Innovative strategies to improve antenatal and intrapartum care in ... [PDF]

Innovative strategies to improve antenatal and intrapartum care in tribal districts of Gujarat D

r

Dr Amarjit Singh Joint Secretary, Ministry of Human Resource Development, Government of India Nutrition Foundation of India, New Delhi August 29th , 2011

Causes of Maternal Death Haemorrhage 24.8% Infection 14.9% Indirect causes 19.8% Eclampsia 12.9% Other direct causes 7.9%

Unsafe abortion 12.9%

Obstructed labour 6.9%

The setting 15% women have pregnancy related complications 5 lac deaths globally 1.5 lacs in India Huge morbidity

In Place

Rural Popu

OBGYs posts

AP

55401067

167

73

94

7.59

Gujarat

31740767

273

7

266

45.5

M’ashtra

55777647

407

202

205

2.7

MP

44380878

229

13

216

3.41

India

742490639

3910

1338

2010

5.55

100

Gap Popu /gynec

Source

Time Period

Urban

Rural

NFHS - 1

1992-93 (424)

397

448

NFHS - 2

1998-99 (540)

267

619

80 60 100 80

40

60 20

5

30 10

0 Untrained dai

Quack

Trained dai

ANM

Homeopath

Ayurved

Bonus - saving neonates When do babies die Week 1

73.3

Week 2

13.8

Week 3

8.7

Week 4

4.2 0

10

20

30

40

50

60

70

80

Maternal Mortality: UK 1840–1960 Sri Lanka; Kerala & TN have done it 500 400 300 Maternal Deaths

200 100 0 1840 Improvements in nutrition, sanitation Maine 1999.

1860

1880

1900

1920

Antenatal care

1940

1960

Antibiotics, banked blood, surgical improvements

The Gujarat experience Chiranjeevi

Looking for a strategy  Failure to operationalise FRUs in the last 10 years  Efforts to get OBGYs in rural areas fail  Efforts to rope in Insurance companies fail  Successful example of NPCB  Experience of GPs in the UK  Tradition of public private participation in Gujarat; involving private sector a viable option

The process 

Long consultative process IIMA; GTZ; insurance companies; SEWA Rural; FOGSI



Fixing rates for deliveries with NGOs



Meetings with the panchayat functionaries; elected representatives and FOGSI members in the districts



Advance to the OBGYs on signing the MOU



Taking responsibility of low HB women



Ensuring prompt payments

Service Package Service Normal delivery Complicated cases Eclampsia Forceps/vacuum/breech Episiotomy Septicemia Blood transfusion Cesarean (7%) Predelivery visit Investigation Sonography NICU Support Food Dai Transport Grand total

No. of cases Rate Per Case 85

3 2 3 7 100 100 30 10 100 100 100

800 1000 1000 800 3000 1000 5000 100 50 150 1000 100 50 200

Cost 68000

3000 6000 3000 35000 10000 5000 4500 10000 10000 5000 20000 179500

Gynecologist involvement in Chiranjeevi Total # enlisted OBGY Total # of under deliveries District Specialists Chiranjee Performed in the vi scheme district BK

50

Dahod

18

Kutch

47

P'mahal

29

SK

73

Total

217

63

59293

14 19 29 49 174

65867 21606 84713 66193 297672

Average delivery per Doctor

941 4705 (8.5 million)

1137 2921 1351 1711

Chiranjeevi Scheme - 5 Pilot Districts Performance January 2006 – June-2011 Nature of Deliveries District BK Dahod Kutch P'mahal SK Rest of Gujarat

