Chiranjeevi Maternal Health Financing Issues and Options

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Chiranjeevi Maternal Health Financing Issues
and Options

• Dr Amarjit Singh
• Commissioner Health
• Secretary Family Welfare
• Government of Gujarat

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Lessons from HSRs

• Steer dont row
• Finance rather than directly provide
• Explore options for PPP
• Regulate quality, cost-effectiveness
• Protect the marginalised groups

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Maternal Death Watch-Global

• 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

Every Minute...
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Gujarat A Profile
Overview Overview 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
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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
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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

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Timing of maternal deaths-General Conditions
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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

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Maternal Mortality UK 18401960
Improvements in nutrition, sanitation
Antibiotics, banked blood, surgical improvements
Antenatal care
Maine 1999.
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Maternal Mortality ReductionSri Lanka 19401985
85 births attended by trained personnel
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New Global Understanding ofMMR 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 OG experts
• surgical interventions
• injections of antibiotic
• blood transfusion
• aggressive treatments

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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

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WHY Do Women Die?
FIRST DELAY
Delay in problem recognition and decision making
SECOND DELAY
THIRD DELAY

Delay in reaching a referral facility
Delay in getting care at the health facility
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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

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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.

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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

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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

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Service 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 20000
179500
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Service Charges
Normal delivery 85 200 17000
Complicated cases
Eclampsia 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 Investigation
Sonography 30 150 4500
Dai 100 50 5000
Transport 100 200 20000
65900
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Population and Births
Kachchh 1526321
Banas Kantha 2502843
Sabar Kantha 2083416
Panch Mahals 2024883
Dohad 1635374
 Total 9772837
Total Births 234548
 BPL births 96432
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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.

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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

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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
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Specialist Involvement
District Total OG Specialists available enlisted under chiranjivi Total of deliveries Performed Average delivery per OG
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
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Miles 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
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Maternal Health- ANC, deliveries, PNC 2002- 2006
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Effect on Government deliveries
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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

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Issues in expansion

• Additional days 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

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The bill for Gujarat India
BPL Population Delivery Load Estimated BPL births Costs _at_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
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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
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THANKS