Case Study of Safe Motherhood Programme from Gujarat, India

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Case Study of Safe Motherhood Programme from
Gujarat, India

• Dr Dileep Mavalankar, team
• Center for Management of Health Services,
• Indian Institute of Management
• Ahmedabad

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Profile of Gujarat State

• Gujarat is a state in western India.
• Total population of 51 million(2001) with 15 SC
  and 7 ST population
• It has 25 districts, 242 towns and 18,618
  villages.
• One of the most urbanized states of India - with
  37 urban population
• Economically rapidly growing state SDP 8-10
  per year

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Objective of the case study

• To analyses the maternal health situation and
  safe motherhood program efforts
• To identify challenges and provides
  recommendations for improvement

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Methodology

• Review of literature, secondary data from
  government MIS, interview with stakeholders,
  process evaluation
• Primary data collection on Chiranjeevi Yojana. (
  PPP voucher scheme)
• Review of recent initiatives improve maternal
  health

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Four Tier Health Care System

• District hospital with 4-5 specialist services
  for 1-3 million people
• Community Health Center with 1-2 specialist for
  100,000 to 300,000 population
• Primary health Center with MO for 30,000
  population
• Sub-health Center with ANM for 5,000 pop.

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Government Health Infrastructure
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Key problems with health infrastructure
services delivery

• Substantial shortfall in health infrastructure in
  rural areas
• Problem of availability of specialists in public
  hospitals
• Lack of accountability ANMs and MOs not staying
  at place of posting. availability very limited
• Too much focus on FP and Immunization neglect
  of maternal care esp. delivery care

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Inadequate management structure at state level

• Only two technical staff at the state level for
  managing maternal health services state has 50
  m pop 1.2 m births

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Effect on Performance Indicators
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Challenges in SM program

• Human resource for EmOC major problem
• ANMs and MOs- not Skilled birth attendants and
  not accountable for delivery
• Inadequate infrastructure for delivery care
  poor O M, no blood available in rural areas
• Lack of managerial capacity and positions
• Weak vital registration system- poor Maternal
  death recording
• Absence of socio-political priority MH

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Recent Initiatives to improve MH under the
leadership of Dr. Amarjeet Singh, Commissioner of
Health

• Chiranjeevi Yojana
• Janani Suraksha Yojana incentive for
  institutional delivery
• Training General doctors for BEmOC, CEmOC and
  Anesthesia
• Skill up gradation training to ANMs
• Emergency transports system with Satyam
  foundation
• Establishment of Blood storage units with NGOs

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Chiranjeevi Yojana a Flagship scheme for
delivery care for poor

• Rationale very few obgyns in govt system but
  lots in private sector even in rural areas
• Public Private partnership (PPP) to improve
  access to institutional delivery for poor
• Voucher - like scheme for poor
• Piloted in five backward districts for 1.5 years
  now scaled up to all 25 districts
• Package of 100 deliveries including CS given to
  Private Ob for providing services delivery care,
  basic newborn care transport money
• Average per delivery payment to private obgyn is
  40
• Payment in advance !!!

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Our study in one dist showed

• 81 of poor utilized the scheme in first year
• Almost all beneficiaries are really poor
  leakage of benefits to non-poor very less
• Cost per delivery much lower to the beneficiaries
  than non-beneficiaries financial burden
  lessened
• Post delivery complications were less for
  beneficiaries(10) than non- beneficiaries(26)
• Issues in implementation need to be addressed
  maternal deaths, stillbirths, referral not
  monitored

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Summary recommendations

• MH programs especially delivery care neglected
  in government sector Focus on SBA and EmOC
• Efforts needed for improving staff skills,
  infrastructure and accountability
• Monitoring functionality of service delivery
  centers is needed.
• Chiranjeevi Scheme needs fine tuning.
• Improving management capacity including HR
  management is the key intervention
• Rebuilding the public health system needed

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Thanks

• Any questions ?

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MMR declining in Gujarat