STUDY OF PPPs for EmoC under the JSY A rapid assessment in a selected district of Maharashtra Conducted by Foundation for Research in Community Health, Pune Investigators:Dr. Bharat Randive Dr. Sarika Chaturvedi

PPP for EmOC in JSY of NRHM Subsidisation of cost for management of obstetric complications and for CS Hiring private / public specialist Rs.1500 as specialist charges Free EmoC in public facilities JSY Eligible clients (Maharashtra)- BPL, SC, ST Over 19 years Upto 2 live births

OBJECTIVES- To understand 1. Design of PPPs in Ahmednagar district (partner selection / contract mechanisms, performance measurement / facility accreditation processes / monitoring) 2. Execution of PPPs Experiences in implementing / using the scheme (Referral & transport / cost & consequences / financial provision for PPPs) 3. Perceptions of providers and users about PPPs for EmOC

Ahmednagar district health system Best SIS score Moderate performance Source – Health for Millions oct 07- jan 08 (IIPS Mumbai)

STUDY AREA Ahmednagar district in western Maharashtra MMR <2 for 1000 live births SC-12.39% ST-7.2% 96 PHCs ,23 CHCs, 1 District Hospital Mushrooming of private hospitals

SAMPLE SIZE 5 /14 blocks selected randomly 2 PHCs/ block selected randomly 2 beneficiaries/block selected randomly Respondents: Implementers- DHO, THO, MO/ANM (16) Beneficiaries (10) Non beneficiaries (8) Private EmOC providers ( 3)

DATA COLLECTION AND PROCESSING Semi structured interviews, Focus group discussions Data for deliveries during June 07 to Oct 08 Thematic analysis

CONSENT

LIVING CONDITIONS

PROBING

.. VENTILATING…

FINDINGS

Implementation of PPP No contracting-in of private specialists No empanelment/accreditation of private facilities Private providers not approached for PPP, vaguely aware through patients Thus NO PPPs in place

… Implementation of PPP Benefit only to C- section, not to other obstetric complications Thus, 2/3 rd women in need of EmOC barred from eligibility Rs. 1500 utilised as subsidy for C- section Cash assistance rather than service provision

…Financial provision Rs.1500 paid as assistance post CS to women/doctor or either Provision unattractive for hiring obstetrician, prevailing charges above Rs. 3000 Inadequate public infrastructure for EmOC provision by hiring specialists

Financial assistance & Consequences Average expenses incurred by women Rs. 15,000 (range 10,000 to 30,000) Assistance received under PPP Rs 1500 Thus, assistance Grossly Insufficient “enough only for pharmacy bills”- beneficiary 1 Delay in disbursement - On avg recd 3 mths after delivery Indebtedness - pvt. loans @ 60%pa

Proportion of JSY assistance to CS charges paid by women

.. Referrals No referral chains, no referral slips Women mostly approaching private facilities directly Women's experiences Difficulties in arranging transport “ ..We walked to the highway asking for lift..” -3 pm, “…reached the civil hospital- 8 pm”- Nonbeneficiary 2 Reached civil hospital at 40 Kms almost 5 hrs after diagnosis of obstructed labour

..Transport provision Women unaware of provision for transport facility for EmOC Women experiences Transport facilities not provided by PHCs Average spending of Rs.600 for transport Providers views Varying provisions across blocks: Rs250/ Rs.500/ Cashless arrangements Reimbursement from sub centre strengthening funds

Reasons for non-utilisation and denials Women unaware of provision for EmOC- no micro birth planning Service area constraints- deliveries mostly at maternal homes Difficulties in producing required documents in time - ? 7 days of delivery Varying conditions for accessing the scheme- eg. registration before 12 wks, BPL survey rounds

HMIS data at district office about JSY: April -September ‘08

Findings- Views Useful only for cities, not for rural areas “calling a doctor from town is equally good as taking the patient to the town”- District official Services rather than cash subsidy “..provide the facility instead of the money… we poor do not have the money at that time to pay for the hospital, what if the government gives us the aid later on….” - Beneficiary 2 Difficulties in implementation – frequent changes in guidelines, time and documents criteria, funds flow issues

CONCLUSIONS…too little, too late No PPPs for EmOC under JSY in study district Inadequate financial provision for hiring specialists Subsidy mechanism minimally influences out of pocket payments for EmOC services Scheme implemented is exclusive Infrastructural inadequacies, low motivation - barriers to implementation of PPPs

Causes of maternal deaths addressed under PPP Antenatal Delivery Postnatal Causes Hemorrhage Sepsis Hypertensive disorder Unsafe abortion Others Obstructed labor Addressed under PPP None (LSCS)

RECOMMENDATIONS Emphasis on micro-birth planning- Ensure birth preparedness and complication readiness Contracting-in / out rather than cost subsidisation & onus of negotiating charges should not be on the woman Scheme should include all life threatening complications of pregnancy Charges for hiring specialists should be based on area specific competitive rates Capacity building for management of PPPs

……Too far to go…. THANK YOU! Dr.Sarika Chaturvedi Dr.Bharat Randive