A Journey to safe

motherhood
CHIRANJEEVI YOJANA
GUJARAT
Department of Health & FW
Government of Gujarat
PRESENTED BY:-Neeraj Sharma
ICICI LOMBARD
GUJARAT:SNAPSHOT
 Gujarat – A Profile
Overview

Area 196,000 km 6% of India

Population 50.5 million 5% of India
Urbanization 37% India avg. 28%
SDP Rs 1,425.60 billion 6.33% of India
(2003-04) (€ 26.40 bill.)

Per Capita Income Rs 26,979 India average -Rs.

(2003-04) (€ 496.24) 20,989
(€ 388.69)

Recognizing Gujarat potential the Planning Commission set a target growth rate of 10% p.a.
for Gujarat
 Maternal Death Watch
Global

Every Minute...  380 women become pregnant

 190 women face unplanned or
unwanted pregnancy
 110 women experience a
pregnancy related complication
 40 women have unsafe abortions
 1 woman dies from a pregnancy-
related complication
 Current Status
Indicator India Gujarat

Maternal Mortality Ratio 453 389

Infant Mortality Rate 63 57

Maternal Deaths in one year 1,20,000 5000

Infant Deaths in one year 25,00,000 72000

FOR THE YEAR 2000

 Causes of Maternal Death
Haemorrhage
24.8%

Infection
14.9%

Indirect
causes
19.8%

Eclampsia
12.9%
Obstructed labour
Other direct
causes Unsafe 6.9%
abortion
7.9% 12.9%
Timing of maternal deaths-
General Conditions

Postpartum
60%

During
pregnancy
24%

During
delivery
16%
 Broad Issues
 Non - availability of O & G specialists

 Accessibility of services-Tribal and urban slums

 Poor utilization of services-

 Low felt need of health & medical services
 Lack of user friendly & quality public health services
 Costly private health and medical services
 No health insurance coverage
Outsourcing Options

 Private Gynecs/ GIA in their facility

 Payment to Gynecs for working in government hospital

 PPP in health
 Public-Private Partnership is an instrument for improving the health
of the population

 PPP is to be seen in the context of viewing the whole medical

sector as a national asset with health promotion as goal of all health
providers, private or public

 The Private and Non-profit sectors are also very much accountable
to overall health systems and services of the country

 Therefore, synergies where all the stakeholders feel they are part of
the system and do everything possible to strengthen national
policies and programmes needs to be emphasized with a proactive
role from the Government.
Five basic mechanisms in the health sector

CONTRACTING CONTRACTING
IN OUT

SUBSIDIES LEASING/RENTALS

PRIVATIZATION
Examples
1) The Uttaranchal Mobile Hospital and Research Center (UMHRC)
is three-way partnership among the Technology Information,
Forecasting and Assessment Council (TIFAC), the Government of
Uttaranchal and the Birla Institute of Scientific Research (BISR)
2) The Government of Andhra Pradesh has initiated the Arogya
Raksha Scheme in collaboration with the New India Assurance
Company and with private clinics. It is an insurance scheme fully
funded by the government
3) The Govt. of Gujarat has provided grants to SEWA-Rural in
Gujarat for managing one PHC and three CHCs
4) The Government of Tamil Nadu has initiated an Emergency
Ambulance Services scheme in Theni district of Tamil Nadu in
order to reduce the maternal mortality rate in its rural area.
Chiranjeevi Scheme, Gujarat:2005

AIM
To improve the access of poor families in Gujarat to
institutional delivery and to give them financial protection
from the health care costs
 Chiranjeevi Yojna
 Till 2005 government: To develop their own rural hospitals as FRUs under
the CSSM and RCH program, without much success

 Most FRUs could not become functional due to lack of obgyns and
pediatricians in rural areas.

 Gujarat health department worked out a scheme of PPP in 2005:

collaborations with key stakeholders to provide delivery care to the poor
in rural areas

 Stakeholders: IIM Ahmedabad

NGOs (Sewa Rural)
GTZ

 This scheme was called “Chiranjeevi Yojana” (CY) – a local name meaning
long life (of mothers and babies).
 Implementation
 Pilot basis in 5 backward districts of the state with a total
population of 9.7 million

