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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Gujarat A Profile
Recognizing Gujarat potential the Planning
Commission set a target growth rate of 10 p.a.
for Gujarat
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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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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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Current Status
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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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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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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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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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Package Rates for Chiranjivi
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Service Charges In Govt and GIA Institutions
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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 Oct 2006
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Specialist Involvement
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Miles to go
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Issues

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

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UNFPA Report

• it is beyond doubt that the pilot in 5 districts
  has showed significant improvement in increase of
  institutional deliveries among the BPL population
  with high levels of clients satisfaction
• This is not only sustainable but can be stretched
  more from optimal capacity-utilization point of
  view

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IIM-A

• The Chiranjivi Scheme has put the purchasing
  power in the hands of BPL families. The
  monitoring of the scheme lies with the district
  authorities and Block Health Officers.
• Voucher method has instilled a sense of
  competition amongst the Obstetricians and made
  them more accountable.
• Attempt to extract extra payment is reduced to
  bare minimum as it is now important to win the
  loyalty of the beneficiaries for sustained
  revenue in the long run

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The bill for Gujarat
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Points for consideration

• Innovation
• Sustainability- financial and organizational
• Measurability of process, output and outcome
• Replication and scaling up
• Scheme contributions in improving quality of life
  of people and productivity

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Innovation

• Shortage of Gynecogists in public sector with
  solution in near future
• Worst sufferers of the shortage are marginalized
  group mothers
• MMR is also high in the marginalized groups for
  various reasons
• Availability of Gynecologists in private sector
• Outsourcing thorough PPP in social sector for
  Institutional delivery and Emergency Obstetric
  Care Services with private sector Gynecogists
• Cashless scheme
• Problem of delay in transportation is also solved

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SustainabilityOrganization and Financial

• Enough Gynecologists available in private sector
• Additional income to gynecologists without
  additional costs in establishment or overhead
• New comer Gynecologists are more attracted, as
  the scheme help them to get assured income in
  initial period of their practice and enlarge the
  clientele
• Demand will be increased and sustained by
• One to One contact between ANM and beneficiary,
• Mass awareness generation activity and
• community mobilization
• Currently the funds are available from Gujarat
  Government Budget, RCH II budget and Tribal
  development budget. Planning Commission of India
  is also considering the scheme for large scale
  replication of the scheme

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Measurability of Process, output and outcome

• Process can be measured in terms of numbers of
  beneficiaries getting obstetric services though
  the scheme
• Output can be measured in terms of beneficiaries
  taking benefit of the scheme against the
  expected deliveries during the month from BPL
  group
• Outcome in terms of MMR reduction can measured
  through SRS and comparison can be made with
  identical period. Special evaluation studies for
  scheme can also be undertaken

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Replication and Scaling Up

• The scheme is fit to be replicated where there is
  
• Large chunk of marginalized community
• Political commitment for MMR reduction
• Weak public health system unable to take up load
  of institutional delivery and Emergency Obstetric
  Services load on services
• Rapid expansion of Health services in terms of
  service delivery is not possible for various
  reasons
• Availability of large number of Gynecologists in
  private sector.

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Improving quality of life of people and
productivity

• Assured availability of quality services for
  maternity to mother and newborn care at zero cost
• Saving of Rs 500 to 5000 to family on delivery
  and complication related treatment
• Prompt and effective treatment leads to
• reduction of maternal mortality morbidity
• Reduction of Still Birth rate,
• Reduction in direct IMR
• Indirectly the scheme plays part in reduction of
  IMR and Child Mortality rate as mothers who are
  saved plays a major role in care of children

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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