1 DEVELOPMENT ENVIRONMENT IN SINCE 2005

Gujarat State was formed on 1 May The state is administratively divided 1960, covering the Gujarati speaking in to 26 districts, spread over three areas of the erstwhile Bombay State. regions. These are: 1) , Gujarat is situated on the west coast of comprising the Districts of , , . It is bordered by Pakistan to the Panchmahal, , , , north, by the states of Rajasthan to the Tapi, , Narmada, , Anand north-east, Madhya Pradesh to the east, and The Dangs; 2) , Maharashtra and the union territories of comprising Banaskantha, Sabarkantha, Dadra and Nagar Haveli to the south- Patan, , and east, and by the Arabian Sea to the west ; and 3) and and south-west. Gujarat has an area of Kutch, comprising , , 196 024 km, representing around 6% Surendranagar, , Amreli, of the total area of the country. , and Kachchh.

DEVELOPMENT ENVIRONMENT IN GUJARAT SINCE 2005 1 The state is further divided into 226 According to 2004–2005 estimates by talukas. Gujarat has 18 622 villages the National Sample Survey Office, and 242 cities/towns. Ahmedabad, about 16.8% of Gujarat’s population is Surat, Vadodara and Rajkot are the estimated to be below the poverty line four urban centers with a million-plus (BPL—rural 19.1%, urban 13%). The population, and there are six municipal corresponding figure for the country is corporations.1 27.5% (rural 28.3%, urban 25.7%).

With a population of 50.7 million in the Gujarat is among the better performing 2001 census, Gujarat is the tenth most Indian states in terms of demographic populous state in India, with 5% of the indicators. It has a higher literacy rate country’s people in 6% of the total area. (69%), higher life expectancy at birth The decadal growth rate of 22.6% is for women and a lower total fertility slightly higher than the national average rate than the national average. The of 21.5%. Gujarat’s overall economic population of backward tribes in the growth has been among the highest in state is 14.8%, and that of scheduled the country—the state economy had castes is 7.1% (See Table 1.1 for further a growth rate of 10.86% during the demographic indicators). fifth plan period, against the national average of 7.8%. However, there is much disparity between rural and urban areas and Gujarat is one of the most urbanized among different population groups. states in the country, with 37% of the There is also gender disparity, with population living in cities (compared literacy rates for women (59%) much to the Indian average of 27%). lower than those for men (81%). The Interestingly, the towns and cities, state has an exceptionally adverse large and small, are evenly distributed sex ratio (the number of females per all over the state, unlike some other 1000 males), which has decreased states where a large proportion of urban significantly from 934 (1991) to 920 population is concentrated in one me­ (2001). The sex ratio is low even in tropolis (AM Shah, PJ Patel and L Lobo, areas where the literacy rate is higher 2008). One indication of the level of than the state average. “development” in the state is the fact that Gujarat is better equipped with Gujarat is one of the most industrially mobile phones compared to the rest advanced states in the country, and of India (14 million people—more than has been proactively promoted as an a quarter of the population—had one investors’ haven. Since 2003, the state cell phone in 2007) (Jaffrelot, 2008). government has been hosting “”, a biennial global investors’ [1] 1 RCH II _Gujarat State Implementation Plan_2005

2 IMPROVING MATERNAL AND CHILD HEALTH IN GUJARAT : Initiatives for Achieving MDGs 4 and 5 Table 1.1: Demographic and health indicators of Gujarat and India

Gujarat India Population (Census 2001) in million 50.6 1027.0 Decadal Growth Rate (1991-2001)- % 22.6 21.5 Population density per sq km (2001) 258 324 Birth rate (Sample Registration System [SRS] 2006) 23.5 23.5 Death rate (Total) (2006) 7.3 7.5 Total fertility rate (2005) 2.9 3.2 Age (years) of effective marriage (2005) 20.3 20.2 Literacy rate 69.9 65.4 Male (%) 80.5 75.9 Females (%) 58.6 54.2 Sex ratio (no. of females per 1000 males: Census 2001) 920 933 Proportion of child population to percent of 0-6 years of total population (%) 14.2 15.4 Life expectancy at birth for females (2005) years 69 66.1 Infant mortality rate (Total) 2006 per 1000 live births 53 57 Child mortality rate (2005) per 1000 16 17.3 Maternal mortality ratio (SRS 2004­–2006) per 100 000 live births 160 254

Source: Ministry of Health and Family Welfare, Family Welfare Statistics in India-2006, Table A-7(2) meet, which aims to promote industry in the red, has been reformed, ensuring the state by bringing together “business widespread power supply in the leaders, investors, corporations, thought entire state and making it profitable leaders, policy and opinion makers”.2 (Jaffrelot, 2008). The , aimed at providing 24-hour domestic The government has also been active electrification and eight hours of good- in developing the agriculture sector quality agricultural electrification, has through investments in infrastructure been successful, leading to tremendous and irrigation networks, resulting in improvement in the quality of daily life. agriculture recording a very high annual The Jyotigram Yojana has paved the growth rate of 9.6%, the highest way for better functioning of schools, amongst all Indian states from 2001 to primary health centres and co- 2008, even as India’s target is a modest ops, and better communication (T. Shah 4%.3 & S.Verma, 2008).

In recent years the State Government has increased the efficiency of public systems. For instance, the Gujarat State Electricity Board, which was in

2 http://www.vibrantgujarat.com/ 3 Business Daily, The Hindu group of publications, Wednesday, May 20, 2009

DEVELOPMENT ENVIRONMENT IN GUJARAT SINCE 2005 3 4 IMPROVING MATERNAL AND CHILD HEALTH IN GUJARAT : Initiatives for Achieving MDGs 4 and 5 2 PUBLIC HEALTH FACILITIES IN GUJARAT4

4 This section draws heavily on Mavalankar et al. (2009)

This section presents the current Above the sub center is the PHC, which service delivery system for public health serves a population of 30 000 persons. services in Gujarat. It focuses on human A PHC has six beds for inpatient care resources and organizational structure. and is staffed by a Medical Officer (who is an MBBS doctor) and a staff nurse. 2.1 Public health delivery The PHC is equipped to handle normal structure deliveries and immunizations. A CHC serves a population of 100 000 persons,5 Gujarat has a three-tier public health is equipped with 30 beds, an operation care system, following the guidelines of theatre, an X-ray , a labour the National Health Policy of 1983. The room and laboratory facilities. It is first tier includes subcentres, Primary staffed by a Medical Officer, a specialist Health Centres (PHC) and Community and nurses. Health Centres (CHC) and provides primary-level care. A subcentre is The second tier includes taluka and staffed by an district hospitals, which have 100–300 (ANM) and a male multipurpose worker beds. A district hospital has specialists; (MPW) for each population group of 5000 some of these facilities are designated persons (three to five villages). This is as First Referral Units (FRU) and have the unit that is closest to the village an obstetrician serving on staff. CHCs, community and offers a mix of centre- FRUs and district hospitals provide based and field outreach services. The secondary-level care. An FRU covers a subcentre is expected to provide population of 500 000. services for a range of primary health care interventions, but is substantially For tertiary-level care, the state has focused on maternal and child health. 5 According to the Health review, Gujarat: 2007–2008 issued by the government, each CHC in the state was serving a population of 121 000 as against the norm of 100 000 persons (Government 4 This section draws heavily on Mavalankar et al. (2009) of Gujarat, 2008b).

PUBLIC HEALTH FACILITIES IN GUJARAT 5 13 teaching hospitals associated with health workers at the health centres. medical colleges. In addition to these Relevant to MDGs 4 and 5, Gujarat has a there are super-specialty hospitals shortage of obstetricians, anaesthetists, (, 2008b). paediatricians and nurses/midwives in government hospitals. According to In 2007-2008, there were a total of 2007-2008 data, only 37% of the CHCs 7274 subcentres, 1073 PHCs, 273 CHCs and FRUs are staffed with obstetricians and 25 district hospitals in the state. (Government of Gujarat, 2008a). This According to the Annual Administrative shortage of trained personnel in public Report of the Government of Gujarat for facilities primarily affects poor families, 2007–2008, 56 government facilities, who are more likely to seek government including district hospitals, subdistrict health services due to their lower cost. hospitals and CHCs were functional as By contrast, about 2000 obstetricians FRUs (Government of Gujarat, 2008a). are available in the private sector The state had a total of 42 855 doctors, (Government of Gujarat, 2008a). 17 551 nurses, 9585 midwives and 6638 ANMs in 2008 (Government of Gujarat, The public health service delivery 2008b). system is compromised in its functioning for a number of reasons, key among As indicated in Table 2.1, there is a which are a shortage of human severe shortfall of human resources resources, inadequate infrastructure at all levels, from specialists to skilled and equipment, insufficient supplies of

