Policy Barriers Preventing Access to Emergency Obstetric are in Rural India

India with its one billion people contributes to about 20% of all maternal deaths in the world. Even though infant mortality has declined in India maternal mortality has remained high at about 540 per 100,000 live births. Recent scientific evidence shows that access and use of high quality emergency obstetric care is the key to reducing maternal mortality and that high risk approach in ante natal care do not help in reducing maternal mortality significantly. This paper analyzes the policy level barriers, which restrict access of rural women to life saving emergency obstetric care in rural India. The paper is based on study of policies, research reports and experience of working in the area of maternal health over last several years. The paper describes how policies restrict basic doctors from performing obstetric surgical procedures including cesarean section even in remote areas where there is no specialist obstetrician available. The para-medical staff such as the Auxiliary Nurse Midwife is also not allowed to manage obstetric emergencies in rural areas. The policy also does not allow nurses or basic doctors to give anesthesia. As there is limited number of anesthetists in rural areas, this further reduces access to life saving emergency surgery. New blood banking rules are very utopian, requiring many unnecessary things for licensing of a blood bank. Due to this, already limited access to blood transfusion in rural area has further reduced. Thus many restrictive polices of the government have made emergency obstetric care inaccessible in rural areas leading to continued higher maternal mortality in India.

The Changing Role of Auxiliary Nurse Midwife (ANM) in India: Implications for Maternal and Child Health (MCH)

The world’s democracy and its second most populous country, India was the first developing country to have a national family planning program and has implemented countrywide reproductive health programs such as RCH I. India’s primary health care and the family planning programs have come a long way after the independence in improving health indicators in general, yet it has high material and under five mortality rates. The country has developed an extensive network of primary health centers and sub- to provide basic medical care to huge (80%) rural population. In the rural health care system, the ANM is the key field level functionary who interacts directly with the community and has been the central focus of all the reproductive child health programs. In contrast with resident ANM of sixties who was providing delivery and basic curative services to the community, today’s commuting multi purpose worker is more involved in family planning and preventive services. This has implications on the implementation and coutcomes of maternal health programs in rural India. The midwifery role of the ANM should be restored if the goal of dcreasing maternal mortality has to be met. The priority will have to change from family planning immunization to comprehensive reproductive health including maternal and neonatal care. These changes will require sustained and careful planning/resource allocation. Increasing resources along with systemic reforms will improve health status for women and children who are the focus of Reproductive Child Health programs.

Management Capacity Assessment for National Health Programs: A study of RCH Program in Gujarat State

The Ministry of Health and Family Welfare, Government of India administers a large number of national health programs such as Malaria control program, Blindness control program, National AIDS control program, Reproductive and Child Health (RCH) Program and so on. However, effective management of these programs has always come under scrutiny, as these programs consume a large amount of resources. As health is a state government subject in India, it is necessary to assess the management capacity of the department of Health and Family Welfare (H & FW) in each state. In this paper, we focus on the management capacity assessment for RCH program. Based on extensive literature survey, and discussions with senior officers in charge of RCH program at the centre and several states, we have developed a conceptual framework for management capacity assessment. Central to our conceptual framework are the following determinants of management capacity at the state dept of H & FW: (1) Capacity to formulate a clear statement of the state’s RCH Policy, Goals, and a Strategic Plan to achieve the Objectives, consistent with the resources available, (2) A well designed organizational structure for the H&FW department to provide the necessary support for achieving the policy goals, (3) Capacity of the H & FW department for effective management of RCH program, (4) Clear documentation of HR policies (qualifications, transfer, promotions, training etc) for RCH managers, (5) Role of External Stakeholders (6) Management Systems for Planning, Implementation and Monitoring RCH program, and (7) Institutional Processes and procedures For each of the above determinants, we have identified a set of indicators to assess the management capacity and designed a management capacity assessment tool to estimate these indicators. A pilot survey of our management capacity assessment tool in a few states helped us to refine certain instruments in our tool and finalize the same. Our management tool has been accepted by the Ministry of H & FW, Government of India and it has asked all the states and union territories to carry out a self assessment of their management capacity for RCH program. We have also recommended a suitable structure for effective management of RCH program for each state based on its population, the number of people in the reproductive age group, expected number of childbirths, and the current status of its H&FW department in delivering RCH services. This recommended structure can be used as a guideline by each state to identify its capacity gaps and take the necessary steps to augment its management capacity.

Strengthening Midwifery Services in India based on lessons learnt from Sweden and Sri Lanka

Objective: The objective of the paper is to know how India can strengthen midwifery services to reduce maternal mortality based on the lessons learnt from Sweden and Sri Lanka. Method: The paper is based mainly on the literature review, field visit to Sweden and interaction with maternal health experts from Sweden and Sri Lanka. Conclusion: High maternal mortality in India is due to absence of skilled attendance at the time of delivery and poor post-natal care. Seventy percent Indian population is rural and it is not possible to have doctors for all births. Adopting evidence-based interventions such as developing a skilled cadre of locally available midwives backed up by efficient referral and emergency obstetric care services like Sweden and Sri Lanka will help India achieve the goal of reducing maternal mortality with the existing resources. Analysis also shows that establishing quality training, independent regulating body and standardizing midwifery practices in India requires sustained efforts from government, professionals and society, and reorganization of health systems. Creating the scope for career advancement will help to improve status of midwifery as a profession.

