Improving Maternal Healthcare in Gujarat
Health and Family Welfare

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Before this initiative, the maternal healthcare statistics were surprisingly poor and meant that mothers are not getting adequate care and services that are essential at the time of child birth. It was huge challenge to provide institutional deliveries to 1.33 million pregnant women, especially when complex socio-economic factors play important role in women’s decision making to go for institutional deliveries. The situation before this initiative is summed up below. A.Higher Maternal Mortality As per the Sample Registration System (SRS) Bulletin for year 2001-03, Gujarat had higher Maternal Mortality Ratio (MMR) of 172 maternal deaths per 1, 00, 000 live births. As per the estimates of nearly 1.33 million pregnancies, nearly 2300 women lost their lives every year due to a natural phenomenon as simple as pregnancy. Ten times more suffered post delivery morbidity. It also led to newborn deaths. Inadequate trained manpower and specialists in Govt healthcare institutions was a major bottleneck. B.Lower Institutional Delivery Rates One of the major determinants of maternal mortality is skilled birth services availability. As per the District Level Household Survey (DLHS – II) for year 2003-04, Institutional delivery in Gujarat was as low as 52.2%. Furthermore, there was huge intra state variation in institutional delivery rates which range from 74.6% institutional delivery in Mehsana district to 10.7% institutional deliveries in The Dang district. C.Lower proportion of home deliveries assisted by skilled birth attendant Safe delivery is defined as either institutional delivery or home delivery assisted by skilled birth attendant (SBA). As per DLHS – II, out of 47.8% home deliveries only 20.8% deliveries were assisted by skilled birth attendant. Furthermore, this proportion varied from district to district ranging from 49.3% SBA assisted home deliveries in Amreli district to 5.8% SBA assisted deliveries in Vadodara district. D.Lower Public Health Institutional Deliveries Out of 52.2% institutional deliveries as per DLHS – II, only 12.7% deliveries were conducted in public health institutions. Private institutions were catering to nearly 39.5% of deliveries in Gujarat. Lower proportion of public health institutional deliveries increases catastrophic health expenditure for pregnant women.

B. Strategic Approach

 2. What was the solution?
Improving Maternal Health is 5th Millennium Development Goal and Gujarat is committed to achieve MDG-5. With baseline MMR of 600 in year 1990, India envisages reducing maternal mortality to 150 maternal deaths per lakh live births by year 2015 and Gujarat aims for the same. As mentioned earlier major problem in Gujarat was improving institutional deliveries and thereby reducing maternal mortality. With this gigantic problem of improving institutional deliveries with quality, Government of Gujarat along with various Non Governmental Organizations joined hands together to improve maternal health in Gujarat Major Objectives 1.Reducing maternal mortality to <100 by year 2015 2.Improving institutional Deliveries to >95% by year 2015 3.Provide complete free institutional deliveries to at least 50% of pregnant women to prevent catastrophic health expenditure. Multipronged strategies to achieve major objectives State government was committed in achieving ambitious targets within MDG timeframe. After careful consideration with various stakeholders following initiatives were undertaken to achieve above mentioned objectives. A.Chiranjeevi Yojana (Public Private Partnership) Chiranjeevi scheme envisaged garnishing support from private sector specialists for improving maternal health. Under the scheme Government partnered with private gynecologists to provide complete free institutional deliveries to pregnant women belonging to families living Below Poverty Line (BPL) and non income tax paying Tribal women. Government pays to gynecologist on pro rata basis. This made access to private specialist services possible even in remote tribal areas. B.e-Mamta (an IT based application for tracking of mother) Mamta means love of a mother to her child. Counting an event is one of the primary principles of public health. Effective system of recording service delivery to pregnant women is pre requisite for measuring any change in overall performance. e-Mamta provides and technical platform to measure various service delivery aspects to pregnant women starting from Early Ante Natal care (ANC) registration to institutional delivery, place of delivery etc. C.Mamta Diwas (Monthly Outreach Service Day) Concept of Mamta Diwas was launched to provide ANC services to pregnant women in their respective villages. Plan was prepared to organize one outreach session every month per one thousand population. Frequent encounters with health staff and counseling to pregnant mother can greatly improve intuitional delivery. D.Providing Emergency Transport to Pregnant Women through 108 Ambulance services across the State More than 550 Emergency Transport Ambulances transfer pregnant mothers to the place of delivery free of cost through a single telephone number – 108. E.Capacity Building measures in public health institutions Government of Gujarat partnered with John Hopkins Program for International Education in Gyencology and Obstetrics (JHPIEGO) to train MBBS medical officers in Gynecology and Anaesthesia. Planned task shifting of work of specialist was done for expanding caesarean services in periphery to improve maternal health. F.Maternal Death Review Evidence based public health interventions are most likely to be successful. Maternal Death Review process in Gujarat provides detailed insight in to every maternal death occurring in state. State level policy decisions are taken based on the findings of maternal death review. G.Identification of High Priority Talukas (HPT) Health is dependent on various determinants such as socio economic status, geography, education etc. Gujarat is divided in 248 Talukas (administrative units). Government identified 77 Talukas as High Priority Talukas to augment ongoing health efforts in these areas to reduce health inequalities. H.Increased funding and relaxed HR norms for identified High Priority Talukas Separate funding mechanism is established for complementing and supplementing ongoing effort in these areas. Similarly, higher remuneration to health workers is provided to ensure availability of trained manpower in these areas for service delivery.

