chiranjeevi scheme neeraj
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A Journey to safe
motherhood
Department of Health & FW
Government of Gujarat
CHIRANJEEVI YOJANA
GUJARAT
PRESENTED BY:-Neeraj Sharma
ICICI LOMBARD
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GUJARAT:SNAPSHOT
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Gujarat A Profile
Overview
Area 196,000 km 6% of India
Population 50.5 million 5% of India
Urbanization 37% India avg. 28%
SDP(2003-04)
Rs 1,425.60 billion( 26.40 bill.)
6.33% of India
Per Capita Income
(2003-04)
Rs 26,979
( 496.24)
India average -Rs.
20,989( 388.69)
Recognizing Gujarat potential the Planning Commission set a target growth rate of 10% p.a.
for Gujarat
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Every Minute...
Maternal Death Watch
Global
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
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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
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Infection
14.9%
Haemorrhage
24.8%
Indirect
causes19.8%
Other direct
causes
7.9%
Unsafe
abortion12.9%
Obstructed labour6.9%
Eclampsia
12.9%
Causes of Maternal Death
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Timing of maternal deaths-General Conditions
Postpartum
60%
During
pregnancy
24%
During
delivery
16%
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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
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Outsourcing Options
Private Gynecs/ GIA in their facility
Payment to Gynecs for working in government hospital
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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.
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Five basic mechanisms in the health sector
CONTRACTINGIN
CONTRACTINGOUT
SUBSIDIES LEASING/RENTALS
PRIVATIZATION
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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 CHCs4) 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.
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Chiranjeevi Scheme, Gujarat:2005
AIM
To improve the access of poor families in Gujarat toinstitutional delivery and to give them financial protection
from the health care costs
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Chiranjeevi Yojna
Till 2005 government: To develop their own rural hospitals as FRUs underthe CSSM and RCH program, without much success
Most FRUs could not become functional due to lack of obgyns andpediatricians in rural areas.
Gujarat health department worked out a scheme of PPP in 2005:collaborations with key stakeholders to provide delivery care to the poorin rural areas
Stakeholders: IIM Ahmedabad
NGOs (Sewa Rural)GTZ
This scheme was called ChiranjeeviYojana (CY) a local name meaninglong life (of mothers and babies).
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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
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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 clearlybeen clearly defined
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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
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To allay the fears of private doctors that, governmentdoes 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 healthoffice
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 urbanareas covering a population of 55 million)
Financial aid
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Package Rates for ChiranjiviNo. of cases Rate Per Case Cost
Normal delivery 85 800 68000
Complicated cases
Eclampsia 1000
Forceps/vacuum/breech3 1000 3000
Episiotomy 800Septicemia 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
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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
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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 fundsand money being provided by central government under
NRHM
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Assessment
A recent evaluation undertaken by the Indian Institute ofManagement, Ahmadabad in one district : 81% of the total
deliveries among eligible poor women
On an average, a chiranjeevi client is estimated to save aroundRs. 3273 (about USD 86) per delivery
However, despite medicines being covered under the scheme
these clients incurred an average expenditure of Rs. 654 (USD17) for the purchase of medicines for the mother as well as
for the child
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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
G h h i i d li i d
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Graph shows increase in deliveries under
Chiranjeevi in the state from AprilNovember
2007.
Ex t d d t d t l d w b
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Expected and reported maternal and new born
deaths and estimated lives saved by
Chiranjeevi Scheme up to Nov 2007
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Effect on institutional deliveries
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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
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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 authoritiesand Block Health Officers
Attempt to extract extra payment is reduced to bare
minimum as it is now important to win the loyalty of thebeneficiaries for sustained revenue in the long run
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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
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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
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Possible challenges
Private doctors who are paid on a fixed fee schedule may delaydoing 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 asnurses 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.
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Summary
Form of partnership voucher scheme to involve privateproviders in delivering maternity care
Geographical scope 1 year pilot in 5 districts & then to entire
state of Gujarat
Reasons for contracting High MMR, low institutional deliveries
Service For institutional deliveriesInformation to private parties Memoranda of understanding
Financing NRHM & state budget
Target group Women below poverty line
Implementation problems Inadequate awareness among private
providers about the scheme
Shortage of specialists
Uniform service package(for high risk
groups also)
Monitoring quality of care
Management responsibility District health officials
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Private-public partnership benefits women
and newborns in India
Source: WHO website
This 21-year-old poor woman
was able to give birth to herfirst son through caesarean
section thanks to the free
service offered at a private
hospital in Mehsana district
under the Chiranjeevi scheme.
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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 Chiranjeevischeme 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 isvery 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.
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Private practitioners check the
newborns in order to detect and treat
as early as possible health problems,
including asphyxia, low birth weightand 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 betterequipped 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
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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 staffto 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 coverscare 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 Chiranjeevischeme
runs.
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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 ofChiranjeeviYojana 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
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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 challengingin 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:
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Our Mission:
Save the lives of
thousands ofMothers and
Children dying with
no reason of theirsand prevent the
spread of infections
and promote healthy
life styles
Working together for a healthy Bharat
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Good Healthcareduring pregnancy
Healthy and HappyNext Generation
Good RCH care
Healthy adulthood
Healthy ChildhoodGood care of Infants
Healthy babies
Health Care from Womb to tomb
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Let Us Make Every Mother and Child Count
-Thank You