United Nations Public Service Awards Case Studies

The thrust for the institutional deliveries in the state of Madhya Pradesh has been a unique and innovative in many respects. First of all, it has addressed the human urge. Each pregnant woman is entitled to skilled care at birth. We have sought to position this entitlement across the board throughout the state and among all stakeholders. Second, we have taken a keen and judicious look at health institutions in readying them to rise to the challenge of increasing demand for institutional deliveries. We believe that the nomination of the state for the award is a tribute to the 2 million pregnant women of the State. Our sustained drive to reach the proactive and responsive care to them goes on.

What is the initiative about? (the solution)
The Department of Health & Family Welfare, Government of Madhya Pradesh has brought about noteworthy improvement in the status of maternal health in the State. About 2 million deliveries take place in the State every year and majority of them (79%) taking place in homes. Now, however, the pregnant women can look to the opportunity and promise of institutional deliveries with confidence and faith. The State has come out of the dismal level of institutional deliveries which has been hovering around 20% for more than a decade. The proportion of institutional deliveries has crossed the mark of 50% during April-October 2006 and is poised to register an ever-increasing graph. The women, particularly belonging to the below poverty line and those among Scheduled Caste and Scheduled Tribes are now well-equipped with the knowledge that pregnancy and delivery related emergencies cannot be predicted and have an assurance that their needs for hospital-based delivery care as well as those for emergency obstetric care can be effectively met with. They know that they can and must exercise this choice for institutional delivery care services. Women in each of 52143 villages in the State are now on their path to chart out their Birth Preparedness and Complications Readiness Plans as part of their enfranchisement with institutional deliveries. Their transportation, treatment and care at the hands of skilled staff and specialists have been secured in their favor, thanks to the strategic thrust for institutional deliveries by the Department of Health & Family Welfare, Government of Madhya Pradesh (GoMP). Towards this end, under the aegis of National Rural Health Mission, the State has embarked upon the massive social mobilization in favor of an inclusive approach to health and its determinants and accordingly 23051 Gram Panchayats, the third tier of governance have now gone about bringing about Village Health & Sanitation Committees in all the villages. Interestingly, these committees have the prime agenda of addressing the issue of maternal health in the Village Health Plans being formulated by them. The GoMP’s strategic thrust for institutional deliveries is positively aligned with the global consensus on what must be done to eliminate the menace of maternal deaths once and for all. The State’s missionary approach to the agenda of institutional deliveries can be termed as an ingredient of social justice by way of ensuring that all women and newborns have skilled care during pregnancy, childbirth and the immediate postnatal period.

Who proposed the solution, who implemented it and who were the stakeholders?
Key Dates Activity May 2004 State Programme Implementation Plan, RCH II – The State initiated this integrated planning approach together with decentralized planning in all 48 districts, the process deepening up to the level of all 313 blocks. 15th August 2005 Dhanwantari Yojna 25th September 2004 Launch of Prasav Hetu Parivahan Evam Upchaar Yojna (PHPY) 25th September 2004 Deendayal Antyodaya Upchar Yojna (DAUY) 12th May 2006 Vijaya Raje Janani Kalyan Beema Yojna (VRJKBY) 29th May 2006 11 Deendayal Chalit Aspatal (11 Mobile Hospitals)

Describe how and when the initiative was implemented by answering these questions
a. What were the strategies used to implement the initiative? In no more than 500 words, provide a summary of the main objectives and strategies of the initiative, how they were established and by whom.
Madhya Pradesh, as its name implies, is located at the geographic centre of India. It shares its border with five states, namely, Maharashtra, Gujarat, Rajasthan, Uttar Pradesh, and Chhattisgarh. Covering an area of 308,000 square kilometers with the population of 60.4 million (Census 2001), it has a large proportion of scheduled castes and tribes (15.4% and 19.9% respectively) with 73% of the population living in rural areas. The State has been witnessing a rather stagnant and unacceptably high Maternal Mortality Ratio (MMR) over the years. According to the Sample Registration System (SRS), Government of India, the MMR of Madhya Pradesh stood at 498 per 100,000 live births in 1997-98. Recently released report of the SRS informs that the MMR in Madhya Pradesh has come down to 379 in 2001-03. The Millennium Development Goals require that the Maternal Mortality Ratio should be reduced by three-quarters 1990-2015. Thus, the road is long and calls for re-engineering the public service system that can infuse vitality in the providers and instill hope and trust amongst the users of the services. The State, in recognition of this challenge has sought to position a much stronger programme to increase institutional deliveries by informing the community about its entitlements as well as the advantages of availing skilled care during pregnancy, child birth and post partum care. On the one hand, it seeks to ensure that the canvas of service delivery system is vibrant with the functionality of Basic and Comprehensive Emergency Obstetric and Neonatal Care (BEmONC and CEmONC) services in its health institutions. The State acknowledges that 15% of all births in the community may entail pregnancy and/or delivery related emergencies, on the other and hence access to these services is seen to be crucial to the reduction of maternal mortality. Madhya Pradesh has had a dismal record of institutional deliveries in the region of 20% for many years. According to Rapid Household Survey II, 2003, about two third of State’s districts were having institutional deliveries pegged at less than 20%. District Sidhi showed the enormous vulnerability at the poorest level of 3.8% whilst district Bhopal has been at the highest level of 35.9%. The National Rural Health Mission (NRHM) has been launched with a view to bringing about dramatic improvement in the health system and the health status of the people, especially those who live in the rural areas of the country. The Mission seeks to provide universal access to equitable, affordable and quality health care which is accountable and also responsive to the needs of the people. It was with the launch of National Rural Health Mission in August 2005 that the GoMP undertook a holistic approach to the Reproductive & Child Health Programme.

