Chiranjeevi Chiranjeevi

Maternal Health Maternal Health Financing Issues Financing Issues

and Optionsand Options

Dr Amarjit SinghDr Amarjit SinghCommissioner Health & Commissioner Health &

Secretary Family Welfare Secretary Family Welfare Government of GujaratGovernment of Gujarat

Lessons from HSRsLessons from HSRs

Steer don’t rowSteer don’t row

Finance rather than directly provideFinance rather than directly provide

Explore options for PPPExplore options for PPP

Regulate quality, cost-effectivenessRegulate quality, cost-effectiveness

Protect the marginalised groupsProtect the marginalised groups

Every Minute...

Maternal Death Watch-Maternal Death Watch-GlobalGlobal

380 women become pregnant380 women become pregnant

190 women face unplanned or 190 women face unplanned or unwanted pregnancyunwanted pregnancy

110 women experience a 110 women experience a pregnancy related complicationpregnancy related complication

40 women have unsafe 40 women have unsafe abortionsabortions

1 woman dies from a 1 woman dies from a pregnancy-related complicationpregnancy-related complication

Gujarat – A ProfileGujarat – A Profile

Overview

Area 196,000 km 6% of India

Population 50.5 million 5% of India

Urbanization 37% India avg. 28%

SDP(2003-04)

Rs 1,425.60 billion(€ 26.40 bill.)

6.33% of India

Per Capita Income(2003-04)

Rs 26,979 (€ 496.24)

India average -Rs. 20,989

(€ 388.69)

Recognizing Gujarat potential the Planning Commission set a target growth rate of 10% p.a. for Gujarat

Current StatusCurrent Status

Indicator India Gujarat

Maternal Mortality Ratio

453 389

Infant Mortality Rate 63 57

Maternal Deaths in one year

1,20,000 5000

Infant Deaths in one year

25,00,000 72000

OBJECTIVES- OBJECTIVES-

Vision 2010, Population Policy & RCH Vision 2010, Population Policy & RCH IIII

Reduce MMR from 389 (in 1998) to Reduce MMR from 389 (in 1998) to 100 per 100,000 live births by 2010100 per 100,000 live births by 2010

Reduce IMR from 60 to 30 by 2010Reduce IMR from 60 to 30 by 2010

Stabilize population by reducing TFRStabilize population by reducing TFR from 3.0 to 2.1 by 2010from 3.0 to 2.1 by 2010

Infection14.9%

Haemorrhage24.8%

Indirect causes19.8%

Other direct causes

7.9%

Unsafe abortion

12.9%

Obstructed labour

6.9%

Eclampsia12.9%

Causes of Maternal Death

Timing of maternal deaths-Timing of maternal deaths-General ConditionsGeneral Conditions

Postpartum60%

During pregnancy

24%

During delivery

16%

Time from Time from onset of complication to deathonset of complication to death

PPHPPH 2 hour2 hour

APHAPH 12 hour 12 hour

Ruptured uterusRuptured uterus 1 day1 day

EclampsiaEclampsia 2 days2 days

Obstructed laborObstructed labor 1 day1 day

SepsisSepsis 6 days6 days

When do babies die

73.3

4.2

13.8

8.7

0 10 20 30 40 50 60 70 80

Week 4

Week 3

Week 2

Week 1

Maternal Mortality: Maternal Mortality: UK 1840–1960UK 1840–1960

0

100

200

300

400

500

MaternalDeaths

Improvements in nutrition, sanitation

Antibiotics, banked blood, surgical improvements

Antenatal care

Maine 1999.

Maternal Mortality ReductionMaternal Mortality ReductionSri Lanka 1940–1985Sri Lanka 1940–1985

0

400

800

1200

1600

2000

1940–45 1950–55 1960–65 1970–75 1980–85Ma

tern

al

De

ath

s p

er

10

0 0

00

liv

eb

irth

s

85% births attended

by trained personnel

New Global Understanding ofNew Global Understanding ofMMR ReductionMMR Reduction

Once major obstetric complication Once major obstetric complication develops- even a trained TBA or a nurse develops- even a trained TBA or a nurse cannot do much at home cannot do much at home

These complications require effective back These complications require effective back up by trained O&G expertsup by trained O&G experts

surgical interventions surgical interventions injections of antibiotic injections of antibiotic blood transfusion blood transfusion aggressive treatments aggressive treatments

Three Delays Responsible for Three Delays Responsible for Maternal DeathsMaternal Deaths

