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PPPs for EmOC under the JSY

PPPs for EmOC under the JSY. A rapid assessment study in a selected district of Maharashtra June 08-June 09 Conducted by Foundation for Research in Community Health, (FRCH), Pune

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PPPs for EmOC under the JSY

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  1. PPPs for EmOC under the JSY A rapid assessment study in a selected district of Maharashtra June 08-June 09 Conducted by Foundation for Research in Community Health, (FRCH), Pune Investigators Dr. Bharat Randive, Dr. Sarika Chaturvedi

  2. India • Health care industry is fast growing • State of the art infrastructure • Known to produce amongst the best doctors in the world • Attractive hub for medical tourism

  3. …But • Fails to provide basic health care to its population • Contributes to 20% of maternal deaths worldwide Hopes for a better change after the NRHM

  4. ( SRS 2001-2003)

  5. Indian public health system • Studies show inadequate infrastructure • Shortage of drugs and supplies • High vacancy rates especially of specialists in rural areas Of 20,000 obstetricians in India only 780 work in public system at sub district level

  6. Indian private medical sector • Largest proportion of resources and services • 93% of Hospitals • 64% of Bed strength • 80-85% of doctors • 80% of Out patients • 57% of In patients Source: World Bank 2001 • 60% of MCH case load

  7. Maharashtra • CHCs having functional OT-84.6% • CHCs having Obstetrician - 40% • FRUs offering Caesarean section-14.3% • FRUs having blood storage facility-11.6% - DLHS-3(2007-08) Annual intake for specialisation in obstetrics- 102 compared to none in certain states

  8. PPP for EmOC under JSY of NRHM Contracting–in model • Hiring private specialist for management of obstetric complications and for CS • Rs.1500 as specialist charges • Free EmoC in public facilities • JSY Eligible clients (Maharashtra)- BPL, SC, ST women Over 19 years, Upto 2 live births

  9. Objectives- To understand 1. Design of PPPs in Ahmednagar district (partner selection / contracting mechanisms/ performance measurement / facility accreditation processes / monitoring) 2. Execution of PPPs Experiences in implementing / using the scheme (Referral / cost & consequences / financial provision) 3. Perceptions of providers and users about PPPs for EmOC

  10. Methodology Rapid Assessment of Health Programmes (RAHP) approach • Mid course adjustments to programmes • Documentation and analysis of lessons learnt • Results not meant to be statistically valid • Link between information and decision making focusing on why and how problems occur

  11. Study area • Ahmednagar district in western Maharashtra • MMR <2 for 1000 live births • SC-12.39%, ST-7.2%, BPL- 30% • 96 PHCs ,23 CHCs, 3 Subdistrict and 1 District Hospital • Mushrooming of private hospitals, 2medical colleges

  12. Ahmednagar district health system Moderate performance • Best SIS score Source – Health for Millions oct 07- jan 08 (IIPS Mumbai)

  13. SAMPLE SIZE 5 /14 blocks selected randomly 2 PHCs/ block selected randomly Respondents: Implementers- DHO, THO, MO/ANM (16) Beneficiaries (10) Non beneficiaries (8) Private EmOC providers ( 3)

  14. Data collection and processing • Semi structured interviews • Focus group discussions • Data for deliveries during June ‘07 to Oct ‘08 • Thematic analysis

  15. CONSENT

  16. LIVING CONDITIONS

  17. PROBING

  18. .. VENTILATING…

  19. FINDINGS

  20. Implementation of PPP • No contracting-in of private specialists • No empanelment/accreditation of private facilities • Thus NO PPPs in place

  21. Implementation • Passive support of administrators • Private providers not approached for PPP, vaguely aware through patients • No contract execution plans

  22. Cost subsidisation preferred to PPP • Rs. 1500 utilised as subsidy post C-section • Benefit only to C- section, not to other obstetric complications Thus, 2/3 rd women in need of EmOC barred from eligibility Cash assistance rather than service provision

  23. Financial provision • Inadequate financial provision for hiring specialist • Prevailing charges above Rs. 3000 “…He is not willing to do any work there because of interests in private hospital, otherwise all patients will get it done in the subdistrict hospital, who will want to spoil their own practice?....” (Mo-4)

  24. Financial assistance & Consequences • Average expenses incurred by women Rs. 15,000 (range Rs. 10,000 to 30,000) • Assistance received under PPP Rs. 1500 • Grossly insufficient ” ….enough only for the tablets and medicines…”- Beneficiary 1 • Delay in disbursement - On avg recd 3 mths after delivery • Indebtedness - pvt. loans @ 60%pa

  25. Proportion of JSY assistance to CS charges paid by women

  26. .. Referrals • No referral chains, no referral slips • Women mostly approaching private facilities directly • Women’s experiences: Difficulties in arranging transport “..We walked to the highway asking for lift…”3pm“….Reached the civil hospital….” 8pm • Travelled 40 km in 5 hrs after diagnosis of obstructed labour

  27. Analysis of Ahmednagar HMIS data : April –Sept. ‘08

  28. Poorly managed scheme • Poor reach • Lack of funds at grassroots • Non uniform implementation across blocks- ambiguous guidelines • No demand generation

  29. Reasons for non-utilisation and denials • Women unaware of provision for EmOC • Service area constraints- deliveries mostly at maternal homes • Difficulties in producing required documents in time - ? 7 days of delivery • Varying conditions for accessing the scheme- eg. registration before 12 wks, BPL survey rounds

  30. Views • Useful only for cities, not for rural areas “calling a doctor from town is equally good as taking the patient to the town”-District official • Inadequate public infrastructure for EmOC provision through contracting-in specialists - Public providers • Difficulties in implementation – • frequent changes in guidelines • eligibility conditions- time and documents criteria • funds flow issues • Demand for services rather than cash subsidy “..provide the facility instead of the money… we poor do not have the money at that time to pay for the hospital, what if the government gives us the aid later on….” – Non beneficiary 2

  31. Conclusions…Too little, Too late • No PPPs for EmOC under JSY in study district • Inadequate financial provision for contracting-in specialists • Infrastructural inadequacies, low motivation - barriers to contracting-in • Subsidy mechanism minimally influences out of pocket payments for EmOC services • Scheme implemented is exclusive

  32. Causes of maternal deaths addressed under PPP

  33. Recommendations • Model of PPP should be chosen considering local feasibility by dialogue among partners rather than directives from top • Service provision rather than sudsidy; Contracting-in / out such that onus of negotiating charges is not on the woman • Capacity building for management of PPPs • Charges for hiring specialists should be based on area specific competitive rates

  34. Recommendations • Evolution and enforcement of mechanisms for monitoring,quality assurance and grievance redressal • Scheme should include all life threatening complications of pregnancy and child birth • Emphasis on micro-birth planning- Ensure birth preparedness and complication readiness

  35. ……Too far to go…. THANK YOU! Acknowledgements: Dr. Abhijit Das, CHSJ, New Delhi Amy Hagopian, Peter House, Univ. of Washington, USA UNFPA India

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