Maternal Health Financing – Issues and Options A Study of Chiranjeevi Yojana in Gujarat

Abstract

Government of Gujarat announced a “Chiranjeevi Yojana” in April 2005 to improve access to institutional delivery and at the same time provide financial protection to poor families in Gujarat. The scheme covers below poverty line (BPL) families who are generally under-represented, have limited access to institutional facilities and may experience economic and social hardships due to complications during delivery.

The average distance travelled by families to reach public health facilities is high and ranges from 8 to 10 kms. Given the availability of private providers it is imperative to include the private providers in delivery of services to improve the access and thereby improving the institutional delivery rate. This scheme covers the BPL families by making their utilisation of private facility a cash-less event and also covers direct and indirect out-of-pocket costs such as travel and cost of accompanying person.

The scheme is implemented by empanelling private medical practitioners to provide maternity health services in remote areas which record the highest infant and maternal mortality and thereby improve the institutional delivery rate in Gujarat. The scheme was finally launched as a one year pilot project in December 2005 in five districts viz., Banaskantha, Dahod, Kutch, Panchmahal, and Sabarkantha covering all BPL families. The private empanelled providers are reimbursed on capitation payment basis according to which they are reimbursed at a fixed rate for deliveries carried out by them. The payments are made for a batch of 100 deliveries. This is expected to take care of case-mix differences (i.e., normal or complicated deliveries) and help the providers to keep the costs below the reimbursed amounts. The scheme uses a voucher type of system or BPL cards to target the BPL families.

The contribution of this scheme at district level has been in identification and referral of delivery cases among BPL families to private providers, follow-up of delivery cases and their risk status, ensuring the service provision, and protecting the most vulnerable (BPL) families from adverse financial burden. The mapping exercise carried out by the district health officials identified the private providers providing maternity services in five districts. A detailed survey of providers and their infrastructure facilities was carried out in one district to assess the service provision conditions. Meetings, interviews and consultations were held with these providers and professional bodies such as FOGSI and SEWA Rural to discuss the package of maternity services and cost of providing these services. Based on this a package of institutional delivery was finalised at Rs. 179,000 for 100 deliveries including both normal and complications. Each empanelled provider is given up-front advance of Rs. 20,000 to start providing services. The delay in payments has been found critical impediment in participation of private providers in any scheme.

Five districts covered by this scheme have population of about 10.5 million of which 43 per cent are below poverty line having about 110,000 deliveries per annum. The scheme during first year of its implementation has covered 31,641 deliveries including 2518 complicated cases and 1502 LSCS.

Of the total 217 providers in these districts 133 (61 per cent) have been empanelled in this scheme. The average number of deliveries carried out by these providers has been 238 deliveries.

The scheme shows that by providing financial protection through 100% subsidy of delivery cost of BPL families through involving private provider has potential to increase the institutional delivery rate and reduce the MMR and IMR substantially among the most vulnerable groups of population. During first 10 months of scheme implementation, no maternal deaths and 13 infant deaths were reported in the pilot districts. As per MMR and IMR, 70 – 80 mothers and 350 – 450 infants would have died in the districts. During this period, institutional deliveries in the five districts have increased from 38 per cent to 59 per cent. Due to packaging of services in the scheme, unwanted caesarean operations among the BPL expectant mothers has reduced from 15 per cent to 4.7 per cent. This scheme has increased the access to institutional facilities for maternity care. The cost of seeking delivery in private facilities by BPL families is high. This scheme covers both direct and indirect cost (for example travel and cost of accompanying person). The financial burden in case of complications can be catastrophic for BPL families which this scheme covers.

The objective of this paper is to describe the process and development of this scheme and discuss pathways of creating and strengthening capacity in health system to implement this scheme. The paper also discusses performance of this scheme and finds whether the scheme has been successful in providing access to BPL families for institutional delivery and thereby providing financial protection to these families. We also discuss the challenges and key issues in up-scaling this scheme further.

