1 Averting Maternal Mortality Situation, Strategies and Future Dr. Dileep Mavalankar MD, Dr. P.H. Public Systems Group Indian Institute of Management Ahmedabad

2 Maternal Mortality in India Levels and trends Maternal health care programs Situation of maternal care services Reasons for present situation AMDD experiences and lessons Strategies for future

3 Levels and trends of MMR No system of recording of MM Indirect estimates by Mari Bhat etal: MMR 580, MMR 440 NFHS ( Urban 397, Rural 448 ) NFHS II ( Urban 267, Rural 619 ) RGI - SRS Low in south and high in eastern and central India

4 Policy Commitment for MMR Reduction 1983 health policy: by 1990, below 200 by Nat population policy: 100 by Nat health policy: 100 by tenth five year plan: 200 by 2007 Policy commitment on paper is clear but Was there correct understanding of how to achieve reduction in MMR?

5 Maternal Health Programs MCH - PHC, ANMs target oriented FP program started UIP - ( UNICEF ) CSSM ( UNICEF & world bank) - FRU - EmOC RCH ( world bank), health and FW sector (reform) program ( EC...), State health systems projects ( world bank), ORET ( Netherlands)………… RCH II & state health systems project ( world bank….)

6 Implementation of MH Interventions ANC, TT immunization and IFA - key interventions. PHC system neglected delivery care Delivery by ANMs and doctors neglected. TBA training - seen as key to reduce MMR CSSM on wards : EmOC through FRUs - one of the many strategies RCH - isolated schemes to improve institutional delivery care. No focus on EmOC

7 Current Situation Many interventions are not implemented properly. Lack of specialists & trained staff in rural areas Delegation of EmOC functions not done Weak monitoring of implementation – FRUs operationalization, Deliveries & EmOC care, Maternal deaths. Lack of accountability at many levels - 50% staff not staying at place of posting Too many activities and programs - no focus on EmOC or Delivery care.

8 Staff Pyramid in a District vs. Work Load (50,000 del, 7,500 complications, 2,500 CS)

9 Are Indicators of MH Improving? NFHS I & II - small improvement in ANC and more in TT & IFA. Deliveries by ANMs same (11-12%) Deliveries by doctors increased. But main increase in private hospitals. CS rate gone up - may be in private sector. No data on FRUs functionality, quality….

10 Design & Implementation of RCH Program No large scale or systematic evaluation Many problems in design: Bunch of “schemes” not well though through Lack of integration & coordination of inputs Lack of monitoring of outputs and weak supervision FRUs still not functional - no monitoring Availability of blood remains as a problem - not many blood storage units started. Referral transport money not much used. Some success in Tamil Nadu and Andra Pradesh.

11 Reasons Behind the Slow Progress Lack of institutional/management capacity - national and state level. Frequent changes.. Lack of resources Poor program design Lack of focus on effective strategies - EmOC and skilled birth attendance neglected. Lack of monitoring & evaluation. Lack of real political and administrative will. Inflexibility of schemes.

12 Averting Maternal Death & Disability Program (AMDD) Global program: 50 projects in 41 countries – 50 Million $ over 5 years. In India In: 13 districts through UNFPA (IPD) and UNICEF (BDCS). Maharashtra and Rajasthan - 3 Million $.

13 Averting Maternal Death & Disability Program (AMDD) Key objectives are : Improving availability, utilization and quality of EmOC. Stepwise improvements: Need assessment, training, equipment, renovation, management improvement, MIS monitoring, quality improvement, team building….

14 AMDD Program Experience Availability is increasing - more centers are functional - more EmOC functions are done. Utilization is gradually increasing. Quality is also improving slowly. Policy barriers remain - posting and transfer, delegation - who can do what. CS and anesthesia by GP, Basic EmOC by nurses and midwives….Management problems Improving EmOC is doable – but it needs focus

15 Lessons and Future Directions Need to focus on effective strategies - Systematic process of planning and implementation, with proper monitoring. Making FRUs and selected PHCs to provide 24/7 EmOC. Increasing skilled birth attendance by ANMs, LHVs, PHC MOs. Series of focused and coordinated implementation steps to ensure readiness - Training, supplies, R& R...

16 What is needed ? More resources for MH and health system. Better monitoring & recognizing performers. Ensuring staffing in rural areas for EmOC. Efforts to improve quality. Addressing policy barriers - delegation & posting and transfers. Newer thinking - social health insurance.

17 India Can Reduce MMR. But Needs Political & Societal Commitment Thanks