Total

Normal 53677 54856 14961 79997 58291

LSCS 2638 1202 931 3118 5973

314835 576617

26355 40217

Compli cated

2978 9809 5714 1598 1929

Total 59293 65867 21606 84713 66193

9743 31771

350933 648605

% LSCS

4.4 1.8 4.3 3.7 9.0 7.5 6.2

Chiranjeevi Yojana Report June-2011 (21 District) Compli Total cated

% # of Doctors LSCS Enrolled

Sr # District Name

Normal

LSCS

1 Gandhinagar

6181

1083

910

8174

13.25

23

2 Mehsana

30433

2556

1915

34904

7.32

44

3 Patan

47188

3957

973

52118

7.59

31

4 Ahmedabad

48932

2295

8

51235

4.48

98

5 Kheda

11700

1318

240

13258

9.94

18

6 Anand

19590

3048

625

23263

13.10

30

7 Surendranagar

16119

573

126

16818

3.41

18

8 Vadodara

22649

1214

945

24808

4.89

37

9 Bharuch

5834

747

974

7555

9.89

10

10 Narmada

6177

296

305

6778

4.37

5

11 Surat

13482

1030

117

14629

7.04

24

12 Tapi

1949

218

23

2190

9.95

3

13 Navsari

11166

1361

317

12844

10.60

10

Sr #

District Name

Normal

Compli LSCS cated

Total

# of % Doctors LSCS Enrolled

15 Ahwa-Dang

1445

37

13

1495

2.47

0

16 Rajkot

24497

1987

642

27126

7.33

44

17 Jamnagar

4362

78

11

4451

1.75

15

18 Bhavnagar

11302

755

621

12678

5.96

19

19 Amreli

3326

329

290

3945

8.34

9

20 Junagadh

17066

2034

458

19558

10.40

22

21 Porbandar

2010

20.30

22 21 District Total

1566 408 36 314835 26355 9743

350933

7.51

7 488

23 5 District Total

261782 13862 22028 297672

4.66

24 26 District Total

576617 40217 31771 648605

6.20

174 662

Chiranjeevi Scheme: Outcomes

Mothers & New Born babies saved ( Up to Dec - 2010)

Total Deliveries under Chiranjeevi scheme

Maternal

648605

1944

Likely Deaths

Maternal death reported under Chiranje evi scheme

Mothers saved under Chiranje evi scheme

102

1842

likely Neo-Natal deaths

Early NeoNatal death reported under Chiranjeevi scheme

Early Neonat es saved

12169

2071

10098

Normal Deliveries: 576617 C-Section: 40217 (6.2%) Complicated Deliveries: 31771 (5.0%) Private OBGYNs enrolled: 662 Package has been revised from Rs.1795 to Rs.2800 per delivery

Emergency Medical Response Service Initiative (EMRI) (August 2007 – December 2010) Services Total Ambulances at Services Districts Covered

Status as on December 2010 453 26

Population Covered

5.70 Cr.

Emergency Handled

1913892

Pregnancy Related Cases

638542

Road Traffic Accidents

301095

Cardiac Related Cases

97701

Respiratory Related Cases

91378

Lives Saved

85729

Deliveries in Ambulances

16884

Beneficiaries

Chiranjeevi Yojana Performance 180000

Number of Beneficiaries

160000

155721

135706

140000

121043

120000

107839

100000 80000 60000

47706

40000 20000

7793

0 2005-06

2006-07

Source: Chiranjeevi Yojana Report

2007-08

2008-09

2009-10

2010-11 (Up to Dec -10)

IIM study -1 •

The Chiranjeevi scheme is being used by relatively younger mothers and having lesser number of children.

•

Most of the Chiranjeevi users have income levels less than Rs. 12,000 per annum indicating the scheme is able to target the poor families in these three blocks of the district,

•

The expenditure incurred by non-user group on the recent delivery at a private facility is Rs. 4000.

•

The average expenditure incurred by the Chiranjeevi beneficiary on their previous delivery was Rs. 3070. On index delivery a Chiranjeevi client has spent out-of-pocket on an average Rs. 727 per delivery on medicine (self Rs. 297, child Rs. 358) and transportation Rs. 72 indicating that the delivery is not really cash-less. However, the average amount saved by the Chiranjeevi client by availing the benefit of the scheme is Rs 3273 (Rs. 4000 minus Rs. 727.

IIM study - 2 •

The average distance travelled by a Chiranjeevi client to reach the health care facility is 13.79 kms and the average time taken is 44 minutes.

•

The average expenditure on transportation using mostly private transport by a Chiranjeevi client is Rs. 272 as compared to Rs. 200 which the Chiranjeevi client is reimbursed,

•

Private doctors have conducted 41 per cent of deliveries where as rest of the deliveries have been conducted by staff at the private health care facility under the Chiranjeevi scheme,

•

ANMs have been the source of information to 55 per cent of Chiranjeevi scheme users. Anganwadi workers provided information to 17 percent of the clients and Female Health Workers to 10 per cent of the Chiranjeevi clients. Thus, 82 per cent of the total beneficiaries of the Chiranjeevi scheme were provided information by the community health workers.

Costs

All BPL Gujarat

Rs 54 crs

All BPL in India

1798 crs

54 poor performing talukas (having less than 70% institutional delivery rate) reduced to 39 Above 80% 60 – 79.99 % Below 59.99 %

OCT 07

OCT 08

Incentive Scheme S. No.

