NARENDRA MALHOTRAM.D., F.I.C.O.G., F.I.C.M.C.H

• Prof. Dubrovick International university,croatia• Indian FOGSI representative to FIGO• President FOGSI (2008)• Dean of I.C.M.U. (2008)• Director Ian Donald School of Ultrasound• National Tech. Advisor for FOGSI-G.O.I.—Mc Arthur Foundation EOC Course• Hon Prof Ob Gyn at DMIMS,Sawangi,Advisor ART unit at MAMC & SMS Jaipur• Editor od SAFOG journal• Chairman publication committee of AOFOG• Practicing Obstetrician Gynecologist at Agra. Special Interest in High Risk Obs., Ultrasound, Laparoscopy and

Infertility, ART & Genetics• Member and Fellow of many Indian and international organisations• FOGSI Imaging Science Chairman (1996-2000)• Awarded best paper and best poster at FOGSI : 5 times, Ethicon fellowship, AOFOG young gyn. award, Corion

award, Man of the year award, Best Citizens of India award• Over 30 published and 100 presented papers• Over 50 guest lectures given in India & Abroad.Presented 10 orations.• Organised many workshops, training programmes, travel seminars and conferences• Editor 8 books, many chapters, on editorial board of many journals• Editor of series of STEP by STEP books• Revising editor for Jeatcoate’s Textbook of Gynaecology (2007) and DONALD OBS MANNUAL(2012)• Very active Sports man, Rotarian and Social worker

MALHOTRA HOSPITALS & RAINBOW HOSPITALS,Agra-282 010

Phone : (O) 0562-2260275/2260276/2260277, (R) 0562-2260279, (M) 98370-33335; Fax : 0562-2265194mnmhagra3@gmail.com;drnarendra@malhotrahospitals.com;n.malhotra@rainbowhospitals.org

www.malhotrahospitals.com;www.rainbowhospitals.org

jallandhar,ludhiana,ambala,bhiwani,gwalior,allahabad,gorakhpur,kolkata,bariely,jaipur,delhi,sirsaNeapal & Bangladesh

MATERNAL HEALTH ECONOMICS IN SOUTH ASIA

WILL WE ACHIEVE MILLINIUM DEVELOPMENT GOALS 5 ?

Narendra MalhotraJaideep Malhotra

Neharika MalhotraKeshav Malhotra

www.rainbowhospitals.orgProf Alokendu Chatterjee

Prof Rubina Sohailwww.safog.org

“Small opportunities are often the beginnings of great enterprises” (Helen Keller)

"Children are our future, and their mothers are its

guardians.” Kofi Annan

Let the life of every Mother

and Neonate Count !!!

• Each year more than half a million women die from pregnancy related causes and 10.6 million children die, 40% of them in the first month of life.

• Almost all of these deaths are in developing countries. Many could be pre- vented with well-known interventions, if only they were more widely available.

• In establishing the Millennium goals,years ago, the international community made a commitment to reducing maternal deaths by three quarters, and reducing child mortality by two thirds by the year 2015.

EVERY DAY A JUMBO JET FULL OF PREGNANT WOMEN CRASHES IN THE WORLD DAILY,KILLING OVER 400 WOMEN

DURING PREGNANCY AND CHILDBIRTH

THIS NEWS NEVER MAKES DAILY HEADLINES WHY ??

“mothers are not dying because of disease we cannot treat.They are dying because society has to decide whether their lives are worth saving”-Prof Fathalla

MAJORITY SOUTH ASIAN WOMEN ARE POOR ,POWERLESS &PREGNANT

It is a call for radical progress in ensuring the health of women and their children. These members of society are often neglected because they are vulnerable. But wherever that happens the whole society is harmed. Today we want to make it absolutely clear to everyone that the health of women, the newborn and children are a priority for our world as a whole, and for every society, every community, and every family.

