1. 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

3. 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

4. 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

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

6. 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

7. 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)

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

9. CONSENT

10. LIVING CONDITIONS

11. PROBING

12. .. VENTILATING…

13. FINDINGS

14. 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

15. … 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 utilised as subsidy for C- section
Cash assistance rather than service provision

16. …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

17. 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. 60%pa

18. Proportion of JSY assistance to CS charges paid by women

19. .. 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

20. ..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

21. 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

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

23. 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

24. 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

25. 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)

26. 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

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