Initiatives to address shortage of

specialists for EmOC in Maharashtra

Dr.Sarika Chaturvedi Dr.Bharat Randive

Foundation for Research in Community Health (FRCH), Pune

2009-2010

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Strategies: Utilise private sector: PPPs - Contracting In

Task Shifting – Skill building of providers

EmOC & LSAS trainings

Study objectives:Influence of PPP and Task shifting on

size and distribution of EmOC providers service uptake

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Methodology

Mix of qualitative & quantitative methods

Provisioning: Health facility survey, record review,

interviews

Users: Community level survey & interviews

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Districts InstitutionalDeliveries

HDIRank

Rural(%) Total(%)

Satara 85.6 87.4 10

Amravati 50.5 63.6 15

Nandurbar 16.5 25.3 32

MH 54 63.6

Study Area

Source: Human Development Report Maharashtra 2002; DLHS-3

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Data collection

ProvisioningHealth Facility Survey: n=44

Rural Hospitals, Sub District & District Hospitals

Interviews: n=40 CS, DHO, DPM,BMO,MS,MO

Obstetricians, Anaesthesists (Public & Private)

Mapping of private EmOC specialists

UsersBirth survey:

272 villages in 6 blocks (n=1833) Identification of

pregnancy /birth complications in JSY eligible women in recent one year

Interviews: n=120

Women who had pregnancy/ birth complications

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Specialists availability at sub district level

District Facility Ob/Gyn & Anaes

Ob/Gyn only

Anaesonly

Neither

Satara 17 4 8 3 2

Nandurbar 11 3 2 0 6

Amravati 13 0 1 0 12

Total 41 7(17%) 11 3 20

Potential for contracting in / Task shifting in 83% facilities

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Obst. Ans CS OT Blood

1 1 20 2 3 2 3 2 4 2 5 1 6 6 2 7 1 6 8 1 9 1

10 2 11 1

Satara

12 2 13 1 14 1 15 1 16 1

Nandurbar

17 1 Amravati 18 1

Total 25 34

Utilisation of public Obstetricians (Apr-Sept 09)

Under utilization: 25 Ob/Gyn - 34 C sections

Placement: specialists at CHCs with no OT

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Distribution of obstetricians

District

Govt.Ob/population (,000)

Pvt.Ob/population (,000)

Total Ob/population

(,000) Amravati

1 /325 1 /23 1 /21

Satara

1 /187 1 /21 1 /19

Nandurbar

1 /163 1 /69 1 /48

Total 1 /217 1 /25 1 /23

District Obst. District HQ (%) Sub district(%)

Amravati 111 86 (77) 25 (23)

Satara 130 33 (25) 97 (75)

Nandurbar 19 14 (74) 5 (26)

Distribution of private obstetricians

8 times more Ob/Gyn in private sector

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Facility Obst Anaes CS(Apr-Sep09)

OT Blood

1 1 6

2 1 6

3 1 0

4 1 4

5 1 0

6 1 1

7 1 78

8 1 62

9 1 0

10 0

11 1 0

10 157

Contracting in

Task shifting

Regular

Contracting in at 7 of 34 facilities with such potential

Task shifting- placement with no skill mix

Contracting in/ task shifting - hardly influenced service output

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Distance of private specialist for contracting in

0 10 20 30 40 50 60 70 80 90 100 110

SDH AchalpurRH Warud

RH ShahadaRH Wai

RH KhandalaRH KhandmaliRH Gondavale

RH RanalaRH Patan

RH KoregaonRH Dhanora

RH AnjangoanRH KaledhoneRH Dhebewadi

RH Chandur BzRH Chikhaldara

RH Chandur RH Somardi

RH TiwasaRH Nandgoan

RH MedhaRH Aundh

SDH DaryapurSDH morshiSDH Taloda

RH A.WaRH Dhamangoan

RH DhadgoanRH Molgi

RH ChurniSDH Dharni

RH VadujRH M'shwarRH Pimpode

Distance (km)

