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INVESTMENT CASE & EQUITY: A QUASI-EXPERIMENTAL ANALYSIS OF MATERNAL & CHILD HEALTHCARE SERVICES IN PUNJAB

Aim: This research aims to define equities determinants in maternal and child care in Punjab, a Pakistan province. The study focuses on the impact on Reproductive/ Maternal/ Newborn/ Child Adolescent Health (RMNCAH), introduced in 2016 through the Investment Case (IC) approach. Methodology: A complex-sample-analysis modified the weight of the sample. Weighted disaggregated data were produced by cross-tableting with Confidence Interval (CI). A DiD analysis was performed based on a linear model of regression. Finally, the effect of the involvement was calculated by multivariate linear regression. Principal Findings: The results show that changes had been measured in both the involvement and reference areas in involvement and no significant associations in the variables. Changes in involvement and contrast areas were similar. Also, there was no substantial improvement in aggregate outcomes from the multivariable regression analysis. In most developing countries, the IC approach is successful. Following the IC's introduction, some MNCH indicators such as ANC and the delivery of expert delivery of assistant birth showed improvements in involvement and contrast districts. Applications of this study: The research will provide a proper guideline for the policymaker to design a need-based policy for equitable admission to child health care and maternal facilities Novelty/Originality of this study: This study first analyzed the influence of investmentcase in the RMNCAH program in Punjab.


INTRODUCTION
A global commitment to reducing maternal mortality has also been an essential share of the sustainability plan (Magni, 2017). Goal three purposes to facilitate the global mother mortality rate to less than 70 per 100,000 live births. (Geller et al., 2018). In developed countries, nearly all (99 percent) mother deaths occur (Thompson-Dudiak, 2021). The primary cause of death and disability in Pakistan remains pregnancy and birth complications (Nigussie et al., 2021). Pakistan is one of six countries with an annual mortality ratio of 297 to 100000 live births and more than 50 percent of all maternal deaths worldwide (Cabero-Roura & Rushwan, 2014). Pakistan's formal maternal health policy reflects broadly endorsed strategies to promote safe childbirth, skilled birth attendance, and a timely emergency referral to a sound health system (Vogel et al., 2016). This policy was implemented with considerable efforts, first in the context of Safe Motherhood and later in MDGs, to improve service delivery (Patel et al., 2016).
Pakistan is unlikely to meet the fifth MDG objectives (Jin et al., 2018), which, despite these efforts, including reducing maternal mortality and access to universal reproductive health care (Dawson et al., 2014). One reason humans did not understand and address the factors limiting women who live on the economic and social margins of society's access to care (Khan et al., 2020). The most recent national data indicate that widespread maternal care socioeconomic inequalities have continued for all indicators (Novignon et al., 2019). Since this 92% of women report having antenatal care in the highest quintile wealth, 37% of women are in the lowest quintile rate (Ahinkorah et al., 2021). In the same way, 74% of women are present in the most significant higher-income households, particularly in contrast with 12% of women in the smallest quintile (El-Kak et al., 2020).
The current Pakistan NMN 2007 (Viswanath & Kreuter, 2007) recognizes these inequalities and strives to ensure care for disadvantaged and vulnerable groups (Bhutta et al., 2013). To date, policies and practical measures continue to be "more equal," with a significant focus on enhancing district healthcare organizations through optimized technology and managerial ability and creating a new community skilled workers Structure (Heerdegen et al., 2020). However, efforts were made to increase demand for maternal health care using targeted, socially acceptable communications strategies in government (Fotso et al., 2015). A simple technical approach is not enough in terms of supply to address the discriminations to get the maternal healthcare services and in the maternal death levels reflected in this growing recognition (Okoli et al., 2020). on mother-and-child health services in Punjab (Tsolaki et al., 2020;Bärnighausen et al., 2017). The PDHS was used to measure the influence of the IC approach of the sixteen involvement and twenty contrast districts in Punjab (Thapa et al., 2020). Two surveys contain data, namely PDHS 2017 and 2019. Both survey methods were identical.

Data Sources
The Punjab population and healthcare analysis assess the involvement bundle established through the IC (Investment Case) method on child & mother healthcare facilities in Punjab (Hao et al., 2020). The Multiple Indicator Cluster Survey (MICs) has a standardized analysis that accumulates statistics about the people, fitness, and diet of households. The MICS research is descriptive at the national level and uses a multi-stage analysis (Nisar & Dibley, 2014). There are two polls, i.e., MICS 2017 and 2019. Both methods of the survey were similar. Due to the length of involvement, data on several prenatal cares, at least four prenatal care, and professional care is limited to the last three years (from 2016 to 2020), i.e., back to 2017 studies and back to 2019.

Conceptual Framework
Figure2 showed the variables analyzed in this study.

Data Analysis
Any differences between the involvement and the contrast group were measured by DiD analysis, based on time changes rather than as a result of the participation itself (Gardezi, 2021 Table 2 shows differential (DiD) outputs about the allocation of female exogenous factors by participating and contrast region, due to the minimum 4 ANC practitioners' involving period. Minimum four ANCs increased in involvement after the participation, the value 41.3-55.8 and the contrast area 42.8-65.7. The difference in the rate of increase of 4.8% was statistically insignificant. The contrast area Far from all variables, both involvement and contrast districts have improved. District enhancements seem to be more prevalent for most of the variables than the participating districts.