Table 2.1: Human resources at public health facilities in Gujarat

Particulars Required In position Shortfall Multipurpose worker (Female)/ANM at Subcentres & PHCs 8 347 7 071 1 276 Health Worker (Male) MPW(M) at Subcentres 7 274 3 347 3 927 Health Assistant (Female)/Lady Health Visitor (LHV) at PHCs 1 073 267 806 Health Assistant (Male) at PHCs 1 073 2 421 - Doctor at PHCs 1 073 1 034 39 Obstetricians & Gynaecologists at CHCs 273 6 267 Physicians at CHCs 273 0 273 Paediatricians at CHCs 273 6 267 Total specialists at CHCs 1 092 82 1 010 Radiographers 273 124 149 Pharmacist 1 346 814 532 Laboratory Technicians 1 346 899 447 Nurse/Midwife 2 984 1 585 1 399

Source: Bulletin of Rural Health Statistics, Ministry of Health & Family Welfare, , March 2007

6 IMPROVING MATERNAL AND CHILD HEALTH IN GUJARAT : Initiatives for Achieving MDGs 4 and 5 drugs and consumables, and inadequate Welfare (DHFW). The DHFW is headed monitoring and supervision (Mavalankar by a Principal Secretary (Health) and et al., 2009). a Secretary for Family Welfare. Figures 2.1 and 2.2 show the organizational 2.2 Organizational structure structures for maternal health services in Gujarat. 2.2.1 State-level organizational structure Two maternal health consultants have recently been hired at the state level to Maternal and child health services fall under strengthen the state’s initiatives towards the State Department of Health and Family improving maternal health.

Figure 2.1: Organizational structure for maternal and child health services in Gujarat: state level

Principal Secretary (Health)

Secretary (FW) and Commissioner (Health)

Additional Director Additional Director Additional Director Additional Director (Health), (Medical Services) (Family Welfare) (Medical Education) ex-officio NRHM

Joint Directors(4) Deputy Directors (4) Assistant Directors (4)

Regional Deputy Directors (6 for 6 regions) Maternal Health Consultants (2), (Administration)

PUBLIC HEALTH FACILITIES IN GUJARAT 7 2.2.2 District-level organizational structure

Figure 2.2: Organizational structure for maternal and child health services in Gujarat: district level

Regional Deputy Director (n=6)

Chief District Chief District Medical Officer Health Officer

Programme Management Unit

Superintendents Additional District RCH Block Health Medical Officer FRUs, CHC Health Officer Officer Officer Primary Health Center

FRU=First Referral Center, CHC = Community Health Center, RCH=Reproductive & Child Health

2.3 Building the evidence block, district, regional and state levels. base: monitoring systems Electronic reports are available to and indicators officers at each level to enable regular monitoring and planning. As recommended by the Government of India’s National Rural health Mission In a recent study of reproductive child (NRHM), Gujarat has introduced health (RCH) services in two districts programme management units at block, in Gujarat, the authors report that the district and state levels to ensure sound district offices receive regular reports monitoring of public health programmes. from the PHCs, and the monitoring Each programme management unit at systems are “well organized”. They the district level is staffed by a health also mention that there are regular management graduate and support meetings of the Medical Officers at the staff. PHCs with the district officials to review programmes and activities (Desai & S. Data is collected from the village level Bhavsar, 2007). by the ANMs and aggregated at the

8 IMPROVING MATERNAL AND CHILD HEALTH IN GUJARAT : Initiatives for Achieving MDGs 4 and 5 3 SITUATION ANALYSIS OF MATERNAL AND CHILD HEALTH IN GUJARAT

3.1 Background to maternal mortality ratio and the child mortality and child health in Gujarat rate. In the context of maternal health, RCH-2 emphasizes skilled attendance The present policies for maternal and at birth, in addition to the focus on child health in Gujarat and in India institutional deliveries and availability can be traced back to the International of emergency obstetric care featured in Conference on Population and RCH-1. Development (ICPD) held in Cairo in 1994. In line with ICPD perspectives, Around the time that RCH-2 was launched, the National Population Policy 2000, and the Central Government launched the National Rural Health Mission (NRHM) Gujarat Vision 2010, the GoG released in recognition of the need to strengthen the State Population Policy 2002. The the public health sector in rural areas. policy aimed to lower both infant and RCH-2 was subsequently subsumed maternal mortality to less than one third under NRHM, which NRHM further spelled of the prevailing levels. The concept of out the activities and programmes to be reproductive and child health (RCH) taken up for reducing maternal and child guiding this policy re-emphasized the mortality. target-free approach in family planning services, and the importance of providing To reduce maternal mortality, the key an integrated package of need-based, strategies enumerated in NRHM were: client-centered, demand-driven, high- quality RCH services. • Operationalizing 24X7 PHCs for essential obstetric care In 2005 the second phase of the RCH • Operationalizing FRUs with facilities programme, RCH-2, was launched. The for caesarean section, blood storage primary objectives of RCH-2 are reducing and referral linkages for emergency the total fertility rate, the maternal obstetric care

SITUATION ANALYSIS OF MATERNAL AND CHILD HEALTH IN GUJARAT 9 • Setting up blood storage units (ARIs) and diarrhoeal diseases • Training MBBS doctors in • Supplementation with micro- anaesthesia nutrients: vitamin A and iron • Training MBBS doctors in pregnancy • The School Health Programme is to care and emergency obstetric care be launched with health-promoting • Making available safe abortion schools. services at PHCs and FRUs NRHM aims to decentralize the • Making available neonatal care at functioning of the public health system 24x7 PHCs by instituting structural changes and • Making available medical termination involving local government institutions of pregnancy (MTP) at up to eight in service delivery. In recognition of the weeks using manual vacuum multidimensional causality of ill-health, aspiration (MVA) it advocates intersectoral linkages, • Management of reproductive tract particularly with programmes that have infections (RTIs) and sexually a bearing on health outcomes of women transmitted infections (STIs) at PHCs and children such as the Integrated and CHCs/FRUs Child Development Services (ICDS). • Comprehensive RTI/STI services: convergence between RCH To enable better uptake of public health programme and National Aids Control services and to forge stronger linkages Programme between the communities and the public For reducing child mortality, NRHM listed health system, NRHM has created the the following key strategies: position of village-level female health activists. An Accredited Social Health • Integrated management of newborn Activist (ASHA) is expected to work with and childhood illness (IMNCI) communities for social mobilization and • Home-based newborn and child care improved access to services; including • Facility-based newborn care identifying pregnant women and • Infant and young child feeding, ensuring that they get adequate care including improving early and during and after pregnancy. The ASHA exclusive breastfeeding and is supported by the Worker complementary feeding (AWW), the village schoolteacher, • Malnutrition treatment centres, members of local community-based especially in areas of acute organizations such as self-help groups, malnutrition. and the Village Health Committee. • Reduction in morbidity and mortality due to acute respiratory infections

10 IMPROVING MATERNAL AND CHILD HEALTH IN GUJARAT : Initiatives for Achieving MDGs 4 and 5 The IMR in Gujarat has seen a reduction NRHM and RCH-2 provide a from 60 in 2001 to 52 per 1000 in 2007 supportive context, both in terms (Figure 3.2). According to the Sample of guidelines and funding, for the Registration System (SRS)6 data for initiatives takeZn up by the GoG 2007, Gujarat ranks 11th from the for reducing maternal and child bottom among the 35 Indian states and mortality in the last few years. union territories with regard to its IMR. The state aims to reduce infant mortality 3.2 Status of infant and child to 30 by 2010. mortality in Gujarat Figure 3.2: Infant mortality rate in Gujarat by sex, 2001–2007

The infant mortality rate (IMR) is defined as the number of deaths among children below one year of age per 1000 live births in a given year. The child mortality rate (CMR) is defined as the number of deaths among children between the ages of one and five years per 1000 live births in a given year.

Figure 3.1 Child mortality rates in Gujarat, 2001–2006 Source: Health Review, Gujarat: 2007–2008 (Data taken from SRS)

Based on mortality estimates from the Interagency Child Mortality Estimation Group (IACMEG)7 for 2005, 72% of all under-five deaths in India occur during the first year of life, i.e. among infants. Further, almost two-thirds of all infant deaths occur in the neonatal period (0–28 days), with the remaining third

Source:Health Review, Gujarat: 2007–2008 (Data occurring between the second and taken from SRS) twelfth months. The latest estimate of the CMR in Gujarat As seen in Table 3.1, data from 2006 for 2006 was 16 per 1000 (Figure 3.1). indicate that the neonatal period is even The rate has declined from 18.5 per more critical in Gujarat, where more 1000 in 2001, but stayed the same 6 Sample Registration System, Office of the Registrar General and between 2004 and 2006. The Indian Census Commissioner, India 7 This group includes WHO, UNICEF, the World Bank, the UN average CMR for 2006 was 17.3. Population Division, Harvard University, the US Bureau of the Census, and others.

