Chiranjeevi Maternal Health Financing Issues and Options Dr Amarjit Singh Secretary Family Welfare Government of Gujarat

Lessons from HSRs Steer don’t row Finance rather than directly provide Explore options for PPP Regulate quality, cost-effectiveness Protect the marginalised groups

Maternal Death Watch- Global Every Minute... 380 women become pregnant 190 women face unplanned or unwanted pregnancy 110 women experience a pregnancy related complication 40 women have unsafe abortions 1 woman dies from a pregnancy-related complication

Gujarat – 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 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 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

Vision 2010, Population Policy & RCH II OBJECTIVES- Vision 2010, Population Policy & RCH II Reduce MMR from 389 (in 1998) to 100 per 100,000 live births by 2010 Reduce IMR from 60 to 30 by 2010 Stabilize population by reducing TFR from 3.0 to 2.1 by 2010

Timing of maternal deaths- General Conditions

Time from onset of complication to death PPH 2 hour APH 12 hour Ruptured uterus 1 day Eclampsia 2 days Obstructed labor 1 day Sepsis 6 days

Maternal Mortality: UK 1840–1960 Other interventions can make a difference, but not as substantial as skilled attendants. For example, in this graph, the implementation of antenatal care did not reduce maternal mortality in the UK. Improvements came only with skilled attendants who could provide surgical intervention if needed, and who had access to and could use appropriate antibiotics and blood products. Nevertheless, antenatal care remains an important intervention in maternal care because it provides an opportunity to detect problems and be prepared to handle them. Improvements in nutrition, sanitation Antenatal care Antibiotics, banked blood, surgical improvements Maine 1999.

Maternal Mortality Reduction Sri Lanka 1940–1985 85% births attended by trained personnel Even with TBA’s and other interventions, maternal mortality decreased in Sri Lanka. The reduction, however, was the greatest (maternal mortality was the lowest) after having births attended by skilled providers The government’s commitment to this intervention was crucial.

New Global Understanding of MMR Reduction Once major obstetric complication develops- even a trained TBA or a nurse cannot do much at home These complications require effective back up by trained O&G experts surgical interventions injections of antibiotic blood transfusion aggressive treatments

Three Delays Responsible for Maternal Deaths Delay in deciding to seek care (Individual & family) Lack of understanding of complications Gender issues, Low status of women Socio-cultural barriers to seeking care Poor economic conditions of the family Delay in reaching care ( Community & System) Lack or underutilization of transport funds Non availability of referral transport in remote places Lack of communication network Delay in receiving care (System) Poor facilities, personnel and Supplies Poorly trained personnel with indifferent attitude Multiple factors affect WHY a woman dies during pregnancy. The “three delays” model”: Delay in decision to see care: lack of information about problems/warning signs, social factors Delay in reaching care: having transportation, road conditions Delay in receiving care: lack of equipment or personnel at facility, lack of funding, poor attitude of personnel

Options Improve Government Health Service Competent staff Adequate infrastructural facilities User friendly, good quality Competitive Services Marketing of services Public Private Partnership Outsourcing- Curative services Health Insurance

Maternal Health- Gujarat Objectives ( by 2010): Universalize coverage of antenatal care (100%) Increase the deliveries attended by SBAs 90% Increase institutional deliveries by 80% increase access to Emergency Obstetric Care for complicated deliveries Increase coverage of Post Natal Care (90%) Increase access to Early & Safe Abortion services Improve access to RTI/ STI services Introduce AFHS in all PHC/ CHCs.

Broad Issues Non - availability of O & G specialists Accessibility of services-Tribal and urban slums Poor utilization of services- Low felt need of health & medical services Lack of user friendly & quality public health services Costly private health and medical services No health insurance coverage

Chiranjeevi Yojna - Options Service Coverage through outsourcing- voucher system Emergency Obstetric Care & Neonatal Care Private Gynecs/ GIA in their facility Payment to Gynecs for working in government hospital

Service Charges Normal delivery 85 800 68000 Complicated cases Eclampsia 1000 Forceps/vacuum/breech 3 3000 Episiotomy Septicemia 2 6000 Blood transfusion Cesarean (7%) 7 5000 35000 Predelivery visit 100 10000 Investigation 50 Sonography 30 150 4500 Dai Transport 200 20000 179500

Service Charges Normal delivery 85 200 17000 Complicated cases Eclampsia 300 Forceps/vacuum/breech 3 900 Episiotomy Septicemia 2 600 Blood transfusion Cesarean (7%) 7 1000 7000 Predelivery visit 100 10000 Investigation Sonography 30 150 4500 Dai 50 5000 Transport 20000 65900

Population and Births Kachchh 1526321 Banas Kantha 2502843 Sabar Kantha 2083416 Panch Mahals 2024883 Dohad 1635374  Total 9772837 Total Births 234548  BPL births 58637

Implementation of Chiranjeevi-1 District level FOGSI members workshops organized for orientation on Chiranjeevi scheme and enrollment of doctors on the panel Honorable Health Minister wrote a letter about the scheme to presidents of district and talukas in 5 districts. District level Advocacy workshops of Presidents of district and taluka panchayat, along with BHO and Chiranjeevi panel doctors organized in each district.

Implementation of Chiranjeevi-2 In each district IEC activities were undertaken. Awareness through Gramsabhas Rs 15000/ advance was given to each obstetrician. No delay in reimbursement to doctors. Regular interaction with Chiranjeevi Panel doctors by CDHOs

Preliminary results Total O&G Enrolled Deliveries Average/ doc BK 50   Total O&G Enrolled Deliveries Average/ doc BK 50 52 2712 Dahod 16 18 1749 97 Kutch 47 20 1214 61 P’mahals 29 27 3395 126 S’kantha 73 46 2736 59 215 163 11806 72

Caesarian/complicated deliveries LSCS Complicated Average/ BK 2712 91 209 3 Dahod 1749 88 310 5 Kutch 1214 65 199 P’mahals 3395 38 1 S’kantha 2736 282 10 11806 564 718

% age against BPL delivery workload for comparable period Miles to go District % age against BPL delivery workload for comparable period BK 23 Dahod 30 Kutch 18 Panchmahal 44 SK 38 State 31

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

Effect on Government deliveries

Issues Surge of demand - boon to the poor Unprecedented support from the private practitioners Unindicated C-section in check Availability of blood Still asking for additional funds from the BPL Non-BPL beneficiaries also being attended Under utilisation of Public facilities

Issues in expansion Additional day’s stay after delivery Sanitary pads supply More funds for accompanying person – Dai Other services Sterilisation/ IUD/ RTI/ STI/ HIV/AIDS/pap smear More charges for transportation in Kutch Cost likely to increase to 2,00,000/100 deliveries

The bill for Gujarat BPL Population Delivery Load Costs @1795/delivery Estimated BPL births Costs @1795/delivery Five pilot districts 4 months 11,806 Rs 21 million Five districts (annual) 58,637 Rs 105 million Entire Gujarat BPL Beneficiaries 3,00,000 Rs 540 - 600 million India --12000 million*

Working together for a healthy Bharat Our Mission: “Save the lives of thousands of Mothers and Children dying with no reason of theirs and prevent the spread of infections and promote healthy life styles” Working together for a healthy Bharat

THANKS