Ans

Obst

Pvt. Specialist > 30kms for 50% facilities

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Contracting in

Feasibility: Contracting in feasible only at CHCs in towns with private specialist

Concerns: Private specialists concerned of post op management at CHCs

Used only for planned cases: “no complications have occured at the periphery because we select patients properly, we take only good, non risky cases there”

Contracted in Drs: Hidden motives -setting own clientele base, attend CHCs only in spare time

Financial issues: “nobody will be willing to come in 1500 Rs. in the JSY, we are paying from IPHS funds,”

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Task Shifting

No buy-in for task shifting: Senior practitioners disbelieve it builds skills/confidence

Implementation issues: Wrong selection of trainees, improper postings,

Trainers views: Doubtful if trainees can perform independently in peripheral settings

Trained MOs views: Concerns of medico legal issues, demand for incentives, certification, more duration, proper postings, refresher courses

“They send us for laproscopy (sterilization) camps at the periphery nothing else..”

“ This is additional load to me, what incentive I get is Rs.25 for a case of

tubectomy.”

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HR issues

Specialists posted as generalists

Specialists in public health department underpaid than counterparts in medical education department

Non performance - Frustration with systems: “The government does not even appreciate those who work, those who do not work make progress in the system

…The salary is going to be the same, whether I operate or not”

Suggest better salaries, no general duties, in service specialisation opportunities as solutions to curb specialists shortage

Job security and better pay attractive to young specialists : “For people like me from middle class Govt jobs are good, only thing is there should be an assurance that we will not be expelled, otherwise it is not possible for one to start private practice after age of 35 years”

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Availability of CS services

District

JSY eligible deliveries

CS

Satara 218 38 Nandurbar 812 4 Amravati 803 99 Total 1833 141(8%)

District level

Sub district level

Total

Public 58 3 61 Private 39 41 80

57% women had CS in private hospitals

CS at sub district level: Public-5%, Pvt.- 51%

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Govt. hospital with CS facility ≥ 50km from most non functional CHCs

0 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160

RH KhandmaliRH Aundh

RH KoregaonRH MedhaRH Ranala

RH DhanoraRH KhandbaraRH Dhebew adi

RH UndaleRH Chandur

RH Chandur BzRH Somardi

RH NandgoanRH PimpodeRH Tiw asa

RH KhandalaSDH Taloda

RH A.w aRH Mhasaw ad

SDH morshiRH Dhamangoan

RH VadujSDH NavapurRH Dahiw adi

RH MolgiRH M'shw ar

RH GondavaleRH AnjangoanRH DhadgoanRH Kaledhone

RH ChikhaldaraRH Churni

SDH Dharni

Distance(km)

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Cost of CS in Private hospitals

0%

2%

20%

37%

21%

20%

Rs 0

<5000

5001-10000

10001-15000

15001- 20000

>20000

n = 80

For 78% users CS cost ranges Rs.10000-20000

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Summary Findings

Shortage of EmOC specialists limited to public sector in Maharashtra

Low utilisation of Govt. obstetricians for CS

services.

Contracting in private specialists has limited feasibility and use in obstetric emergencies

Enabling conditions for success of Task Shifting for CS and obstetric anaesthesia have not been met

Availability of CS services in public hospitals scare at sub district level

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Recommendations

Performance measurement to improve utilization of Govt. specialists

EmOC specialists to be designated & paid as specialists and payments linked to performance

Contracting in to be considered as short term measure and not for emergency services

Choice of task shifting to be revisited in contexts with overall high density of specialists

Enablers for success of task shifting be met- training quality, licensing, posting and incentives

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Acknowledgements

John D. & Catherine T. Mac Arthur Foundation

IIM, Ahmedabad

THANK YOU !

Technical Advisors: Dr. Dileep Mavalankar, IIMA

Dr.P.P.Doke,SHSRC,Maharashtra

Dr.C A K Yesudian,TISS,Mumbai

Dr.Nerges Mistry, Director, FRCH,Pune