"Make every mother and child count"

Millennium Goals 2015

GOAL 1: Eradicate extreme poverty & hunger

GOAL 2: Achieve universal primary education

GOAL 3: Promote gender equality & empowering women

GOAL 4 Reduce child mortality

Millennium Goals 2015GOAL 5: Improve maternal health

GOAL 6: Combat HIV/AIDS, Malaria & other communicable diseases

GOAL 7: Ensure environmental sustainability

GOAL 8: Develop a global partnership for development

MILLINEUM DEVELOPMENT GOALS 5

BangladeshBhutanIndiaNepalMaldivesPakistanSrilanka

ASSESMENT OF HEALTH OF A COUNTRY ____ • Adolescent health care – routinely practiced or not• Pre-conception care – routinely practiced or not• Ante Natal Care % -- 1 visit, 3 /4 visits & by whom• Skilled Birth Attendance – % delivered by SBA• Institutional Delivery -- % of Inst delivery• Post natal care -- % of PN care & when • Functional referral system -- how much functional & how quick; who pays for it• MMR – current estimate i.e. for 2011

BANGLADESH

Maternal health care scenario is dismal in all South Asian countries (except Sri Lanka)

the reasons in Bangladesh

• Political will • Infrastructural issues, including basics• Dr/Nurse strength—human resources• Organisational failures • Social evils –female education (%), early marriage (age & %), domestic violence (%) & attitude of your society, particularly attitude of men, on women’s health

Maternal health scenario- Bangladesh

Political will -very much positive in improving MCH

Infrastructural issues- CMOC services in:• Community clinic• Upazilla health complex-132 (BMOC in rest UHC)• General hospitals-3 District hospitals - 59• MCWC-under DG family planning -63• All medical colleges & specialized hospitals-95

Human Resources in Health in Bangladesh

• Doctor : Patient – 1:4000• Nurse : Patient - 1:8000• Nurse : Dr – 1 : 4 • Private Dr : Pt at rural area – 1: 29000• Health care provider : Population -1:10000• 5 physicians & 2 nurses /10000 population

Organizational failure

• Failure to increase the budget for MOHFW

• Health Workers shortage (specially in rural areas)

• Unable to retain trained HWs at EmONC centers

• Hard to reach areas ; Logistic ; scarcity

• Failure of monitoring

• Failure to co-ordinate between H & FP of MOHFW

Social evilsFemale education-• Primary education (complete)-14.3%• Secondary education (complete) or higher-9%• No education-27.7% Rest ???

Early marriage-• At 13-14 yrs - 4%• At 15-19 yrs -10.6%• 25% become mothers before 20 years Source-(BDHS 2011)

Domestic violence- high ,mainly unrecorded.

Attitude of society towards women’s health - Unsatisfactory• women has No decision making power -so repeated child birth. • No regular ANC, under nutrition, anemia • women not allowed to attend hosp even during emergency

Health economics

National health expenses as % of GDP- 1.03%

• Health budget - 5.4% total budget in 2011-12 & 4.9% in 2012- 2013 . $ 16 per capita for health/yr

• Maternal health budget- 15% of total health budget

• Public expenditure as % of total health exp. 33.59%

• Private expenditure as % of total health exp. 2.29%

• External support as % of total health exp 30%

• Health insurance in Preg & child birth No provision

Strategies to improve Maternal health scenario in Bangladesh

• Strengthen health facilities for EmONC services (1994)

• Demand Side Financing: Maternal Health Voucher Scheme (DSF:2006)

• Maternal & neonatal health (MNHI) program 2007 • Free Tetanus Toxoid for women of child bearing age:2008

• Community based SBA (C-SBA) Program 2003(Target 13,500)

• Nurse midwifery training :2010 (Target 3,000)

Regular financial flow is maintained by • Government’s own fund • Aids from Donor agencies

• Development partners (USAID,DFID,CIDA,WHO,UNFPA)

• Partial cost recovery

• GOB finances 70% (93.55 billion for this fiscal year) and parallel funders contribute remaining 30%, including 15% loans by World Bank

Role of Bangladesh OBGY Society * OGSB working on Maternal health programs along with GOB, NGOs,

UN agencies and development partners • EmoNC-training & monitoring of doctors , paramedics

• C-SBA training and monitoring at govt .& private level

• Treatment of Eclampsia at community level

• Prevention of unsafe abortion –IPAS,FIGO

• Human resource development - LSTM, UNICEF

• F.P-Training on long acting contraceptions etc

Will MDG 5 targets be reached by Bangladesh

Targets & indicators Unlikely Potentially No data

5A: Reduce MMR by 75% between 1990- 2015

Maternal mortality ratio ✓most births attended by SBA ✓

5B: Achieve universal access to reproductive health by 2015

Contraceptive prevalence rate ✓Adolescent birth rate ✓ ANC (one/ four visits) ✓ Unmet need or family planning ✓