SITUATION ANALYSIS OF MATERNAL AND CHILD HEALTH IN GUJARAT 11 than 70% of infant deaths occur within to health services in remote areas and the first month. among disadvantaged groups.

Table 3.1: Infant mortality rates in The variation in rural and urban IMR may Gujarat and India be related to the pattern of institutional Gujarat India deliveries. According to the 2005-

(2006) (2005) 2006 National Family Health Survey % infant deaths 0–28 70.8 62.5 days (NFHS-3), 78% of the total births taking place in urban areas were in institutions, % infant deaths 2–12 29.2 37.5 months and 83.9% of births were attended by

TOTAL 100 100 skilled personnel. The corresponding figures for rural areas were 42.2% and Sources: Gujarat data—Health Review Gujarat 2007– 54.6%. 2008; India data: Child Health Profile, India, World Health Organization (WHO) 3.2.2 Male/female differences 3.2.1 Rural/urban differences In Gujarat, the IMR is somewhat higher There is significant difference in the for females than for males, but the IMR in Gujarat between urban and rural difference between the two appears areas, with rural IMR being 60 compared to be gradually reducing (Figure 3.2 to 36 in urban areas (Figure 3.3). One above). In 2007, the IMR for females of the reasons is the lack of accessibility was 54 compared to 50 for males.8 8 SRS Bulletin October 2008 [spell out SRS]

Figure 3.3: Infant mortality rates in Gujarat by residence, 2001–2007

Source: Health Review, Gujarat: 2007–2008 (Data taken from SRS)

12 IMPROVING MATERNAL AND CHILD HEALTH IN GUJARAT : Initiatives for Achieving MDGs 4 and 5 3.3 Causes of child death in due to infections (severe infections including India pneumonia, neonatal tetanus, and diarrhea). Another 60% were due to preterm births It is estimated that malnutrition and (31%), birth asphyxia (23%), and congenital anaemia are contributory factors in anomalies (6%)11 (Table 3.2). 11 Ibid. over 50% of the deaths of under-fives in the country.9 Infectious diseases such The ongoing RCH programme as diarrhoea (20%), pneumonia (19%), comprehensively integrates and measles (4%) accounted for 43% interventions to improve child health of the 2.2 million deaths that occurred and was initiated to address each of among under-fives in India in 2005.10 the major factors contributing to high infant mortality rates and under-five Major causes of infant mortality in mortality. Components of child health India continue to be premature birth care include: and low birth weight, poor intrapartum Essential newborn care and newborn care, diarrhoeal diseases, • Immunization acute respiratory infections and other • Nutrition infections. • • Exclusive breastfeeding for 6 months Of the one million neonatal deaths in India Timely introduction of complementary in 2005, more than one-third (35%) were • feeding 9 WHO [needs more specific reference] 10 http://www.who.int/child_adolescent_health/data/media/cah_ • Detection and management of growth chp_india.pdf faltering

Table 3.2: Most common causes of child mortality in India, 2005

Third most common Period of childhood Primary cause Second most common cause cause

Severe infections (diarrhoea, Neonatal pneumonia, Pre-term birth (31%) Birth asphyxia (23%) (0–28 days) neonatal tetanus) (35%)

Premature birth Infant Low birth weight (2–12 months) Poor intra-partum and newborn care

Under 5 Under-nutrition Infectious diseases (diarrhoea, (13–59 months) anaemia (50%) pneumonia, measles) (43%)

Source: Child Health Profile, India, WHO. http://www.who.int/child_adolescent_health/data/media/cah_chp_india.pdf

SITUATION ANALYSIS OF MATERNAL AND CHILD HEALTH IN GUJARAT 13 • Massive-dose Vitamin A 3.5 Causes of maternal supplementation mortality in Gujarat • Iron supplementation • Early detection and appropriate State-specific data for Gujarat on the management of acute respiratory causes of maternal mortality are not infections available. However, we can assume • Controlling diarrhoea and other that the causes for maternal mortality infections in Gujarat mirror the causes that are 3.4 Status of maternal health common across India. in Gujarat 3.5.1 Immediate causes

Maternal mortality is defined as the death Studies have shown that haemorrhage is of a woman while pregnant or within the single major cause of maternal deaths, 42 days of termination of pregnancy, especially in rural areas. Haemorrhage, regardless of the site or duration of puerperal sepsis, obstructed labour, pregnancy, from any cause related to abortions and toxaemia account for more or aggravated by the pregnancy or its than three-quarters of maternal deaths management. The maternal mortality in India. Anaemia is the leading cause ratio (MMR) is calculated as the number among the “other causes”, followed of such deaths per 100 000 live births. by pregnancy with TB/malaria, viral hepatitis and others factors. In Gujarat, The latest official estimate of the MMR 61% of pregnant women were anaemic in Gujarat is 160 per 100 000 live births, according to NFSH-3 (2005-06). against a national average of 254. (An expert group of organizations calculated Figure 3.4: Causes of maternal death in India that these estimates are an undercount, and that the actual ratio is almost 50% higher.) While the ratio for Gujarat is better than several other states in the country, it is far lower than the well- performing states of Kerala (95) and Tamil Nadu (111).

The GoG acknowledges that the MMR of Gujarat has not improved significantly in the last ten years (Government of Gujarat, 2008a). The aim is to reduce Source: Registrar General of India, 2006 MMR in the State to 100 by the year 2010.

14 IMPROVING MATERNAL AND CHILD HEALTH IN GUJARAT : Initiatives for Achieving MDGs 4 and 5 3.5.2 Evidence regarding maternal reducing maternal deaths. A skilled mortality birth attendant is trained to recognize complications, treat them to the extent Research done at the School of Public possible and make timely referrals for Health at Columbia University, New York, advanced emergency care. over the last 15 years has conclusively shown that the best and most cost- Several factors prevent universally effective strategy for reduction in available skilled obstetric care in India maternal mortality is to have Emergency and in Gujarat. For one, trained doctors, Obstetric Care (EmOC) services within nurses and midwives are in short supply. reach of all pregnant women. While The situation is further aggravated by it is often not possible to predict or the fact that “…India has one of the prevent complications of pregnancy and most privatized medical systems in the childbirth, there is generally a gap of world” (Krupp & Madhivanan, 2009). several hours between the development The public health system is severely of complications and death. Timely EmOC understaffed. In 2005, when the GoG set services can therefore significantly to work to lower rates of maternal and reduce maternal death. WHO, The United infant mortality in the state, there were Nastions Population Fund (UNFPA) and only seven public sector obstetricians/ the United Nations Childrens Fund gynaecologists (Ob/Gyn) for a rural (UNICEF) have also now accepted population of almost 32 million. By this strategy of promoting EmOC and contrast, there were 700 private Ob/ recommend using the availability and Gyns practicing in Gujarat’s rural areas use of EmOC as process indicators for (Krupp & Madhivanan, 2009). measuring progress towards reducing maternal mortality (Mavalankar, 2001). 3.5.3 Process indicators of maternal health Studies done in the states of Andhra Pradesh, Maharashtra, and Rajasthan The process indicators for maternal showed that 52%, 47% and 42% of health (Table 3.3) throw additional light maternal deaths respectively happened on the situation regarding maternal in the home or in transit to a hospital mortality in Gujarat. According to (Mavalankar, 2001). If these had been NFHS-3 (data collected in 2005–2006), institutional deliveries, it is likely that a only 65% of pregnant women in large proportion of these women could Gujarat received three antenatal check- have been saved. ups and 36% consumed iron and folic acid supplements (IFA) for 90 days or Skilled birth attendants and institutional more. deliveries are important strategies for

