Investigating PPP Health Model – Chiranjeevi Yojana District : Sabarkantha, Gujarat

Anuja Kastia, Research Officer CEHAT

Dr Ramila Bisht, Associate Professor, JNU

Area Profile- Sabarkantha District - One of the pilot district where CY was

started.- Total population - 20,82,531

173,325 is scheduled caste (8.32%) 420,242 is the schedule tribe (20.18%).

Bhil, other Generic tribes and Naikda comprises of the three largest tribes in the district

10 blocks - Khedbhrama situated on the northern side of Sabarkantha

district and has a population of 2,50,289 and over 137 villages. (census 2001)

- Khedbhrama is one of the poorest performing blocks in CY (district data source).

- Approximately 70% of the population is Tribal population.

Maternal and Child health indicators of Tribal population .vs. General population.

Table showing the comparative scenario of maternal and child health indicators of Tribal population and General population.

Indicator/Outreach Tribal population General population

Maternal Mortality 16% 10%

Infant Mortality 83% 61.80%

Child Mortality 46.30% 22.20%

Fully immunized children 26.40% 46.80%

Anaemic children 79.80% 72.70%

Anaemic mother 64.90% 47.60%

Antenatal checked mothers 34.70% 56.50%

Institutionalized delivery 17.10% 40.10%

Data source: NFHS II / 2000

Aims & Objectives

Explore the Program Reach in Study Area Study the Mechanism & Operation of Scheme Examine the reasons for Non Adoption of the

Scheme Perception of Private Practioners in the Study

Area Encompass View Point of Stakeholders & State

towards Chiranjeevi Yojana

Research Methodology

Exploratory in Nature Research Tool : Semi structured Interviews,

Observation Sampling : Purposive / snow ball Site : selected villages of Khedbrahma Period of Research : April ‘08 – May ‘08 Sample Size : 32 women

Nature of the Data set and Analysis

Type Qualitative Quantative

Analysis Manually coded SPSS

and Thematically

analyzed

Profile of the women

All the 32 women were BPL women. Heterogeneous Minimum age – 20 where as maximum was 45

years 30 – Hindu, 2 – Muslim women. 68.7% ST, 12.5% SC, and 9.3 % General and

OBC category All with different obstetric history. Peculiar cultural practices in the area –

engagement of the men of the family in delivery process.

FINDINGSReach of the scheme

Mechanism and Operation of the Scheme in the study area.

Program Reach - SabarkanthaDistrict Nature of Delivery (2006 – 2008 )

  Normal Lower Segment Cesarian Section (LSCS)

Complicated Total % LSCS

Banaskantha 14571 833 1095 16499 5

Dahod 15882 669 4614 21165 3.2

Kutch 6947 456 2417 9820 4.6

Panchmahal 24651 922 424 25997 3.5

Sabarkantha 16606 1754 529 18889 9.3

Rest of Gujarat

65225 5644 2039 72908 7.7

TOTAL 143882 10278 11118 165278 6.2

Program Reach –KhedbrahmaTotal number of deliveries conducted in Khedbhrama by the three empanelled doctors from

December 2005 to December 2007.

Date Doctor 1 Doctor 2 Doctor 3

December-05 5 0 2

January-06 41 13 10

February-06 50 18 10

March-06 37 36 10

April-06 36 13 9

May-06 55 10 4

June-06 18 0 15

July-06 0 0 4

August-06 0 0 9

September-06 0 0 11

October-06 17 0 6

November-06 0 0 8

December-06 0 0 2

  259 90 100

Program Reach - KhedbrahmaTotal number of deliveries conducted in Khedbhrama by the three empanelled doctors

from December 2005 to December 2007.

Date Doctor 1 Doctor 2 Doctor 3

February-07 0 0 0

March-07 0 0 0

April-07 17 0 4

May-07 47 0 0

June-07 46 0 7

July-07 53 0 2

August-07 61 0 3

September-07 81 0 0

October-07 28 0 4

November-07 12 0 1

December-07 42 0 6

  387 0 34

total deliveries under CY in 2007-2008 is 421

Maternal and child health indicators of Khedbhrama Block for financial year 2005-2006, 2006-2007 and 2007-2008.

