Can Public Private Partnership (PPP) reduce Maternal Mortality Rate (MMR)? Assessing efforts made by the ‘Chiranjeevi’

1. Can Public Private Partnership (PPP) reduce Maternal Mortality Rate (MMR)? Assessing efforts made by the‘Chiranjeevi’ scheme in Gujarat Akash Acharya and Paul McNamee Cehat Conference, Mumbai (25th, 26th September 2009)

2. Outline of the Presentation • Overview of the problem (2) • Maternal Health Situation in India (1) • Explaining the Chiranjeevi scheme in Gujarat (4) • Discussion, regulation issues and the need for probing further…(4) Cehat Conference, Mumbai (25th, 26th September 2009)

3. Overview of the problem (1) • Maternal Mortality remains a serious public health problem in the developing world and its reduction has been one of the major MDGs (MDG 5, reduce maternal deaths by 3 quarters by 2015) • WHO estimates over 5,00,000 deaths due to pregnancy related causes which leaves over a million mother less children. Almost all of this is happening in the developing countries (<1% in the developed world) • The MMR difference between Developed and Developing world is dramatic as well as pathetic. e.g. About 1000 for Africa and 10 for North America Cehat Conference, Mumbai (25th, 26th September 2009)

4. Overview of the problem (2) • This difference is more tragic as nothing new (technology, drugs etc.) is needed to save these lives and they are preventable. The problem is of access to ANC and EmOC • Maternal health interventions like access to SBA and EmOC referral in case of need has worked in Sri Lanka and Malaysia • Maternal Mortality is increasingly being seen not only as a health issues but human rights issues in terms of women’s right to life, equal access of health and non discrimination Cehat Conference, Mumbai (25th, 26th September 2009)

5. Maternal Health Situation in India • More than 1,00,000 women are dying every year in India through MM. This is about 20% of global MM. [MMR 540-WHO 2006] Pakistan, China and Sri Lanka are doing better. • In rural area the problem is of access to EmOC as most CHCs are running short of gynecologists and obstetricians as well as anesthetists(India doesn’t allow a Nurse of even a doctor with post graduate degree to administer anesthesia or perform EmOC services)The only option left is to travel to DH, mostly several kilometers away • Even at the DH problems of availability of relevant doctors, medicines, transport cost, attitude towards the poor etc. remain. Many women are hesitant to travel and die at home or in transit (>50%) • It is now widely belived that India won’t reach the MMR related MDG target by 2015 (MDG 5, reduce maternal deaths by 3 quarters by 2015-MDG Monitor) Cehat Conference, Mumbai (25th, 26th September 2009)

6. The Chiranjeevi Yojna (CY) in Gujarat (1) • It seems that availability of qualified gynecologists with EmOC facility in vicinity can check the MMR through improved rate of institutional delivery which is the logic behind CY • Although Gujarat is highly industrilised high per capita state, it doesn’t fare very well on HDI (e.g. IMR, Malnutrition, Domestic violence etc.) • More 5000 women die every year through MM mostly in remote rural, coastal and tribal areas • Like other states, Gujarat also faces acute shortage of gynecologists in public health facilities (only 7 against 273 CHC positions) but they are available almost everywhere in private sector and therefore GoG decided to enlist their support Cehat Conference, Mumbai (25th, 26th September 2009)

7. The Chiranjeevi Yojna (CY) in Gujarat (2) • CY (Meaning long life in Gujarati) is a PPP model where a poor women can go to EPPs and get the delivery done free. The cost will be borne by GoG Moreover Rs. 200 for transport and Rs. 50 for accompanying person- A bridge between private sector and the poor • Thus it aims to remove the financial barrier to access of qualified health care facility in vicinity. The scheme was launched in five poor districts in 2005 and since 2007 it has been extended to entire Gujarat • Qualified EPPs are paid Rs. 1,79,000 for a bunch of 100 deliveries including CS. The CS rate has been worked out at about 7 per cent and there is no separate payment for CS to discourage unnecessary CS- a practice widely prevalent in the private sector • Remuneration package has been designed by group of experts and EPPs get an advance payment of Rs. 15,000 while registering in the scheme. CDHO responsible for EPP identification Cehat Conference, Mumbai (25th, 26th September 2009)

8. The Chiranjeevi Yojna (CY) in Gujarat (3) Cehat Conference, Mumbai (25th, 26th September 2009)

9. The Chiranjeevi Yojna (CY) in Gujarat (4) • It is being claimed that through CY, MMR and IMR has been reduced substantially. CY is by now a celebrated scheme and has also received Asian Innovations Award by the Wall Street Journal. It is flagship scheme of GoG MoHFW and being recommended for upscaling into other states Cehat Conference, Mumbai (25th, 26th September 2009)

10. Discussion based on Field Work (1) • These unusual success claims need to be examined in details before replicating the scheme to other states/countries as scaling up involves a major resource transfer from public to private sector • To understand the scheme better, we undertook a round of fieldwork in Surat city with GoG officials (CDHO staff), EPPs and beneficiaries • Out of more than 200 gynecologist in Surat district, only 56 were registered for CY. Most of them located in Surat city and remaining in peri urban area. None in remote rural areas • Even out of registered 56, very few have been active and conducting deliveries under the scheme, other have taken the advance from CDHO and haven’t been active under CY despite the fact that scheme remains well advertised, under performance needs to be further investigated Cehat Conference, Mumbai (25th, 26th September 2009)

11. Discussion based on Field Work (2) • Two main motivational factor for EPPs to join the scheme: Either new in “practice” and joined the scheme to build “reputation” through “numbers” or at the end of the career wanting to do some “charitable” work for the poor. None considered CY as part of their mainstream activity and leading mid career professionals in the field seem not be interested as they view CY as “government, poor, charity” etc. None of the interviewed EPPs viewed the CY as PPP • Some EPPs joined CY in hope that they will get license/certificate for MTP by joining hands with government. • It was observed that some EPPs were taking only “safe” cases and diverting complicated cases to public hospitals. This has profound implication for the dataset claiming high success. Cehat Conference, Mumbai (25th, 26th September 2009)

12. Discussion based on Field Work (3) • EPPs claims that the remuneration package is unjust especially in case of complications. Many also informed that CS rate of 7% is totally unrealistic and in their experience it was more than 30%. This has also resulted in some EPPs opting out the scheme • BPL card is required to become beneficiary of the scheme but migrants don’t have documentary evidences and therefore are left out of the scheme. Since most EPPs are located in posh areas of city, poor also hesitate in approaching them fearing some latent charges. • Aanganwadi workers are the links between poor HHs and EPPs but sometime the trust is broken as EPPs demand money. On the other hand EPPs claim that many BPL card holders are fake and they don’t deserve free treatment Cehat Conference, Mumbai (25th, 26th September 2009)

13. Discussion based on Field Work (4) • If EPPs are mostly treating safe cases, then the whole purpose of the scheme will be defeated as the need is to treat EmOC cases, main reason behind high MMR. If complicated cases are not part of the dataset, obviously MMR will drop but that might be a false indicator as the scheme might just be shifting the problem to public providers? This requires detailed evaluation of CY at the community level not just beneficiaries. • However, shortage of HRH is important problem in achieving health MDGs. Since the private sector is present as well as preferred in India, it has a potential to contribute towards public health goals (MMR, equity, health care financing for the poor etc.) through PPP but proper regulatory framework with continuous M&E is required. Cehat Conference, Mumbai (25th, 26th September 2009)

14. Thanks! Akash Acharya Centre for Social Studies (CSS) University Campus Surat akash.acharya@gmail.com Cehat Conference, Mumbai (25th, 26th September 2009)