Achieving Millennium Development Goals 4 and 5 in BangladeshS Chowdhury,LA Banu,TA Chowdhury, S Rubayet, S Khatoon BJOG Sep, 2011

Per

10

0000

liv

e b

irth

s

0

200

400

600

800

1000

1200

1400

1600

1800

2000

1950-57

1963-64

1977-81

1992 2001 2008 2011

186.5

CHANGING TRENDS IN MMR IN INDIA (1950-2011)

Target- M M R 109 by 2015 Source- RGI, Lancet, vol 378 ; sept, 2011

Unfavorable maternal health in India Reasons ---Political Will

• Not a priority agenda for any political party

• National opinion has never focused on

maternal health as a burning issue

• We need to decide to save women’s lives

Unfavorable maternal health in India Reasons -- Infrastructure

• Nearly 80% of Mat Health care provided by private sectors in India

• Dr :Pt 1:1953 or 0.5 Dr /1000 Indian (WHO-- 1/ 1000)

• Only 0.86 hospital beds per 1000 people

• Health facilities maldistributed & mostly in urban areas

• Transport & connectivity need vast improvement Times of India, March 6, 2012 Financial Express, July 8, 2009

Unfavorable maternal health in India Reasons-- Organisation

• No central theme

• Diffusion of focus from EmOC and SBA cares

• Lack of integration

• Inadequate monitoring and evaluation

Unfavorable maternal health in India Reasons -- Social Issues

Female Education - Adult literacy rate: females as a % of males, 2005-2010, is 68%

• Age at Marriage – 18% by age 15, 47% by age 18

• Domestic violence – ‘Wife beating’ justified by 51% of men and 54% of women. violence by husband on > 40% married Indian women

• Sexual violence -- 1 in 2 women suffer in India

NFHS III, 20005 – 6 http://www.unicef.org/infobycountry/india_statistics.html

Health Economics -- lop sided

State health exp as % of GDP: 1. 4%(2011)-- 3%(2022) Public expenditure on health: 20. 3% ** Private expenditure on health: 77.4% mostly own/family exp External Support: 2.3% Source : National Health Accounts India (2001 – 2002), NHA Cell, MoHFW, GOI

Effect of hospitalisation – 35% pt drop to BPL , 40% borrow/sale assets,20% (U) 28%(R)- no funds for health care. Insurance coverage -just 1%

** USA Public health exp. 50% ; West European states > 80% (Scieber & Poullier, 1988)

Health Economics - Insurance

• Chiranjeevi Scheme of GOI--PPP model, where fees paid to Drs. For Obst & other RH services

• In private insurance, most policies exclude pregnancy and childbirth related expenses

• Corporate employees & members of certain large groups, health policies cover pregnancy

Strategies to improve Maternal Health & its financing, in India

Janani Suraksha Yojana--Encourages Inst.delivery through cash incentives by central Govt, to Pt.& female community health workers

• Chiranjeevi scheme – PPP model; Govt pay Private empanelled Drs for every delivery in their hospital to encourage institutional delivery

• Benefits from other schemes aimed at population stabilization,

reducing neonatal & infant mortality

Strategies to improve Maternal Health in India

• Upgradation of physical facilities at all PHCs

• Skills upgradation of PHC workers

• Training in obst. & anesthesia skills

• Over 35000 personnel trained as health workers

FOGSI and maternal health

• To built a bridge between private Drs & Govt

• Catalyst to bring about changes

• Opinion creator and the leader

• Advocacy-Advocate Central & state govts for changes to policies,

laws, rules, regulations & practices to increase access to safe

abortion services in public & private sectors

FOGSI & Maternal Health …contd

• Emergency Obstetric Care ( EmOC ) Objective -- develop skills of non-specialist Drs.(GPs & MO), to provide

high quality EmOC services in underserved areas to prevent maternal mortality & morbidity

• Comprehensive Abortion Care( CAC )

District level model, to deliver safe abortion services,

through public health system & expand use of MVA & MA

Will MDG 5 targets be reached by India ?