SITUATION ANALYSIS OF MATERNAL AND CHILD HEALTH IN GUJARAT 15 Institutional deliveries in Gujarat have Table 3.3: Process indicators of maternal been increasing over the last several health in Gujarat and India years, from 36% in 1992–1993 to 55% Gujarat India in 2005–2006. According to the most Source Date Indicator % recent NFHS estimates, a further 10% Pregnant women NFHS-3 2006 61 58 of deliveries are attended by health (15-49) with anaemia personnel in the women’s homes. No Mothers who had trained birth attendant was present NFHS-3 2006 at least 3 antenatal 65 51 care visits at 35% of births in Gujarat in 2005– Mothers who had 3 2006. DLHS-3* 2008 or more antenatal 56.8 check-ups Mothers who consumed IFA The process indicators for maternal NFHS-3 2006 35.7 22 tablets for at least 90 health in Gujarat are generally better days than the all-India average, except the Mothers who DLHS-3 2008 consumed 100 IFA 50.7 prevalence of anaemia in pregnant tablets women. Institutional births 54.6 41 Institutional DLHS-3 2008 56.5 There is a rising trend in institutional deliveries Deliveries deliveries in Gujarat over the last 17 conducted by skilled 64.7 48 personnel** years as recorded in the NFHS and DLHS Safe deliveries data (Figure 3.5). DLHS-3 2008 (institutional or 62.1 skilled personnel) Mothers who 3.5.4 Sociodemographic variations received postnatal in maternal mortality NFHS-3 2006 care within 2 days of 54 36 delivery from skilled personnel There is evidence to show that women Mothers who received post natal living in urban areas and those who are DLHS-3 2008 59.5 care within 2 weeks literate are better off regarding maternal of delivery health compared to their counterparts in rural areas or those with less education. *DLHS: District Level Household & Facility Survey (International Institute for Population Sciences, Mumbai) Gujarat is one of the more industrially developed states in the country, yet 63% **“Skilled personnel” include doctors, nurses, LHVs and of its population lives in rural areas and ANMs. 16.8% falls below the official poverty line. Rural areas are poorly serviced and connected. The literacy rate for women average of 933. The age of effective in Gujarat is 58% compared to 80% for marriage is 20 years in Gujarat as it is men (Census 2001). The sex ratio in in India. the state is 920, lower than the national

16 IMPROVING MATERNAL AND CHILD HEALTH IN GUJARAT : Initiatives for Achieving MDGs 4 and 5 Figure 3.5: Trend in institutional deliveries in Gujarat

Source: NFHS

Table 3.4 shows the disparities in the women in these two areas. In addition sociodemographic profiles of rural and to lower levels of awareness among urban populations and the difference in rural families, lack of transportation to utilization of health services among the health facilities is a constraint.

Table 3.4 Rural/urban differences in demographic and maternal health indicators in Gujarat

Source Date Indicator Rural (%) Urban (%) Census 2001 Population Percent 62.6 37.4 Census 2001 Sex ratio [not percentage] 945 880 Census 2001 Literacy rate 61.29 81.84 Census 2001 Population BPL 19.1 13 NFHS-3 2006 Mothers who had at least 3 ante natal care visits 55.8 81.5 DLHS -3 2008 Mothers who had 3 or more antenatal check-ups 50.0 79.0 NFHS-3 2006 Mothers who consumed IFA tablets for at least 90 days 28.9 48.3 DLHS -3 2008 Mothers who consumed 100 IFA tablets 45.4 52.3 NFHS-3 2006 Births assisted by skilled personnel* 54.6 83.9 DLHS -3 2008 Safe deliveries (institutional or skilled personnel) 54.5 86.7 NFHS-3 2006 Institutional births 42.2 78 DLHS -3 2008 Institutional deliveries 48.1 83.7 Mothers who received postnatal care from skilled personnel NFHS-3 2006 43.8 72.7 within 2 days of delivery Mothers who received postnatal care within 2 weeks of DLHS -3 2008 52.9 81.1 delivery

*Skilled personnel include doctors, nurses, LHVs and ANMs.

SITUATION ANALYSIS OF MATERNAL AND CHILD HEALTH IN GUJARAT 17 NFHS-3 data show a direct relationship the lowest wealth quintile used basic between years of schooling and uptake maternal healthcare much less than of maternal health services. As seen in their literate or wealthier­ counterparts Table 3.5, women who have had formal and were far less likely to see a doctor.­ schooling tend to use maternal health Only 18% of 39 677 illiterate mothers services more than those who have had institutional deliveries compared never been to school. to 86% of 39 Not clear what this refers to.677 mothers with 12 or more years The educational and economic status of of education; simi­lar differences were women influences the use of maternal observed in the use of skilled care at care. Figures 2 and 3 illustrate that delivery and use of postnatal care (Vora illiterate mothers and mothers from et al., 2009).

Table 3.5: Relationship between mother’s educational level and use of maternal health services

No education Ten or more years’ Indicator (%) education (%) Mothers who had 3 antenatal visits 45.5 89.9 Mothers who consumed IFA for 90 days or more 21.7 56.7 Birth assisted by skilled personnel 49.5 92.1 Institutional birth 38.4 83 Motherswho received post natal care from health personnel 36.5 80.5 within 2 days of last delivery

Source: NFHS-3

18 IMPROVING MATERNAL AND CHILD HEALTH IN GUJARAT : Initiatives for Achieving MDGs 4 and 5 4 INITIATIVES TO IMPROVE MATERNAL AND CHILD HEALTH IN GUJARAT

In recent years, the GoG has taken up mortality. Similarly, newborns need several evidence-based initiatives to extra attention in the early period after reduce maternal and child mortality in birth, especially through the first week the state. The government recognizes and the first month, as this is the most that it needs to take a holistic approach critical period for their survival. This is to address these issues. It has therefore also a crucial time for reinforcing the initiated improvements on multiple importance of exclusive breast feeding fronts. The following figure shows the six to new mothers and their families. At broad focus areas taken up by Gujarat the same time, there is the need to for intensive inputs. improve the general health of pregnant

Figure 4.1: Focus areas in Gujarat for improving and lactating mothers and children maternal and child health through nutrition and immunizations. For all of these services to be delivered in an efficient manner, the public health Institutional Deliveries; New born care Skilled attendance at birth system needs to be staffed appropriately and managed well. This requires effective

Initiatives for ANC, PNC, leadership, sound human resource Campaigns for MDGs 4 and 5 Nutrition and demand creation immunizations deployment and good monitoring and supervision. In addition, the physical

Human resources Physical infrastructure of health facilities needs and management Infrastructure systems to be maintained satisfactorily. Finally, an improvement in supply needs to be matched with a corresponding increase There is strong evidence that skilled in demand for these services from the attendance at birth and especially community. The initiatives discussed institutional deliveries are a critical in section fall under these six focus strategy for improving maternal areas.

INITIATIVES TO IMPROVE MATERNAL AND CHILD HEALTH IN GUJARAT 19 4.1 Institutional deliveries for the delivery as well as for surgical and skilled attendance at interventions, if required. Expenses of birth the family member accompanying the mother are also taken care of by the 4.1.1 Chiranjeevi Yojana government.

To create awareness about the scheme, The most high-profile scheme of the GoG the Medical Officer and the ANM at the for improving maternal health has been subcentre inform pregnant mothers the Chiranjeevi Yojana (literally the “long about the scheme and motivate them life scheme”). The Chiranjeevi Yojana was launched in 2005 on a pilot basis to register for prenatal care and in five of the more backward districts institutional delivery (Bhat et al., 2009). of the state. In September 2007, To make it a demand led service, BPL the scheme was extended to all 26 pregnant women are given a voucher districts. It targets pregnant women to cover the costs of delivery services, from BPL families and aims to promote medicines and transportation, which institutional deliveries. they can use with a local obstetrician of their choice. The scheme was designed to overcome the severe shortage of trained The government’s initiative is a gynaecologists in the public health departure from previous practice in that system in rural areas. The Gujarat the government took sole responsibility DHFW contracted with private providers for the reimbursement of private who had a postgraduate degree in health-care providers, rather than obstetrics and gynaecology, owned their relying on intermediary parties such as own nursing home which had a labour insurers. To plan and implement these room, operation theatre and blood bank, arrangements, the state government and had access to an anaesthetist’s works with professional agencies such services. as associations of obstetricians and academic organizations. This scheme is based on the public- private partnership (PPP) model The Chiranjeevi Yojana scheme has led to a wherein the government and the private large increase in institutional deliveries, sector come together to ensure safe from 54% three years ago to 87% at deliveries. Mothers are cared for right present (Table 4.1). More than 90% of through pregnancy through the public the beneficiaries are from the poor and health system, and linked to a qualified deprived sections of society. From the time doctor who supervises the delivery. the scheme was started in 2005 until March The government bears all expenses 2008, a total of 37 maternal deaths were

20 IMPROVING MATERNAL AND CHILD HEALTH IN GUJARAT : Initiatives for Achieving MDGs 4 and 5 reported among Chiranjeevi beneficiaries. According to a recent study of the Chiranjeevi The expected number of deaths out of 153 scheme (Bhat et al., 2009), 81% of eligible 717 deliveries conducted during that period women delivered under the scheme. The (based on the existing MMR in Gujarat) would scheme has been successful in terms of have been 265. In other words, 228 mothers’ targeting the poor: 94% had incomes below lives were saved (Government of Gujarat, Rs.12 000 per annum. Among those who 2008b). took advantage of the scheme and those who did not, education levels were similar. In 2006, a United Nations Population While the scheme has been successful, Bhat Fund study of Chiranjeevi Yojana et al. (2009) suggest that it is not entirely reported that the programme had free of cost for the beneficiary as originally successfully raised the number of designed. On average beneficiaries spent births delivered in health facilities, and Rs.727 (primarily on medicines for the that private practitioners were mostly mother and the child, and Rs.72 for enthusiastic about their participation in transportation, since the scheme gives the initiative.12 only Rs.200 for this purpose.