Management of Blood Transfusion Services in India: An Illustrative Study of Maharashtra and Gujarat States

Blood is a vital healthcare resource routinely used in a broad range of hospital procedures. It is also a potential vector for harmful, and sometimes fatal, infectious diseases such as HIV, HBV, and HCV. Morbidity and mortality resulting from the transfusion of infected blood have far-reaching consequences. The economic cost of a failure to control the transmission of infection is visible in countries with a high prevalence of HIV. Shortfalls in blood supply have a particular impact on women with pregnancy complications, trauma victims and children with severe life-threatening anaemia. Ensuring a safe, source and ethical supply of blood and blood products and rational clinical use of blood are important public health responsibilities of every national government. Blood transfusion services in India rely on very fragmented mix of competing independent and hospital based blood banks of different levels of sophistication, serving different types of hospitals and patients. Voluntary and non-remunerated blood is in short supply. The SACS ensure only the availability of safe blood in blood banks. Clinical use of blood is not monitored, and the use of blood components is very low. Managing blood transfusion services involves donor management, blood collection, testing, processing, storing, issue of safe blood and blood products when clinically needed, and staff training. Maharashtra Government, by setting up its State Blood Transfusion Council as an independent unit under the Department of Health, has set up an excellent example to address the above managerial issues in meeting the transfusion requirements than any fragmented system. We strongly recommend the Maharashtra model to all other states and union territories in India.

Chikungunya Epidemic Mortality in India: Lessons from 17th Century Bills of Mortality Still Relevant

Chikungunya is a virus spread by the bite of the Aedes mosquito, which recently reemerged as a massive epidemic in the Indian Ocean islands and India. Chikungunya is generally considered self-limiting and has been reported as non-fatal but, since March 2005, one-third of the 770,000 people in the Indian Ocean Island of R�union (a French territory) have been affected by Chikungunya with 237 deaths. India reported 1.3 million cases of Chikungunya however the Government of India has not reported any deaths. However there is evidence that deaths due to Chikungunya did occur. The lack of official reports of deaths is mainly due to the poor recording of ‘Causes of Death’ in India. The London Bills of Mortality from the 17th provides a very good example of the importance of proper reporting of deaths especially during an epidemic period. This paper reflects on the London bills of mortality and modern day lessons to be drawn from it as well as the reasons behind the apparent lack of death reporting in 2006’s Chikungunya epidemic.

Management of RH Services in India and the Need for Health System Reform

For the last ten to fifteen years, a comprehensive agenda of health sector reforms and health systems development has engulfed the health system in many countries in structural and organisational changes. Experience with varying degrees and types of reforms have now been reported from many countries. In our paper, we begin by describing some important issues facing the management of RH programs in India, based on our research done in a few states over the last five years. The failures in the management of RH services are complex and multi-factorial, and cannot all be addressed through health system reform. It is therefore necessary to identify which failures in service are attributable to causes, which could be removed or changed by reform in the health system. In our paper, we identify those failures and causes which could be corrected through health system reforms and propose certain concrete steps to expedite the reforms in the health system to enable the improvement of RH services in India.

Managing Equipment for Emergency Obstetric Care in Rural Hospitals

In resource poor countries substantial sums of money, from governments and international donors, are used to purchase equipment for health facilities. WHO estimates that 50-80% of such equipment remains non-functional. This article is based on the experiences from various projects in developing countries in Asia and Africa. The key issues in the purchase, distribution, installation, management and maintenance of equipment for emergency obstetric care (EmOC) services are identified and discussed. Some positive examples are described to show how common equipment management problems are solved.

Maternal Health Financing in Gujarat: Preliminary Results from a Household Survey of Beneficiaries under Chiranjeevi Scheme