Target 5A Unlikely Potentially No data

Reduce MMR by 75% possible✓ between 1990 to 2015 Most births by SBA possible ✓

Target 5BIncrease CPR Possible✓

Reduce Adolescent birth rate Unlikely

ANC 4visits 1 visit Possible✓

Unmet need for FP Possible✓

Source :--Chatterjee A, Paily VP. Achieving MDG 4 and 5 in India. BJOG 2011;118 (Suppl. 2):47–59

Maternal health care scenario in Nepal –reasons • Total Hospital Beds 6944 Community Hospital- 10-15 beds District Hospital 50 beds

2349 person for a single bed • Organizational failures – Availability of electricity, drinking water ,emergency medicines etc -- are available but sometimes there is shortage of medicine • Social evils Female education (%): 52% Literate Early marriage (age & %) Median age 17.5yrs; < 17 yrs-- 5% ; Domestic violence (15-49) (%) = 22% • Attitude of men on women’s health --in 35% cases men decides for

women and in 65% cases she decides

Total health expenditure by function 2005/6

Per capita income in Nepal is less than US $650, About 38% of the population live <1US$ a day.

Nepal is aiming to decrease it to 17% by the year 2015 (Health Sector Strategy: An Agenda for Reform, MOH 2004)

Total health expenditure by source 2005/6

CEOC/BEOC/BC-making it functionalHuman resources-train/in place/transferTertiary Level hospitals are too busyEquity access/demand/need Flow and monitoring of fund Sustainability-tapping local resourcesInvolvement of private/medical colleges health facilities

CEOC/BEOC/BC-making it functionalHuman resources-train/in place/transferTertiary Level hospitals are too busyEquity access/demand/need Flow and monitoring of fund Sustainability-tapping local resourcesInvolvement of private/medical colleges health facilities

33 CEOC functioning-HR/qualityPoor Monitoring and EvaluationPoor reporting and recordingHow to reach special groupsIntegration with SRH/FPReferral mechanisms

33 CEOC functioning-HR/qualityPoor Monitoring and EvaluationPoor reporting and recordingHow to reach special groupsIntegration with SRH/FPReferral mechanisms

Policy

Program

Major Challenges in Ama Surachha Program

NESOG ROLEAdvocacy

Work with Ministry of Health, Govt of Nepal

Identify short comings & Propose for changes

Prepare Guide books for training purposes

To cope with the demands & support Ministry of Health’s initiative

Will MDG 5 targets be reached by Nepal?

Target Unlikely Potentially No data

5A: Reduce MMR by 75%between 1990 & 2015

Maternal mortality ratio ✓most births attended by SBA ✓

5B: Achieve universal access to reproductive health by 2015

Contraceptive prevalence rate ✓Adolescent birth rate ✓ANC (one/ four visits) ✓Unmet need or family planning ✓Achieving Millennium Development Goals 4 and 5 in Nepal-- D S Malla, K Giri, C Karki, P Chaudhary BJOG Sep, 2011

Present scenario of maternal health in Pakistan

• Adolescent health care – patchy

• Pre-conception care – not routinely practiced

•ANC by health prof. – 1 ANC -- 61% ; 4 & more ANC --28% ; Urban: Rural = 48%: 20%• Delivered by SBA --39% ; urban : rural = 60% : 30%

• Institutional delivery– 35 % ; Public 11%, Private 24%,

• Home delivery --65% ; urban : rural = 56% : 25%

•Postnatal check up -- 43%

• Referral system – informal, paid by patient’s relatives

[2006-7 PDHS,NIPS, Macro international ]

MMR By Province

Punjab227

Sindh314

Balochistan

785

NWFP275

MMR for 3 yrs prior to survey .

MMR 260 in 2010

MMR is significantly higher in the RURAL areas and in BALOCHISTAN province

2006-07 PDHS, NIPS and Macro International

Present scenario of maternal health in Pakistan ……contd

Poor Maternal Health Care in Pakistan- Reasons

Political Will

In theory only

Infra structure Exists, not utilised. Inadequate equipment; lack of staff & quality training; lack of public confidence does not operate 24X7

Drs : nurses 1 : 1.4

Organisational failure

Inferior health care in rural & urban areas, lack of adequate community & Pvt sector involvement, lack of strong DHS & implementation of short / long term policy measures.

