PPPs for EmOC under the JSY

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PPPs for EmOC under the JSY

• A rapid assessment study in a selected
• district of Maharashtra
• June 08-June 09
• Conducted by
• Foundation for Research in Community Health,
• (FRCH), Pune
• Investigators
• Dr. Bharat Randive, Dr. Sarika Chaturvedi

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India

• Health care industry is fast growing
• State of the art infrastructure
• Known to produce amongst the best doctors in the
  world
• Attractive hub for medical tourism

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But

• Fails to provide basic health care to its
  population
• Contributes to 20 of maternal deaths worldwide
• Hopes for a better change after the NRHM

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( SRS 2001-2003)
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Indian public health system

• Studies show inadequate infrastructure
• Shortage of drugs and supplies
• High vacancy rates especially of specialists in
  rural areas
• Of 20,000 obstetricians in India only 780 work in
  public system at sub district level

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Indian private medical sector

• Largest proportion of resources and services
• 93 of Hospitals
• 64 of Bed strength
• 80-85 of doctors
• 80 of Out patients
• 57 of In patients
• 
  Source World Bank
  2001
• 60 of MCH case load

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Maharashtra

• CHCs having functional OT- 84.6
• CHCs having Obstetrician - 40
• FRUs offering Caesarean section- 14.3
• FRUs having blood storage facility- 11.6
  
• -
  DLHS-3(2007-08)
• Annual intake for specialisation in obstetrics-
• 102 compared to none in certain states

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PPP for EmOC under JSY of NRHM

• Contractingin model
• Hiring private specialist for management of
  obstetric complications and for CS
• Rs.1500 as specialist charges
• Free EmoC in public facilities
• JSY Eligible clients (Maharashtra)-
• BPL, SC, ST women Over 19 years, Upto 2 live
  births

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Objectives- To understand

• 1. Design of PPPs in Ahmednagar district
• (partner selection / contracting mechanisms/
  performance measurement / facility accreditation
  processes / monitoring)
• 2. Execution of PPPs
• Experiences in implementing / using the scheme
• (Referral / cost consequences / financial
  provision)
• 3. Perceptions of providers and users about PPPs
  for EmOC

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Methodology

• Rapid Assessment of Health Programmes
• (RAHP) approach
• Mid course adjustments to programmes
• Documentation and analysis of lessons learnt
• Results not meant to be statistically valid
• Link between information and decision making
  focusing on why and how problems occur

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Study area

• Ahmednagar district in western Maharashtra
• MMR lt2 for 1000 live births
• SC-12.39, ST-7.2, BPL- 30
• 96 PHCs ,23 CHCs, 3 Subdistrict and 1 District
  Hospital
• Mushrooming of private hospitals, 2
  medical colleges

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Ahmednagar district health system

• Moderate performance

• Best SIS score

Source Health for Millions oct 07- jan 08 (IIPS
Mumbai)
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SAMPLE SIZE

• 5 /14 blocks selected randomly
• 2 PHCs/ block selected randomly
• Respondents
• Implementers- DHO, THO, MO/ANM (16)
• Beneficiaries (10)
• Non beneficiaries (8)
• Private EmOC providers ( 3)

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Data collection and processing

• Semi structured interviews
• Focus group discussions
• Data for deliveries during June 07 to Oct 08
• Thematic analysis

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CONSENT
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LIVING CONDITIONS
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PROBING
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.. VENTILATING
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• FINDINGS

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Implementation of PPP

• No contracting-in of private specialists
• No empanelment/accreditation of private
  facilities
• Thus NO PPPs in place

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Implementation

• Passive support of administrators
• Private providers not approached for PPP, vaguely
  aware through patients
• No contract execution plans

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Cost subsidisation preferred to PPP

• Rs. 1500 utilised as subsidy post C-section
• Benefit only to C- section, not to other
  obstetric complications
• Thus, 2/3 rd women in need of EmOC barred from
  eligibility
• Cash assistance rather than service provision

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Financial provision

• Inadequate financial provision for hiring
  specialist
• Prevailing charges above Rs. 3000
• He is not willing to do any work there because
  of interests in private hospital, otherwise all
  patients will get it done in the subdistrict
  hospital, who will want to spoil their own
  practice?.... (Mo-4)

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Financial assistance Consequences

• Average expenses incurred by women Rs. 15,000
  (range Rs. 10,000 to 30,000)
• Assistance received under PPP Rs. 1500
• Grossly insufficient .enough only for the
  tablets and medicines- Beneficiary 1
• Delay in disbursement - On avg recd 3 mths after
  delivery
• Indebtedness - pvt. loans _at_ 60pa

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Proportion of JSY assistance to CS charges paid
by women
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.. Referrals

• No referral chains, no referral slips
• Women mostly approaching private facilities
  directly
• Womens experiences Difficulties in arranging
  transport
• ..We walked to the highway asking for
  lift3pm.Reached the civil hospital. 8pm
• Travelled 40 km in 5 hrs after diagnosis of
  obstructed labour

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Analysis of Ahmednagar HMIS data April Sept.
08
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Poorly managed scheme

• Poor reach
• Lack of funds at grassroots
• Non uniform implementation across blocks-
  ambiguous guidelines
• No demand generation

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Reasons for non-utilisation and denials

• Women unaware of provision for EmOC
• Service area constraints- deliveries mostly at
  maternal homes
• Difficulties in producing required documents in
  time - ? 7 days of delivery
• Varying conditions for accessing the scheme- eg.
  registration before 12 wks, BPL survey rounds

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Views

• Useful only for cities, not for rural areas
• calling a doctor from town is equally good as
  taking the patient to the town- District
  official
• Inadequate public infrastructure for EmOC
  provision through contracting-in specialists -
  Public providers
• Difficulties in implementation
• frequent changes in guidelines
• eligibility conditions- time and documents
  criteria
• funds flow issues
• Demand for services rather than cash subsidy
• ..provide the facility instead of the money we
  poor do not have the money at that time to pay
  for the hospital, what if the government gives us
  the aid later on. Non beneficiary 2

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ConclusionsToo little, Too late

• No PPPs for EmOC under JSY in study district
• Inadequate financial provision for contracting-in
  specialists
• Infrastructural inadequacies, low motivation -
  barriers to contracting-in
• Subsidy mechanism minimally influences out of
  pocket payments for EmOC services
• Scheme implemented is exclusive

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Causes of maternal deaths addressed under PPP
Antenatal Intranatal Postnatal
Causes Hemorrhage Sepsis Hypertensive disorder Unsafe abortion Others Hemorrhage Obstructed labor Sepsis Hypertensive disorder Others Hemorrhage Sepsis Others
Addressed under PPP None Obstructed labor (LSCS) None
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Recommendations

• Model of PPP should be chosen considering local
  feasibility by dialogue among partners rather
  than directives from top
• Service provision rather than sudsidy
  Contracting-in / out such that onus of
  negotiating charges is not on the woman
• Capacity building for management of PPPs
• Charges for hiring specialists should be based on
  area specific competitive rates

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Recommendations

• Evolution and enforcement of mechanisms for
  monitoring,quality assurance and grievance
  redressal
• Scheme should include all life threatening
  complications of pregnancy and child birth
• Emphasis on micro-birth planning- Ensure birth
  preparedness and complication readiness

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Too far to go.

• THANK YOU!
• Acknowledgements
• Dr. Abhijit Das, CHSJ, New Delhi
• Amy Hagopian, Peter House, Univ. of Washington,
  USA
• UNFPA India