1. Chiranjeevi Maternal Health Financing Issues and Options Dr Amarjit Singh Commissioner Health & Secretary Family Welfare Government of Gujarat

2. Lessons from HSRs Steer don’t row Finance rather than directly provide Explore options for PPP Regulate quality, cost-effectiveness Protect the marginalised groups

3. Every Minute... Maternal Death Watch- Global 380 women become pregnant 190 women face unplanned or unwanted pregnancy 110 women experience a pregnancy related complication 40 women have unsafe abortions 1 woman dies from a pregnancy-related complication

5. Gujarat – A Profile Overview Area196,000 km6% of India Population50.5 million5% of India Urbanization37%India avg. 28% SDP (2003-04) Rs 1,425.60 billion (€ 26.40 bill.) 6.33% of India Per Capita Income (2003-04) Rs 26,979 (€ 496.24) India average -Rs. 20,989 (€ 388.69) Recognizing Gujarat potential the Planning Commission set a target growth rate of 10% p.a. for Gujarat

6. Current Status IndicatorIndiaGujarat Maternal Mortality Ratio 453389 Infant Mortality Rate6357 Maternal Deaths in one year 1,20,0005000 Infant Deaths in one year 25,00,00072000

7. OBJECTIVES- Vision 2010, Population Policy & RCH II  Reduce MMR from 389 (in 1998) to 100 per 100,000 live births by 2010  Reduce IMR from 60 to 30 by 2010  Stabilize population by reducing TFR from 3.0 to 2.1 by 2010 from 3.0 to 2.1 by 2010

9. Timing of maternal deaths- General Conditions

10. Time from onset of complication to death PPH2 hour APH 12 hour Ruptured uterus1 day Eclampsia2 days Obstructed labor1 day Sepsis6 days

12. Maternal Mortality: UK 1840–1960 Improvements in nutrition, sanitation Antibiotics, banked blood, surgical improvements Antenatal care Maine 1999.

13. Maternal Mortality Reduction Sri Lanka 1940–1985 85% births attended by trained personnel

14. New Global Understanding of MMR Reduction Once major obstetric complication develops- even a trained TBA or a nurse cannot do much at home These complications require effective back up by trained O&G experts surgical interventions injections of antibiotic blood transfusion aggressive treatments

15. Three Delays Responsible for Maternal 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

16. Delay in problem recognition and decision making SECOND DELAY Delay in reaching a referral facility FIRST DELAY THIRD DELAY Delay in getting care at the health facility WHY Do Women Die?

17. Options Options Improve Government Health Service Competent staff Adequate infrastructural facilities User friendly, good quality Competitive Services Marketing of services Public Private Partnership Public Private Partnership Outsourcing- Curative services Health Insurance

18. Maternal Health- Gujarat Objectives ( by 2010):  Universalize coverage of antenatal care (100%)  Increase the deliveries attended by SBAs 90%  Increase institutional deliveries by 80%  increase access to Emergency Obstetric Care for complicated deliveries  Increase coverage of Post Natal Care (90%)  Increase access to Early & Safe Abortion services  Improve access to RTI/ STI services  Introduce AFHS in all PHC/ CHCs.

19. Broad Issues Broad Issues Non - availability of O & G specialists Accessibility of services-Tribal and urban slums Poor utilization of services- Low felt need of health & medical services Low felt need of health & medical services Lack of user friendly & quality public health services Lack of user friendly & quality public health services Costly private health and medical services Costly private health and medical services No health insurance coverage No health insurance coverage

20. Chiranjeevi Yojna - Options Chiranjeevi Yojna - Options Service Coverage through outsourcing- voucher system Service Coverage through outsourcing- voucher system Emergency Obstetric Care & Neonatal Care Emergency Obstetric Care & Neonatal Care Private Gynecs/ GIA in their facility Payment to Gynecs for working in government hospital

21. Service Charges Normal delivery8580068000 Complicated cases Eclampsia1000 Forceps/vacuum/breech310003000 Episiotomy800 Septicemia230006000 Blood transfusion310003000 Cesarean (7%)7500035000 Predelivery visit100 10000 Investigation100505000 Sonography301504500 Dai100505000 Transport10020020000 179500

22. Service Charges Normal delivery8520017000 Complicated cases Eclampsia300 Forceps/vacuum/breech3300900 Episiotomy300 Septicemia2300600 Blood transfusion3300900 Cesarean (7%)710007000 Predelivery visit100 10000 Investigation Sonography301504500 Dai100505000 Transport10020020000 65900

23. Population and Births Kachchh1526321 Banas Kantha2502843 Sabar Kantha2083416 Panch Mahals2024883 Dohad1635374 Total9772837 Total Births234548 BPL births96432

24. Implementation of Chiranjeevi - 1 District level FOGSI members workshops organized for orientation on Chiranjeevi scheme and enrollment of doctors on the panel Honorable Health Minister wrote a letter about the scheme to presidents of district and talukas in 5 districts. District level Advocacy workshops of Presidents of district and taluka panchayat, along with BHO and Chiranjeevi panel doctors organized in each district.

25. Implementation of Chiranjeevi - 2 In each district IEC activities were undertaken. Awareness through Gramsabhas Rs 15000/ advance was given to each obstetrician. No delay in reimbursement to doctors. Regular interaction with Chiranjeevi Panel doctors by CDHOs

26. Chiranjiv Yojna - performance as on June 2006 District NormalLSCSComplicatedTotal% LSCS BK308112531035163.6 Dahod184211343024154.7 Kutch13869534518265.2 P'mahal477780048571.6 SK34223830380510.1 Total145087961085163894.9

27. Specialist Involvement District Total O&G Specialists available # enlisted under chiranjivi Total # of deliveries Performed Average delivery per O&G BK 5058351661 Dahod 16152415161 Kutch 4720182691 P'mahal 29204857243 SK 7345380585 Total 21515816389104

28. Miles to go District BPL deliveries workload for 6 months BPL chiranjivi beneficiaries for 6 months % age against BPL delivery workload for 6 months BK9464351637 Dahod7686241531 Kutch7576182624 P'mahal8100485760 SK15390380525 Total482161638934

29. Maternal Health- ANC, deliveries, PNC: 2002- 2006

30. Effect on Government deliveries

31. 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 Under utilisation of Public facilities

32. Issues in expansion Additional day’s stay after delivery Sanitary pads supply More funds for accompanying person – Dai Other services Sterilisation/ IUD/ RTI/ STI/ HIV/AIDS/pap smear More charges for transportation in Kutch Cost likely to increase to 2,00,000/100 deliveries

33. The bill for Gujarat & India BPL PopulationDelivery Load Estimated BPL births Costs @1795/delivery Five pilot districts 4 months 16,389Rs 29 million Five districts (annual) 96432Rs 172 million Entire Gujarat BPL Beneficiaries 3,00,000Rs 540 - 600 million India --10000 million*

34. Our Mission: “ Save the lives of thousands of Mothers and Children dying for no fault of theirs and prevent the spread of infections and promote healthy life styles” Working together for a healthy Bharat