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Assessing Gujarat's 'Chiranjeevi' Scheme

More than 5,000 women die every year in Gujarat due to pregnancy complications in remote and tribal areas. The state, which faces an acute shortage of qualified gynaecologists in public health facilities, devised the Chiranjeevi Yojana wherein women below poverty line can go to empanelled private nursing homes at the government's cost. A survey in Surat district shows that empanelled private providers are situated in urban areas and most of them take on only safe cases, sending the complicated ones to public hospitals. This defeats the entire purpose of the scheme as complications requiring emergency obstetric care are the major cause of maternal mortality. Also, if only safe cases are treated, the reduction in maternal mortality shown under the scheme is questionable.

COMMENTARY

Assessing Gujarat’s health issue but also a human rights issue, relating to women’s rights to life, health,
‘Chiranjeevi’ Scheme equality and non-discrimination (UN 2008), suggesting other societal changes are
required alongside implementation of
new health policy.
Akash Acharya, Paul McNamee

More than 5,000 women die every year in Gujarat due to pregnancy complications in remote and tribal areas. The state, which faces an acute shortage of qualified gynaecologists in public health facilities, devised the Chiranjeevi Yojana wherein women below poverty line can go to empanelled private nursing homes at the government’s cost. A survey in Surat district shows that empanelled private providers are situated in urban areas and most of them take on only safe cases, sending the complicated ones to public hospitals. This defeats the entire purpose of the scheme as complications requiring emergency obstetric care are the major cause of maternal mortality. Also, if only safe cases are treated, the reduction in maternal mortality shown under the scheme is questionable.

Akash Acharya (akash.acharya@gmail.com) is with the Centre for Social Studies, Surat. Paul McNamee (p.mcnamee@abdn.ac.uk) is Senior Research Fellow, Health Economics Research Unit, Aberdeen University, UK.

Economic & Political Weekly

EPW
november 28, 2009

M
aternal mortality remains a serious public health problem in developing countries and its reduction has been emphasised as one of the major Millennium Development Goals (MDGs). The World Health Organisation (WHO) estimates that, every year more than 5,00,000 women die due to pregnancyrelated causes worldwide (leaving over a million motherless children) and almost all of these deaths occur in the developing world. The reasons for maternal mortality due to pregnancy complications include obstructed labour and ruptured uterus, post-partum haemorrhage, post-partum infection, hypertensive disease of pregnancy and eclampsia. Emergency Obstetric Care (EmOC) is required to tackle such complications; however such care is usually not available in resource poor settings. In developed countries, maternal mortality was a serious problem till the late 19th century. For example, in England and Wales, the maternal mortality rate was 441 in 1934, which was brought down to 39 by 1960, due to improvements in maternity care that included sepsis control, availability of blood transfusions, introduction of antibiotics, access to safe caesarean sections and abortion services (Loudon 1992).

Today the difference in the maternal mortality rate (MMR) between the developed and the developing world, reflected in current MMR statistics of 1,000 (per 1,00,000 live births) for Africa and 10 for North America (WHO 2001), is dramatic. This difference is all the more tragic as no new drugs or technologies are needed to save these lives; the problem is lack of access to antenatal care and life-saving EmOC services. Developing countries like Sri Lanka and Malaysia have reduced their maternal mortality substantially, through maternal health interventions such as increased access to skilled birth attendance accompanied by referral to EmOC in case of need (Mavalankar and Rosenfield 2005). However, maternal mortality is not only a

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Maternal Health in India

India reports a maternal mortality of 540 (WHO 2006). This means that more than 1,00,000 women are dying every year in India due to pregnancy complications, which is more than 20% of the worldwide maternal deaths. In the rural areas it is often difficult to access EmOC facilities in case of need, as most of the public providers are running short of qualified gynaecologists and obstetricians as well as anaesthetists.1 In such cases, women in need of EmOC services have to travel a great distance to reach district hospitals (DH) where the obstetrician and anaesthetist might be available. However, the barriers such as distance, transport cost, problems with supplies of medicines at the DH and negligent staff attitudes towards the poor remain. Many women thus hesitate to travel and seek care at a faraway place and many die at home or in transit if they do decide to travel. Studies conducted in Andhra Pradesh, Maharashtra (Ganatra et al 1998) and Rajasthan found that 42% to 52% of maternal deaths occurred at home or in transit to a hospital (Mavalankar and Rosenfield 2005). Even though the Indian rate of maternal deaths is declining, at the present rate neither India nor any of its states will reach their MDG maternal mortality targets for 2015 (UN 2008). Better availability of qualified obstetricians with EmOC facility in the vicinity is likely to encourage institutional delivery and thereby reduce maternal mortality but the question of how such a policy can be implemented, remains. The next section considers a possible solution.

