Transcript ASSESSMENT OF PPPs for EmoC under the JSY

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
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
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
Ahmednagar district health system
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Best SIS score
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Moderate performance
Source – Health for Millions oct 07- jan 08 (IIPS Mumbai)
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
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)
DATA COLLECTION AND
PROCESSING
• Semi structured interviews,
• Focus group discussions
• Data for deliveries during June 07 to
Oct 08
• Thematic analysis
CONSENT
LIVING CONDITIONS
PROBING
.. VENTILATING…

FINDINGS
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
… 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. 1500 utilised as subsidy for C- section
Cash assistance rather than service provision
…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
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
only for pharmacy bills”- beneficiary 1
“enough
• Delay in disbursement - On avg recd 3 mths after
delivery
• Indebtedness - pvt. loans @ 60%pa
Proportion of JSY assistance to CS
charges paid by women
100%
Expenditure of CS (Rs.)
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
1
2
3
4
5
6
7
8
9
10
11
12
Women with CS
JSY assistance for CS
CS charges paid by women
13
14
15
16
.. 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
..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
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
HMIS data at district office about JSY: April -September ‘08
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
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
Causes of maternal deaths addressed
under PPP
Antenatal
Delivery
Postnatal
Causes
Hemorrhage
Sepsis
Hypertensive
disorder
Unsafe abortion
Others
Hemorrhage
Obstructed labor
Sepsis
Hypertensive
disorder
Others
Hemorrhage
Sepsis
Others
Addressed
under PPP
None
Obstructed labor
(LSCS)
None
RECOMMENDATIONS
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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
……Too far to go….
THANK YOU!
Dr.Sarika Chaturvedi
Dr.Bharat Randive