DiD for a minimum of four ANC
Except for service or companies, the highest income quintiles, and hilly areas, other variables indicate a more significant gain than districts. Age groups 15-24 and 25-35, schooling, lowest and middle tertiary wealth, and married are substantial advancements in districts. Other factors have improved by a moderate to minimal amount as compared to districts. Only the service and company categories' variations were statistically relevant because there were at least four ANC.    Table 4 represents the regression of binary and multivariate for at least four ANCs. In at least four ANC visits, the independent variables that contributed to the changes included wealth indicator's p-value 0.006, a p-value of ethnicities is 0.009), the p-value of gender is 0.001 and p-value of husband's education is 0.000, and the p-value of the ecological region is 0.05. Minimum 4 ANC visits between 2017 and 2019 did not have an essential role in involvement, and the pvalue is 0.053.  Table 5 represents the multivariate and binary regression analysis for the delivery of expert delivery of assisting Analysis. The independent variables contributing to SBA delivery changes included wealth, education for women, residence, the age for women, Distance from health facilities, and the green region. For expert delivery of assisting birth delivery between 2017 and 2019, involvement played no significant role.

DISCUSSION
This Analysis aims to determine the involvement efficiency of the 16 districts compared to other districts. The study's main objective was to assess the response bundle's effect in Punjab using the Investment Case (IC) procedure (Prinja et al., 2015). In sub-Saharan African states, maternal and child healthcare factors are higher, with an increased proportion (Corsi & Subramanian, 2014). There have been some changes in the at least 4 ANCs and qualified care providers, but these improvements are essentially identical in both involvement and contrast. The discrepancies in the Involvement and Contrast regions showed haven't noticeable change. This action played no essential action in any of the leading investment case metrics between 2017 and 2019. Studies in 54 countries found that more minor equal involvements were accompanied by four or more prenatal visits to eligible childbirth involvements (Ameyaw & Dickson, 2020). A systematic meta-analysis of 11 randomized and clustered randomizations from countries such as Nepal, Bangladesh, India, and Pakistan shows that there has not any difference among the combined set involvement and control and three or more ANC visits and children's education (Colbourn et al., 2013). According to Baqui et al. (2016), In Bangladesh, a randomly controlled cluster study was carried out the bundle of public-based neonatal motherly involvement in the functional and awareness measures relating to improvement in maternal and neonate involvement in comparative areas was performed.
In contrast with the individual involvement programs, a systematic review of mother's health programs in resourcelimited countries found a substantial effect on maternal health. A research group in India has demonstrated essential changes in health and health care (Metwally et al., 2020). Also, in 259 tests and reports, which include systemic and descriptive Analysis, randomized controlled trials, classified, controlled, and regulated pre-post and uncontrolled timeseries studies, cross-sectional tests, and expert opinion documents, a systematic analysis that analyses 208 novel methods to MNH has completed creative technologies with inventive implants. Applied by the Government of Punjab to identify hurdles in recuperating maternal health services in Punjab (MHS), the Punjab Safe Motherhood Initiative (PSMI) Project is a successful well-coordinated program to reduce the blocks within the health and financial state services.

INVOLVEMENT
The involvement structure already constitutes a complex project involving multiple approaches to various motherly, newborn, and child healthcare measures. The work comprises all the factors that make it difficult and complicated to target healthcare professionals in the Tanahashi model. Findings from various tests and studies were done in all the other countries may lead to investment cases, and the situations may not have the same as in neighboring states. The investment case involves all health stakeholders in the districts. Suppose there are many treatments in the equipment. In this situation, the entire involvement has been diminished because of service providers' dispersed focus and policymakers, and judgment creators. An appraisal of the Asia-Pacific IC has also shown how complicated the District Managers' approach is over and above the staff capability.

IMPLEMENTATION OF INTENSITY AND QUALITY
There was a greater emphasis on budgeting and technical support in the districts when carrying out an investment event.
The district workshop concluded with action plans with different stakeholder roles for various tracers. However, both stakeholders and implementing partners have not monitored the action plans regularly. In the districts, there were no technicians who monitored the involvement regularly. The restriction of resources was also an essential factor in the participants' quality since minimal resources (mainly staff) were available for the hard-to-access activities.

CONCLUSION
The structure, workforce, and time frame of the study are significant factors in the framework to show the possible impact on communities. Thrift Data from services and health surveys were obtained. The study used assessed approximately experimental results using distinctions and multivariable linear regression. To evaluate the effects of an investment in the Punjab districts, the study used PDHS data of 2017 and 2019. A significant increase has been shown from the 2017 and 2019 Punjab Health and Demography Survey. Certain variations were observed in essential facts such as a minimum of 4 ANCs and qualified health workers, but these enhancements are generally identical in both participation and contrast regions. The results have shown that participation methods need to be redesigned so that the IC approach is efficient.

LIMITATION AND STUDY FORWARD
Since the study is almost experimental, various potential biases may be present. The MICS samples cannot be taken to account for the entire district population since some district samples are more extensive and some may have sample data. The people from each study area may vary. The data for the respective MNCH indicators is smaller, which reduces the analysis frequency and impacts the strong relation of variables. The districts selected as population contrasts had almost the same HDI (Human Development Index) as the involvement regions; however, it is comparatively easy to achieve. By IC method, all districts not accessible were selected as districts of involvement. Therefore, the interference and contrast districts are only-this study first time analyzing the impact of investment case in the RMNCAH program in Punjab. The research will provide a proper guideline for the policymaker to design a needbased policy for good entree to motherly and child healthcare facilities.

ACKNOWLEDGEMENT
Thank you to all my colleagues who have been so supportive on the way to research. I would like to take this opportunity to thank you warmly. I would also like to thank my family most sincerely for their support during the entire lifetime and primarily through the research paper. I have the opportunity to finish this paper because of their unconditional love and prayers. Last but not least, thanks to all those who participated in this research.