Initiative

Delivering Safely

Thanks to a unique PPP between the Government of Gujarat and private gynaecologists and obstetricians, Gujarati women are having safer delivery. Sonal Vij finds out what makes this scheme unique

Even if India has the second largest population with highest birth-rate (27 million per year), it also bears the burden of maternal deaths which is as alarming as 1, 17,100 per year and neonatal deaths of 1, 98,000 per year. "There are several reasons for high Maternal Mortality Rate (MMR) in India — the poor socio-economic status (female education), lack of investment in public health by the Government as well as trying ineffective strategies like birth attendant training, anti natal clinic without backup of skilled birth attendant or Emergency Obstetric Care (EmoC), etc," opines Dr Amarjit Singh, Secretary, Department of Health and Family Welfare, Government of Gujarat.

The Need

Various researches conducted in the early 1990s showed that emergency obstetric care is the most cost-effective way to reduce MMR. Despite sincere efforts from various organisations like the World Bank and UNICEF who initiated and funded projects like 'Child Survival and Safe Motherhood' in 1992, they have not done well due to non-availability of obstetrics and gynaecology specialists in rural areas.

A Gloomy Picture

India has more than 22,000 obstetrics and gynaecologists in the country, but less than 1,300 work in rural areas. In some states such as Gujarat the situation is dismal. Only seven obstetricians are working in rural areas of Gujarat in the Government sector. This is primarily because Government salaries are very low as compared to private sector earnings and Gujarat Government does not allow private practice by Government specialists. Hence, very few obstetrics and gynaecologist want to join or continue with Government service, especially in rural region.

The Start

The Gujarat Government pays private doctors an amount of Rs 1, 79,500 for 100 deliveries, including normal and caesarean

An activist exposed the an unholy nexus where doctor charged poor women instead of free-of-cost

The patient is paid Rs 200 and her attendant Rs 50 to encourage visit to the specialist

The State realised that the small towns have many private obstetricians and gynaecology specialists practicing. So finally, the Government of Gujarat health department worked out a Public Private Partnership (PPP) with these doctors to provide 'child-delivery care' to the poor. Thus was born the scheme

—'Chiranjeevi Yojana' (Chiranjeevi means 'long life') in 2005. The Gujarat Government, collaborated with academic institution (IIM- Ahemadabad), NGO (Sewa Rural - Jhagadia), and facilitated by German Technical Co-operation (a German Government-owned corporation coming under the aegis of the Federal Ministry of Economic Cooperation and Development) to come up with this scheme. "The efforts of the state Government to post obstetrics and gynaecology specialists in rural area have not been successful. Hence, a need was felt to come up with an innovative scheme that bridges this gap," says Dr Singh.

The Pilot Project

Five backward districts (Banaskantha, Dahod, Kutch, Panchmahal and Sabarkantha) with a total population of 9.7 million were initially chosen for the pilot project. The district health centres after a detailed survey of their infrastructure chose the private practitioners. Professional bodies such as the Federation of Obstetrics and Gynaecology Societies of India (FOGSI) and the Society of Welfare and Action-Rural facilitated the meetings and consultations with the doctors, for deciding the maternity care service package and fees that needs to be given to these doctors.

The Package

Finally, it was decided that the Government would pay the doctors an amount of Rs 1,79,500 for 100 deliveries, including normal and caesarean. This amounts to Rs 1,795 per delivery. But, the cost of delivering a caesarean is much higher (seven per cent) compared to a normal delivery. How can the Government fix the same amount for both? Replies Dr Singh, "This amount was worked out to reduce the number of caesarean deliveries. The monetary incentive to do more caesarean deliveries was removed." The responsibility of the doctors is to provide skilled care for deliveries of poor women and provide comprehensive EmOC free-of-cost in their own hospital.

The Next Step

After finalising the amount, the Chiranjeevi team then went to all the five villages and conversed with panchayatiis, MLAs and gynaecologists about the scheme. The doctors who met the criteria (see box on earlier page) were made to sign the MoUs on-the-spot. "All the doctors who signed the MoU were given Rs 25,000 on the spot," reveals Dr MS Ranawat, Consultant, Family Welfare, Government of Gujarat. Explaining the reason, he says, "Doctors are respectable individuals. They should not come begging to us for money."

Results

The pilot project covered 31,641 deliveries. Around 61 per cent of the private practitioners in the area participated encouragingly and each performed an average of 238 deliveries in one year. The results were very encouraging:

• Institutional deliveries in the five states increased from 38 per cent to 59 per cent.
• Zero maternal deaths and only 13 infants' death.
• Only 4.7 per cent caesarean operations as opposed to an average of 15 per cent, included in financial calculations.

