INTEGRATION, REPRODUCTIVE HEALTH, INCLUSIVE DEVELPOMENT PROGRAMME IN INDIA 1 EXTENDED ABSTRACT Integration of Reproductive Health Service Utilization and Inclusive Development Programme in Uttar Pradesh, India Diwakar Yadav 1 and Chander Shekahr 2 1. FHI 360, New Delhi, India 2. International Institute for Population Sciences, Mumbai, India Background Uttar Pradesh is most populous state of India (Census, 2011) and significantly diverges in their socioeconomic, demographic, geographic and cultural profiles (NFHS, 2007). Nowadays Uttar Pradesh has been passing through the third stage of demographic transition, with an estimated death rate of 8.2 per 1000 population and Infant Mortality Rate (IMR) of 63 per 1000 live births (Office of the Registrar General, 2011). A large proportion of the state s population suffers from poverty, with low female literacy and low women autonomy. In the Human Development Index (HDI), it ranked 13the among the 15 major states of India (Planning Commission, Government of India, 2002). Still, question is remain unanswered in India particularly in Uttar Pradesh, does existence of an inclusive (health and rural) development programme enhance the utilization of maternal-child health care and family planning (MCH-FP)? Does integration between exclusive development programmes have an effect on MCH-FP service utilization in Uttar Pradesh?, become critical to execute the programme in efficient manner. The answer to above questions holds important for advocating healthy people, healthy village, and healthy nation. The integration of family planning programs and maternal child health care services are not a new. In the early 1980s, various empirical evidences from experimental studies of developing countries were introducing the integration of family planning programs with the subsequent development programs (Faruqee, 1982; Rahman, et. al, 1980; Reinke, 1985; Taylor et. al, 1983). In India, early 1990s decentralization and integration seems to be the similar words underlying the implementation of various social development programme, especially the reproductive and child health program. It is pointed out that service integration has received renewed emphasis following 1994s International Conference on Population and Development (ICPD) in Cairo (Hardee & Yount, 1995). It was found that the pace of annual progress after 1998 in many RCH indicators is slower than before and a few indicators (child immunization) have worsened, despite the expenditure on the programme being doubled (Srinivasan, K. et al. 2007). From a demographic point of view, little information has accumulated on how a woman decides simultaneously to use two types of health care services, one for the survival of her children and the other for controlling her own fertility. Testing the link between MCH service and contraceptive use with inclusive development programme is untested. Although a few studies have explored the association between maternal-child health care and family planning in developing countries, no studies to date have investigated the effect of inclusive development programme on their relationship. Therefore, this study attempt to examine the effect of inclusive development programme at village level on the relationship between the use of MCH services and contraceptive use. 1 P a g e
INTEGRATION, REPRODUCTIVE HEALTH, INCLUSIVE DEVELPOMENT PROGRAMME IN INDIA 2 METHODS Data The data for this paper derived from the District Level Household and Facility Survey (DLHS-3) 2007-08, India (IIPS, 2010). The analysis of this study is based on both individuallevel and the service availability at village level data related to the contraceptive use and MCH service utilization. The sample for this objective consisted only those women who had last children aged at least 12 months. However, we assumed that bias would be at a minimum level. The sample for this objective is 9889 women. Structural equation model This research study explain by the economic demand model, which guiding the study assumes that individuals and households make maternal child health (MCH) care and family planning service decisions in order to maximize their total level of welfare. For assessing the relationship involving the latent variables, structural equation models (SEM) were used. In the econometrics literature these simultaneous models are referred to as simultaneous equation models with measurement error or shock error models (Geraci, 1982; Wansbeek & Meijer, 2000). LISREL software originally evolved as the full-information maximum likelihood solution for solving the equation simultaneously. In LISREL, we fitted non-recursive models (Berry 1984; Joreskog 1979) to take in to consideration the simultaneity between the two latent endogenous variables. RESULTS The mean age of women is 26 years, 3.4 children per women ever born and average 7.6 years of schooling were important characteristics of women (Table 2). At least 25 percent of women were scheduled caste/scheduled tribes (SC/ST), more than three fourth women are Hindu and nearly half of women s households were in poor (first and second quintile) stratum. About 85 percent of villages were connected by all-weather road, having health facility and health providers. Of 11 inclusive development programme, four development programme were fully/partially associated with women health, adolescent and education and rural development programme and implemented in each villages of Uttar Pradesh. We examined the common factors that determined the use of family planning/contraceptive methods and MCH care services in rural Uttar Pradesh, particularly the simultaneity between these two behavioral outcomes. It was found that there were no specific pattern of common exogenous predictors except children ever born (p<0.05), mothers education (p<0.05), wealth index of households (p<0.05), and beneficiaries of women development programme (p<0.05), for the use of contraceptives and MCH care services (Table 4). It can be also viewed that use of these two services is simultaneously determined in rural Uttar Pradesh. It is mention that families develop a joint demand for improving the quality of their health and for children. It could be translate these demands in to action by adopting contraceptive methods and by using health services for children and for mothers simultaneously. However it could be also possible that women experience with either the health or family planning systems removes the barrier to using other. Model 2, the use of any contraceptive methods and use of MCH care services are simultaneously related and statistically significant, independent of other intervening covariates. In the other three models, contraceptive use significantly influenced the use of MCH care services. Because the and are close in most setting, we also fitted models with 2 P a g e
