1. Chiranjeevi Maternal Health Financing Issues and Options
Dr Amarjit Singh
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. Maternal Death Watch- Global
Every Minute...
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 Area 196,000 km 6% of India Population
50.5 million
5% of India
Urbanization
37%
India avg. 28%
SDP
( )
Rs 1, billion
(€ bill.)
6.33% of India
Per Capita Income
Rs 26,979
(€ )
India average -Rs. 20,989
(€ )
Recognizing Gujarat potential the Planning Commission set a target growth rate of 10% p.a. for Gujarat

6. Current Status Indicator India Gujarat Maternal Mortality Ratio 453
389
Infant Mortality Rate 63 57
Maternal Deaths in one year
1,20,000
5000
Infant Deaths in one year
25,00,000
72000

7. Vision 2010, Population Policy & RCH II
OBJECTIVES-
Vision 2010, Population Policy & RCH II
Reduce MMR from 389 (in 1998) to 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

9. Timing of maternal deaths- General Conditions

10. Time from onset of complication to death
PPH 2 hour
APH hour
Ruptured uterus 1 day
Eclampsia 2 days
Obstructed labor 1 day
Sepsis 6 days

12. Maternal Mortality: UK 1840–1960
Other interventions can make a difference, but not as substantial as skilled attendants. For example, in this graph, the implementation of antenatal care did not reduce maternal mortality in the UK. Improvements came only with skilled attendants who could provide surgical intervention if needed, and who had access to and could use appropriate antibiotics and blood products.
Nevertheless, antenatal care remains an important intervention in maternal care because it provides an opportunity to detect problems and be prepared to handle them.
Improvements in nutrition, sanitation
Antenatal care
Antibiotics, banked blood, surgical improvements
Maine 1999.

13. Maternal Mortality Reduction Sri Lanka 1940–1985
85% births attended
by trained personnel
Even with TBA’s and other interventions, maternal mortality decreased in Sri Lanka. The reduction, however, was the greatest (maternal mortality was the lowest) after having births attended by skilled providers The government’s commitment to this intervention was crucial.

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
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
Delay in reaching care ( Community & System)
Lack or underutilization of transport funds
Non availability of referral transport in remote places
Lack of communication network
Delay in receiving care (System)
Poor facilities, personnel and Supplies
Poorly trained personnel with indifferent attitude
Multiple factors affect WHY a woman dies during pregnancy.
The “three delays” model”:
Delay in decision to see care: lack of information about problems/warning signs, social factors
Delay in reaching care: having transportation, road conditions
Delay in receiving care: lack of equipment or personnel at facility, lack of funding, poor attitude of personnel

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

17. 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.

18. 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
Lack of user friendly & quality public health services
Costly private health and medical services
No health insurance coverage

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

20. Service Charges Normal delivery 85 800 68000 Complicated cases
Eclampsia
1000
Forceps/vacuum/breech 3
3000
Episiotomy
Septicemia 2
6000
Blood transfusion
Cesarean (7%) 7
5000
35000
Predelivery visit
100
10000
Investigation 50
Sonography 30
150
4500
Dai
Transport
200
20000
179500

21. Service Charges Normal delivery 85 200 17000 Complicated cases
Eclampsia
300
Forceps/vacuum/breech 3
900
Episiotomy
Septicemia 2
600
Blood transfusion
Cesarean (7%) 7
1000
7000
Predelivery visit
100
10000
Investigation
Sonography 30
150
4500
Dai 50
5000
Transport
20000
65900

22. Population and Births Kachchh 1526321 Banas Kantha 2502843
Sabar Kantha
Panch Mahals
Dohad
 Total
Total Births
234548
 BPL births
58637

23. 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.

24. 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

25. Preliminary results Total O&G Enrolled Deliveries Average/ doc BK 50
Total O&G
Enrolled
Deliveries
Average/
doc BK 50 52
2712
Dahod 16 18
1749 97
Kutch 47 20
1214 61
P’mahals 29 27
3395
126
S’kantha 73 46
2736 59
215
163
11806 72

26. Caesarian/complicated deliveries
LSCS
Complicated
Average/ BK
2712 91
209 3
Dahod
1749 88
310 5
Kutch
1214 65
199
P’mahals
3395 38 1
S’kantha
2736
282 10
11806
564
718

27. % age against BPL delivery workload for comparable period
Miles to go
District
% age against BPL delivery workload for comparable period BK 23
Dahod 30
Kutch 18
Panchmahal 44 SK 38
State 31

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

29. Effect on Government deliveries

30. 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

31. 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

32. The bill for Gujarat BPL Population Delivery Load Costs @1795/delivery
Estimated BPL births
Five pilot districts 4 months
11,806
Rs 21 million
Five districts (annual)
58,637
Rs 105 million
Entire Gujarat
BPL Beneficiaries
3,00,000
Rs million
India million*

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

34. THANKS