Scaling it Up

With such encouraging results, the logical step was to extend the project in the entire state, which the State executed in 2007. The total direct cost of the pilot scheme was Rs 11 crore for one year for five districts. Expanding it to the entire state meant an estimated first year cost of Rs 54 crore, which is just 3.5 per cent of the total health budget of the State. This is being currently met from the state Government funds and money is provided by the Central Government under the National Rural Health Mission (NRHM).

One Hurdle

Posters of the scheme

It was found that a poor pregnant woman, due to transportation expenses, avoided going to the specialist. Hence, to tackle this, it was decided that the doctor would pay Rs 200 as soon as the patient arrives to the clinic. Also, the patient attendant is paid Rs 50. "This is normally the woman's husband, who may have missed on his daily wages to accompany the woman," says Dr Singh. This amount also helped to reduce the delay in reaching the hospital. There is also a tie-up with EMRI ambulance services. EMRI is updated about the various clinics where pregnant women are to be taken.

The Action Plan

When a rural Auxiliary Midwife (ANM) worker identifies a pregnant woman, she informs the pregnant woman about the scheme. ANM also gives the pregnant woman a list of doctors to choose from. When the expectant mother is in her trimester, she is taken to the authorised gynaecologist who helps deliver her baby safely.

The BPL card is checked and the doctor keeps a photocopy of this card. In case, the woman is poor but doesn't have a BPL card, she is issued a certificate by the ANM to make her eligible for safe delivery. These services are provided free-of-cost to the pregnant woman. As deliveries take place in the private hospitals, the doctors are reimbursed very fast by the district health office. Paper-work is also kept to the bare minimum.

The Dark Side

All that glitters is certainly not gold! On the face of it, the scheme looks fantastic with enough evidence that it is out and out success story. But take a second look and you become aware of the many blotches that exist in this system.

The Nexus: Shirin Patel and a Nadiad-based activist Michael Mackwan exposed the unholy nexus of corrupt doctors, through an RTI filed by them. The report suggests that Patel, a local businessman in Dariapur, came to know about a gynaecologist in his neighbourhood, who used to charge poor women for deliveries despite signing a MoU with the health department. The doctor made money from nearly 300 families and did not mention on his signboard that he was a signatory to this scheme.

The doctor also claimed the requisite funds from the health department too. This was just the beginning. The RTI was filed in February 2008 to know the number of women who delivered at his nursing home. Every single woman complained that the doctor had charged.

Reportedly, a similar story was in Kheda district when Mackwan, during the course of his investigation, found that some gynaecologists were forging records by claiming money on dummy names under the scheme. A RTI was filed in September last year to procure details of BPL women who underwent deliveries under the scheme and the doctors who were involved. When the beneficiaries were approached individually, it was realised that they were delivered at homes. Reportedly, when Mackwan followed each case individually, he realised that most of the deliveries took place at a lady gynaecologist's nursing home whose husband was posted in the health department at Nadiad. Undoubtedly, monitoring is the need of the hour.

"After these cases came into light, appropriate actions were taken," shares Dr Singh.

Quality Woes: The quality-of-care at the private sector hospitals is an issue. "It is possible that private doctors who are paid on a fixed-fee schedule may delay surgery or referring complicated cases to public facilities to avoid extra costs. This needs further monitoring and quality auditing," shares Dr Singh.

In-adequately Trained Staff: Many a times private gynaecologists do not employ qualified nursing staff, and get work done from trained women who work as nurses and midwives, thus compromising the safety of the mother and child.

Future Plans

The scope of current package of services under the Chiranjeevi Yojana currently is delivery care only. Plans are there to soon include care for sick newborn. "The Chiranjeevi doctors will now be included for cancer screening, HIV and sterilisation," informs Dr Singh.

Trying to replicate this model, the Government has rolled out Bal-Sakha scheme, especially aimed to save the lives of newly born babies. In the wake of successful implementation of the Chiranjeevi Yojana, it has roped in many gynaecologists to ensure safe motherhood, and also effectively promoting institutional deliveries. Gujarat Government's official website reads -'It is the devotion of many expert doctors, that Chiranjeevi has remained instrumental in social cause. The Bal-Sakha scheme would forge a constructive partnership with the expert paediatricians to take care of the newly born baby at the time of birth.’

Undoubtedly, the scheme is benefiting many, but close monitoring is the need of the hour.

sonal.vij@expressindia.com