Chiranjivi - GujaratUsing vouchers to reduce maternal mortality

Dr Amarjit SinghSecretary, Department of Health & Family Welfare

Government of Gujarat

April 12-13, 2007, Best Western Resort Country Club,Gurgaon, India

Vouchers for health

Increasing access, equity and quality

Gujarat – A Profile

Overview

India average -Rs.20,989

(€ 388.69)

Rs 26,979(€ 496.24)

Per Capita Income(2003-04)

6.33% of IndiaRs 1,425.60 billion(€ 26.40 bill.)

SDP(2003-04)

India avg. 28%37%Urbanization

5% of India

6% of India

50.5 million

196,000 km

Population

Area

Recognizing Gujarat potential the Planning Commission set a target growth rate of 10%per annum for Gujarat

Every Minute...

Maternal Death Watch-Global

• 380 women become pregnant

• 190 women face unplanned orunwanted pregnancy

• 110 women experience apregnancy related complication

• 40 women have unsafeabortions

• 1 woman dies from apregnancy-related complication

State of Maternal Health

• 5.29 lacs maternal deaths

• Out of this, 1.36 lacs (25.7%) in India, thehighest burden in any country

• Variations between region & States as well associo-economy groups

• MMR higher in SCs & Tribal communities andamong those living in less developed villages.

Variations amongst states

466India

284Tamil Nadu

262Kerala

389Gujarat

Socio-Economic Variation inMMR

646488

Village DevelopmentLowHigh

555484

Socio-Economic StatusPoorNon-Poor

584652

CasteSCST

MMR Over Time

RuralUrbanTime PeriodSource

6192671998-99(540)

NFHS - 2

4483971992-93(424)

NFHS

Strengthen service delivery:Reaching the poor

Percent of deliveries attended bydoctor, nurse or trained midwife

0

25

50

75

100

Richest Fourth Middle Second Poorest

Quintiles

%

Brazil

Indonesia

India

Bulletin of WHO 2003:81:616-623

Distance from the nearest PHC

2 to 5 km,25%

18 to 20 km,10%

6 to 9 km,25%

10 to 11 Km10%

12 to 13 km30%

Health care facilities available

10080

60

3010

5

0

20

40

60

80

100

Untrained dai Quack Trained dai ANM Homeopath Ayurved

Timing of maternal deaths-General Conditions

Postpartum60%

Duringpregnancy

24%

Duringdelivery

16%

Infection14.9%

Haemorrhage24.8%

Indirectcauses19.8%

Other directcauses

7.9%

Unsafeabortion

12.9%

Obstructed labour6.9%

Eclampsia12.9%

Causes of Maternal Death

Time fromonset of complication to death

• PPH 2 hour• APH 12 hour• Ruptured uterus 1 day• Eclampsia 2 days• Obstructed labor 1 day• Sepsis 6 days

When do babies die

73.3

4.2

13.8

8.7

0 10 20 30 40 50 60 70 80

Week 4

Week 3

Week 2

Week 1

Year

1999199619931990198719841981197819751972

Mor

talit

yR

ate

per

1000

Live

Birt

hs

160

140

120

100

80

60

40

20

0

Infant

Neonatal

Post-neonatal

2.9 %

1.4 %

1.5 %

Trends in Infant Mortality Components

P < 0.001

R2 = 0.74

0

200

400

600

800

1000

1200

1400

1600

1800

2000

0 10 20 30 40 50 60 70 80 90 100

Y Log. (Y)

Higher the proportion of deliveriesattended by SBA, lower the country’s

MMR

% skilled attendant at delivery

Mat

ern

ald

eath

sp

er10

0000

0liv

eb

irth

s

Maternal Mortality: UK 1840–1960

0

100

200

300

400

500

1840 1860 1880 1900 1920 1940 1960

MaternalDeaths

Improvements innutrition, sanitation

Antibiotics, banked blood,surgical improvements

Antenatalcare

Maine 1999.

Maternal Mortality ReductionSri Lanka 1940–1985

0

400

800

1200

1600

2000

1940–45 1950–55 1960–65 1970–75 1980–85Mat

ern

alD

eath

sp

er10

000

0liv

ebir

ths

85% births attended

by trained personnel

New Global Understanding ofMMR Reduction

• Once major obstetric complicationdevelops- even a trained TBA or a nursecannot do much at home

• These complications require– surgical interventions– injections of antibiotic– blood transfusion– aggressive treatments

Three Delays Responsible forMaternal Deaths

1. 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

2. Delay in reaching care ( Community & System) Lack or underutilization of transport funds Non availability of referral transport in remote places Lack of communication network

3. Delay in receiving care (System) Poor facilities, personnel and Supplies Poorly trained personnel with indifferent attitude

Current Status

7200025,00,000Infant Deaths in one year

50001,20,000Maternal Deaths in one year

5763Infant Mortality Rate

389453Maternal Mortality Ratio

GujaratIndiaIndicator

OBJECTIVESOBJECTIVES--

Vision 2010, Population Policy & RCH IIVision 2010, Population Policy & RCH II

Reduce MMR from 389 (in 1998) toReduce MMR from 389 (in 1998) to100 per 100,000 live births by 2010100 per 100,000 live births by 2010

