Can Public Private Partnership (PPP) reduce Maternal Mortality Rate (MMR)? Assessing efforts made by the

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Can Public Private Partnership (PPP) reduce
Maternal Mortality Rate (MMR)? Assessing
efforts made by the Chiranjeevi scheme in
Gujarat

• Akash Acharya and Paul McNamee

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Outline of the Presentation

• Overview of the problem (2)
• Maternal Health Situation in India (1)
• Explaining the Chiranjeevi scheme in Gujarat (4)
• Discussion, regulation issues and the need for
  probing further(4)

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Overview of the problem (1)

• Maternal Mortality remains a serious public
  health problem in the developing world and its
  reduction has been one of the major MDGs (MDG 5,
  reduce maternal deaths by 3 quarters by 2015)
• WHO estimates over 5,00,000 deaths due to
  pregnancy related causes which leaves over a
  million mother less children. Almost all of this
  is happening in the developing countries (lt1 in
  the developed world)
• The MMR difference between Developed and
  Developing world is dramatic as well as pathetic.
  e.g. About 1000 for Africa and 10 for North
  America

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Overview of the problem (2)

• This difference is more tragic as nothing new
  (technology, drugs etc.) is needed to save these
  lives and they are preventable. The problem is of
  access to ANC and EmOC
• Maternal health interventions like access to SBA
  and EmOC referral in case of need has worked in
  Sri Lanka and Malaysia
• Maternal Mortality is increasingly being seen not
  only as a health issues but human rights issues
  in terms of womens right to life, equal access
  of health and non discrimination

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Maternal Health Situation in India

• More than 1,00,000 women are dying every year in
  India through MM. This is about 20 of global MM.
  MMR 540-WHO 2006 Pakistan, China and Sri Lanka
  are doing better.
• In rural area the problem is of access to EmOC as
  most CHCs are running short of gynecologists and
  obstetricians as well as anesthetists (India
  doesnt allow a Nurse of even a doctor with post
  graduate degree to administer anesthesia or
  perform EmOC services) The only option left is to
  travel to DH, mostly several kilometers away
• Even at the DH problems of availability of
  relevant doctors, medicines, transport cost,
  attitude towards the poor etc. remain. Many women
  are hesitant to travel and die at home or in
  transit (gt50)
• It is now widely belived that India wont reach
  the MMR related MDG target by 2015 (MDG 5, reduce
  maternal deaths by 3 quarters by 2015-MDG
  Monitor)

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The Chiranjeevi Yojna (CY) in Gujarat (1)

• It seems that availability of qualified
  gynecologists with EmOC facility in vicinity can
  check the MMR through improved rate of
  institutional delivery which is the logic behind
  CY
• Although Gujarat is highly industrilised high per
  capita state, it doesnt fare very well on HDI
  (e.g. IMR, Malnutrition, Domestic violence etc.)
• More 5000 women die every year through MM mostly
  in remote rural, coastal and tribal areas
• Like other states, Gujarat also faces acute
  shortage of gynecologists in public health
  facilities (only 7 against 273 CHC positions) but
  they are available almost everywhere in private
  sector and therefore GoG decided to enlist their
  support

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The Chiranjeevi Yojna (CY) in Gujarat (2)

• CY (Meaning long life in Gujarati) is a PPP model
  where a poor women can go to EPPs and get the
  delivery done free. The cost will be borne by GoG
  Moreover Rs. 200 for transport and Rs. 50 for
  accompanying person- A bridge between private
  sector and the poor
• Thus it aims to remove the financial barrier to
  access of qualified health care facility in
  vicinity. The scheme was launched in five poor
  districts in 2005 and since 2007 it has been
  extended to entire Gujarat
• Qualified EPPs are paid Rs. 1,79,000 for a bunch
  of 100 deliveries including CS. The CS rate has
  been worked out at about 7 per cent and there is
  no separate payment for CS to discourage
  unnecessary CS- a practice widely prevalent in
  the private sector
• Remuneration package has been designed by group
  of experts and EPPs get an advance payment of Rs.
  15,000 while registering in the scheme. CDHO
  responsible for EPP identification

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The Chiranjeevi Yojna (CY) in Gujarat (3)
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The Chiranjeevi Yojna (CY) in Gujarat (4)

• It is being claimed that through CY, MMR and IMR
  has been reduced substantially. CY is by now a
  celebrated scheme and has also received Asian
  Innovations Award by the Wall Street Journal. It
  is flagship scheme of GoG MoHFW and being
  recommended for upscaling into other states

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Discussion based on Field Work (1)

• These unusual success claims need to be examined
  in details before replicating the scheme to other
  states/countries as scaling up involves a major
  resource transfer from public to private sector
• To understand the scheme better, we undertook a
  round of fieldwork in Surat city with GoG
  officials (CDHO staff), EPPs and beneficiaries
• Out of more than 200 gynecologist in Surat
  district, only 56 were registered for CY. Most of
  them located in Surat city and remaining in peri
  urban area. None in remote rural areas
• Even out of registered 56, very few have been
  active and conducting deliveries under the
  scheme, other have taken the advance from CDHO
  and havent been active under CY despite the fact
  that scheme remains well advertised, under
  performance needs to be further investigated

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Discussion based on Field Work (2)

• Two main motivational factor for EPPs to join the
  scheme Either new in practice and joined the
  scheme to build reputation through numbers or
  at the end of the career wanting to do some
  charitable work for the poor. None considered
  CY as part of their mainstream activity and
  leading mid career professionals in the field
  seem not be interested as they view CY as
  government, poor, charity etc. None of the
  interviewed EPPs viewed the CY as PPP
• Some EPPs joined CY in hope that they will get
  license/certificate for MTP by joining hands with
  government.
• It was observed that some EPPs were taking only
  safe cases and diverting complicated cases to
  public hospitals. This has profound implication
  for the dataset claiming high success.

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Discussion based on Field Work (3)

• EPPs claims that the remuneration package is
  unjust especially in case of complications. Many
  also informed that CS rate of 7 is totally
  unrealistic and in their experience it was more
  than 30. This has also resulted in some EPPs
  opting out the scheme
• BPL card is required to become beneficiary of the
  scheme but migrants dont have documentary
  evidences and therefore are left out of the
  scheme. Since most EPPs are located in posh areas
  of city, poor also hesitate in approaching them
  fearing some latent charges.
• Aanganwadi workers are the links between poor HHs
  and EPPs but sometime the trust is broken as EPPs
  demand money. On the other hand EPPs claim that
  many BPL card holders are fake and they dont
  deserve free treatment

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Discussion based on Field Work (4)

• If EPPs are mostly treating safe cases, then the
  whole purpose of the scheme will be defeated as
  the need is to treat EmOC cases, main reason
  behind high MMR. If complicated cases are not
  part of the dataset, obviously MMR will drop but
  that might be a false indicator as the scheme
  might just be shifting the problem to public
  providers? This requires detailed evaluation of
  CY at the community level not just beneficiaries.
  
• However, shortage of HRH is important problem in
  achieving health MDGs. Since the private sector
  is present as well as preferred in India, it has
  a potential to contribute towards public health
  goals (MMR, equity, health care financing for the
  poor etc.) through PPP but proper regulatory
  framework with continuous ME is required.

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Thanks!

• Akash Acharya
• Centre for Social Studies (CSS)
• University Campus
• Surat
• akash.acharya_at_gmail.com