| 4. In which ways is the initiative creative and innovative?
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Political and administrative willingness to address the challenges are at the heart of any successful public health program. Maternal Health received utmost support from political and administrative leadership in state.
Chief Minister of the State led from the front to address issue of higher maternal mortality. To garner support from private sector, Chiranjeevi Yojana was launched by Chief Minister in year 2005.
Chiranjeevi Yojana was timely introduction as higher institutional deliveries lead to lower maternal mortality and morbidity. Furthermore, Gujarat has a huge private sector and presence of specialists in public sector is very low. Introduction of Chiranjeevi Yojana expanded availability of CEmOC services across the state even in periphery. Nearly 800 doctors from private sector joined hands with government under this scheme.
Meanwhile, Government of Gujarat strengthened its own facilities by training MBBS doctors in performing Caesarean Section operations and handle obstetric emergencies in collaboration of JHPIEGO. Around 100 pairs of medical officers have been prepared who are trained in CEmOC (Comprehensive Emergency Obstetric Care) and LSAS (Life Saving Anesthetic Skills) and posted at peripheral institutions to expand coverage of services.
Another major bottleneck of transportation was addressed by use of 108 ambulance services. 108 services have more than 500 ambulances deputed across the states which address any emergency within half an hour.
Financial protection during the pregnancy is another such important aspect which Government addressed through program called JSSK (Janani Shishu Suraksha Karyakram). This program envisions complete free service provision to all pregnant women without any conditions. JSSK program has tremendously increased public institutional deliveries.
All above mentioned initiatives has worked in great synergy leading increased institutional delivery along with provision of quality CEmOC services to pregnant women leading to improved maternal outcome and lower maternal deaths. State government is continuously striving to improve further on these indicators to ensure safe childbirth to every pregnant woman.
Kindly see Annexure – 1 at the end for detailed implementation plan for Chiranjeevi Yojana, E-Mamta, Maternal Death Review and Identification of High Priority Areas.
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| 5. Who implemented the initiative and what is the size of the population affected by this initiative?
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Maternal Health received utmost priority from all segments of the society. Any health program becomes successful when there is political will to achieve the same. Gujarat’s Chief then Chief Minister spearheaded entire movement to improve maternal health in Gujarat.
Chiranjeevi Yojana was launched by Hon. Chief Minister in year 2005 to improve institutional deliveries in Gujarat. The scheme was designed by health division and led by Commissioner of Health in close collaboration with Indian Institute of Management (IIM), Ahmedabad. Private sector including FOGSI provided tremendous support to the scheme by way of enrolling themselves with the scheme. There were more than 800 Gynecologists from private sector who registered themselves in Chiranjeevi Yojana.
Outreach session (Mamta Diwas) concept was designed by health division with support from Development partner UNICEF, Gujarat for pilot testing followed by state level roll out of the program.
e-Mamta program was entirely developed by state IT team called National Informatics Center (NIC) with technical inputs from the state team. Entire health department contributed towards effective implementation of e-Mamta. Primary users of e-Mamta are field level workers and their dedication has made e-Mamta very good system.
Maternal Death Review is conducted by Taluka level health officers. At state level UNICEF supports technical team involved in maternal death review. Apart from that, various nongovernmental organizations and FOGSI (Federation of Obstetricians and Gynecologists Society of India) are members of the state level MDR Committee.
Identification of High Priority Taluka was done by health division and received tremendous support from Hon. Chief Secretary of Gujarat. Gujarat Socio Economic Development Society from Finance department was given to health department based on mutual understanding.
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| 6. How was the strategy implemented and what resources were mobilized?
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There are multiple initiatives taken simultaneously to address larger challenge of improving maternal health in Gujarat. Hence, it will not be justified to single out any of the components of bouquet of interventions.
Technical resources along with administrative willingness to implement the program have made all the difference in maternal health. Multi disciplinary team has made necessary protocols and essential guidelines for dissemination.
All above mentioned schemes are financed by State Government. Budget allocation to health has increased tremendously over last couple of year. Health budget has increased from nearly 20 million USD in year 2005-06 to more than 70 million USD for year 2014-15, an increase of more than 300% in last 8 years. The flexible support through National Rural Health Mission was also leveraged.
Similarly recently Government of Gujarat decided to leverage Corporate Social Responsibility (CSR) funds for complementing and supplementing health efforts in 77 HPTs. Society was transferred to health department from finance department with more than 10 million USD as start up fund for health activities in HPTs.