Reduce IMR from 60 to 30 by 2010Reduce IMR from 60 to 30 by 2010

Stabilize population by reducing TFRStabilize population by reducing TFRfrom 3.0 to 2.1 by 2010from 3.0 to 2.1 by 2010

Options

• Improve Government Health ServiceCompetent staffAdequate infrastructural facilitiesUser friendly, good quality Competitive ServicesMarketing of services

• Public Private PartnershipOutsourcing- Curative services

• Health Insurance

Service Charges

179500

20000200100Transport

500050100Dai

450015030Sonography

500050100Investigation

10000100100Predelivery visit

3500050007Cesarean (7%)

300010003Blood transfusion

600030002Septicemia

800Episiotomy

300010003Forceps/vacuum/breech

1000Eclampsia

Complicated cases

6800080085Normal delivery

Package Rates for Chiranjivifor Private Institutions (Dollars)

3988100Total

4444.4100Transport

1111.1100Dai

2222.2100Food

22222.210NICU support

1003.330Sonography

1111.1100Investigation

2222.2100Predelivery visit

777111.17Cesarean (7%)

6622.23Blood transfusion

13366.72Septicemia

17.8Episiotomy

6622.23Forceps/vacuum/breech

22.2Eclampsia

0.0Complicated cases

151117.885Normal delivery

CostRate Per CaseNo. of casesService

Service Charges

65900

20000200100Transport

500050100Dai

450015030Sonography

Investigation

10000100100Predelivery visit

700010007Cesarean (7%)

9003003Blood transfusion

6003002Septicemia

300Episiotomy

9003003Forceps/vacuum/breech

300Eclampsia

Complicated cases

1700020085Normal delivery

Chiranjivi Scheme--5 Pilot DistrictsPerformance January 2006 - March 2007

5.0429704226216436580Total

10.064221056435674SK

3.11346022342212815P'mahal

4.3550712602374010Kutch

4.0997020853997486Dahod

6.176115534636595BK

% LSCSTotalComplicatedLSCSNormal

Nature of DeliveriesDistrict

Gynecologist involvement in ChiranjiviAverageCompensationperDoctorRs in Million

Averagedelivery per

doctorTotal # ofdeliveriesPerformed

# enlistedunder

Chiranjivischeme

Total OBGYSpecialists

in the districtDistrict

0.4625642970168217Total

0.2614664224473SK

0.83464134602929P'mahal

0.4425055072247Kutch

1.1966599701518Dahod

0.2413176115850BK

62.6

72.0

53.3

62.6

36.5

55.0

46.0

67.8

45.1

55.5

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

Sabarkantha Banaskantha Panchmahals Dahod Kutchh

Effect of Chiranjivi on Institutional Delivery

% Institutional Delivery at the time of Initiation of Chiranjivi

% Institutional Delivery - Current Status

Chiranjivi performancefor the stateMarch 2007 Ending

Normal Deliveries 47518C sections 3276Complicated Deliveries 4547Total Delivery 55341

C sections Percentage 5.9%Private specialist enrolled 742Maternal Deaths Reported 6

Institutional deliveries Gujarat trends

0

20

40

60

80

1992-93 1998-99 2005-06 2007-08 2008-09

NFHS 137%

NFHS 246%

NFHS 355%

MIS67%

Goal80

Infant Mortality Rate - Gujarat

50

30

54

6369

0

10

20

30

40

50

60

70

80

NFHS-1 NFHS-2 SRS NFHS-3 2010

Rat

e

Target

NFHS-1:1992-93 NFHS-2:1998-99 SRS: 2005

NFHS-3:2006

Costs

BPL in 5 worst districts Rs 10.5 Crs

All BPL Gujarat Rs 54 Crs

All BPL in India 1000 crs

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

• Demand side effort

• Under utilisation of Public facilities

Category Normal BEMOC CoEmOC

RKS 75 175 250Doctors 100 200 500Staff Nurse 50 75 150Class IV 25 50 100Total 250 500 1000

Conditions:

Additional Incentives for Government Institutional Deliveries

1. At PHC minmum delivery per month 30. Incentives will given from 31 st delivery2. At CHC/Subdistrict Hospital minimum deliveries 50, Incentives will be given from 51stdelivery

Lessons• Country wide problem country wide effort - Involvement of all stakeholders• Political commitment• Evidence based• Keep it simple – use existing mechanisms

• Trust the private partners, they want to contribute• Advance payment and prompt payment of dues, no incentives for caesarian surgeries• Responsibility for complications deaths

• Monitoring quality and feedback to OBGYs & CDHOs• Recognise and reward contribution of OBGY partners

• Demand side?• Coverage of non BPL card holders

• Incentives for government facilities

• Opportunity to link FP, HIV AIDs, Cervix cancer screening

• Care of neonates?

• It works

Let us join hands to save our mothers andchildren.

We make a living by what we get;

we make a life by what we give!

Dr Amarjit SinghSecretary, Department of Health & FWGovernment of Gujarat, Gandhinagar,Gujarat

Distance from the nearest PHC

2 to 5 km,25%

18 to 20 km,10%

6 to 9 km,25%

10 to 11 Km10%

12 to 13 km30%

Health care facilities available

10080

60

3010

5

0

20

40

60

80

100

Untrained dai Quack Trained dai ANM Homeopath Ayurved