The objective of this paper is to provide preliminary analysis of information collected at household level from beneficiaries of the Chiranjeevi scheme and from those who have not used the scheme (non-user group). The key findings have been discussed. Some of the questions which have guided this exercise are: understanding the socio-economic profile and differences of the households who have used the scheme and those who have not used the scheme, ability of scheme to target the poor and out-of-pocket expenditures incurred both users and non-users of the scheme. We have discussed this by analysing education, land holding, number of earning members in the family, possession of specific assets, age of women at the time of delivery, ANC services received, place of delivery, distance and time taken to reach the facility, status (normal or complication) of delivery, complications experienced, and cost incurred during the process. The total sample size consists of 656 respondents from 3 talukas of Dahod District. Of these total 656 respondents, 262 (40 per cent) are Chiranjeevi clients and 394 (60 per cent) comprise the non-user group. Key findings of the study are: * The Chiranjeevi scheme is being used by relatively younger mothers and having lesser number of children at the time of index delivery. * Most of the Chiranjeevi users have income levels less than Rs. 12,000 per annum indicating the scheme is able to target the poor families in these three blocks of the district, * The expenditure incurred by non-user group on index (recent) delivery at a private facility is Rs. 4000. * The average expenditure incurred by the Chiranjeevi beneficiary on their previous delivery was Rs. 3070. On index delivery a Chiranjeevi client has spent out-of- pocket on an average Rs. 727 per delivery on medicine (self Rs. 297, child Rs. 358) and transportation Rs.72 indicating that the delivery is not really cash-less. However, the average amount saved by the Chiranjeevi client by availing the benefit of the scheme is Rs 3273 (Rs. 4000 minus Rs. 727). * The average distance travelled by a Chiranjeevi client to reach the health care facility is 13.79 kms and the average time taken is 44 minutes. * The average expenditure on transportation using mostly private transport by a Chiranjeevi client is Rs.272 as compared to Rs. 200 which the Chiranjeevi client is reimbursed, * Private doctors have conducted 41 per cent of deliveries where as rest of the deliveries have been conducted by staff at the private health care facility under the Chiranjeevi scheme, * ANMs have been the source of information to 55 per cent of Chiranjeevi scheme users. Anganwadi workers provided information to 17 percent of the clients and Female Health Workers to 10 per cent of the Chiranjeevi clients. Thus, 82 per cent of the total beneficiaries of the Chiranjeevi scheme were provided information by the community health workers.

Assessing the Regional and District Capacity for Operationalizing Emergency Obstetric Care through First Referral Units in Gujarat

Maternal mortality remains to be one of the very important public health problems in India. The maternal mortality estimates, is about (300-400/100,000 live births). There are diverse management issues, policy barriers to be overcome for improving maternal health. Especially, the operationalization of Emergency Obstetric Care (EmOC) and access to skilled care attendance during delivery. This study focuses on understanding the regional and district level capacity of the state government to operationalize First Referral Units for providing Emergency Obstetric care. This study is a part of a larger project for strengthening midwifery and Emergency Obstetric Care in India. The study apart from giving an in-depth insight into the functioning of various health facilities highlights the results from the basic to the more comprehensive level of EmOC services. It gives recommendation on various measures to rectify shortcomings noticed and make EmOC a more effective at different levels in the State of Gujarat. The study uses both primary and secondary data collection. The study was conducted in six regions of Gujarat -one district from each of these regions was selected. Out of these districts 27 health facilities were examined, which consists of seven district hospitals, eight designated as first referral units (FRU), four community health centers (CHC) and eight 24/7 primary health centers (PHC). Detailed field notes for individual facilities were prepared and analyzed subsequently for all facilities together. A common feature among all health centres were issues related to general infrastructure. Many times infrastructure planning (location, layout and maintenance) is left to engineers, who have limited knowledge about proper EmOC services. Poor infrastructure leads to poor quality of health services and wastage of resources. Through National Rural Health Mission (NRHM) and Rogi Kalyan Samiti funds major and minor repair/renovations are taking place to improve hospital buildings. In some health facilities from poor resource setting with high demand from patients were still able to deliver services. Human resources analysis suggests that there is shortage of specialists at FRUs, and committed nursing staff in labor room. As result of the Chiranjeevi initiative, the Below Poverty Line (BPL) population who earlier used to public health facilities are now accessing private facilities for delivery, and this has affected and decreased the workload of the public health facilities. Furthermore, there is lack of managerial skills at senior level hospital staff. Registers like birth, drug, Medical Termination of Pregnancy are maintained but not in standard format. Since complicated cases are not registered properly, maternal deaths are not reported. Even though the system of monitoring is well established at the state and district level, they are not properly followed. The funds for operationalization of First Referral Units come from department of family welfare. However, the administrative control is in the hands of department of medical services. Due to this factor monitoring system has become weak. The weak link between these two departments is the Regional Deputy Director who has only one administrative staff to take care of the issues in their region. The problem of monitoring the Primary Health Centres has become smooth with the appointment of new District Project Coordinators. Some facilities especially in district hospital reported that internal meetings and monitoring are happening because of the special interest of facility managers and newly appointed assistant hospitals administrators. In lower facilities this type of internal monitoring exists in a weak form. Underutilization of government facilities is a result of poor quality of services provided. In spite of reasonably developed health system, several problems of infrastructure, staffing, accountability and management capacity contribute to the poor functioning of facilities to act as an EmOC service delivery center. Some of the major bottlenecks in improving EmOC services are limited management capacity, lack of availability of blood in rural areas and poor registration of births and deaths and no monitoring of EmOC. District hospitals, FRUs, CHCs and Sub district hospitals come under the administrative control of the department of medical services. The clinical monitoring of these facilities lies with the department of health and family welfare. At the district level monitoring of these facilities are not properly done, therefore it effects directly the operationalization of the facilities. In the absence of adequate management capacity, the operationalization of EmOC is not well planned, executed or monitored, which results in delays in implementation and poor quality of care.