Table 4.1: Deliveries conducted and doctors enrolled under Chiranjeevi since inception

Deliveries conducted

Lower Doctors segment Other % LSCS enrolled Year Normal caesarean Total complications (cumulative) section (LSCS)

2005–2006 6 809 417 567 7 793 6.1 163

2006–2007 40 828 2 913 3 965 47 706 7.1 742

2007–2008 106 080 7 651 7 312 121 043 7.2 865

2008–2009 122 217 7 846 5 643 135 706 6.4 867

TOTAL 275 934 18 827 17 487 312 248 6.8 867

Source: Draft Health Review 2008, DHFW, GoG, with data for 2008–2009 received directly from the DHFW, GoG

INITIATIVES TO IMPROVE MATERNAL AND CHILD HEALTH IN GUJARAT 21 “When I joined the Chiranjeevi Scheme in 2007, I used to get one Chiranjeevi delivery per month. Today [September 2009] there are 30 deliveries every month in my hospital through Chiranjeevi. The AHSA workers and ANMs are responsible for motivating pregnant women and their families. In rural areas, the sister’s (ANM) word carries a lot of weight.

“The other change I have observed in the last two and a half years is that now none of the women coming to me have severe anaemia, unlike earlier when pregnant women would come with 2% and 3%.

“What is needed is more awareness about the importance of a healthy diet and adequate rest. The family of the pregnant woman needs to recognize that she needs both rest and a good diet to stay healthy and deliver a healthy child.

“Also, the IFA supplement given to through Mamta Abhiyan* could be improved in quality to lead to better results.”

Dr Aashish Jayswal, Chiranjeevi Doctor, , Panchmahal District

*For an explanation of Mamta Abhiyan, see section 4.3.1 below.

CHIRANJEEVI BENEFICIARY IN A PRIVATE HOSPITAL

22 IMPROVING MATERNAL AND CHILD HEALTH IN GUJARAT : Initiatives for Achieving MDGs 4 and 5 “For my first delivery, I went to my mother’s home. That was two and a half years ago. My first delivery was done at home by a dai. This time I stayed here [near Vejalpur PHC). I had the IFA tablets given on Mamta Diwas.* When my labour pains started, we told the ASHA worker. She called the 108 ambulance and I went to the hospital. I stayed in the hospital for one day, and then came back home.”

Surajben Alpeshbhai Rawal, Nadarkha village in Kalol Taluka, Panchmahal District

*See section 4.3.1 below.

4.1.2 Extended Chiranjeevi in transportation faced by the rural Yojana population to health centres. To address the need for transportation Chiranjeevi Yojana draws on private during medical emergencies, the state obstetricians/gynaecologists for government launched a free ambulance institutional deliveries. In certain service in collaboration with Emergency remote areas, even private specialists Management and Research Institute are unavailable. The extended (EMRI) Hyderabad in August 2007. Chiranjeevi Yojana is planned for 54 Gujarat was the second state in the poorly performing blocks in the state. country to launch the 108 Emergency Under this scheme, Ob/gyns are given Ambulance Services which run a fleet of a one-time assistance of Rs.740 000 400 ambulances in the state, attending (USD14,800) to conduct at least 300 over 1800 emergencies every day. The deliveries among BPL women. This ambulances have wireless connection to scheme has failed to attract private a central call centre that can be reached specialists so far. This underscores the by a single phone number. The response difficulty of providing health services in time in rural areas is between 30-45 remote and thinly populated areas due minutes, depending on the location. to the unwillingness of doctors to work in such areas. To enable pregnant women to reach hospitals quickly at the time of delivery, each block office 4.1.3 Emergency transport prepares a monthly list of expected deliveries system and passes it on to the concerned EMRI centre. The Medical Officer at the block level As seen above, institutional deliveries maintains information on the expected due are significantly higher in urban areas. date of each registered pregnant woman in An important reason is the difficulty his block. This information is used to prepare

INITIATIVES TO IMPROVE MATERNAL AND CHILD HEALTH IN GUJARAT 23 the monthly list of expected deliveries which women from BPL families are given a is given to the emergency transport service. cash incentive for nutrition (Rs.500) This information is also used to monitor in the last trimester and Rs.200 for whether the deliveries were conducted in an transportation for institutional deliveries institution and who was in attendance at the in government institutions and selected time of the delivery. private institutions. State governments have the flexibility of managing the Appendix III shows an example of the scheme at the local level. form that is completed by the paramedic in the 108 ambulance and given to the In Gujarat, pregnant women from BPL doctor on arrival at his hospital. families benefit from both JSY and the Chiranjeevi Scheme, since both schemes 4.1.4 Janani Suraksha Yojana target BPL, scheduled caste and tribal (JSY) families.

Under the NRHM, the Central Government As seen in the experiences reported launched the Janani Suraksha Yojana below in the United Nations Development (JSY—Women’s Protec­tion Scheme) in Programme’s (UNDP) Solution Exchange 2006 to promote institutional deliveries Forum on Maternal and Child Health, and post-delivery care for poor monitoring of JSY is being carried out women, to address maternal and child by both government functionaries and mortality. Under the scheme, pregnant NGOs.

“I am working with the Health and Family Welfare Department, Governmentt of Gujarat as a Project Officer—Child Health and Immunization under NRHM. I have worked closely on JSY during my posting as District & Regional Programme Coordinator. We were also facing problems of late payments of JSY, so we started monitoring the payments made under JSY. We prepared detailed forms for this exercise. We created levels of monitoring right from Medical Officer of the PHC to the state level. All the concerned authorities were told to do 10% verification of JSY cases. Based on the reports received, the districts having poor performance were asked for an explanation of the issue. This exercise helped in improving the timely payments under JSY.”

Mridula Pandey, Health and Family Welfare Department, Gujarat

24 IMPROVING MATERNAL AND CHILD HEALTH IN GUJARAT : Initiatives for Achieving MDGs 4 and 5 “I am working in Navasari District of Gujarat State... The JSY scheme implemented in the state of Gujarat has provision of Rs.500 to pregnant women during the 7th–9th months of pregnancy. In our area we realized that the women were not fully aware about this entitlement. In some villages they were receiving less than Rs.500.

“We have the experience of involving panchayat and self-help group members to monitor the access to maternal health care services. Many young sarpanches have taken this initiative. They remain present during Mamta Day* and make sure that the women of his/her village receive the JSY money and other health services. We did extensive campaign informing people about their rights and to empower them to demand health care.”

Pallavi Patel, CHETNA, Ahmedabad

*See Section 4.3.1 below.

4.1.5 Incentivizing the public simultaneously expanding the pool of health system skilled persons for safe deliveries in the public sector. The government’s To increase institutional deliveries in strategy is to train MBBS doctors and public health facilities, staff at PHCs try and place them in health facilities in and CHCs are given incentives if they the remote areas, because in such areas conduct above a certain number of even private specialists are scarce. deliveries. For instance, each PHC received Rs.1000 for every delivery Initially, even before the launch of the after the first 25 deliveries, and each Chiranjeevi Scheme, Gujarat started to CHC receives Rs.1000 per delivery after train MBBS doctors and staff nurses in the first fifty deliveries per month. basic EmOC in 2003. This was a two- week training programme given at the 4.1.6 Training of MBBS doctors in district hospitals. CEmOC In 2005, the state government and The Chiranjeevi Scheme draws on private the Federation of Obstetric and specialists to address the immediate Gynaecological Societies of India need of increasing the number of (FOGSI) started an initiative to train institutional deliveries because of the MBBS doctors in comprehensive care shortage of specialists in the public (CEmOC). This course was designed health system. The government is with inputs from the Johns Hopkins