1.1. Delay in deciding to seek careDelay in deciding to seek care (Individual & family) (Individual & family) Lack of understanding of complicationsLack of understanding of complications Gender issues, Low status of womenGender issues, Low status of women Socio-cultural barriers to seeking careSocio-cultural barriers to seeking care Poor economic conditions of the familyPoor economic conditions of the family

2.2. Delay in reaching careDelay in reaching care ( Community & System) ( Community & System) Lack or underutilization of transport fundsLack or underutilization of transport funds Non availability of referral transport in remote placesNon availability of referral transport in remote places Lack of communication networkLack of communication network

3.3. Delay in receiving careDelay in receiving care (System) (System) Poor facilities, personnel and SuppliesPoor facilities, personnel and Supplies Poorly trained personnel with indifferent attitudePoorly trained personnel with indifferent attitude

Delay in problem recognition and decision makingSECOND DELAYSECOND DELAY

Delay in reaching a referral facility

FIRST DELAYFIRST DELAY

THIRD DELAYTHIRD DELAY

Delay in getting care at the health facility

WHY Do Women Die?WHY Do Women Die?

OptionsOptions

Improve Government Health ServiceImprove Government Health ServiceCompetent staffCompetent staff

Adequate infrastructural facilitiesAdequate infrastructural facilities

User friendly, good quality Competitive User friendly, good quality Competitive Services Services Marketing of servicesMarketing of services

Public Private PartnershipPublic Private Partnership

Outsourcing- Curative servicesOutsourcing- Curative services

Health Insurance Health Insurance

Maternal Health- GujaratMaternal Health- GujaratObjectives ( by 2010):Objectives ( by 2010):

Universalize coverage of antenatal care Universalize coverage of antenatal care (100%)(100%)

Increase the deliveries attended by SBAs Increase the deliveries attended by SBAs 90% 90%

Increase institutional deliveries by 80%Increase institutional deliveries by 80% increase access to Emergency Obstetric increase access to Emergency Obstetric

Care for complicated deliveries Care for complicated deliveries Increase coverage of Post Natal Care Increase coverage of Post Natal Care

(90%) (90%) Increase access to Early & Safe Abortion Increase access to Early & Safe Abortion

servicesservices Improve access to RTI/ STI servicesImprove access to RTI/ STI services Introduce AFHS in all PHC/ CHCsIntroduce AFHS in all PHC/ CHCs..

Broad IssuesBroad Issues

Non - availability of O & G specialistsNon - availability of O & G specialists

Accessibility of services-Tribal and Accessibility of services-Tribal and urban slumsurban slums

Poor utilization of services- Poor utilization of services- Low felt need of health & medical servicesLow felt need of health & medical services Lack of user friendly & quality public health Lack of user friendly & quality public health

servicesservices Costly private health and medical servicesCostly private health and medical services No health insurance coverageNo health insurance coverage

Chiranjeevi Yojna - OptionsChiranjeevi Yojna - Options

Service Coverage through Service Coverage through outsourcing- voucher systemoutsourcing- voucher system

Emergency Obstetric Care & Emergency Obstetric Care & Neonatal CareNeonatal Care

Private Gynecs/ GIA in their facilityPrivate Gynecs/ GIA in their facility

Payment to Gynecs for working in Payment to Gynecs for working in government hospitalgovernment hospital

Service ChargesService Charges

Normal delivery 85 800 68000

Complicated cases

Eclampsia 1000

Forceps/vacuum/breech 3 1000 3000

Episiotomy 800

Septicemia 2 3000 6000

Blood transfusion 3 1000 3000

Cesarean (7%) 7 5000 35000

Predelivery visit 100 100 10000

Investigation 100 50 5000

Sonography 30 150 4500

Dai 100 50 5000

Transport 100 200 20000179500

Service ChargesService Charges

Normal delivery 85 200 17000

Complicated cases

Eclampsia 300

Forceps/vacuum/breech 3 300 900

Episiotomy 300

Septicemia 2 300 600

Blood transfusion 3 300 900

Cesarean (7%) 7 1000 7000

Predelivery visit 100 100 10000

Investigation

Sonography 30 150 4500

Dai 100 50 5000

Transport 100 200 20000

65900

Population and BirthsPopulation and Births

Kachchh 1526321

Banas Kantha 2502843

Sabar Kantha 2083416

Panch Mahals 2024883

Dohad 1635374

 Total 9772837

Total Births 234548

 BPL births 96432

Implementation of Chiranjeevi - 1Implementation of Chiranjeevi - 1

District level FOGSI members workshops District level FOGSI members workshops organized for orientation on Chiranjeevi scheme organized for orientation on Chiranjeevi scheme and enrollment of doctors on the paneland enrollment of doctors on the panel

Honorable Health Minister wrote a letter about the Honorable Health Minister wrote a letter about the scheme to presidents of district and talukas in 5 scheme to presidents of district and talukas in 5 districts.districts.

