Details for Reform Option "Chiranjeevi scheme to improve institutional deliveries, Gujarat"
In Gujarat it was realised that simply improving the access to the trained health attendant during delivery cannot ensure reduction in the maternal mortality. Services need to be backed up by provision of the Emergency Obstetric Care (EmOC) facilities to save the lives of women who develop complications during pregnancy and delivery. Availability of services, especially to the poor and tribal people becomes difficult from the government institutions due to lack of adequate staff. Vacant position for gynaecologist in Community Health Centre (CHC) was 65 percent and in District hospital was 30 percent; whereas paediatrician shortage was 67percent in the District hospital.
It was noticed that out of approximate 17738 registered doctors (with 2000 gynaecologist) three fourth are working in the private sector. However access of the private health facilities by the poor segment of society was limited due to cost constraints.
In order to address the financial barrier and to bring the large private sector in the provision of maternity services Government of Gujarat announced Chiranjeevi Yojna (CY) in April 2005 and operational from December 2005.
Chiranjeevi Yojna (CY) was initiated as a scheme to increase institutional deliveries and to encourage private practitioner to provide maternity services in remote areas that record the highest infant mortality and maternal mortality rates in the States. Based on low institutional deliveries and low sex ratio five districts were selected for one-year pilot project. These districts are: Banaskantha, Dahod, Kutch, Panchmahal and Sabarkantha.
CY is a maternity insurance scheme for the families that are under Below Poverty Line (BPL). Broad guideline for designing and developing a proposal for maternity insurance are: (1) treatment coverage in designated public and private institutions (2) Sum assured would account for compensation in case of maternal death (3) Inclusive of transport allowance and incentives to the Trained Birth Attendent (TBA) (4) inclusion of pre existing condition like hypertension and complication from previous pregnancies etc.and (5) Sum of INR 10,000 in name of baby, in case of maternal death.
In the process of involving the Private Practitioners (PP) in the five selected districts, meeting was carried out at their respective Zila Panchayats in the convership of District Development Officer (DDO) and Chief District Health Officer (CDHO). Doctors who volunteered to render their services signed a Memorandum of Understanding (MoU) with CDHO. MoU expects a doctor to display a board outside their hospital stating: “ This hospital is supported by district RCH society, for providing free delivery and emergency obstetric care to BPL families”.
On entering the contract each gynaecologist is given INR 15000 as an advance to commence deliveries at their facilities. Though mother receive cash less maternity services, but in the benefit of service providers a package for service charge was developed for a batch of 100 deliveries as capitation payment on fixed rate for each delivery. A batch size of 100 deliveries is taken in to account for case mix i.e. normal or complicated deliveries. Package for service charge was developed in consultation of State representative of Federation of Obstetrics and Gynaecological Societies of India (FOGSI). Service package include service fee for pre-delivery consultation, ultra sonography, transportation and incentive to the accompanying attendant. (For the service package please see the Cost Section).
Implementation management of CY is under district health authorities. All empanelled doctors maintain a case file for each beneficiary. Weekly records of the deliveries conducted by the PP are submitted in the local Zila Panchayat by Block Health Officer (BHO) . Also random visit is paid by BHO in the community to cross check for cash less services from the PP. A monthly report is sent to State by all district for review and feed back. (For broad structure of CY administration, please see the reference section).
Since December 2005:
73 percent of total specialist has enrolled with the scheme.
34 percent of expected BPL deliveries are institutional deliveries under the scheme.
On an average 116 deliveries took place per doctor during the first six months of scheme implementation.
One maternal deaths was reported from five pilot districts during the scheme implementation period.
Capitation payment for the size of 100 deliveries cost for:
In private health facility- 1, 79,500
In Public health facility: 65,900
(For break up of different elements, please see: Package of Service Charges)
Five districts in Gujarat fron December 2005. Districts are: Banaskantha, Dahod, Kutch, Panchmahal and Sabarkantha.
Approximately one year.
Cash less services to the BPL families: Community is encouraged to visit health facilities by attracting them through cash less services.
Wider network for health facilities: Involving private practitioners in the health care delivery system widen the network for skilled services during delivery.
Competition for accountable business: To make long term profitable business reputation in the community health care providers are accountable for their services and undue operation are checked.
Purchasing power in hands of BPL family: BPL have the ultimate power to decide and choose the private / public health facility to avail services.
Monitoring of quality of care: Mechanism to monitor the private health facilities for quality of care provided during pregnancy and delivery is not incorporated.
Drift towards private health facilities: Tendency for preference of private health facility would increase, thus lead to under utilisation of public health facilities.
Dissatisfaction among Service Providers: Growing dis- satisfaction among few health care providers due to cost package need to address timely otherwise opting out from the scheme contract would leave a set back.
Networking with private practitioners
Management capacity at district officials
Who needs to be consulted
District health Officials
Good. Scheme implementation is through established decentralised administrative system and health care providers are practising practitioners in the area.
Chances of Replication
Scheme is a viable option for States where MMR is high and public health infrastructure is not fulfilling the demand.
As high maternal mortality is the priority concern for policy makers as well as implementers, to devise a mechanism that reaches to the socio economically weaker section, especially in rural area has become a challenge for the nation. In such scenario, Chiranjeevi yozna can be adopted with regional specification to make more successful.
Dr. Anuradha Davey, Research Consultant, National Institute of Medical Statistics, August, 2006.