Chiranjeevi Yojana of Gujarat

Though Gujarat ranks very high on variables like growth of the state gross domestic product (SGDP), industrial investment, per capita income, etc, it does not fare very well on human development indicators such as education, health and gender equality (Mahatma Gandhi Labour Institute 2004). The infant mortality rate (IMR), considered

COMMENTARY

a good indicator of women’s status in general and of healthcare facilities for pregnant women in particular, is 54 for Gujarat, which is above Maharashtra, Uttarakhand, Jharkhand and West Bengal. Further, there has been an increase in malnourished children in the state from 45% in 1998-99 to 47% in 2005-06 (International Institute for Population Sciences 2007). More than 5,000 women die every year in the state while delivering babies mostly in remote, coastal and tribal areas. The state maternal mortality rate has been estimated to be 389 per 1,00,000 live birth. As is the case with other states in the country Gujarat also faces acute shortage of qualified gynaecologists in public health facilities. However, many of the deprived and lowincome areas have presence of private gynaecologists with EmOC facilities and therefore the Gujarat government decided to enlist the support of the private sector in reducing maternal mortality.

The Chiranjeevi (long life) Yojana (CY) is a scheme based on the public-private partnership (PPP) model in which a poor woman can go to empanelled private nursing homes for delivery, the cost to be borne by the state government. Moreover, eligible women are also entitled to receive Rs 200 towards transport cost and Rs 50 for the accompanying person. Thus, CY aims to remove financial barriers for the poor in accessing qualified private providers. Any private qualified gynaecologist with basic facilities like labour and operating room, access to blood and anaesthetist, etc, can enrol under the CY. These empanelled

Table: 1 Remuneration Package for EPPs under the CY

Procedure Cases per 100 Cost per Total (Rs) Deliveries Procedure (Rs)

Normal delivery 85 800 68,000
Complicated cases 15
Eclampsia/forceps/
vacuum/breech 3 1,000 3,000
Septicaemia 2 3,000 6,000
Blood transfusion 3 1,000 3,000
Caesarean section 7 5,000 35,000
Other costs
Pre delivery visit 100 100 10,000
Investigation 100 50 5,000
Sonography 30 150 4,500
NICU support 10 1,000 10,000
Food 100 100 10,000
Dai 100 50 5,000
Transport 100 200 20,000
Total 100 1,79,500

Source: CDHO Office, Surat.

private providers (EPPs) have to agree to perform free delivery for women designated below the poverty line (BPL). EPPs are paid Rs 1,79,500 (about $4,000) for every 100 deliveries including caesarean sections and complicated deliveries. To discourage unnecessary caesarean sections (a common problem with the Indian private sector), there is no separate or additional payment for them. The remuneration package has been designed by a group of experts in which all possible complications (15% of all cases) have been included (Table 1). EPPs receive an advance payment of Rs 15,000 while signing an agreement with the state government and the chief district health officer (CDHO) is responsible for identifying and recruiting eligible private providers into the scheme.

Chiranjeevi Yojana was launched in five poor districts of the state on a pilot basis in December 2005, and from January 2007 it has been extended to the entire state.

Need for Detailed Assessment

The Chiranjeevi Yojana is considered to be a successful PPP model and has also received a prestigious Asian Innovations Award given by the Wall Street Journal. It is a flagship scheme of the Gujarat state ministry of health and family welfare and is being recommended for scaling up at the national level. It has been claimed by the government that maternal as well as neonatal deaths have been substantially reduced under the scheme. The reported maternal deaths within the scheme have been compared with the expected maternal deaths based on Gujarat’s maternal mortality rate and are found to be more than 20 times lower (Table 2).

Table 2: Lives Saved through the CY Scheme

Total Deliveries under Chiranjeevi scheme 1,31,329
Expected maternal death 393
Maternal death reported under
Chiranjeevi scheme 30
Mothers saved under Chiranjeevi scheme 363
Expected new born death 5,252
New born death reported under
Chiranjeevi scheme 429
New born saved 4,823

Source: Presentation by Health Ministry, Gujarat government, Gandhinagar.

Such unusual success in reducing maternal mortality needs further examination so that the success factors can be replicated elsewhere. A range of aspects need to be studied, such as whether poorer women prefer institutional delivery over home delivery, the influence of location of CY EPPs, the existence of other social or cultural barriers faced by the poor in using private providers, how well CY is targeted towards

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BPL families, and the extent to which the current remuneration package for the CY EPPs is appropriate to cover expenditures. Further, scaling up such a scheme involves major resource transfer implications from the public to private sector, which need to be estimated for meaningful comparison before replicating in other states.

To gain a preliminary understanding of the scheme, recently we undertook a small number of discussions with government health officials in CDHO, enrolled private obstetricians, and a few beneficiaries in Surat city. We found that out of around 200 gynaecologists and obstetricians in Surat district, only 56 were registered for the scheme as per the CDHO data. Most of these were located in Surat city, with the remainder in bigger towns like Bardoli, which is only about 25 km from Surat. Thus, no private nursing homes from remote areas have volunteered to be part of the scheme. Out of the registered 56 EPPs, very few have been active and performed deliveries under the scheme. The majority of EPPs in Surat have taken the first instalment of Rs 15,000 from the CDHO and have not performed the number of deliveries that would be expected. Although the scheme appears to be well advertised, the reasons for such underperformance were unclear, and as such require further investigation.