b. What were the key development and implementation steps and the chronology? No more than 500 words
The Department of Health & Family Welfare, Government of Madhya Pradesh has identified a range of core issues and prioritised the same in its RCH Phase II Programme. These issues include health care service delivery system at one end of the continuum and awareness and demand generation in the community, at the other end. The issues pertaining to the health care service includes problems of accessibility, availability and functionality of Basic and Comprehensive Emergency Obstetric and Neonatal Care (BEmONC and CEmONC) health institutions, poor referral linkages, inadequacy of skilled birth attendants at Sub Health Centres, Primary Health Centres and Community Health Centers and poor motivation and low performance of staff. Recognising that the community has been predominantly practising home-based delivery care through Traditional Birth Attendants, the department thus sought to place the dual focus on making the health service delivery system attractive whilst encouraging the community to wean away from home-based deliveries to institutional delivery services.

c. What were the main obstacles encountered? How were they overcome? No more than 500 words
With a view to addressing the overall objective of improving maternal health and create an enabling environment, a set of key strategies were selected following planned and sector-wide consultations with a range of stakeholders including representatives of Panchayati Raj Institutions (PRIs) and functionaries at district and sub-district levels. The strategies included community and social mobilization for institutional deliveries, strengthening antenatal and postnatal services, enhanced availability of facilities for institutional deliveries and emergency obstetric care, increased access to safe abortion services and prevention of RTI/STI. The state Government has identified 170 institutions as Comprehensive Emergency Obstetric and Neonatal care (CEmONC) and 500 Basic Emergency Obstetric and Neonatal care (BEmONC) care institutions across the State. This configuration is exceeds the norms of UN Process Indicators for Safe Motherhood to ensure access and availability of services for meeting the needs of emergency obstetric care. The operationalisation of this configuration has received planned attention. Towards the improvement of the accessibility and availability of 24-hour delivery service health institutions, some specific schemes were introduced as follows: A scheme known as Prasav Hetu Parivahan Evam Upchaar Yojna (PHPY) has been instituted under which a transportation grant of Rs. 300/- is paid to pregnant women belonging to Scheduled Caste and Scheduled Tribe and those below poverty line who avail the institutional delivery service at government health facility. The scheme includes free health care services. In addition, the escort motivating the pregnant woman for institutional delivery also receives an incentive payment of Rs.200/-. Under this scheme, more than 200,000 women have availed the benefits of referral transport. The state launched the Vijaya Raje Janani Kalyan Beema Yojna (VRJKBY) which focuses on promotion of ante natal health check ups for the below poverty line pregnant women and also promotes 3 days stay for women undergoing delivery at government health institution in order to effectively address the needs of immediate post partum care. The Scheme includes a remittance of Rs. 1, 000/- to the women availing the service. The Scheme is administered through a public sector insurance company. Within 6 months of the lunch of the scheme, more than 73,000 women have availed the benefits. A public sector insurance company is assisting the implementation of this scheme. With a view to reaching the unreached, the State has introduced Deendayal Chalit Aspatal under which 11 Mobile Hospitals in select 11 tribal and forest blocks, one in each district provide free treatment to populations in tribal-intensive and backward areas. Administered under public-private partnership, the scheme has benefited more than 199,000 persons within six months of its launch. Under its Deendayal Antyodaya Upchar Yojna (DAUY, free diagnosis and treatment is given to members of below poverty line families on admission to hospitals, up to Rs.20, 000/- per year. More than 2 million Family Health cards have been issued to the people and more than 255,000 persons have been benefited from the scheme. The State Government has instituted a novel scheme to focus regular monitoring of key parameters of various services in the pilot development blocks. Popularly known as Dhanwantari Yojna, this Scheme focuses on developing the select 50 development blocks (at least one per district) as model blocks where access to and availability of all basic health services are sought to be keenly pursued and monitored.