Major contribution has come from the ground level staff. Their untiring efforts in field to motivate pregnant women to opt for public institutional delivery have made all the difference. Early identification of danger signs of pregnancy and timely referral has further reduced maternal mortality. This has been possible because of capacity building measures for specialists, Comprehensive Emergency Obstetric Care (CEmOC) trained doctors and mainstreaming of ISM&H doctors to work as SBA trained professionals.
e-Mamta has brought in huge change in public system with reference to tracking and monitoring concept. State wide facility wise availability of computer technology with connectivity has improved reporting form periphery and live time update to state office. Entire team of E-mamta including data operators at peripheral most health institutions are the pillars of this program it is their effort which makes huge difference.
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| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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All the programs have been highly successful during implementation phase. Health department collects information from field regarding performance of all programs. Following 5 are major outputs which speak for themselves.
A.Chiranjeevi Yojana
Monthly report is collected from district regarding performance of this scheme. Till date more than 9 lakh women have benefitted from this program. Furthermore, rate of Caesarean Section is also within acceptable range.
Number of delivery conducted under Chiranjeevi Yojana has steadily increased from 7793 deliveries in year 2005-06 to around 75,000 deliveries in year 2013-14. More than 9 lakh pregnant women has availed complete free institutional deliveries since inception of the scheme. Furthermore, Caesarean Section operation rate has continuously remained less than 10% which is welcome sign.
B.e-Mamta
Every year more than 1 million pregnant women gets registered under this scheme and followed up till complete immunization of children. Over the years performance of program has improved tremendously. Below mentioned table provides year wise performance of e-Mamta
The number of mothers registered between has 2009 and 2013 has increased by 3 times approximately. The number of delivery registrations has gone up by almost 20 times. Child registration has gone up by 3 times almost and the numbers of fully immunized children have increased around 4 times.
Maternal Death Review:
Maternal Death Review process has streamlined. Every year more than 800 maternal deaths are reported and thoroughly investigated by taluka team.
C.Identification of High Priority Talukas
Data intensive exercise was carried out to identify High Priority Talukas for effective implementation of health interventions in these areas. Total of 7 indicators were selected for this process which ranged from availability of health infrastructure to education status of given taluka and so on.
1. Backward Taluka identified by Cowlagi Committee, 2004
2. Taluka with gap of PHC more than 3
3. Desert Development Taluka
4. Taluka with female literacy rate less than state average
5. Talukas under Tribal Development division
6. Taluka with literacy rate less than state average
7. Backward region grant fund taluka
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| 8. What were the most successful outputs and why was the initiative effective?
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Chiranjeevi Yojana is flagship program for the Government of Gujarat for improving maternal health. Furthermore, it involved public fund transfer to private sector. Hence, a robust checking mechanism was put in place to measure service delivery as well as prevent any financial irregularities.
Monthly report submission from Chief District Health Officer is mandatory for Chiranjeevi Yojana where every detail regarding number of beneficiaries and financial transactions is furnished for review and feedback.
Similarly, monitoring formats were developed and incorporated in e-Mamta for real time data review. De segregation of data till taluka and Primary health center helps in identification of poor performing facilities requiring special attention to improve performance.
Mamta Diwas are also well planned activity. Every year number of sessions to be planned and later on performance monitoring is done using number of sessions organized / no. of sessions planned.
Maternal Death Review involves reporting of maternal deaths in prescribed standard formats for uniformity. Similarly, detailed verbal autopsy forms are used for detailed analysis of maternal deaths. Recently state has shifted to MDR software for easy transfer of data to the state for analysis and feedback.
Development partner UNICEF has supported with 8 district level consultant who have conduced District Gap Analysis with reference to RMNCH+A (Reproductive, Maternal, Newborn, Child Health and Adolescent Health) services. Currently they are following up on recommendation based on gap analysis to be filled through state budget or other sources.
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| 9. What were the main obstacles encountered and how were they overcome?
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1.Non availability of gynecologists in Govt institutions was a major challenge. This was overcome by contracting out delivery services, skill building medical officers for multi-tasking, contracting in services of private gynecologists for Govt hospitals through hourly remuneration under CM-SETU (Chief Minister’s Specialists Services at Treatment Units), part time contractual appointments under NRHM, etc.
2.Tracking of pregnancy ensuring full antenatal care was overcome by tracking each mother through e-Mamta and at ground level by a 33,000 strong force of Accredited Social Activists- ASHAs.
3.Management of 550 ambulances, appointing their manpower, training of emergency medical technicians, integrated IT solution for mobilizing and tracking them was a great challenge, hence a PPP model of management was entered into with GVK EMRI organization.
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