Details

1

MO

2

MO training Anesthesia

3

Normal delivery (Rs)

BEMOC Caesarian (Rs) & BT (Rs)

100

200

275

-

-

275

SN

50

100

150

4

Cl IV

25

50

75

5

RKS

75

150

225

250

500

1000

OLD LABOUR ROOM

LABOUR ROOM

OPERATION THEATER

Bamanbor - PHC, Surendranagar

Gomata PHC (Rajkot)

HMIS for effective management of health facilities Blocks performing poorly

Institutional Deliveries – Vadodara Region

Bharuch Vagra

Narmada Nandod Dediapada Sagbara

Vadodara Nasvadi Kawant Chota Udaipur

Dahod Halol

Panchmahal Ghoghamba

Institutional Deliveries – Panchmahal District

Institutional Deliveries in the PHCs in a Block in Panchmahal District

GRADING OF PHC IN % OF GUJARAT STATE 60.0

49.5 50.0

42.0

45.0 35.9

40.0 % OF P H C 30.0

21.2

25.7

21.8

20.9

20.0 10.0

16.3 7.6

6.7

4.8

0.0

Dec 06

Dec 07 A

Dec08

Dec 06

Dec 07

Dec08

Dec 06

B

Dec 07 C

GR A D E OF P H C

Dec08

Dec 06

Dec 07 D

Dec08

Capacity building • Training MBBS doctors in BeMOC, CeMOC & paediatrics • Training as SBAs - Midwifery programme • Public health training

• Induction of young professionals in health management • Accreditation of hospitals and PHCs • Recognising and honouring good performance

Institutional deliveries trends 100.00 77.83

80.00 63.24

60.00

55.87 57.03 53.21 51.43

40.00

48.57 46.79 44.13 42.97 36.76

20.00

200304

200405

200506

8.7

32.37

200607

Institutional deliveries % Source: State MIS

10.6

82.04

17.96

0.00 200203

91.3

67.63

22.17

200102

89.4

200708

200809

2009- 2010-11 10 (Up to Dec 10) Home %

The impact - MMR

450 400

389

350 300

MMR

250

202

172

200

160 136

150 100

100

50 0 1989

Source: SRS

1999-01

2001-03

Year

2005-07

2007-8

2010

Break up of Institutional Deliveries with CY deliveries

100%

5.88

13.15

16.18

16.53

58.25

54.11

50.77

28.6

29.71

32.7

90% 80% 70%

66.21

60% 50% 40% 30% 20%

27.91

10% 0% 2006-07

2007-08 Public Institution

2008-09

2009-10

Private Institution

CY

Lessons •

Not either or / use both – talk to the private sector from a position of strength

•

Surge of demand - boon to the poor

•

Unprecedented support from the private practitioners; Explore private sector availability before investing in public sector

•

Unindicated C-section in check

•

Availability of blood

•

Still asking for additional funds from the BPL; Non-BPL beneficiaries also being attended

•

Quality monitoring - Accrediting providers

•

Include cervix cancer, Sterilisation, HIV/AIDS

•

Collaboration with pediatricians

•

Ongoing rigorous evaluation

The Gujarat Government initiative is a departure from previous practice in that it took sole responsibility for the reimbursement of private health care providers, rather than relying on intermediary parties such as insurers. The state government is working with professional agencies such as associations, obstetricians and academic organizations to plan and implement the new arrangements. Showing remarkable success, the programme has been expanded from five to all 25 districts of Gujarat. Between January 2006 and January 2009, 869 doctors were enlisted. Nearly 2,79,236 deliveries were performed, with each doctor performing an average of 322 deliveries.

  

SEARO, WHO conference in Guj Asian innovation award Prime Minister’s award

Bal Sakha Scheme Up to December -2010

District

Total In-service Government Pediatricians in State-18 (Except Medical Colleges)

District

Pvt. Pediatricians Enrolled

1,21,124 Newborns Attended

No. Of Doctors

Ahmedabad

15

Anand

15

Kheda

7

Surendranagar

6

Gandhinagar

13

Mehsana

17

District

No. Of Doctors

266

No. of Doctors

Narmada

1

Panchmahal

12

Surat

18

Tapi

6

Valsad

6

Navsari

4

Dang

1

Bhavnagar

11

Patan

9

Junagadh

13

Sabarkantha

11

Amreli

4

Banaskantha

13

Porbander

6

Vadodara

12

Rajkot

25

Bharuch

6

Jamnagar

9

Dahod

20

Kutchh

6

Let us join hands to save our mothers and children.

We make a living by what we get; we make a life by what we give!

Dr Amarjit Singh MHRD GOI, New Delhi