PPPs for EmOC under the JSY

A rapid assessment study in a selected

district of Maharashtra

June 08-June 09

Conducted by

Foundation for Research in Community Health,

(FRCH), Pune

Investigators

Dr. Bharat Randive, Dr. Sarika Chaturvedi

India

Health care industry is fast growing

State of the art infrastructure

Known to produce amongst the best doctors in the world

Attractive hub for medical tourism

…But

Fails to provide basic health care to its population

Contributes to 20% of maternal deaths worldwide

Hopes for a better change after the NRHM

( SRS 2001-2003)

Indian public health system

Studies show inadequate infrastructure

Shortage of drugs and supplies

High vacancy rates especially of specialists in rural areas

Of 20,000 obstetricians in India only 780 work in public system at sub district level

Indian private medical sector

Largest proportion of resources and services 93% of Hospitals 64% of Bed strength 80-85% of doctors 80% of Out patients 57% of In patients Source: World Bank 2001

60% of MCH case load

Maharashtra

CHCs having functional OT- 84.6% CHCs having Obstetrician - 40% FRUs offering Caesarean section- 14.3% FRUs having blood storage facility- 11.6%

- DLHS-3(2007-08)

Annual intake for specialisation in obstetrics-

102 compared to none in certain states

PPP for EmOC under JSY of NRHM

Contracting–in model

• Hiring private specialist for management of obstetric complications and for CS

• Rs.1500 as specialist charges

• Free EmoC in public facilities

• JSY Eligible clients (Maharashtra)- BPL, SC, ST women Over 19 years, Upto 2

live births

Objectives- To understand

1. Design of PPPs in Ahmednagar district(partner selection / contracting mechanisms/ performance measurement / facility accreditation processes / monitoring)

2. Execution of PPPsExperiences in implementing / using the scheme

(Referral / cost & consequences / financial provision)

3. Perceptions of providers and users about PPPs for EmOC

Methodology

Rapid Assessment of Health Programmes (RAHP) approach

• Mid course adjustments to programmes

• Documentation and analysis of lessons learnt

• Results not meant to be statistically valid

• Link between information and decision making focusing on why and how problems occur

Study area

• Ahmednagar district in western Maharashtra

• MMR <2 for 1000 live births

• SC-12.39%, ST-7.2%, BPL- 30%

• 96 PHCs ,23 CHCs, 3 Subdistrict and 1 District Hospital

• Mushrooming of private hospitals, 2 medical colleges

Ahmednagar district health system

Moderate performance

Source – Health for Millions oct 07- jan 08 (IIPS Mumbai)

Best SIS score

SAMPLE SIZE

5 /14 blocks selected randomly

2 PHCs/ 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

• Thus NO PPPs in place

Implementation

Passive support of administrators

Private providers not approached for PPP, vaguely aware through patients

No contract execution plans

Cost subsidisation preferred to PPP

• Rs. 1500 utilised as subsidy post C-section

• Benefit only to C- section, not to other obstetric complications

Thus, 2/3 rd women in need of EmOC barred from eligibility

Cash assistance rather than service provision

Financial provision

• Inadequate financial provision for hiring specialist

• Prevailing charges above Rs. 3000

“…He is not willing to do any work there because of interests in private hospital, otherwise all patients will get it done in the subdistrict hospital, who will want to spoil their own practice?....” (Mo-4)

Financial assistance & Consequences

• Average expenses incurred by women Rs. 15,000 (range Rs. 10,000 to 30,000)

• Assistance received under PPP Rs. 1500

• Grossly insufficient ” ….enough only for the tablets and medicines…”- Beneficiary 1

• 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

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Women with CS

Exp

endi

ture

of C

S (R

s.)

JSY assistance for CS CS charges paid by women

.. 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…”3pm“….Reached the civil hospital….” 8pm

• Travelled 40 km in 5 hrs after diagnosis of obstructed labour

Analysis of Ahmednagar HMIS data : April –Sept. ‘08

Estimated no. of JSY beneficiaries 7694

No. of JSY beneficiaries registered 5609

No. of JSY beneficiaries paid Rs.1500/- for LSCS

197 (2.5% of estimated beneficiaries)

Expected complicated deliveries (eligible for assistance by GoI guidelines)

1154 (15% of estimated beneficiaries)

Expected minimum no. of LSCS (eligible for assistance by state guidelines)

385 (5% of estimated beneficiaries)

Missed out by state guidelines 769 (1154 -385) ( 66% of complicated deliveries)

Reach (GoI guidelines) 17%

Reach (state guidelines) 51%

Poorly managed scheme

Poor reach

Lack of funds at grassroots

Non uniform implementation across blocks- ambiguous guidelines

No demand generation

Reasons for non-utilisation and denials

• Women unaware of provision for EmOC

• 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

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

• Inadequate public infrastructure for EmOC provision through contracting-in specialists - Public providers

• Difficulties in implementation – • frequent changes in guidelines • eligibility conditions- time and documents criteria• funds flow issues

• Demand for 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….” – Non beneficiary 2

Conclusions…Too little, Too late

• No PPPs for EmOC under JSY in study district

• Inadequate financial provision for contracting-in specialists

• Infrastructural inadequacies, low motivation - barriers to contracting-in

• Subsidy mechanism minimally influences out of pocket payments for EmOC services

• Scheme implemented is exclusive

Causes of maternal deaths addressed under PPP

Antenatal Intranatal 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

Model of PPP should be chosen considering local feasibility by dialogue among partners rather than directives from top

Service provision rather than sudsidy; Contracting-in / out such that onus of negotiating charges is not on the woman

Capacity building for management of PPPs

Charges for hiring specialists should be based on area specific competitive rates

Recommendations

Evolution and enforcement of mechanisms for monitoring,quality assurance and grievance redressal

Scheme should include all life threatening complications of pregnancy and child birth

Emphasis on micro-birth planning- Ensure birth preparedness and complication readiness

……Too far to go….

THANK YOU!

Acknowledgements:

Dr. Abhijit Das, CHSJ, New DelhiAmy Hagopian, Peter House, Univ. of Washington, USAUNFPA India