Selection criteria for private ob gyns for enrolment in to

CY
 1. Doctor must by having post-graduate qualification in Obgyn
 2. Must have his/her own hospital
 3. Must have Labour room and OT
 4. Must be able to access blood in emergency situation
 5. Must be able to arrange for anesthetists and do emergency
surgery
 Health Minister wrote a letter about the scheme to presidents
of district and talukas in 5 districts.
 District level Advocacy workshops of Presidents of district and
taluka panchayat
 In each district IEC activities were undertaken
 Regular interaction with Chiranjeevi Panel doctors
 The poor are to be identified either by Below Poverty Line
card or a certificate issued by designated village leader
 The roles and responsibilities of different officers have clearly
been clearly defined
 Private ob gyns: To provide skilled care for deliveries of poor
women and required comprehensive Em OC free of cost in
their own hospital
 In return the government would pay the doctors 4000$ for
100 deliveries (40$ per delivery)
 The monetary reimbursement was worked out based on costs
in an NGO hospital in rural areas by Dr. Pankaj Shah (SEWA
Rural)
 Discussed with private providers
 Obgyn: To pay the poor women 5 $ for transportation out of
the 40$ he/she got from the state government per delivery
 This was to reduce the delay in reaching the hospital
 Financial aid
 To allay the fears of private doctors that, government
does not pay on time, in this scheme doctors were given
advance payment of about 624 $ on signing the contract
with government
 Reimbursed rapidly after delivery by the district health
office
 Based on the successful experience of one year of the
scheme it was extended to all the poor in the whole state
in November 2006(covering all the 25 districts and urban
areas covering a population of 55 million)
Package Rates for Chiranjivi
No. of cases Rate Per Case Cost

Normal delivery 85 800 68000

Complicated cases
Eclampsia 1000

3 1000 3000
Forceps/vacuum/breech
Episiotomy 800
Septicemia 2 3000 6000
Blood transfusion 3 1000 3000
Cesarean (7%) 7 5000 35000
Predelivery visit 100 100 10000
Investigation 100 50 5000
Sonography 30 150 4500
NICU support 10 1000 10000
Food 100 100 10000
Dai 100 50 5000
Transport 100 200 20000
Total 100 179500
 Service Charges In Govt and GIA Institutions

Item cases Rate Cost

Normal delivery 85 200 17000
Complicated cases
Eclampsia 300
Forceps/vacuum/breech 3 300 900
Episiotomy 300
Septicemia 2 300 600
Blood transfusion 3 300 900
Cesarean (7%) 7 1000 7000
Predelivery visit 100 100 10000
Investigation
Sonography 30 150 4500
Dai 100 50 5000
Transport 100 200 20000
Total Cost 65900
Cost of the scheme
 Total cost of the pilot scheme:11 Cr Rs (2.75 million $)
for one year for 5 districts

 When extended to the whole state:

1st year cost: 54 Crores
(3.5%) of the total health budget

 This is being currently met from the state government funds

and money being provided by central government under
NRHM
 Assessment
 A recent evaluation undertaken by the Indian Institute of
Management, Ahmadabad in one district : 81% of the total
deliveries among eligible poor women

 On an average, a chiranjeevi client is estimated to save around

Rs. 3273 (about USD 86) per delivery

 However, despite medicines being covered under the scheme

these clients incurred an average expenditure of Rs. 654 (USD
17) for the purchase of medicines for the mother as well as
for the child
 Results
 Assessed in terms of improved availability of EmOC

 Services through enrollment of private obgyn

hospitals, number of deliveries done of poor

 Women and comparing reported and expected

maternal deaths and neonatal deaths
Graph shows increase in deliveries under
Chiranjeevi in the state from April – November
2007.
Expected and reported maternal and new born
deaths and estimated lives saved by
Chiranjeevi Scheme up to Nov 2007
Effect on institutional deliveries
 UNFPA Report

 The pilot in 5 districts: significant improvement in

increase of institutional deliveries among the BPL
population with high levels of clients satisfaction

 This is not only sustainable but can be stretched more

from optimal capacity-utilization point of view
 IIM-A

 The Chiranjeevi Scheme has put the purchasing power in the

hands of BPL families

 The monitoring of the scheme lies with the district authorities

and Block Health Officers

 Attempt to extract extra payment is reduced to bare

minimum as it is now important to win the loyalty of the
beneficiaries for sustained revenue in the long run
 Recognition

 UNFPA Evaluation
“Chiranjeevi is indeed an innovation in the area of Public-Private
Participation leading to increased access to poor for safe delivery
services. Given adequate support and guidance, this programme
can become a forerunner for many other interventions in NRHM.
States looking for models for successful PPP mechanisms will be
immensely benefited with dissemination of the experiences gained
from this scheme”

 Asian innovation award, by the Wall Street Journal at Singapore

 Nominated for the IBM Innovations Award in Transforming

 Innovation
 Availability of Gynecologists in private sector met with the
shortage of gynecologists in public sector

