1. 1 Health Minister’s Decision How to Save Women Dr. Dileep Mavalankar IIM Ahmedbad Magdegene Rosenmoller IESE Business School

2. 2 Minister goes to address FOGSI Conference in Agra History of Taj - a maternal death Minister reminded of the fact that even today 100,000 women die in child-birth Minister promises to do something to improve MMR - Calls for a meeting in dept on return

3. 3 India Basic Health and MM Data 1 billion people, 600 + districts… Large health infrastructure - DH, CHC, PHC, SC…. Many public health programs - Family welfare, MCH, Substantial private sector health care

4. 4 MM Rate data MMR estimate 400-500 per 100,000 LB Nationally 100,000 mothers die 20% of global maternal deaths. MMR has not declined in recent past - may have increased NFHS I & II data show rural MMR of 449 and 619 for 1992 and 1998

5. 5 India’s policy commitment to MMR reduction MMR reduction is a health objective for many years Health policy 1983 - below 200 by yr 2000 Nat Population Policy 2000 and Nat Health Policy 2002 - MMR of 100 by 2010 Tenth five year plan: MMR 200 by 2007

6. 6 Programs for Maternal Health Since 1960 MH programs MH important part of Primary Health Care Development of cadre of ANMs 130,000 for MH TBA training, antenatal care, TT immunization by mid 1980s program attention got diverted to immunization and child survival.

7. 7 Change in Strategy International evidence and opinion changed - TBA training, ANC not effective in reducing MMR - Need Emergency Obstetric Care (EmOC). 1992 on wards some efforts to bring back attention to MH and add EmOC to strategy under CSSM, RCH program But programs for MH esp. EmOC not well implemented

8. 8 Top Management structure of Health & FW dept for MH Dept of Health, Family Welfare, ISM, NACO … MH division has only 3 technical offices for the whole country - DDG, 2 AC All technical offices from CGHS Over-burdened with administrative work poor support services poor office infrastructure

9. 9 Other relevant institutions Planning commission: 1 health advisor NIHFW - not much work on MH State Health depts: weak No state has technical offices solely for MH Most MCH directors are not trained or qualified in MH, Public Health, Obgyn …. Hardly any delegation of authority to technical offices No International Org has technical officer solely for MH.

10. 10 World Bank’s and other studies on implementation capacity of MH Limited technical capacity in MH at central and state levels. Review of CSSM program showed that only 30% of FRUs are providing EmOC services - without blood transfusion Key problems - lack of obgyns and anesthetists Program monitoring poor - no data Lack of clarity of roles of staff - ANM

11. 11 Not much technical standards or protocols developed Technical managers so overburdened that they can not do much technical work.

12. 12 What have other countries done Sri Lanka ( 18 m), Malaysia (23 m) have 2-3 technical offices for MH Offices take technical decisions Sri Lanka took lot of technical steps over last 40 years to develop maternal health services in rural areas - systematic identification of deficiency and addressing them. Close monitoring of the program

13. 13 How expensive is technical top management capacity At central level 1 technical offices for MH for 100 million people At state level 1 technical office for MH for 10 million people Need 110 technical office for MH for the whole country - Annual cost 6.6 Crore - or 3 % of total RCH program budget.

14. 14 Minister calls a meeting Joint secretary - lack of infrastructure and equipment - donor assistance possible DDG MH: shortage of specialists, 24 hours servics - posting and transfers, training of MBBS doctors to do EmOC. Secretary: cautions about training MBBS doc for EmOC, legal implications. Suggests TBA training based on NGO experience.

15. 15 Nutrition advisor: suggestions treatment of Anemia - special program Minister: met with private obgyns - –suggests increasing awareness among women –Free ANC through private obgyns once a month –dismisses other options of infrastructure up- gradation and staffing improvement

16. 16 DDG does not agree but keeps quiet. Secretary supports the ministers idea of involving private obgyns giving free ANC Minister is happy: want a quick inauguration of the scheme by PM DDG is thinking - did the minister make a right decision?