Managing maternal health care services through public private partnerships: policy issues and implications " a study of the Chiranjeevi scheme in Panchmahals district of Gujarat, India"

Abstract

Background: The UNDP Millennium Development Goal aims at reducing the maternal mortality ratio by three-quarters between 1990 and 2015. An estimated 1.2 million children are born in the state of Gujarat each year, including both institutional and domiciliary deliveries, about 4,600 of the mothers die during delivery owing to several reasons. In 2005, the Government of Gujarat launched the chiranjeevi scheme to promote institutional deliveries and reduce the financial risks borne by Below Poverty Line(BPL) families in availing of maternal care services. The scheme was initially launched in five districts-Banaskantha, dahod, Kachchh, Panchmahals, and Sabarkantha. The scheme was later scaled up to cater to the targeted population of the state. Objectives: The first objectives of research is to see why and how the scheme was conceptualized, formulated and examining the role and interests of major stakeholder groups, namely policy makers, programme implementers, service providers, beneficiaries, civil society organization (CSOs) and Panchayati Raj Institution (PRI) members. The second objective of the study is to look at the link between the incentives through payments mechanisms, offered by the scheme to the service providers and beneficiaries, and its relationship with the service delivery out comes. The third and final objective of the study is to investigate some unintended consequences of the PPP and the payment system being adopted in the scheme, on the client. Methods: The study was focused on Panchmahals district of Gujarat, India. The primary data was collected through interviews of the key stakeholders and a household survey. In all sixteen stakeholders were interviewed and many informal discussions were held with them. For the household survey the population was divided into four groups based on their delivery namely, Chiranjeevi delivery group, Non- Chiranjeevi delivery group, Government facility delivery and Home delivery group. The household survey covered 1,252 respondents encompassing these four groups. Findings: Stakeholder analysis 1. The Chiranjeevi Scheme seems to focus on increasing institutional deliveries in the targeted population. The package tends to ignore the Post Natal Care (PNC) components. Hence it has a limited impact on maternal morbidity and deaths. 2. Service delivery provisions are not mentioned in the contract. 3. The beneficiaries were not involved in the process of developing the scheme. 4. The monitoring system is very weak at the state and district levels. Its focus is primarily on the number of practitioners empanelled in the scheme and the number of deliveries. 5. A majority of the empanelled practitioners are not clear about the Chiranjeevi package and the amount of money to be reimbursed to the beneficiaries, and feel that the package is inadequate. They want separate packages for normal deliveries and cesarean sections. Under-provision of care and referrals Proportion of cesarean section (C-sections) 1. The C-section rate in chiranjeevi scheme in panchmahals district is 3.9 percent (the recommended range of C-sections by WHO is 5-15 percent). 2. The block with the most deliveries (3631) in the district has a C-section rate of 1.3 percent 3. The practitioner doing the most deliveries (1862 deliveries) in the district has a C-section rate of 0.5 percent. Length of stay 1. The average length of stay for normal deliveries is about 1.37 days (about 33hrs), 1.53 (about 37 hours) days and 1.36 days (about 33hrs), in case of Chiranjeevi, Non Chiranjeevi and deliveries at public facilities respectively. Guidelines of the American Academy of pediatricians and American College of Obstetricians and Gynecologists recommend an average postpartum stay at an institution, of 48 hours for vaginal and 96 hours for cesarean deliveries. This excludes the day of delivery (CDC, 1995). The above length of stay includes both ante partum and postpartum stay at the facility. Hence there seems an under-provision of care in all the three groups. Unintended consequences of the scheme: Out-of- pocket expenses 1. Chiranjeevi beneficiaries had to spend an average of Rs.939 on Ante-Natal Care (ANC), Rs. 652 on medicines and Rs. 893 on treatment of the child. Nine beneficiaries incurred an expenditure of Rs. 1000 towards procuring blood. Sex ratio: 1. The sex ratio of children delivered under the Chiranjeevi scheme is 713 females per 1000 male children. It is 859 for the non-scheme group and 824 for deliveries in public facilities. Recommendations: Based on the finding of the work, it has been recommended that the terms of the contract between the government and the private providers need to be revised with a provision for performance appraisal. The Chiranjeevi package has to be redesigned to incorporate elements to ensure reduction in maternal deaths. The study also suggests measures to improve monitoring and feedback mechanisms and development of a referral model to make the scheme more effective. Conclusion: Before designing a scheme like Chiranjeevi, policy makers should take into account the implication of the payment mechanism of service delivery outcomes which should be reflected in the MoU between the service provider and service procurement agency. A monitoring mechanism should be set in place at the time of implementing such initiatives. The monitoring tools being used in such initiatives should capture the impact of payment mechanism on the service delivery outcomes.