d. What resources were used for the initiative and what were its key benefits? In no more than 500 words, specify what were the financial, technical and human resources’ costs associated with this initiative. Describe how resources were mobilized
The State’s initiatives and focused interventions in safe motherhood have demonstrated that the concerted actions on inclusive planning, addressing the needs of the poor and the deprived for improved referrals, accessibility and availability of health care services and focused sustained monitoring have paved the way for establishing better process indicators. These indicators include the configuration of health system in terms of access and availability and met need for emergency obstetric care. The results have thus far been excellent depicting a success story enveloping both the policy and programmatic thrusts. The rise of institutional deliveries from 25% to 35% in April 2005-March 2006 and more than 51% during April 2006 to October 2006 is phenomenal by any standards for a vast state like Madhya Pradesh. It demonstrates that the endeavor has been accompanied by vigor and commitment across the community as well as the entire spectrum of health care service delivery system. An analysis of State’s reported data shows that district Sidhi has registered an 8 fold improvement in performance in terms of institutional deliveries. Two thirds of the State’s districts which were below 20% in institutional deliveries in government health facilities have all come out of the shame of immobilization. Now, one third of State’s districts have proudly registered institutional deliveries ranging from more than 50% to 65% while 7 districts report a performance above 65%. Thus, it is evident that the rise in institutional deliveries is massive. The increasing proportion of institutional deliveries is also an insurance against the possible and yet unpredictable complications that may occur to any pregnant woman. The institutional deliveries would ensure that such complications are captured and competently addressed so that a lasting dent may be made in reducing the maternal mortality in the State. A survey by UNICEF in November 2006 has shown that the dent is in the making. The results are quite encouraging at 345, adjusted Maternal Mortality Ratio. The targeting of health care for pregnant women has clearly been a differentiated one and has been embedded in equity and quality in care. So far, during the current year as many as 73925 pregnant women have availed the institutional delivery care services. The achievement is full of promise and gives a ray of hope to all the 136,832 pregnant women who registered themselves early for antenatal care.

Is the initiative sustainable and transferable?
The initiatives are being sustained under the ambit of National Rural Health Mission (NRHM). Special schemes for recognising better performing teams of service providers have been introduced. Also, the scheme of ASHA, Accredited Social Health Activist, a woman from each village in the State is being provided under the NRHM for promoting antenatal care and institutional deliveries. The State Government has also included the Prasav Hetu Parivahan Evam Upchaar Yojna (PHPY) under the State budget by taking steps to transfer allocations from plan funds to non-plan funds. The state has also instituted an elaborate initiative of Village Health Planning under which Birth Preparedness and Complications Readiness Plans for the current pregnant women have been centrestaged for all the 52,143 villages in the State through 23,051 Village Panchayats. This effort is being implemented through networking with NGOs and civil society organisations including White Ribbon Alliance for Safe Motherhood. At the State and district level, an endeavor has also been successfully realised to bring about convergence amongst Development Partners for providing coordinated technical assistance in planning and monitoring of the initiatives.

What are the impact of your initiative and the lessons learned?
The shift from the project to programme mode in a sector-wide approach has been very helpful in realizing the envisaged performance. The creation of core planning teams at State and district levels and full policy and leadership support and thrust to them has added tremendous value not only in terms of quality of Programme Implementation Plans but also in giving an impetus to programme implementation. Likewise, creation of integrated State Health Society at state level and District Health societies at the district level has greatly helped in enhancing pace of decision making as well as in heightened ownership of the decisions. There were difficulties in securing adequate role of District Core Teams. Sustained capacity building steps and continued consultations with Block Medical Officers with delegation of powers to them also proved enormously useful. The referral transport funds were placed at the disposal of the health institutions and the women could directly receive the remittances from them.


Institution Name:		Department of Health & Family Welfare
Institution Type:		Government Department
Contact Person:		Madan Mohan Upadhyay
Title:		Principal Secretary, Health & Family Welfare
Telephone/ Fax:		+91-755-2441620
Institution's / Project's Website:		+91-755-2441620
E-mail:		upadhyay.mm@mp.nic.in
Address:		Principal Secretary, health, Mantralaya, GoMP
Postal Code:		462011
City:		Bhopal
State/Province:		Madhya Pradesh
Country:		India

The Problem

Solution and Key Benefits

Actors and Stakeholders

(a) Strategies

(b) Implementation

(c) Overcoming Obstacles

(d) Use of Resources

Sustainability and Transferability

Lessons Learned

Contact Information