PPP: the Gujarat experience
USING population norms, India today, formally speaking, has created public sector health delivery facilities at various levels to cover practically the whole of the country. These range from subcentres, each meeting the basic health needs of 5000 population (or 3000 population in remote hilly areas) with a trained field-based female health worker; primary health centres to cater to a population of 30,000, each with a medical doctor, nurses and support staff to meet the health needs of people even in remote areas; and the 30-bedded community health centres located in block headquarters, with provision for one medical doctor and at least three specialists and a total staff of 25 workers to provide some specialized care for each cluster of 100,000 people. All this in addition to public hospitals in districts and urban centres.
If only all the staff in various public health facilities are actually in position and discharge their duties as per their job specifications, and the facilities are efficiently managed, the public sector as designed and evolved could meet most of the health needs of the people in our country. States like Tamil Nadu and Himachal Pradesh are examples of public sector successfully meeting the health needs of the people.
The reality in most areas of India is that there is many a slip between the lip and the public sector cup that delivers health care. Independent surveys have shown, and the government data support the fact, that a large number of positions in public health facilities often lie vacant for long periods because many trained doctors seem unwilling to work in them. Absenteeism among those who are placed in rural areas is quite widespread. Quality of care, perceived by people in terms of long waiting period, non-availability of drugs and payments demanded for certain services, is poor. The cumulative effect of such factors is evident in the fact that as many as 77 per cent of households in rural areas and 80 per cent in urban areas rely on the private sector for curative care (NSS 60th Round). Evidently, people have greater faith in the quality of services rendered by the private providers than in the public sector facilities and are therefore willing to pay for them even when the cost is high and often unaffordable.
Recognizing and acknowledging that the private sector provides a large component of curative care and therefore its involvement in health care delivery is inevitable, the 11th five year plan (2007-2012) and the National Rural Health Mission (2005-2012) constituted a working group and task force, respectively, on public private partnership (PPP). The terms of reference of these groups was to suggest ways to improve health care delivery so as to ensure universal access that is equitable, affordable and responsive to people’s needs and help reduce maternal and infant mortality. Some individuals or officials were members of both the groups. They viewed the public-private partnership as contributing to improving the accountability of the public sector.
Various mechanisms or arrangements of PPP in health care and delivery have evolved over time and some have been quite successful. In order to reduce maternal and infant mortality and increase institutional deliveries among the poor, the Indian government, as part of the National Rural Health Mission (NRHM), launched the Janani Suraksha Yojna (JSY) in 2003, under which women can choose either the government health facilities or accredited private facilities for delivery.1 However, it was soon evident that the benefits of the scheme were going to be limited due to a number of reasons, important among them the fact that the government facilities in many backward areas are simply not equipped to conduct deliveries. The National Family Health Survey (NFHS-3), conducted in 2005-06, revealed that barely 13 per cent of the bottom quintile in wealth terms in the five-year period prior to survey had delivered their children in a public or private facility or institution as against 84 per cent of those in the highest wealth quintile.2
In order to meet the millennium goal of lowering maternal mortality from the present level by one-third by 2010, one option before the government is to focus on improving the public sector health services by hiring competent staff, creating adequate infrastructural facilities, ensuring user-friendly, good quality and competitive services and marketing them successfully. Another option is to create health insurance packages, especially for the poor or even outsource services by utilizing the available resources – manpower and infrastructural – in the private domain.
In Gujarat, for instance, since the maternal mortality ratio had remained virtually stagnant around 390 during the 1990s, the health personnel considered the option of providing cashless insurance coverage to women if they underwent delivery in formal institutions, public or private. However, the proposed scheme did not get a positive nod from the Centre. The state then adopted the other alternative of enlisting the private obstetricians/gynecologists (ob/gyns) who have their own nursing homes.3 It was observed that Gujarat had only 8 ob/gyns working in the public sector health facilities outside the teaching and district hospitals and there was little scope to increase that number. At the same time, there were more than 1800 of them working as private providers in medium and small towns. The worst sufferers were the poor who could not afford to use private facilities even in emergency situations.
The Directorate of Health Department of Gujarat decided to tap this resource by entering into partnership with the ob/gyns and in 2005 floated the Chiranjeevi Scheme (or scheme for long life) on a pilot basis in five backward districts of the state to encourage institutional deliveries among estimated 20 per cent households living below the poverty line. A lot of homework went into the designing of the scheme. For a start, the support of FOGSI (Federation of Obstetrics and Gynecology Society of India) was sought to bring the ob/gyns on board. Not only was a package of payment for the doctors worked out with the help of a trust-based hospital and others, but mechanisms were also put in place to ensure prompt payment to the doctors.4 Simultaneously, the recording system was simplified, requiring minimum information to be filled in. The women needed only their BPL card in order to access free delivery services from any obstetrician contracted or empanelled under the scheme.
