Chiranjeevi Yojana

An innovative partnership with the private sector obstetricians to provide skilled care at birth to the poor in Gujarat

Background

Chiranjeevi YoganaThe Government of Gujarat aims to stabilize its population growth by reducing the Fertility rate, lowering Infant mortality rate and maternal mortality ratio. For reduction of maternal mortality Govt. of Gujarat launched scheme called Chiranjeevi Yojana (CY) in Dec 2005.




Shortage of obstetricians in rural areas of India

The research studies carried out in early 1990s provided ample evidence to show that EmOC was the most cost-effective way to reduce MMR. Recent review of evidence recommends health center based intra-partum care as the key strategy to reduce MMR. The strategy of EmOC was adopted in India under the World Bank and UNICEF funded project called Child Survival and Safe Motherhood (CSSM) in 1992. In this program there was a specific focus on development of comprehensive EmOC centers throughout India as per the international norm of 1 EmOC facility per 500,000 populations. The establishment of EmOC centers continued in the subsequent program funded during 1997-2004 by the World Bank with the changed nomenclature of the Reproductive and Child Health (RCH) programme However, the programme achieved little progress in establishing CEmOC centres in rural areas. The key constraint was non-availability of obstetricians in the government sector in rural areas. In rural areas the gap between norm for health staff (especially obstetricians) and the actual availability in government hospitals is quite significant.

At that time in Gujarat only 12 to 13 obstetricians were working in rural area’s government facilities. Remoteness of area, inadequate infrastructure, low salaries and policy of not allowing private practice by government employed obstetricians is cited some of the reasons for this situation. From time to time governments in Indian states have tried to post obstetricians in government facilities in rural areas but with little success. At the same time, there is a practice for availing medical care from private sector which has developed abundantly in Gujarat.

The presence of private sector obstetricians is quite significant in Gujarat. But it is difficult to force or lure obstetricians to join government health services and be posted to rural areas, given the administrative, economic and political structure of India. Hence Gujarat struggled for a long time to make government FRUs functional in rural areas without much success. The women particularly belonging to BPL and APL tribal (non taxpaying) are not having adequate financial resources to utilize private medical services. Cost for accessing care in private sector deters the poor from seeking care during delivery.

Gujarat government in collaboration with academic institutions (IIM Ahmedabad), NGOs (Sewa Rural – Jhagadia) and facilitated by GTZ explored various options to provide skilled care at delivery and EmOC through private sector. Through a series of consultations with key stakeholders, the government of Gujarat health department worked out a scheme of Public Private Partnership (PPP) to contract private providers to provide delivery care to the poor in rural areas.

Chiranjeevi Yojana - An Introduction

Chiranjeevi Yojana scheme proved as an exemplary scheme in the area of Public Health which has contributed significantly in improving the access to Institutional deliveries for marginalized section of the society by reducing the maternal deaths. Under the scheme, the government would enter into a contract with the private provider to cater to institutional services for both normal and complicated delivery including C-Sections operation and blood transfusion to targeted group.

  • Chiranjeevi Yojana launched as a one year pilot project in 09/11/20005 in five most vulnerable districts (Banaskantha, Dahod, Kutch, Panchmahal and Sabarkantha) covering below poverty line families.
  • Considering the success of the pilot project this scheme was scaled up to the entire state since 08/09/2006.
  • Since 26/03/2007 APL-Non Income Tax Paying families are also incorporated in beneficiary criteria.

BPL and tribal women (whosoever choose to deliver in Chiranjeevi Hospital) are identified during their ante natal care by ANM/FHW and are given an application form for registration in the scheme during birth microplan preparation in Mamta Diwas. In absence of BPL card and tribal certificate, authorization by local recognized authority is also considered. The field workers also explain to pregnant mothers benefits/services which they can avail under the scheme. At the time of delivery, the women goes to previously identified empanelled doctors, gets the delivery done free of charge. She also receives transportation charges from the doctor.