 Cashless scheme

 Problem of delay in transportation is also solved

 New comer Gynecologists are more attracted, as the scheme help

them to get assured income in initial period of their practice and
enlarge the clientele

 Assured availability of quality services for maternity to mother and

newborn care at zero cost
 Possible challenges

 Private doctors who are paid on a fixed fee schedule may delay
doing needed surgery or refer complicated cases to public
facilities to avoid extra costs.
 Many times private Ob gyns do not employ qualified nursing
staff, but get work done from trained women who work as
nurses and midwives thus compromising quality of care.
 Monitoring of maternal and neonatal deaths and morbidities
needs to improve so that we can assess the impact of the
program much more rigorously.
 Simultaneous efforts are needed to improve the infrastructure,
HR and management of public facilities to provide services to
the mothers and children.
 Summary
Form of partnership
Geographical scope
Reasons for contracting
Service
Information to private parties
Financing
Target group
Implementation problems
Management responsibility
voucher scheme to involve private
providers in delivering maternity care
1 year pilot in 5 districts & then to entire
state of Gujarat
High MMR, low institutional deliveries
For institutional deliveries
Memoranda of understanding
NRHM & state budget
Women below poverty line
Inadequate awareness among private
providers about the scheme
Shortage of specialists
Uniform service package(for high risk
groups also)
Monitoring quality of care
District health officials
Private-public partnership benefits women
and newborns in India
Source: WHO website

This 21-year-old poor woman

was able to give birth to her
first son through caesarean
section thanks to the free
service offered at a private
hospital in Mehsana district
under the Chiranjeevi scheme.
 In this primary health care centre
in Kheda district, auxiliary nurse
midwives provide free antenatal
and postnatal care to women

This private obstetrician works part

time for the Chiranjeevi scheme at a
public hospital in Bharuch district. She
is one of 833 private practitioners who
joined the scheme and are paid about
US$ 32 per delivery. She says she is
very happy with the programme
because it multiplied the number of
her patients and her income.
Institutional deliveries in Gujarat have
increased from 67% to 82% since the
scheme started two years ago.
 Private practitioners check the
newborns in order to detect and treat
as early as possible health problems,
including asphyxia, low birth weight
and infections. They also advise the
mothers on breastfeeding, hygiene and
other issues related to newborn care.

The chances of survival are very good

for this premature baby, thanks to the
services provided by a private clinic in
Mehsana district under the
Chiranjeevi scheme. Private
establishments are often better
equipped to save the lives of
premature babies.They offer special
areas for neonates, have modern
instruments like incubators and
sometimes maintain their own blood
banks
This pregnant 19-year-old girl is being
tested for HIV, malaria and anemia. In
the public hospital she is given a card
with all test results that helps the staff
to monitor the health of women and
babies. Many lives are saved because
possible complications are identified
early in pregnancy and poor women
receive timely and free obstetric care
under the Chiranjeevi scheme

In this nursing school in Mehsana district,

36 students are trained for 18 months to
become skilled nurses. The training covers
care before, during and after childbirth as
well as newborn care and family planning.
After the training, the nurses will work in
rural areas where the Chiranjeevi scheme
runs.
The Chiranjeevi scheme has
made better care available to
pregnant women and
encouraged them to go to
maternity hospital for delivery.
More than a third of the 2000
emergency calls received by a
new ambulance service every
day are related to pregnant
women in rural areas

This young woman lost two

babies she delivered at home
with the help of a traditional
birth attendant.This time she
gave birth in hospital to a healthy
baby girl. The results of
Chiranjeevi Yojana have
encouraged other Indian states to
initiate similar programmes. It is
currently being replicated in the
states of West Bengal, Madhya
Pradesh and Uttar Pradesh
Key messages
CHIRANJEEVI YOJANA -
 It may be more efficient to harness available private
skilled providers in private sector by paying their marginal
costs plus reasonable profit rather than waiting for
improvement in public services, which is very challenging
in some developing countries like India
 Develops health markets in rural areas and makes rural
and remote areas attractive for private health care
providers
 counteracts the pull of urban areas which normally drain
the private providers from rural areas to cities.
 Our Mission:
“Save the lives of
thousands of
Mothers and
Children dying with
no reason of theirs
and prevent the
spread of infections
and promote healthy
life styles”

Working together for a healthy Bharat

 Good care of Infants Healthy Childhood

Healthy babies Healthy adulthood

Healthy and Happy

Next Generation

Good Healthcare
Good RCH care
during pregnancy

“Health Care from Womb to tomb”

Let Us Make Every Mother and Child Count

-Thank You