INITIATIVES TO IMPROVE MATERNAL AND CHILD HEALTH IN GUJARAT 25 Program for International Education years, s/he is a trained resource in Gynecology and Obstetrics and the in the community for institutional Averting Maternal Death and Disability deliveries.” Program at Columbia University (Vora et al., 2009). Dr Ajesh Desai, Director, State Training Institute for Health and Under this initiative, MBBS doctors Family Welfare are trained for basic deliveries and caesarean section deliveries. Gujarat It is believed that the success of the was the first state in the country to training of medical officers is largely train Medical Officers in doing caesarean due to the increase in the management section deliveries. The trained doctors capacity created by appointment of a are placed in an FRU for three years dedicated qualified official to oversee after the training. and manage the training programme. As of June 2009, 50 doctors in Gujarat In addition to government doctors, had been trained in CEmOC. doctors from grant-in-aid hospitals are admitted to the training programme. This 4.1.7 Training of MBBS doctors in ensures that the training programmes anaesthesia run to capacity, and the resource pool of trained persons steadily increases. Providing CEmOC may require the services of an anaesthetist, and as in “The Medical Officer trained the case of other specialists, there is a in CEmOC becomes a nucleus severe shortage of trained anaesthetists around which a whole system in the public health system in rural promoting institutional deliveries Gujarat. The GoG started training MBBS begins to emerge. The ASHAs in doctors for obstetric anaesthesia in four the service area of the CHC/FRU teaching hospitals in the state in 2007. begin to inform the communities This is an 18-week training programme, in their respective villages about and equips doctors to assist in surgeries the presence of a trained doctor during deliveries. Gujarat was the first at the centre. In several centres, state in the country to offer this training, the trained doctors have started and as of June 2009, 72 MBBS doctors training ANMs in their service area, have received this training. which increases the pool of trained personnel in and around the centre. More doctors have been trained in Even if the doctor decides to leave anaesthesia as compared to CEmOC as government service after three there are more training centres for the former.

26 IMPROVING MATERNAL AND CHILD HEALTH IN GUJARAT : Initiatives for Achieving MDGs 4 and 5 While it may be expected that the trusts, followed by government blood placement of MBBS doctors trained in banks, Indian Red Cross Societies­ CEmOC and anaesthesia will lead to (IRCS), and private blood banks. an increase in institutional deliveries in Charitable trust and IRCS blood banks public health facilities, no evaluation of contribute sig­nificantly to voluntary the impact of these trainings has been collection of blood in both the states. carried out so far. In Gujarat, government­ blood banks contribute 13% of the state’s total blood 4.1.8 Blood banking services collection.

Blood transfusion has been identified Lack of voluntary non-remunerated as one of eight key life-saving functions donors of blood is still the main constraint that should be available in healthcare for blood safety in India. Replacement facilities providing CEmOC. According donors (those related to the recipient) to the SRS (2003), 38% of all maternal still provide the bulk of blood for blood deaths in India are caused due to banks. postpartum haemorrhage.­ Further, a large proportion of pregnant women The voluntary blood donation movement in Gujarat are anaemic (61%), and is relatively­ strong in Gujarat. There emergency blood transfusion is critical was an 89% increase in voluntary blood for reducing maternal mortality. In the donation in the state between 1998 and Indian public health care system, FRUs 2005 and the total blood collection went have been identified as the point facility up by 103% over this period. for providing emergency obstetric care. According to some estimates, if all In Gujarat, training programmes for FRUs were equipped with the required blood bank personnel are offered to blood supply, maternal deaths could be update their skills and knowledge. The reduced by 30% (Ramani, Mavalankar training programmes are usually of­fered & Govil, 2009). once in three months in various regions of the state, and address topics such as Currently the total recorded blood the necessity of safe blood, the rational collection in India meets only 40% of use of blood, and clinical procedures.­ need. Furthermore, blood availability is higher in urban areas compared to rural Under the Blood Bank Modernization areas. According to a recent study, scheme of the National AIDS Control Gujarat has 162 blood banks, of which Organization (NACO), by November 71 are run by private organizations. The 2006 the Government of In­dia had majority of blood collection is done by provided support to modernize 883 the blood banks managed by charitable district-level blood banks and 255

INITIATIVES TO IMPROVE MATERNAL AND CHILD HEALTH IN GUJARAT 27 major blood banks, and established first states to start this training based 82 blood component separation units on the national guidelines for skilled in the country. In Gujarat, under the birth attendance (SBAs) (Mavalankar programme, there are 15 major blood et al., 2009). This 15-day, compe­ banks and 42 district-level blood tency-based hands-on training uses banks. models and techniques for adult learning. ANMs are trained to recognize Recently, the Medical Council of India the complications during deliveries, (National Education Regulatory Board) provide immediate treatment and refer has approved a postgraduate­ course the pregnant woman to the FRU. The in blood banking and immunology training is offered in-service and pre- haematology/immunology haematology service. (To enable pre-service training, and blood transfusion. Gujarat is one of the teachers at ANM schools have been the five states in the country that offer trained in the new SBA protocol so that this course. they can transfer these skills to newly graduating ANMs.) Trained ANMs are 4.1.9 Skilled Birth Attendance provided with equipment and supplies (SBA) training for ANMs for conducting deliveries. As of March 2008, about 4500 out of almost 7500 ANMs have to undergo an 18-month ANMs in Gujarat have been trained in training programme. The Government SBA. Unfortunately, there has been of India started an initiative to train no systematic monitoring to evaluate ANMs for skilled birth attendance in whether the trained ANMs have been 2005. Gujarat has been one of the providing more or better maternal care “This training is very essential (Mavalankar et al., 2009). for areas like ours, where there are many difficult-to-reach hamlets. It is not possible to reach a vehicle and transport the pregnant woman to a hospital. In such circumstance, if an ANM is trained in SBA, she can conduct a safe delivery. In the more urbanized districts where people can reach hospitals easily, this training may not be as critical.”

Dr Prakash Vaghela, Chief District Health Officer (CDHO), Panchmahal ANM WITH DISPOSABLE DELIVERY KIT

28 IMPROVING MATERNAL AND CHILD HEALTH IN GUJARAT : Initiatives for Achieving MDGs 4 and 5 4.1.10 Verbal autopsy for maternal this shortcoming was taken care of death audit in January 2009, and since then the activity has moved forward steadily. Registration of maternal deaths and Six regional workshops were held in verbal autopsies enable the authorities May 2009 with district-level officers to to document the number of deaths review the progress. and record the reasons for them. This documentation of the location and On the positive side, there is an increase causes of maternal death enables a in awareness among the commu­ better understanding of the problem nity and field workers regarding the and helps to plan for future reduction of tragedy of maternal deaths because of maternal deaths. the registration of maternal deaths and verbal autopsy. State- and district-level In September 2006, the GoG started officers are also realizing various socio­ a system of recording maternal deaths economic issues and gaps in the public with verbal autopsies. The forms are health sys­tem which lead to maternal completed by block health officers deaths (Mavalankar et al., 2009). who conduct verbal autopsies based on information of maternal death from 4.1.11 Policy changes field workers. These forms are sent to the district office where the data is Until about the middle of 2008, entered into a computer. Software has public health facilities conducted free been developed to record and analyze deliveries only for a woman’s first two the data. children. After that, the family had to pay for the delivery of the child. To There was a delay in putting the encourage institutional deliveries, a system in place because no officer was Government Resolution was passed in solely responsible for the registration 2008, instructing all public facilities to of maternal deaths and analysis and conduct all deliveries free of cost. reporting of the audits. However,

“Based on my experience in the field, I have definitely observed a reduction of maternal and neonatal deaths in Gujarat. In Mahesana district, for example, a total of 12 000 deliveries occurred between April 1 and July 31, 2009. Of these, only six were home deliveries. It is not just one factor that is responsible for this; it is multiple factors. These include aggressive awareness raising campaigns in the community, training of ANMs and improved facilities like free transportation services for deliveries.”

Dr K.B. Patel, Regional Deputy Director, North Gujarat Region

INITIATIVES TO IMPROVE MATERNAL AND CHILD HEALTH IN GUJARAT 29 Figure 4.2 shows the impact of these The GoG has promoted several initiatives on the institutional deliveries initiatives in the last few years to reduce in the state between 2005 and 2008. child and infant mortality. These focus on providing antenatal care, skilled 4.2 Initiatives to improve attendance at birth and postnatal care newborn care and immunization and nutrition for pregnant and lactating mothers and In India, post-neonatal mortality has infants. These are discussed below. declined much faster than neonatal • IMNCI mortality in the last decade. This is • Bal Sakha Yojana I and II mainly due to increased focus on post- • Strengthening newborn care in neonatal care such as immunization, government facilities and medical management of diarrhoea and ARIs, colleges etc. However, neonatal care remains • Upgrading skills of doctors in newborn the most neglected area, with only 42% emergency care of women receiving such care within • Introducing mother and child friendly two months of delivery, and a negligible hospitals number of women being visited in the vulnerable first week after delivery (Vora et al., 2009).