INTEGRATION, REPRODUCTIVE HEALTH, INCLUSIVE DEVELPOMENT PROGRAMME IN INDIA 3 alternative specifications that. The results of showed that the s are statistically significant (p<0.05) in all models. Caste of women and village development index, and beneficiaries of rural development programme doesn t influence the contraceptive use. Another side, age of women are a statistically significant (p<0.05) variable which influence the MCH care services in rural Uttar Pradesh. It was observed that children ever born, mother s education and household wealth index were common determinants which influence both services. It also viewed that implementation of women development programme in villages have statistically significant impact on the MCH use than contraceptive use. It support to assumption that availability of women health programme with other programme in village have influence on MCH use (Catherine, 2008). But, these programmes were not having such significant impact on contraceptive use. It shows programmes were more focus on women s health which helps to increase institutional delivery, children immunization, children health and adolescent health. It is recommended that policymakers can advance support for service integration in the long run, offering service together can save money and better serve the public health needs. At times, nongovernmental organizations can serve women more easily than the public sector can or women may prefer these services. Policymakers can also encourage corporate social responsibility programs to integrate services. Such programmes should be designed to address time and cost barriers that prevent the most economically disadvantaged women from accessing MCH and contraceptive services. Working across sectors to achieve mutually reinforcing objectives such as universal secondary education for girls and integrated services will build consensus for reform. CONCLUSION The study provides empirical evidence for the research that the utilization of one health services influences the acceptors to use other health services, independent of other factors like inclusive development programme. These findings has not only theoretical value but also important for policy implications. Finding suggests that if family planning, MCH care service and inclusive development program are introduce and available, the likelihood of adoption of service is higher, compared only one service is available in state. The rationale for integration of family planning and MCH care services with inclusive development at village level have been based on three grounds: improving the efficiency and effectiveness of services; meeting clients need from one-stop service; and accelerating the pace of health and demographic outcomes. This study further substantiate the rationality of integration, it is likely that if both kind of services are available, the use of both will be increased, compared to if only one type services is available. Table 1. Percentage distribution of contraceptive use and maternal child health care use in the Uttar Pradesh (rural) Indicators Percentage Contraceptive use Current contraceptive use (any) 30.8 Current contraceptive use (modern) 16.9 Current contraceptive use (traditional) 13.7 3 P a g e
INTEGRATION, REPRODUCTIVE HEALTH, INCLUSIVE DEVELPOMENT PROGRAMME IN INDIA 4 MCH care use Antenatal care (ANC) 63.2 Institutional delivery 20.5 Safe delivery 25.7 TT injection received 61.5 Post natal care (PNC) within two weeks 30.8 DPT-3 immunization 37.7 Full immunization 29.3 Table 2. Characteristics of Women, Households, Communities and Services, Rural Uttar Pradesh Age (mean in years) 26.2 Children ever born(mean) 3.4 women's Education (mean in years) 7.6 Religion (Hindu) 84.5 Caste (SC/ST) 24.6 Wealth Index (first and second quintile) 49.8 Village connected by all weather road 87.5 Health facility in Village 87.9 Health provider in Village 94.5 Village Development Index (least &Less Develop) 50.0 Table 3. Correlation among Latent Endogenous Variables Contraceptive Use ( ), and Use of Maternal and Child Health Services ( ) Description Covariance ( ) Correlation Model 1 0.011* 0.054 Model 2 0.015* 0.144 Model 3 0.009* 0.055 Model 4 0.013* 0.154 *p<0.05 4 P a g e
INTEGRATION, REPRODUCTIVE HEALTH, INCLUSIVE DEVELPOMENT PROGRAMME IN INDIA 5 Table 4. Parameter Estimates of Contraceptive Use ( ) and Maternal Child Health Care ( ) from the Structural Equation Models, Rural Uttar Pradesh Estimates (COUNTUSE) Model 1 Model 2 Model 3 Model 4 (MCHUSE) (COUNTUSE) (MCHUSE) (COUNTUSE) (MCHUSE) (COUNTUSE) Lambda Y ( y) Estimates Current Contraceptive use(modern) - - - - 1.000-1.000 - Current contraceptive use(any) 1.000-1.000 - - - - - (MCHUSE) Antenatal care - 1.000-1.000-1.000-1.000 Safe delivery - 0.176* - - - 0.175* - - TT use - 1.034* - - - 1.034* - - Full Immunization - - - 0.781* - - - 0.782* Institutional delivery - - - 1.216* - - - 1.216* Post natal care - - - -1.242* - - - -1.243* DPT_3-0.302* - - - 0.300* - - Beta 12 (Coefficient MCH) -0.003-0.025-0.001-0.014-21 (Coefficient COUNT) 0.047* 0.023* 0.056* 0.031 if 12 = 21) 0 0.022* 0.023* 0.023* 0.028* Gamma ( x) Estimates Age 0.007 0.055* 0.018 0.026* -0.009* 0.056* 0.006 0.026* Children ever born 0.059* 0.115* 0.047* -0.051* 0.054* -0.115* 0.040* -0.051* Mother education 0.045* 0.047* 0.055* 0.053* 0.030* 0.058* 0.040* 0.053* Caste -0.010 0.002-0.005 0.013* -0.002 0.002 0.001 0.013* wealth index 0.038* 0.063* 0.056* 0.067* 0.036* 0.063* 0.053* 0.067* Village Development index 0.008 0.011 0.011* 0.006* 0.006 0.011 0.011 0.005 Model Fitness Indexes Goodness of fit index (GFI) 0.998 0.989 0.998 0.988 AGFI 0.992 0.946 0.992 0.942 5 P a g e
INTEGRATION, REPRODUCTIVE HEALTH, INCLUSIVE DEVELPOMENT PROGRAMME IN INDIA 6 Root Mean Square 0.083 0.100 0.087 0.101 *p<0.05, p=<0.10 6 P a g e