Package of the Scheme:

To develop the costing of the services, the government had carried out consultation with SEWA Rural (an NGO providing health services), individual specialist and Federation of Obstetric and Gynecological Societies of India (FOGSI) representatives of the state to arrive at a uniform fee that could be charged for normal, complicated and as well as C-Section cases to design the package for 100 deliveries. Initial package of Rs. 1,85,000 for 100 deliveries, which was modified by Govt. Resolution No.: FPW/102013/73/B-1 dated 29/07/2013, now revised package of 100 deliveries is Rs. 3,80,000. In Chiranjeevi Yojana, there is provision of Rs. 2500/- per Caesarian Section if enrolled Private gynecologists conduct Caesarian Section in Government health facility.

Selection criteria for private obstetricians for enrolment under the scheme:

  • Doctor must be having post-graduate qualification in Obstetrics and Gynecology.
  • Must have his / her own hospital - preferably minimum of 15 beds.
  • Must have labor room and operating room.
  • Must be able to access blood in emergency situation.
  • Must be able to arrange for anesthetists and do emergency surgery.
  • Facility should be preferably accredited for sterilization procedures by the government.

All the available and willing obstetricians are to be included in the scheme.

Implementation, Monitoring & Evaluation:

As the scheme is implemented and monitored by officers and staff from the government health machinery there is no additional cost is involved. The roles and responsibilities at different level are discussed below:

  • Under the guidance of Commissioner of Health, Additional Director (Family Welfare) and State Maternal Health Program Officers have overall responsibility for planning, implementation and monitoring of Chiranjeevi Yojana.
  • District Development officer is responsible for overall implementation of the scheme in the district.
  • Chief District Health Officer (CDHO) is responsible for identification and enrolment of the Obstetricians, orientation about the scheme and coordination.
  • The RCH Officer (RCHO) and District Project Coordinator (DPC) are responsible for payment to the Chiranjeevi doctors and report collection.

Benefits of the scheme:

It is considered very successful as large numbers of obstetrician/ gynecologist have joined it and many poor women have benefited through delivery at a facility managed by qualified obstetrician/gynecologist as compared to previous option i.e. home deliveries This scheme empowers the poor in several ways:

  • It provides them entitlement for free delivery care in private sector.
  • It provides immediate access to Emergency Obstetric Care (EmOC) when needed.
  • Reduction in out of pocket expenditure.
  • It also provides them choice of several providers nearby from which they can choose from.
  • It also shows that it is possible to develop large scale partnership with private sector to provide skilled birth attendance and EmOC to poor women at a relatively small expenditure.
  • The Chiranjeevi scheme is now linked with Emergency Management and Research Institute (EMRI) services for elimination of transportation time delay. EMRI is providing free ambulance services to all sections of the society in entire Gujarat state.
  • Bal Sakha Yojana is now linked with Chiranjivi Yojana. It is a scheme to provide treatment by private pediatrician to children aged up to 1 month.

Impact of Chiranjeevi Yojana:

  • Exponential rise in Institutional Deliveries: The State has experienced a constant rise in the trend of Institutional Deliveries over the years and a consequent decrease in the trend of Home Deliveries. In the year 2005-06 rate of institutional delivery was 63.24 % which reached to 99% by March-2018.
  • Decline in Maternal Mortality Ratio & Infant Mortality Rate:

    MMR:
    Year (2001-03) (2004-06) (2007-09) (2010-12) (2011-13) (2014-16)
    MMR 172 160 148 122 112 91
    IMR:
    Year 2005 2006 2007 2008 2009
    IMR 54 53 52 50 48
    Year 2010 2011 2012 2013 2016
    IMR 44 41 38 36 30
    Source: Sample Registration Survey
  • The scheme was evaluated by UNFPA and IIM Ahmedabad and they have given favorable comment.
  • In the Study "Directory of Innovations Implemented in the Health Sector” supported by Department for International Development quoted- Several States have adopted the JSY/Chiranjeevi model to further provide services in areas not covered by JSY or to boost the gains from JSY, including Saubhagyawati Scheme (Uttar Pradesh), Janani Suvidha Yojana (Haryana), Janani Sahyogi Yojana (Madhya Pradesh), Ayushmati Scheme (West Bengal), Chiranjeevi Yojana (Assam), and Mamta Friendly Hospital Scheme (Delhi).

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