Figure 4.2: Trend in institutional deliveries in Gujarat

Source: Government of Gujarat, Health Review, Gujarat: 2007–2008 (Data labelled 2009–2010 are for the period April–July 2009)

30 IMPROVING MATERNAL AND CHILD HEALTH IN GUJARAT : Initiatives for Achieving MDGs 4 and 5 4.2.1 Integrated management of health workers and supervisors, AWWs newborn and childhood illnesses and ICDS supervisors have received this (IMNCI) training. Gujarat is the leading state in terms of the numbers of personnel that The IMNCI programme’s key component have received this training, and this has is home-based care for newborns and led to a marked increase in the skills low-birthweight babies during the and capacities of local workers. most vulnerable period of their lives, i.e. the first 28 days. The programme The State Health Department followed aims at training doctors, nurses and an innovative approach of bringing village-level health care functionaries in experts from medical colleges to provide postnatal care and monitor and positioning them as key health newborns. Village-level health workers administrators overseeing IMNCI are trained to treat newborns and training in the state. Dr Amarjit Singh, recognize distress signs. The training Commissioner of Health and Secretary is module-based, with audiovisual and Family Welfare, GoG, explained, “We practical components. accepted that the level of understanding about what was killing children was in Gujarat was among poor within the administrative system. the first 5 pilot districts in the country We also accepted that those who to implement the initiative in 2005. The understood the key issues underlying programme extended to 18 districts neonatal and child survival in general in the State in 2006. (WHO report Guj were in the medical colleges. So the mtg 2008). Training for personnel in next step was to seek out those who the remaining eight districts will be have stature in medical colleges and get completed in 2009–2010. them into the system where they can have a greater impact. This was a new In addition to the in-service training, thing because teachers had not been IMNCI training has now been extended made health administrators earlier.” The to the pre-service period and is part of department has also involved private the training given to doctors, nurses and medical colleges in conducting these health workers. Training in these tools trainings. and methods equips these students with necessary skills for newborn and In 2009 the State appointed six regional child care when they start their practice officers for IMNCI to ensure that the (Government of Gujarat, 2008a). services run smoothly.

As of August 2008, 28 000 health According to Dr Dholakia (Joint Director, personnel, including Medical Officers, MCH, GoG), there are two challenges

INITIATIVES TO IMPROVE MATERNAL AND CHILD HEALTH IN GUJARAT 31 in satisfactory implementation of visit the newborn twice within the first IMNCI. The first is adequate supplies 48 hours. The two-day period is used to and logistics to ensure that the trained monitor the mother and newborn child personnel visit the newborn and and also to emphasize the importance provide the required care. The second of exclusive breastfeeding in the first six is adequate supervision of the field months. As with the Chiranjeevi scheme, workers. The focus now is on ensuring private paediatricians are being signed that supplies are available at all places on for the scheme. and on training supervisors who can monitor the work on the ground. Under Bal Sakha I Scheme, infants born under the Chiranjeevi Scheme are “The best part about doing check- visited by a paediatrician at the hospital ups using the IMNCI protocol is where the baby is delivered. If required, that nothing has to be memorized. the newborn is taken to the clinic of All the information is given in the the paediatrician for treatment. The IMNCI booklet, which we carry with scheme also pays for transportation of us.” critically ill newborns to medical college hospitals. FHS, Vejalpur PHC, Panchmahal District The Bal Sakha II Scheme is for infants from BPL families not born under the Chiranjeevi Scheme. The benefits of 4.2.2 Bal Sakha Scheme I and II Bal Sakha I are available to them. In addition, an incentive is paid to the The Bal Sakha Schemes I and II were ANM/AHSA/ICDS worker who refers the launched in Gujarat in early 2009, and infant to the paediatrician. focus on newborn care for BPL families. The scheme was introduced in response As of July 2009, 11 305 infants had been to the shortage of paediatricians in visited by 226 paediatricians enrolled in the public health system, especially in the scheme. rural areas. Currently there are only 16 paediatricians in the public health It is not always easy to keep the mother system; the number in the private sector and newborn in the facility for 48 hours is estimated to be about 750. Under the after the delivery, as the family often Bal Sakha scheme, Chiranjeevi doctors wishes to leave the hospital and go are encouraged to keep the mother and home. It is hoped that over time this newborn for two days post-delivery in trend will change. the hospital and have a paediatrician

32 IMPROVING MATERNAL AND CHILD HEALTH IN GUJARAT : Initiatives for Achieving MDGs 4 and 5 4.2.3 Upgrading skills of MBBS to be the first hospital to receive this doctors and nurses in emergency certification. newborn care

“It is not easy to persuade a To compensate for the lack of specialist woman to stay in the hospital for paediatricians in public health 48 hours after a normal delivery. facilities and in remote rural areas, a She wants to get back to her house programme for training Medical Officers because there is a cow or a buffalo in emergency newborn care has been to look after. Also she may have designed and initiated in the state. an older child and so wants to get This four-month training is the first of back home. Her family has to be its kind in the country (Government persuaded for her to stay for two of Gujarat, 2008a), with three months days after her delivery.” in the medical college and one month practical training in a district hospital. Nidhi Verma, District Programme The first group of eight MBBS doctors Coordinator, Panchmahal District completed training in July 2009, and a second group of ten doctors will begin 4.3 Antenatal and Postnatal their training in September 2009. care, Nutrition, Growth Moni- toring and Immunization A similar training for nurses in neonatal care is in the planning stages. In addition to institutional deliveries and 4.2.4 Introducing mother and newborn care in the hospital, ensuring child friendly hospitals complete antenatal care and improving the health status of women and children The GoG wants to encourage all hospitals is critical for reducing maternal and in the state to keep the mother and child mortality. Gujarat has introduced newborn child in hospital for 48 hours important initiatives for promoting the after the delivery, to provide inputs on health of these groups. newborn care and to monitor the mother and child during this critical period. The 4.3.1 Mamta Abhiyan government launched an initiative in February 2009 to certify hospitals which In 2006, the Government launched follow this protocol as “Mother and Child Mamta Abhiyan, a comprehensive Friendly Hospitals”. The certification package providing preventive, team will include FOGSI, the Pediatric promotive, curative and referral services Association and the State Government. under the Reproductive and Child Health Hospital is likely Programme. Gujarat has made this into a

INITIATIVES TO IMPROVE MATERNAL AND CHILD HEALTH IN GUJARAT 33 comprehensive programme focusing on of IFA and calcium supplements and antenatal and postnatal care and infant counselling. The service team includes and child health using a centre-based the ANM, the local AWW and helper, approach. In several villages, centres the ASHA worker and trained midwife. existed previously for immunization and Other village-level workers may also were known to the community. These be present on this day at the site. The existing centres are now being used to health department ensures that no deliver a larger set of services. other meetings or events are planned for this day of the week. The innovation lies in using the recognition and credibility of the ICDS The main objective of Mamta anganwadi centre in the village for Divas is to strengthen routine providing a range of services. immunization, reduce infant mortality as well as malnutrition The Mamta Abhiyan is carried out among children through effective through four primary activities: delivery of Health & Nutrition • Mamta Divas (Village Health and services on the same day and Nutrition Day) under the same roof. On the • Mamta Mulakat (Postnatal care Mamta Divas, a mother and child visit) friendly environment is created at • Mamta Sandharb (Referral services) the anganwadi, exhibition panels • Mamta Nondh (Records and reports) on maternal and child health are displayed, to educate the This programme integrates the services community about newborn caring of the Health Department and the Women practices, health and hygiene. and Child Development Department, (Government of Gujarat, 2008a). which are provided by village-level workers from both departments. Mamta Mulakat (postnatal care visit) Mamta Divas (Village Health and Nutrition Day for antenatal care and child health) Mamta Visits are made by the ANM to a new mother and infant on the first, Mamta Day is held on each Wednesday of third and seventh day after childbirth. In the week in each village of the state. The the case of institutional deliveries, the activities on this day include registration first visit is made after the mother and and health check-ups of pregnant child return home. The ANM monitors women and children including weight the mother and infant and counsels the monitoring, immunizations, distribution mother and her family on breast feeding and hygiene.

34 IMPROVING MATERNAL AND CHILD HEALTH IN GUJARAT : Initiatives for Achieving MDGs 4 and 5 Mamta Sandharb (Referral service) 4.3.2 Adolescent girls anaemia control programme A minimum of one Mamta Referral Centre has been developed in each Adolescents (10–19 years) in India constitute block, where services of a paediatrician 22% of country’s population. The health of are available on a fixed day each week. adolescent girls has a bearing on maternal ANMs refer mothers to these services and infant health and is therefore of relevance if they observe the need during home to the discussion here. visits, Mamta Days or Mamta Visits. Until recently, adolescents were being reached Mamta Nondh (Records and through school programmes in coordination reports) with the Department of Education. They were given information on issues of hygiene and Each pregnant woman is registered with reproductive health, etc. and invited for visits the public health system and issued a to the health facilities. This was not found to Mamta Card. This card is used to record be very effective, and was also unsuccessful the data about the progress of her in reaching adolescents who were not in pregnancy, intake of micronutrients and school. immunizations of her child.