Poor Maternal Health Care in Pakistan - Reasons

Social issues Poverty, rapid urbanization, sizeable young population, large refugee population, Male gender preference

Female education Female 46%, Total 58%. (2011)

Early marriage Age of marriage - 21.8 years. 74% girls below 16 married in Charsadda & Mardan

Domestic violence VAW – 8539, DV - 610 cases (2011) Better gender equality. 'Protection against Harassment of Women at Workplace Bill 2009’adopted in 2010

Attitude of society to women's health

Low status, not enough emphasis, not the decision makers

Maternal Health Economics PakistanState health expenses % of GDP 3.2% of GDP

Share of maternal health 0.67% of GDP

Public expenditure 33.32%

Private expenditure 57.33%

External Support 4-16%

Health insurance for Preg & child birth

1.64%

Employers contribution Social security

5.07%

Philanthropy 0.92%

Population not fully covered for health care costs

73.38 %

Maternal Health Economics Pakistan

Other Issues• Limited commitment within system to generate

resources for intended purpose

•Poor correlation between spending & outcomes

• Lack of efficient & equitable use of finances

• Leakage of funds

•Inequitable allocation of revenue-- 26.81% spent on 13% of population

Strategies to Improve Maternal Health Scenario in Pakistan

Key working areas

• Strengthening health systems & promoting interventions focusing on pro-poor policies

• Monitoring and evaluating the burden of maternal & newborn ill-health and its socio-economic impact

• Building effective partnerships to use scarce resources & minimize duplication in efforts.

Strategies to Improve Maternal Health Scenario Pakistan

• Strengthening of MNCH, LHW and SBA programs• Strengthening contraceptive services • Management of unsafe abortions• Creating awareness amongst women• Opportunities for earning for women

Role of SOGP –Supportive Corporate Capacity

• Leadership role • Advocacy

– Dissemination among faculty and students in medical and public health institutions, information about:

• Maternal mortality, Gyn oncology. Abortion DATA• PDHS and status of health indicators• MDGs and way forward, emphasizing their roles

• Impart competency-based training to Drs.& Midwives• Support research to update clinical practice

Role of SOGP – Supportive Corporate Capacity

• Practice best practices in clinical OB/GYN

• Collaborate with Govt to develop health care policies

• Collaborate with agencies & development partners

• Support efforts to ensure quality

Will MDG 5 targets be reached by Pakistan ?Target Unlikely Potentially No data

5A: Reduce MMR by 75%

between 1990 & 2015

MMR ✓ Most births attended by SBA ✓5B: Achieve universal access to reproductive health by 2015

Contraceptive prevalence rate ✓

Adolescent birth rate ✓ ANC (one/ four visits) ✓ Unmet need or family planning ✓source :--Mahmud G, Zaman F, Jafarey S, Khan RL, Sohail R, Fatima S.Achieving

Millennium Development Goals 4 and 5 in Pakistan. BJOG2011;118 (Supp. 2):69–77.

1.Geographical variations : North & East-21% & Estate -18% of NMM

2. Poverty – 30% Estate, 28% Rural3. Septic abortions- increasing (10-15%); PPH commonest 4. Contraceptive compliance - Poor 5. Inadequate health facilities few areas-EMOC, staff ,finance6. Aftermath of ethnic conflict- IDP, single mother7. Emerging communicable diseases- Dengue, H1N1, HIV8. Increase Maternal mortality & morbidity due to NCD, Mental

illnesses and Suicides 9. Domestic Violence – Incidence varied 5-47% during Preg; Highest

among unmarried ,extremes of age. Adverse pregnancy outcome 3 times high.

