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

2. 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. 3 Levels and trends of MMR No system of recording of MM Indirect estimates by Mari Bhat etal: 1982-86 -MMR 580, 1992-96 - MMR 440 NFHS - 1992 - 437 ( Urban 397, Rural 448 ) NFHS II - 1999 - 540 ( Urban 267, Rural 619 ) RGI - SRS 1997-8 - 408-407 Low in south and high in eastern and central India

4. 4 Policy Commitment for MMR Reduction 1983 health policy: 200-300 by 1990, below 200 by 2000 2000 Nat population policy: 100 by 2010 2002 Nat health policy: 100 by 2010 2002-7 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. 5 Maternal Health Programs 1950-60- MCH - PHC, ANMs 1966 - target oriented FP program started 1985 - 1990 UIP - ( UNICEF ) 1992-93 - CSSM ( UNICEF & world bank) - FRU - EmOC 1997-2003 RCH ( world bank), health and FW sector (reform) program ( EC...), State health systems projects ( world bank), ORET ( Netherlands)…………. 2004- 2009 RCH II & state health systems project ( world bank….)

6. 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.1992- on wards : EmOC through FRUs - one of the many strategies. 1997. RCH - isolated schemes to improve institutional delivery care. No focus on EmOC

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

9. 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. 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. 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. 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. 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. 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. 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. 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. 17 India Can Reduce MMR. But Needs Political & Societal Commitment Thanks