The initial data compiled for the five districts (Dahod, Panchmahals, Sabarkantha, Banaskantha and Kutch) was very encouraging. For example, out of the available 217 ob/gyns in the five districts, as many as 170 or 78 per cent joined the scheme and each conducted an average of 274 deliveries in one year.5 Every district reported a significant increase in the percentage of institutional deliveries in just one year, with the predominantly tribal districts of Dahod and Panchmahals reporting an impressive increase of 47-51 per cent. The scheme received the Asian Innovation Award from the Wall Street Journal, Asia at Singapore in 2007, which is given for innovations in the Asia Pacific region in the field of improvement in the quality of life of people, efficiency, productivity and environmental protection.
As a result of the positive response of both the private providers and the women from poor households in the five backward districts, the Gujarat government decided to launch the scheme in the entire state. However, before doing so, it agreed to the UNFPA suggestion to first have the scheme in the pilot districts evaluated by them, since it was an integral component of the UNFPA’s technical assistance to the Reproductive and Child Health Programme Phase 2 (RCH-2) implementation. UNFPA carried out a rapid qualitative assessment in two of the five pilot districts just six months after the scheme was launched.6
One of the interesting findings of the assessment was that some of the private providers in one of the districts tended to refer women having complicated pregnancies to the district hospital rather than attending on them either due to lack of adequate facilities in their nursing homes or for monetary reasons. Nonetheless, the providers seemed happy about having enrolled themselves in the scheme, partly because of an increase in both their clientele as well as social esteem. Discussions with various stakeholders brought out a few issues related to lack of guidelines about what is complication for the health personnel, irregularities in payment for transportation and confusion between JSY and Chiranjeevi Scheme in the minds of women, lack of post delivery follow-up care, and the need to include newborn care. Overall, the UNFPA’s assessment was that the scheme had indeed helped the poor to access institutional facilities in the private sector for delivery and thus qualifies as an innovation in the public-private partnership.
The following year in 2007, the Indian Institute of Management, Ahmedabad also conducted a household survey of the beneficiaries of Chiranjeevi Scheme in the predominantly tribal district of Dahod.7 The survey indicated that most of the beneficiaries were below the poverty line, indicating that the scheme was indeed able to reach the poor. Though the beneficiaries of the scheme did incur some out of pocket expenditure (on medicines, newborn care), compared to the non-users of the scheme (who were eligible for using the scheme but chose not to use it and instead used the private hospital facilities to deliver their child), however, this figure was much lower. Incidentally, the average transport cost incurred by the women to reach Chiranjeevi facility at Rs 272 was higher than the Rs 200 earmarked for the purpose.
The Gujarat government advertised the achievements of the scheme through presentations by officials in a number of forums quite successfully. They highlighted the fact that poor women accustomed to home deliveries would be ready to change their behaviour, if they are convinced that good quality services are available within a short distance and are free of cost. In addition to funding from the NRHM, the Government of Gujarat also received some financial assistance from the Planning Commission of Rs 14.8 crore to extend the scheme to 93 most backward talukas of the state. Acknowledgement of the innovativeness of the scheme by organizations like the WHO also prompted health department officials of several states to visit Gujarat and learn about the implementation of the scheme.
For instance, in May 2008, Uttar Pradesh decided to launch, on a pilot basis, a scheme similar to Chiranjeevi Yojana and named it as Saubhagyawati Yojana (Indian Express, 6 May 2008). The governments of Delhi, Rajasthan, West Bengal, Madhya Pradesh, Uttarakhand, and Karnataka also sought further implementation details after making study trips to Gujarat. Overall, both the assessments (UNFPA/IIMA) were supportive of the scheme, clearly concluding that it was both sustainable and financially viable. Moreover, the scheme appeared very successful in reducing maternal and infant mortality, as evident from the data compiled by health workers using the Management Information System (MIS) that was designed for the purpose.
Nevertheless, it should be noted that despite best efforts, the mortality statistics suffer from a problem of under-reporting and thus cannot be used to assess the success of the scheme in lowering mortality among the poor in quantitative terms. For example, between January 2006 and December 2008, the total number of deliveries according to the MIS based data was 270,000 and of neonatal deaths was 1061, giving a neonatal mortality rate of just 4 per 1000 live births. The Registrar General under its Sample Registration Scheme has in contrast estimated a NNMR of 36 for Gujarat. Notably, the MIS reported only 52 maternal deaths during the same period.8 There are several possibilities why such a huge under-reporting occurs. For one, the MIS captures events that occur in the facilities, whereas since both neonatal deaths and maternal deaths can occur after women are discharged, such events are likely to be missed. Second, the obstetricians could be sending women who develop life-threatening complications to higher level tertiary public hospitals, thereby maintaining their reputation as safe doctors. Third, the MIS system itself may not be very foolproof and thus missing out or not recording those events which result in deaths.