There appeared to be two main motivational factors for EPPs to join the scheme. Either they were new in “practice” and joined the scheme to build their “reputation” by performing more deliveries to gain “experience”, or they were at the end of their career and wanted to do some charitable service for the poor. None of the EPPs joined the cy as part of their mainstream activity. Leading gynaecologists of the city who are mid-career professionals had no incentive to be part of what they viewed as “charitable” schemes of government. An overriding view of all EPPs is that they saw the scheme less as a PPP and more as a charitable activity to help the poor. Some also wished to join hands with the government in the hope of becoming licensed providers for abortion by gaining a Medical Termination of Pregnancy (MTP) certificate.

It was observed that some EPPs only take “safe” cases of normal delivery and divert complicated cases to the public

Economic & Political Weekly

EPW
november 28, 2009

hospitals. Although the financial package does budget for pregnancy complications, some EPPs refuse to continue the treatment in the case of complications requiring EmOC and some warned BPL families before admission that they had to move to the public hospital in case of complications. The rationale provided by EPPs for this is that the cost of treating complications is far more than what is being compensated under the package with the result that they cannot afford to treat complications. Some also claimed that the caesarean section rate of 7% budgeted in the government package was totally unrealistic and in their experience it was more than 30%. In fact, the CDHO office has also received withdrawal applications from some EPPs.

Surat also has a huge influx of migrants, about 21% of the total population of the city (Acharya 2008). These migrants mostly stay in slum-like low-income settlements and do not have documentary evidence like BPL cards that are required to access the scheme. As most of the EPPs are located in better-off areas of the city, poor people fear treatment as they are apprehensive of some latent charges, even if the scheme is free. Aanganwadi workers play a very crucial role in linking the potential BPL beneficiaries with EPPs as they suggest opting for free institutional delivery under the scheme rather than choosing home delivery. Nonetheless, there are reports of EPPs demanding additional money from BPL patients, which clearly breaks the trust between BPL families and the anganwadi workers. Such a situation does not augur well for the continued functioning of the scheme. Further, EPPs claim that many beneficiaries are not really BPL, despite holding a card.

If this is the general scenario then the entire purpose of the scheme is defeated as complications requiring EmOC are the root cause of maternal mortality and not the “safe” cases that these EPPs are treating. It is also clear that if only safe cases are treated then the reduction in maternal mortality under the scheme cases is naturally going to be very high as the complicated cases (the real culprit cause for the death due to delivery) are being diverted elsewhere and not considered as a part of the scheme in the first place. Widespread replication of these motivations and

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behaviours amongst all private providers would pose serious repercussions for the effectiveness and cost-effectiveness of the scheme, were it to be scaled up to other areas. Essentially, the scheme may only end up shifting the problem – the management of complications requiring EmOC – to public providers. At present, what is required is a full-scale evaluation of the costs and outcomes (complications, caesarean section rates, maternal mortality rate) associated with introduction of the scheme from a community sample, not only a selected sample of individuals who were attended to by EPPs.

To conclude, shortage of human resources in the health sector has been one of the most important barriers in achieving health-related Millennium Development Goals. Since the private health sector is present as well as preferred in India, possible contributions through PPP models like Chiranjeevi Yojana should be considered. However, the contribution of such a model should be studied in further detail before widespread replication as a viable healthcare financing strategy in addressing health equity and reducing maternal mortality.

Note

1 Unlike many other countries, the restrictive health policy in India does not allow a nurse or even a doctor without a postgraduate degree to administer anaesthesia or perform EmOC services.

References

Acharya, Akash (2008): “Access and Utilisation of Health Care Services in Urban Low-Income Settlements in Surat, India”, CSS Working Paper No 5.

Ganatra, B R, K J Coyaji and V N Rao (1998): “Too Far, Too Little, Too Late: A Community-based Case Control Study of Maternal Mortality in Rural West Maharashtra, India”, Bulletin of the World Health Organisation, 76(6): 591-98.

International Institute for Population Sciences (2007): “National Family Health Survey-2005-06”, Mumbai.

Loudon, I (1992): Death in Childbirth: An International Study of Maternal Care and Maternal Mortality, 1800-1950 (Oxford, England: Clarendon Press).

Mahatma Gandhi Labour Institute (2004): “Gujarat Human Development Report 2004”, Ahmedabad.

Mavalankar, D and A Rosenfield (2005): “Maternal Mortality in Resource-Poor Settings: Policy Barriers to Care”, American Journal of Public Health, February, 95(2): 200-03.

United Nations (2008): “Report of the Special Rapporteur on the Right of Everyone to the Enjoyment of the Highest Attainable Standard of Physical and Mental Health”, February.

WHO (2001): “Maternal Mortality in 1995: Estimates Developed by WHO, UNICEF, UNFPA” (Geneva: WHO).

– (2006): “World Health Report: Working Together for Health” (Geneva: WHO).

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