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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
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