownership choice, as well as time-use choices, and investigate the extent of association versus causality in the effects of residential density on activity participation and mobility choices. The sample for the empirical application is drawn from a travel survey conducted in the Puget Sound Region in 2014. The results show that residential density effects on activity participation and motorized auto ownership are both associative as well as causal, emphasizing that accounting for residential self-selection effects are not simply esoteric econometric pursuits, but can have important implications for land-use policy measures that focus on neo-urbanist design

A Model of Deadheading Trips and Pick-Up Locations for Ride-Hailing Service Vehicles

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Joint Model of App-Based Ridehailing Adoption, Intensity of Use and Intermediate Public Transport (IPT) Consideration among Workers in Chennai City

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