 3. How did the initiative solve the problem and improve people’s lives?
Chiranjeevi Yojana – the first of its kind in India – involved private sector for service delivery. Out of 4000 Gynecologists in Gujarat, less than 10% actually work in government organizations. Involving private gynecologists helped improve service delivery substantially. eMamta – later known as the Mother and Child Tracking System was so effective that it scaled up to a national level. Another innovative aspect of this initiative is the use of Maternal Death Review which provides deep insight into various socio cultural issues related to maternal deaths. Similarly, it provided an alternative perspective to health services which has been very useful for improving health system. The practice of identifying High Priority Taluks has helped in realigning state’s focus on these disadvantaged areas in service delivery. Furthermore, separate fund provision and relaxation in HR norms has effectively increased availability of health services in these areas.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
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.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
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.
 6. How was the strategy implemented and what resources were mobilized?
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.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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

 8. What were the most successful outputs and why was the initiative effective?
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.

 9. What were the main obstacles encountered and how were they overcome?
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.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
In last 8 years Gujarat has made tremendous progress in improving maternal health. Cumulative effect of all interventions mentioned above has resulted in increased institutional deliveries with higher public institution share and reduction in maternal mortality. Institutional deliveries have tremendously improved in Gujarat over last couple of years from 52.2% institutional deliveries in year 2003-04 to 96.4% in year 2013-14, which is 42% increase in institutional deliveries in last decade. Considering 1.33 million pregnancies every year, 5, 61, 260 additional women are provided institutional delivery services compared to 2003-04. Public Health institutions have also increased service delivery capacity from 150, 000 deliveries in 2003-04 to 320,000 deliveries in 13-14. These figures are from state HMIS software and correlates to the national sample survey estimations. Furthermore, proportion of Skilled Birth Attendant in case of home deliveries is around 40% which amounts to 1.4% of overall deliveries. Hence effective safe delivery proportion in Gujarat is Safe Deliveries in Gujarat =Institutional Deliveries+ SBA assisted home deliveries = 96.4 + 1.4 = 97.8% safe deliveries Furthermore proportion of public institutional deliveries has also improved from 12.7% in year 2003-14 to 34% in year 2013-14. Furthermore, 7% of deliveries are conducted by chiranjeevi scheme doctors which is completely publicly financed. So, effective coverage against catastrophic health expenditure during pregnancy has increased from 12.7% to 41.1%, which is more than 300% increase in financial protection in one decade. In 2013-14, 34% of the delivery was done through Government Institutions and 58.9 % through private institutions Actual success of any program can be effectively measured through health outcome indicators only. Gujarat has made tremendous improvement with reference to outcome indicator which is reduction of Maternal Mortality Ratio (MMR) in last decade. Maternal Mortality Ratio has declined from 172 maternal deaths per one lakh live births to 122 maternal deaths per one lakh live births in last decade, thus achieving MDG-5 for India to reduce MMR to 150 maternal deaths. Decadal reduction of maternal mortality in Gujarat is around 30%. Furthermore rate of decline is also increased over the years. As per the recent estimates of 122 maternal deaths per lakh live births, Every year Gujarat is preventing 665 maternal deaths compared to maternal deaths in 2003-04