District level Advocacy workshops of Presidents of District level Advocacy workshops of Presidents of district and taluka panchayat, along with BHO and district and taluka panchayat, along with BHO and Chiranjeevi panel doctors organized in each Chiranjeevi panel doctors organized in each district. district.

Implementation of Chiranjeevi - 2Implementation of Chiranjeevi - 2

In each district IEC activities were undertaken. In each district IEC activities were undertaken. Awareness through Gramsabhas Awareness through Gramsabhas

Rs 15000/ advance was given to each Rs 15000/ advance was given to each obstetrician. No delay in reimbursement to obstetrician. No delay in reimbursement to doctors.doctors.

Regular interaction with Chiranjeevi Panel Regular interaction with Chiranjeevi Panel doctors by CDHOsdoctors by CDHOs

Chiranjiv Yojna - performance as on June 2006

District Normal LSCS Complicated Total % LSCS

BK 3081 125 310 3516 3.6

Dahod 1842 113 430 2415 4.7

Kutch 1386 95 345 1826 5.2

P'mahal 4777 80 0 4857 1.6

SK 3422 383 0 3805 10.1

Total 14508 796 1085 16389 4.9

Specialist Involvement

DistrictTotal O&GSpecialists available

# enlisted under

chiranjivi

Total # of deliveries

Performed

Average delivery per O&G

BK 50 58 3516 61

Dahod 16 15 2415 161

Kutch 47 20 1826 91

P'mahal 29 20 4857 243

SK 73 45 3805 85

Total 215 158 16389 104

Miles to goMiles to go

District

BPL deliveries

workload for 6 months

BPL chiranjivi beneficiaries for

6 months

% age against BPL delivery workload for

6 months

BK 9464 3516 37

Dahod 7686 2415 31

Kutch 7576 1826 24

P'mahal 8100 4857 60

SK 15390 3805 25

Total 48216 16389 34

72.5

69.474.0

70.7

81.4 84.1 84.8 86.6

36.843.044.146.8

63.2

53.255.9

57.0

35

40

45

50

55

60

65

70

75

80

85

90

2002-03 2003-04 2004-05 2005-06

Per

cent

age

Complete ANC PNC Domicilliary Deliveries Institutional Deliveries

Maternal Health- ANC, deliveries, PNC: 2002- 2006

Effect on Government deliveriesEffect on Government deliveries

0

20000

40000

60000

80000

100000

120000

140000

160000

180000

200000

2001-02 2002-03 2003-04 2004-05 2005-06

BeMOCs CHCs PHCs Sub Centre

IssuesIssues

Surge of demand - boon to the poorSurge of demand - boon to the poor

Unprecedented support from the private practitioners Unprecedented support from the private practitioners

Unindicated C-section in checkUnindicated C-section in check

Availability of bloodAvailability of blood

Still asking for additional funds from the BPLStill asking for additional funds from the BPL

Non-BPL beneficiaries also being attendedNon-BPL beneficiaries also being attended

Under utilisation of Public facilitiesUnder utilisation of Public facilities

Issues in expansionIssues in expansion

Additional day’s stay after deliveryAdditional day’s stay after delivery

Sanitary pads supplySanitary pads supply

More funds for accompanying person – DaiMore funds for accompanying person – Dai

Other services Sterilisation/ IUD/ RTI/ STI/ Other services Sterilisation/ IUD/ RTI/ STI/ HIV/AIDS/pap smearHIV/AIDS/pap smear

More charges for transportation in KutchMore charges for transportation in Kutch

Cost likely to increase to 2,00,000/100 deliveriesCost likely to increase to 2,00,000/100 deliveries

The bill for Gujarat & IndiaThe bill for Gujarat & India

BPL Population Delivery LoadEstimated BPL births

Costs @1795/delivery

Five pilot districts 4 months

16,389 Rs 29 million

Five districts (annual)

96432 Rs 172 million

Entire Gujarat BPL Beneficiaries

3,00,000 Rs 540 - 600 million

India --10000 million*

Our Mission:

“Save the lives of thousands of Mothers and

Children dying for no fault of theirs and prevent the spread of infections and

promote healthy life styles”

Working together for a healthy Bharat