MMR is low in Sri Lanka but stagnant for last half decade

factors in Sri Lanka

• Political will Good Political commitment to MDG 5 through Presidential task force, Health master plan and “Mahinda Chinthanya”

• Infrastructural issues, including basics Except north & east most people live within 5km of health facility, but in some areas transport & road access are major problem. Estate & some rural areas – poor social indicators like sanitation ,safe drinking water and housing North & East- Disruption of homes( IDP) , roads , health facilities, local economy and community network • Dr/Nurse strength Medical Officers 49, Obstetrician 3, Nurses 87 & Midwifes 26 /100,000 pop

Acute shortage of HR & EMOC in some rural areas, estates & north and east

factors in Sri Lanka

• Organizational failure Decentralisation of health system slow and uneven. Reorganisation of hosp &

referral system has not achieved good results. Existing health information system is

outdated .. Social evils Female literacy -89% Female literacy (15-24y) 99% Female life expectancy -76yrs Marriage by age 15 - 2% Marriage by age 18 - 12% Poverty > 30% of estate pop & 28% rural pop are BPL 18% maternal deaths occur in Estates

. Attitude of men GBV not uncommon but generally men respect women due religious and socio-cultural reasons

0

10000

20000

30000

40000

50000

60000

70000

80000

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Total Health Expenditure (SLR Million)

Increase government spending on health at least 2.5-3.0 % of GDP. Private spending would continue to be about 1.5-2.0 GDP so that the total expenditure would

be 4.5- 5.0 of GDP ---2011

Government to maintain health care expenses at 8% --10% of total public outlays. Only 9% of the health budget allocated to preventive sector.

No National data available for health budget allocation for Maternal Health

Role of SLCOG

Advocacy and help in policy making Training and Education ; Service provider

By 2013 all maternal death inquiries & by 2015 all severe acute maternal morbidity audit – SLCOG to audit in the internationally accepted standard of confidential reporting

By 2014, SLCOG aims to set standard on :-- ANC, IPC,PNC ,EmOC, Post abortion care & Contraceptive services for all

sexually capable people irrespective of age, parity & marital status

Will MDG 5 targets be reached in Sri Lanka ?

Target Unlikely Potentially No data

5A: Reduce MMR by 75%between 1990 and 2015

Maternal mortality ratio ✓Most births attended by SBA ✓

5B: Achieve universal access to reproductive health by 2015

Contraceptive prevalence rate ✓Adolescent birth rate ✓ANC ( 1 & 4 visits) ✓Unmet need or family planning ✓

Senanayake H, Goonewardene M, Ranatunga A, Hattotuwa R, Amarasekera S, Amarasinghe I. Achieving Millennium Development Goals 4 and 5 in Sri Lanka. BJOG 2011;118 (Suppl. 2):78–87.

All the SAFOG countries, except Sri Lanka, urgently need to expedite their efforts many folds, to reach their MDG targets, sooner than later. Need of the hour -- each constituent country of the South Asia, MUST politically, financially & sincerely, work hand in hand, with the Obstetricians of this region, to improve the health of their mothers. More Public expenditure needed on maternal health with all round Infrastructural improvements in health sector and more community involvement. we need --- POLITICAL WILL AT THE HIGHEST LEVEL SAFOG is ready to be the most important stake holder

Maternal health care strategies

Improved Indirectly – by

• Improvement of FP services• Free female education upto 12thstandard• Safe menstrual regulation services• Maternal nutrition project • Increase of Maternity leave upto 6 months• Day care center in public & private sectors

A strong Political will and society is needed to put the simple measure in place to save lives of women dieing in childbirth.We are not attempting to do the impossible. On the contrary, our aim is to do what is well known to be entirely possible. This approach has the potential to transform the lives of millions. Giving mothers, babies and children the care they need is an absolute imperative.PRIVATE SECTOR HAS A MAJOR C.S.R for this cause

how can we private sector help

• Understand that this is our problem tooo??• Keeping mothers alive and healthy is our

responsibility to(cannot blame govt.for all ills)• Enroll in PPP janani suraksha yojanas• Form our own programmes to help BPL• Charity• Free camps and check ups and immunizations• Awareness• Save girl child programmes,walks,rally etc etc

how we are helping ..the 9th camps

pregnancy ….nines

Its time for society to decide whether they want TAJ MAHALSor mothers and neonatesAND IT IS TIME THAT SUMMITS LIKE THISDISCUSS MATERNAL HEALTH IN ALL MEETINGS

if we could have saved this beautiful queen during her 14th childbirth….there would have been no tajmahal……………….

“mothers are not dying because of disease we cannot treat.They are dying because society has to decide whether their lives are worth saving”-Prof Fathalla

Thank You All Long Live SAFOG