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
Sustainability of Initiative 1.Due to continued budgetary support very year from the state budget, the initiative of Chiranjeevi Yojana is sustainable. Since this is now inbuilt in Birth Microplanning, beneficiaries in remote, tribal, inaccessible areas are well aware of their rights. Various nongovernmental organizations also facilitate, monitor and give suggestions for midcourse correction. The service package compensation rates are scaled up twice through Government Resolutions since inception so as to continue private specialists’ participation. Moreover these poor beneficiaries would otherwise have never dreamt to step in private hospitals, hence participation in scheme has also increased the clientele and revenue of private practioners and trust run hospitals. Thus it is a win-win situation for both, the Govt and service partners. 2.Independent reviews and assessments by organizations such as a)Indian Institute of Management “Maternal Healthcare Financing : Gujarat’s Chiranjeevi Scheme and its Beneficiaries “ by Ramesh Bhat et el in Journal of Health, Population, Nutrition, Apr 2009, b)Public Private Partnership by T K Sundari Ravindran in Economic and Political Weekly, Nov 26, 2011, c)The State-Led Large Scale Public Private Partnership ‘Chiranjeevi Program’ to Increase Access to Institutional Delivery among Poor Women in Gujarat, India: How Has It Done? What Can We Learn? by Ayesha De Costa, Kranti S. Vora, Kayleigh Ryan, Parvathy Sankara Raman, Michele Santacatterina, Dileep Mavalankar from Karolinska Institute in PLOSONE May 2014 Bestowed with prestigeous Asia Innovation Award (Singapore) by Wall Street Journal d)Prime Minister’s Award for Administrative Excellence April 2009 e)The scheme finds mention in “The State of World’s Children 2009” report by Unicef as a remarkable successful intervention in the area of Maternal and Child Health. f)Mention in “Demand side financing in Health” Background Paper 27, World Health Report 2010, Indrani Gupta et el. and other studies gave credibility and national and international exposure to the scheme and few other states have then formulated their schemes based on this. Gujarat itself formulated Bal Sakha Yojana for newborn care by private pediatricians based on this model. 3.e-Mamta has been upscaled as Mother and Child Tracking System by Govt of India in all States. Presentation was e-Mamta was included in international deliberations – Strengthening Civil Registration and Vital Statistics Systems through Innovative Approaches in Health Sector, Technical Meeting, Geneva Dec 17-18, 2013 by WHO. 4.WHO has recognized the project as a strategy for increasing coverage for skilled birth attendant at birth 5.Thus the initiative is widely disseminated at National and International level for replication.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
Lessons Learnt: 1.A comprehensive multipronged approach to a challenging problem such as accessible and quality healthcare services for maternal health can significantly reduce maternal morbidity and mortality in resource constrained developing countries. 2.Continuity Of Care Approach, continuity in terms of space (home –hospital-home) and time ( complete antenatal services, safe referral transport, quality delivery services, and postnatal care at doorsteps) can significantly improve outcomes of maternal health, thereby help in attaining MDG 5. 3.Public Private Partnerships can significantly augment the Govt efforts of accessible assured quality care. 4.Harnessing the power of Information Technology ( e-Mamta, total computerized management of emergency 108 referral transport0 can significantly improve the programmatic output) 5.Quality improvement in maternal health services has direct impact on reducing Neonatal Mortality Rate , and thereby Infant Mortality Rate in Gujarat. 6.Such initiates have full scope of replication with fine tuning of operational aspects as per local needs.

Contact Information

Institution Name:   Health and Family Welfare
Institution Type:   Government Agency  
Contact Person:   Nishit Dholakia
Title:   Add. Director (Family Welfare)  
Telephone/ Fax:   07923253311
Institution's / Project's Website:  
E-mail:   nbdholakia@rediffmail.com  
Address:   Block 5 , Jeevraj Mehta Bhavam
Postal Code:   382010
City:   Gandhinagar
State/Province:   Gujarat
Country:  

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