Effectiveness Evaluation On Maternal And Child Safety Project In Rural Area Of Guangxi Autonomous Region

BackgroundThe situation of maternal and child health(MCH) is one of the most significant indicators reflecting social development of a country or a region.There are obvious gaps between our country and developed countries and several developing countries on MCH situation.It is a grand challenge for us to realize the Millennium Development Goals as promised on time.Maternal mortality ratio(MMR) is considered as one of key indicators to measure the development of the health system in a country or a region.Chinese governments at all levels implemented several intervention projects and policies to improve the situation of maternal mortality in central and western China recent years, one of which is Maternal and Child Safety Project(MCSP) in Guangxi Autonomous Region.Existing evaluations towards these kinds of projects or policies always make conclusions from outcome characters,while paying little attention to the structure and process characters.This study is to evaluate the effectiveness of MCSP systematically through structure characters,process characters and outcome characters.Study GoalThe study is to evaluate the effectiveness of MCSP in rural area from a social point of view,and to provide policy suggestion for further improvement of policy effectiveness.Study Contents and Methodologies1) Evaluation on policy effectiveness focus on MCH system of Guangxi from a macro point of viewFirst,taking MCH system of Guangxi as target,the non-equivalent control group design was used to evaluate the policy output compared with the whole country. Statistic reports of national and Guangxi on maternal and infant health index from 1998 to 2006 were collected to compare the changes and trends on maternal and infant health situation,and to analysis the range and speed of improvement.Next,by sampling in rural area of Guangxi and western China,the non-equivalent control group design was also used to evaluate the policy output on rural primary MCH system.12 counties from Guangxi were sampled conveniently as the experimental group,and 27 counties from western China were sampled according to the 3^rd National Health Service Survey framework as the control group.TOPSIS method was used to rank maternal and infant health situation of total 39 counties in 2002 and 2006 respectively,and the change of ranks between different groups was analyzed to reflect the policy effectiveness.2) Evaluation on policy effectiveness focus on service providers from a micro point of view24 township hospitals were stratified non-random sampled based on 12 sample counties according to the distance from the County-level Emergency Obstetric & Neonatal Care(EmONC) Centers.Taking service providers from county level and township level as target,one group pretest-posttest design was used to evaluate the policy output.The evaluation indexes included all kinds of resource inputs and services output,and focused on 2003 to 2006.According to the character of data distribution,paired t-test or paired rank-sum test was used to identify the change.3) Relative efficiency evaluation of decision making unitsTaking three-tier network of MCH in rural area as a decision making unit (DMU),data envelopment analysis(DEA) method with C²R model and BC² model was used to implement input-output relative efficiency evaluation of 12 DMUs.Based on the result of the evaluation,the gap between ideal value and actual value was analyzed to find out the problems of resource allocation and utilization.4) Qualitative research on policy effectivenessIndividual in-depth interviews were performed to collect qualitative data.17 key informants were interviewed followed the topic guideline or the semi-structure outline to find out the policy effectiveness on primary MCH service delivery,MCH service utilization,and administration capacity of local MCH system.Main study results1) Results on systematic outcome and health outcome indicatorsThe goals set by Women's Development Planning of Guangxi Autonomous Region(2001-2010) and Children's Development Planning of Guangxi Autonomous Region(2001-2010) had been realized advanced in 2006.Statistic data indicated that most indicators on systematic outcome,MMR and perinatal mortality of Guangxi had got better improvement than the whole country.Non-equivalent control group analysis was performed based on the comparability of the general situation of the experimental group(Guangxi) and the control group(western China).The result of TOPSIS method indicates that counties from Guangxi got more improvement in maternal and infant health care than counties from western China(P=0.03).2) Results on process indicatorsCompared with 2003,obstetrics outpatient services provided by facilities at county and township level got significant increased(P＜0.05),obstetrics delivery services provided by county level facilities got significant increased(P＜0.01), emergency obstetric services provided by county MCH centers got significant increased(P=0.02),the number of pregnant women who took part in "School for Pregnant Women" to attain information on MCH got significant increased(P=0.02), the number of MCH personnel attending county level capacity training programs got significant increased(P=0.005) in 2006.Compared with 2003,birth attendants in facilities at county and township level got significant improvements in capacity of providing clinical obstetrics services (P＜0.05),the number of high risk pregnant women transferred from township hospitals to higher level facilities didn't increase significantly(P=0.05).Compared with 2003,operating income and expenses of county-level EmONCs and township hospitals got significant increased(P＜0.05),obstetrics delivery services per capital provided by county-level EmONCs got significant increased(P＜0.001),obstetrics outpatient services per capital provided by county-level EmONCs or township hospitals didn't get significant increased(P＞0.05), and obstetrics delivery services per capital provided by township hospitals didn't get significant increased(P＞0.05) in 2006.Compared with 2003,number of traditional birth attendant(TBA) got significant decreased(P=0.01) in 2006.3) Results on structure indexesCompared with 2003,number of obstetrics nurses and obstetrics nurses with certification got significant decreased(P＜0.01),number of other personnel in obstetrics department didn't get significant changed(P＞0.05),the education level and professional title structure of obstetrics personnel didn't get significant improved (P＞0.05) in county-level EmONCs in 2006.During the same period,number of obstetrics doctors and obstetrics doctors with certification got significant increased (P＜0.01),the education level of obstetrics doctors got significant improved(P=0.03) in township hospitals.And numbers of village doctors and village MCH health workers didn't get significant changed(P＞0.05) in 2006 compared with 2003.Compared with 2003,the area of the whole sector got significant increased (P=0.042),beds and area of obstetrics department didn't get significant changed (P＞0.05) in county-level EmONCs in 2006.During the same period,beds,area of the whole sector,bedsòf obstetrics department and area of obstetrics department got significant increased in township hospitals(P＜0.05).Compared with 2003,number of most kinds of equipments for obstetrics and newborn care and emergency treatment got increased with different degree in county-level EmONCs and township hospitals in 2006.Compared with 2003,total fixed assets of county-level EmONCs got significant increased(P=0.001) in 2006,and during the same period,both total fixed assets and government financial provision got significant increased of township hospitals(P＜0.01).4) Relative efficiency evaluationThe result of DEA indicated that 7 DMUs were CCR-efficient,5 DMUs were CCR-inefficient within 12 DMUs and all the DMUs got DEA scores more than 0.78. In all types of input,the utilization efficiency of finance input was the worst;and in all types of output,the productivity of service utilization was the worst.According to the situation of returns to scale(BCC model),3 DMUs were economies of scale.And there was no significant relationship between the general situation of the DMU and its relative efficiency(P＞0.05).5) Qualitative researchThe effectiveness of policy included the improvement of service utilization, service provision and system management.The cooperation of related departments and people-oriented philosophy are the key strategies of the effectiveness of MCSP in Guangxi Autonomous Region.Policy SuggestionThe allocation of all kinds of resources should be optimized to improve the efficiency of policy.The policy content should be adjusted based on the achievements and issues to facilitate the MCH further improvement in this region.And the policy should be taken as an opportunity to improve the administration capability of Guangxi MCH system.The intervention model,including dominant supports from the government, cooperations of related departments and social mobilization,provides essential assurance for policy process.During the decision making of detailed policy strategies, the characteristics of target population should be taken into consideration.And the policy strategies should cover those who provide services,those who utilize services and those who administrate the process of service delivery.