In view of this, both registration and monitoring of maternal and neonatal deaths and morbidities need to be improved substantially so that impact assessment of the scheme can be made more rigorous. In addition, the contract with the private providers must build-in a system of assuring quality and outcomes so that the programme can better attain the goals of reduction in maternal and neonatal mortality. A data base on the infrastructure in terms of beds, management of blood, availability of anesthetists, and so on, in the facilities of private providers too needs to be systematically maintained. In addition, it is important that the quality of care in private sector hospitals is not compromised and that they all adopt evidence-based clinical practice and their facilities have trained qualified nursing staff.
Equally important is evolving a population data base such that the number of yearly deliveries conducted by the private sector providers can be carefully scrutinized against the potential clientele in the region they are working in or from where they draw their clientele. It is important that the scheme is not tarnished because of unethical practices of a few providers. It was, for example, recently reported that some private doctors registered under the Chiranjeevi Scheme had been registering ghost patients and falsely claiming treatment fees from the government.9
As an integral part of the scheme, now almost four years in operation, post-delivery visits and post-partum care need to be strengthened. Anywhere from 40 to 60 per cent of maternal deaths occur after delivery and after women return home. The challenge is to evolve a system that can ensure that women who have delivered in private facilities are followed up for post-partum care. Coordination needs to be established between private providers and government health workers with a feedback mechanism.
Targeting of the beneficiaries is done on the basis of the BPL card, which is issued by the revenue department. Coordination is needed between the health and the revenue department in light of the allegations about the corruption in the issuing of the BPL cards. While the health department cannot question a BPL card, it has a moral responsibility to ensure that the better off do not take advantage of the scheme which is designed for the poor.
Another issue that has recently been raised by the private providers relates to their demand for higher payment. Under the scheme, state-government recognized private doctors are paid a net average of Rs 1,545 per delivery in their hospitals. However, some of them feel that the amount is inadequate because of the overall increase in the cost of medical services. This is partly because they charge more than the amount agreed upon for a normal delivery and significantly more for a complicated case or caesarean delivery. Some doctors have even threatened to withdraw from the scheme unless the payment schedule is revised.
The limited evidence suggests that some of the doctors do not accept women with pregnancy-related complications because of the perception that the actual cost of treating complications is much higher than the amount built into the scheme. A systematic study of the grievances of the private providers and, if need be, revision of the payment structure may be in order almost four years after the scheme was launched.
Finally, it needs to be stressed that a focus on strengthening the PPP in health care and using the resources in the community should not imply that the government can abdicated its responsibility of providing primary health care to people. The government must pay attention to the many limitations of the existing public facilities, such as upgrading infrastructure, making staff more responsive to the needs of the people, providing acceptable quality of care, using standard proto-cols while dispensing services, ensuring that drugs and other supplies are available, ensuring good infection control practices and making facilities more user-friendly. In the ultimate analysis, the public sector must be held accountable to the people.
1. JSY offers cash to all pregnant women in backward states and in other states to women below the poverty line, above 19 years of age and up to two live births. See: nifhw.org/pdf/JSY.doc; accessed on 20 October 2009.
2. International Institute of Population Sciences (IIPS), National Family Health Survey (NFHS-3), India, 2005-06, Mumbai, 2007.
3. Contracts were offered to private obstetricians who met the following criteria: have a post-graduate qualification in obstetrics; have their own hospitals, preferably with at least 15 beds; have labour and operating rooms; and are able to access blood for transfusions, arrange for anestheologists and to do emergency surgery.
4. The compensation package is Rs 179,500 for 100 deliveries or Rs 1,795 per delivery (of which Rs 200 is earmarked for transportation for the beneficiary and Rs 50 for the accompanying person) and is based on the assumption that 85 per cent of the deliveries would be normal, seven per cent would need cesarean section delivery and the remaining eight per cent would need extra treatment for pregnancy-related complications.
5. Amarjit Singh, ‘Chiranjeevi: involving private obstetricians to reduce maternal mortality in Gujarat (India)’, power point presentation, 2007 (accessed on 14 October 2009).
6. UNFPA, Rapid Assessment of Chiranjivee Yojana in Gujarat, 2006, New Delhi, 2006.
7. Bhat, R. et al. ‘Maternal Health Financing: Gujarat’s Chiranjeevi Scheme and Its Beneficiaries’, Journal of Health Population Nutrition, Vol. 2, April 2009, pp. 249-258.
8. A. Singh, D.V. Mavalankar, R. Bhat, A. Desai, P.V. Singh and N. Singh, ‘Providing Skilled Birth Attendance and EmOC to the Poor Through Innovative Partnership with Private Sector Obstetricians in Gujarat, India’, forthcoming in WHO Bulletin, November-December 2009.
D.V. Mavalankar, A. Singh, R. Bhat, A. Desai and S.R. Patel, ‘Indian Public Private Partnership for Skilled Birth Attendence’, Lancet 371, 2008, p. 9613.
9. The Indian Express, 10 April 2009.