  2005-2006 2006-2007 2007-2008

IMR 45.08 33.05 30.21

MMR 1 0.7 0.6

No. of Pregnancy registered 7141 7687 8202

No. of abortions 0 8 0

No. of still birth 0 97 95

No. of delivery Male 3312 3565 3505

No Of Delivery Female 2834 3157 3271

Total 6146 6722 6776

Home delivery 3548 3857 2994

Assisted 666 592 541

Unassisted 0 451 444

No. of trained dias 2667 2750 1974

No. of untrained Dais 215 64 35

Source: District Project Unit, Sabarkantha. May 2008

Reasons For Non Adoption

No Awareness of the Scheme amongst Target Population

Awareness of the Scheme but did’nt opt due to

-Distance- High Expenditure- Fear, Beliefs, Trust- Family Pressure- Bad Past Experience

It is not only knowledge about the scheme which determines the decision of these women

“I’ll still prefer to got to poshina (to the local doctor)” “Our people would prefer here only” “tempo is so costly………even if we want it is not

possible.” “No, not at all, it is very far and it is not that we are given

sarkari gaadi.” “ it is not that one person goes for the delivery, so many

relatives goes and their tea snacks also costs money” “The doctor should be in poshina. If it is near, then it is

easy to go. “My pain started in the night, so we cannot reach there in

time in such times.”

Cross tab showing Institutionalized and non-institutionalized deliver and the knowledge of Chiranjeevi Yojana

  Don’t Know

Know Some knowledge

Total

Institutional

11(34.4%) 5(15.6%) 2(6.3%) 18(56.3%)

delivery

Home

13(40.6%) 0(.0%) 1(3.1%) 14(43.8%)

Delivery

Total

24(75.0%) 5(15.6%) 3(9.4%) 32(100%)75% of the women did not know anything about the scheme

Views of associated doctors with the Scheme

“In emergency situations of blood requirement, even if the patient is under the scheme, I will have to refer it to Idar”

“Unless and until Government takes some action against those doctors (referring to unqualified doctors) there is nothing which is going to happen. I have come across patients wherein they have come to me in worst of condition, one came where the hand of the newborn was tried to be taken out from the anal canal instead of the normal opening”

“Once I got a woman with haemoglobin - 6, I don’t know what kind of ANC is carried out in the field. I didn’t take up that case, I had to refer”

Perception of un-qualified doctors operating in the field

“We are practicing from more than 15 to 20 years at this place. Weekly I carry out so many deliveries, if Government ties up with people like me, it would be so beneficial to them, we would do each delivery in 500 to 700 Rs.”

ARGUMENT :

Institutionalized, Attended yet not medically legalized

Voices on the Ground….ANM s

“I have to walk so much to each of these houses, one house is on this top and one is on that top, and that too with the vaccination bag in this much of heat… it is very difficult” – ANM

“It is very risky to work after 5’ o clock. It is very common to find drunken men on the streets. I have heard comments so many times, but then over a period of time I learned how to manage”- ANC

“During rainy season, the whole path gets blocked, I choose a home, and open my vaccination box here, and the male health worker calls the mothers”, some of them come, some don’t, but what to do.” – ANC

“we go to their place and tell them everything, we give them tablets, (which they sometimes eat and sometimes don’t eat

Views from State Officials

“There are so few doctors in the area”, what to do?”

“In proper Khedbhrama CHC too, there is no General Surgeon or Gynecologist more than last 10 years, forget about Poshina CHC……no one wants to come and work in these areas”

Common feeling was scheme should remain on-going

Also showed helplessness with the number of doctors in the area and how sustaining the partnership making becomes difficult in such circumstances.

Few limitations and experiences during the study

- Non presence of a NGO working in health - Not being able to capture the level of education

variable- Environment during interviewing (Sitting

arrangement, Presence of male member)- Apprehension / reluctance – ‘here you come

again……- Dialect- Exposure to tribal practices/beliefs

CONCLUDING REMARKS

Besides intensifying CY, the area cries a crucial need to review the aims of reducing MMR, IMR among the population in back drop of a high level of unassisted home deliveries and the peculiar socio-cultural environment.

Requires reviewing of partnership and related issues and move beyond CY in terms of having a micro plan to reduce IMR and MMR.

Policy Level Recommendations Detailed research study which would elucidate the

reach within the tribal pockets is essential for greater understanding of the barriers in the scheme.

The efforts to fill the vacant post in public health department of the block need consideration.

The awareness building activities of the CY requires scaling up for better reach in the interior pockets.

The vigilant monitoring is required by the block and district health functionaries in order to see that no monetary gains are achieved by the associated doctors. This would further help in restricting any unpleasant experience to the women and help in promotion of the scheme

In terms of monitoring the progress of the scheme, the analysis of reach needs to be calculated against the total deliveries among vulnerable population.

Tribal Development Budget and District allocation to the block needs to converge.