Transcript Chiranjeevi LBSNAA - cbhi

Chiranjeevi
Maternal Health
Financing Issues
and Options
Dr Amarjit Singh
Commissioner Health &
Secretary Family Welfare
Government of Gujarat
Lessons from HSRs
Steer don’t row
Finance rather than directly provide
Explore options for PPP
Regulate quality, cost-effectiveness
Protect the marginalised groups
Maternal Death WatchGlobal
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
Gujarat – A Profile
Overview
Area
196,000 km
6% of India
Population
50.5 million
5% of India
37%
India avg. 28%
Rs 1,425.60 billion
(€ 26.40 bill.)
6.33% of India
Rs 26,979
(€ 496.24)
India average -Rs.
20,989
(€ 388.69)
Urbanization
SDP
(2003-04)
Per Capita Income
(2003-04)
Recognizing Gujarat potential the Planning Commission set a target growth rate of 10% p.a.
for Gujarat
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
OBJECTIVESVision 2010, Population Policy & RCH II

Reduce MMR from 389 (in 1998) to
100 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
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%
Timing of maternal deathsGeneral Conditions
Postpartum
60%
During
pregnancy
24%
During
delivery
16%
Time from
onset of complication to death
PPH
APH
Ruptured uterus
Eclampsia
Obstructed labor
Sepsis
2 hour
12 hour
1 day
2 days
1 day
6 days
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
500
400
300
200
Maternal
Deaths
100
0
40 850 860 870 880 890 900
8
1 1 1 1 1 1 1
Improvements in
nutrition, sanitation
Maine 1999.
10 920 930 940 950 960
9
1 1 1 1 1 1
Antibiotics, banked blood,
Antenatal
care
surgical improvements
Maternal Mortality Reduction
Maternal Deaths per 100 000 livebirths
Sri Lanka 1940–1985
2000
1600
85% births attended
1200
by trained personnel
800
400
0
1940–45
1950–55
1960–65
1970–75
1980–85
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
Three Delays Responsible for
Maternal Deaths
1.
Delay in deciding to seek care (Individual & family)




2.
Delay in reaching care ( Community & System)



3.
Lack of understanding of complications
Gender issues, Low status of women
Socio-cultural barriers to seeking care
Poor economic conditions of the family
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
WHY Do Women Die?
FIRST DELAY
SECOND DELAY
Delay in problem recognition
and decision making
Delay in reaching a
referral facility
THIRD DELAY
Delay in getting care at
the health facility
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
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.
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
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
Service Charges
Normal delivery
85
800
68000
Complicated cases
Eclampsia
Forceps/vacuum/breech
1000
3
Episiotomy
Septicemia
1000
3000
800
2
3000
6000
3
1000
3000
7
5000
35000
Predelivery visit
100
100
10000
Investigation
100
50
5000
Sonography
30
150
4500
Dai
100
50
5000
Transport
100
200
20000
Blood transfusion
Cesarean (7%)
179500
Service Charges
Normal delivery
85
200
17000
Complicated cases
Eclampsia
Forceps/vacuum/breech
300
3
Episiotomy
Septicemia
Blood transfusion
Cesarean (7%)
Predelivery visit
300
900
300
2
300
600
3
300
900
7
1000
7000
100
100
10000
30
150
4500
100
50
5000
100
200
20000
Investigation
Sonography
Dai
Transport
65900
Population and Births
Kachchh
1526321
Banas Kantha
2502843
Sabar Kantha
2083416
Panch Mahals
2024883
Dohad
1635374
Total
9772837
Total Births
234548
BPL births
96432
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.
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
doctors by CDHOs
with
Chiranjeevi
Panel
Chiranjiv Yojna - performance as on
June 2006
District Normal LSCS Complicated Total % LSCS
BK
3081
125
310
3516
3.6
Dahod
1842
113
430
2415
4.7
Kutch
1386
95
345
1826
5.2
P'mahal
4777
80
0
4857
1.6
SK
3422
383
0
3805
10.1
Total
14508
796
1085
16389
4.9
Specialist Involvement
#
Total O&G
enlisted
District Specialists
under
available
chiranjivi
Total # of
deliveries
Performed
Average
delivery
per O&G
Kutch
50
16
47
58
15
20
3516
2415
1826
61
161
91
P'mahal
29
20
4857
243
SK
73
45
3805
85
215
158
16389
104
BK
Dahod
Total
Miles to go
BPL
deliveries
workload for
6 months
BPL chiranjivi
beneficiaries for
6 months
% age against
BPL delivery
workload for
6 months
BK
9464
3516
37
Dahod
7686
2415
31
Kutch
7576
1826
24
P'mahal
8100
4857
60
SK
15390
3805
25
Total
48216
16389
34
District
Maternal Health- ANC, deliveries, PNC: 2002- 2006
90
85
84.8
84.1
81.4
80
Percentage
75
70
65
60
55
72.5
74.0
69.4
70.7
55.9
53.2
86.6
63.2
57.0
50
45
40
46.8
44.1
43.0
36.8
35
2002-03
Complete ANC
2003-04
PNC
2004-05
Domicilliary Deliveries
2005-06
Institutional Deliveries
Effect on Government deliveries
200000
180000
160000
140000
120000
100000
80000
60000
40000
20000
0
2001-02
2002-03
BeMOCs
2003-04
CHCs
2004-05
PHCs
2005-06
Sub Centre
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
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
The bill for Gujarat & India
BPL Population
Delivery Load
Estimated BPL births
Costs
@1795/delivery
Five pilot
districts 4 months
16,389
Rs 29 million
Five districts
(annual)
96432
Rs 172 million
3,00,000
Rs 540 - 600
million
Entire Gujarat
BPL Beneficiaries
India --10000 million*
Our Mission:
“Save the lives of
thousands of
Mothers and
Children dying for
no fault of theirs and
prevent the spread
of infections and
promote healthy life
styles”
Working together for a healthy Bharat