Government of Gujarat announced a “Chiranjeevi Yojana” in April 2005 to improve access to institutional delivery and at the same time provide financial protection to poor families in Gujarat. The scheme covers below poverty line (BPL) families who are generally under-represented, have limited access to institutional facilities and may experience economic and social hardships due to complications during delivery.

The average distance travelled by families to reach public health facilities is high and ranges from 8 to 10 kms. Given the availability of private providers it is imperative to include the private providers in delivery of services to improve the access and thereby improving the institutional delivery rate. This scheme covers the BPL families by making their utilisation of private facility a cash-less event and also covers direct and indirect out-of-pocket costs such as travel and cost of accompanying person.

The scheme is implemented by empanelling private medical practitioners to provide maternity health services in remote areas which record the highest infant and maternal mortality and thereby improve the institutional delivery rate in Gujarat. The scheme was finally launched as a one year pilot project in December 2005 in five districts viz., Banaskantha, Dahod, Kutch, Panchmahal, and Sabarkantha covering all BPL families. The private empanelled providers are reimbursed on capitation payment basis according to which they are reimbursed at a fixed rate for deliveries carried out by them. The payments are made for a batch of 100 deliveries. This is expected to take care of case-mix differences (i.e., normal or complicated deliveries) and help the providers to keep the costs below the reimbursed amounts. The scheme uses a voucher type of system or BPL cards to target the BPL families.

The contribution of this scheme at district level has been in identification and referral of delivery cases among BPL families to private providers, follow-up of delivery cases and their risk status, ensuring the service provision, and protecting the most vulnerable (BPL) families from adverse financial burden. The mapping exercise carried out by the district health officials identified the private providers providing maternity services in five districts. A detailed survey of providers and their infrastructure facilities was carried out in one district to assess the service provision conditions. Meetings, interviews and consultations were held with these providers and professional bodies such as FOGSI and SEWA Rural to discuss the package of maternity services and cost of providing these services. Based on this a package of institutional delivery was finalised at Rs. 179,000 for 100 deliveries including both normal and complications. Each empanelled provider is given up-front advance of Rs. 20,000 to start providing services. The delay in payments has been found critical impediment in participation of private providers in any scheme.

Five districts covered by this scheme have population of about 10.5 million of which 43 per cent are below poverty line having about 110,000 deliveries per annum. The scheme during first year of its implementation has covered 31,641 deliveries including 2518 complicated cases and 1502 LSCS.

Of the total 217 providers in these districts 133 (61 per cent) have been empanelled in this scheme. The average number of deliveries carried out by these providers has been 238 deliveries.

The scheme shows that by providing financial protection through 100% subsidy of delivery cost of BPL families through involving private provider has potential to increase the institutional delivery rate and reduce the MMR and IMR substantially among the most vulnerable groups of population. During first 10 months of scheme implementation, no maternal deaths and 13 infant deaths were reported in the pilot districts. As per MMR and IMR, 70 – 80 mothers and 350 – 450 infants would have died in the districts. During this period, institutional deliveries in the five districts have increased from 38 per cent to 59 per cent. Due to packaging of services in the scheme, unwanted caesarean operations among the BPL expectant mothers has reduced from 15 per cent to 4.7 per cent. This scheme has increased the access to institutional facilities for maternity care. The cost of seeking delivery in private facilities by BPL families is high. This scheme covers both direct and indirect cost (for example travel and cost of accompanying person). The financial burden in case of complications can be catastrophic for BPL families which this scheme covers.

The objective of this paper is to describe the process and development of this scheme and discuss pathways of creating and strengthening capacity in health system to implement this scheme. The paper also discusses performance of this scheme and finds whether the scheme has been successful in providing access to BPL families for institutional delivery and thereby providing financial protection to these families. We also discuss the challenges and key issues in up-scaling this scheme further.