SUKDI DISTRIBUTION ON MAMTA DIVAS

INITIATIVES TO IMPROVE MATERNAL AND CHILD HEALTH IN GUJARAT 35 To reach the adolescent population more Refresher training on nutrition to effectively, especially the adolescent girl ICDS workers population, the Government has launched the Mamta Taruni Abhiyan to address the The existing ICDS programme is health needs of adolescent girls. The Mamta responsible for providing supplementary Taruni Abhiyan targets preventive and nutrition to pregnant and lactating promotional health services at adolescent women, adolescent girls and children girls. The programme has been designed to aged six months to six years. To increase deliver health and nutrition services using the effectiveness of village-level a fixed-day, fixed-site model with a peer functionaries in their role for promoting educator. The primary activities under the health and nutrition among the target programme include weight monitoring, group, this cadre is being trained in IFA supplementation, treatment of RTIs the fundamentals and importance and STIs information, education and of nutrition. The ICDS and health communication, and behavioural change programmes will focus on underweight communication. The programme will be held women and children. on Mamta Divas at the aanganwadi centre and is expected to begin later in 2009. Fortified foods

4.3.3 Nutrition and growth Gujarat was one of the first states in monitoring the country to introduce fortified flour and edible oil in 2005. Under the Bal Nutrition cell Bhog Scheme, the state distributes take home pre-cooked energy- and protein- The state has instituted a State Nutrition rich food fortified with IFA along with Cell and established nutrition support vitamins A and C under the Micronutrient units in six regions at Medical Colleges Programme for pregnant and lactating for technical oversight. women, adolescent girls and children aged six months to six years. Iodized Twelve Child Development and Nutrition salt is provided to all pregnant women Centres are being set up in tribal blocks to treat and rehabilitate children with 4.3.4 Immunization grade III/IV malnutrition (Government strengthening of Gujarat, 2008a). Each centre will have a ten-bed facility for the malnourished In 1985, India launched the Universal child and her mother to stay for eight to Immunization Programme (UIP) ten days. targeting all infants with the primary immunization schedule and all pregnant women with tetanus toxoid

36 IMPROVING MATERNAL AND CHILD HEALTH IN GUJARAT : Initiatives for Achieving MDGs 4 and 5 immunization. Under the UIP, six Cold chain handlers training vaccines are used to protect children and pregnant mothers against tuberculosis, The data from the VPDS led to the diphtheria, pertussis, polio, measles intensification of cold chain handlers and tetanus. The UIP requires a reliable training in the state. Gujarat has taken cold chain system for storing and a lead in training its team members with transporting vaccines. support from UNICEF.

According to NFHS-3 data, there was a Adverse event following slight decrease in the proportion of fully immunization (AEFI) immunized children in 2005 compared to previous years (Table 4.2). The first state-level workshop on AEFI was held in March 2008. An AEFI The Government of Gujurat has stepped Committee has been formed in every up its immunization programme and district. Three-day trainings in AEFI are taken a number of initiatives to extend being given FHSs and ANMs. full immunization coverage to all children. The following data from the Routine immunization monitoring system (RIMS) government reflects the efforts taken.

Vaccine preventable disease Until recently, data on immunization surveillance were limited to coverage under the immunization programme. Recently, the In the last two years the State has Government of India started using RIMS streamlined its vaccine preventable to record more comprehensive data. The disease (VPD) surveillance systems. data are collected at district level from There is district-wise reporting of VPDs PHCs /Reporting Units in the standard and weekly monitoring of the data that predesigned UIP format and entered on comes in. five broad categories: (A) immunization

Table 4.2: Percentage of children fully immunized in Gujarat, 1992–2008­

NFHS-1 NFHS-2 DLHS-3 NFHS-3 DLHS-3 1992–1993 1998–1999 2002–2004 2005–2006 2007–2008 Percentage of children aged 12–23 months fully immunized (BCG, 50 53 54 45.2 54.9 measles and 3 doses of polio and DPT)

Source: NFHS

INITIATIVES TO IMPROVE MATERNAL AND CHILD HEALTH IN GUJARAT 37 and vitamin A, (B) vaccine supply, (C) “Reaching our target of full VPD surveillance, (D) status of cold chain immunization is a problem especially equipment, and (E) AEFI. These data in tribal areas. A large proportion are used for planning and forecasting of the population migrates out for requirements and monitoring vaccine employment. They are away for supply and availability. several months at a time.”

The RIMS has been instituted in all ANM, Vejalpur PHC, Panchmahal states of India. According to the district Commissioner, DANM, GoG, Gujarat is the only state where all 26 districts 4.4 Human resources and report using RIMS. management systems Linkages with private providers Successful outcomes of the initiatives taken by the GoG depend upon sound Recognizing that a large proportion of management of the health system and persons go to private providers, the adequate and suitable human resources. government has linked up with them The leadership recognizes this and and stationed one ANM at each private has instituted steps to strengthen clinic. All parents who visit private management systems in four broad practitioners are motivated to complete areas. These are: the immunizations for their children (Table 4.3). There have been two notable • Human resource strengthening achievements marking the success of • Decentralization the immunization programme. First, • Community participation there has been no reported case of polio • Management Information Systems in the state since March 2007. Second, in hospitals in June 2008 Gujarat was validated 4.4.1 Human resource as having eliminated maternal and strengthening neonatal tetanus.

Table 4.3: Percentage of Children Fully To strengthen the human resources in the Immunized in Gujarat, 2006–2009 public health system, the state is enhancing Full BCG, measles the technical and managerial capacity of

immunization dropout existing personnel and using innovative ways 2006–2007 89.5 7 to address the shortage of skilled personnel. 2007–2008 86.4 4.6 2008–2009 79.2 10.3 Source: DHFW, GoG

38 IMPROVING MATERNAL AND CHILD HEALTH IN GUJARAT : Initiatives for Achieving MDGs 4 and 5 Capacity building in technical and the Regional Director’s office with the managerial skills required documents and certificates. If they satisfy the criteria, they are hired There is increasing recognition of the on the spot. importance of human resources for ensuring positive health outcomes such Building the specialist pool as improved maternal mortality (Krupp & Madhivanan, 2009). Regular capacity Thirty per cent of postgraduate seats in building of health workers and doctors government-run medical colleges are is carried out and extensive training is reserved for doctors working in remote being given to doctors in public health. At and rural areas. This reservation acts as any time, 50 doctors are under training an incentive for MBBS. (World Health Organization, 2009). Increasing training programmes for Institutes such as the Indian Institute nurses and ANMs of Management Ahmedabad, Mudra Institute of Communications, Under NRHM it is recommended that Ahmedabad and Indian Institute of two ANMs be place in each subcentre. Health Management Research are being Given the shortage of trained ANMs, the used for training in disciplines such as state launched 12 additional schools for management and communications. ANMs in 2009. To upgrade managerial skills in public health, the Indian Institute of Public According to Dr Prakash Vaghela, CDHO Health was launched in collaboration Panchmahal district, the state can look with the Public Health Foundation of forward to an increased number of India (World Health Organization, trained ANMs in the near future. This is 2009). possible because of the state’s initiative to launch more training programmes and Walk-in recruitment corresponding efforts by the districts to quickly identify suitable candidates for There is a chronic shortage of medical training. officers and specialists in the public health system. To address this The government is planning to launch shortage, the GoG has developed an a one-year special course on midwifery innovative method for recruiting staff. to be offered in nursing colleges. It has Candidates interested in joining the been designed and approved by the state public health system can walk into Nursing Council.

INITIATIVES TO IMPROVE MATERNAL AND CHILD HEALTH IN GUJARAT 39 “Having ASHA workers has “The new village health and made a big difference in our work. sanitation committees are given Earlier we had one ANM who was an annual fund of Rs.10 000 to be responsible for a population of 5000 used for health related activities persons. Now she is supported by in the village. The Female Health an ASHA worker for each population Worker and the village teacher are group of 1000 persons. The ASHA signatories for utilizing this fund. plays a critical role in registration In the beginning the ANM was very of pregnant women and helping nervous about being a signatory. pregnant women get to a hospital at She had not handled public monies the time of delivery. She lives in the before this and was afraid about the village and is always available.” type of enquires that might occur, the auditing of the money, etc. Dr Prakash Vaghela, CDHO, However, they were motivated and Panchmahal District encouraged by their supervisors to take on this responsibility. The 4.4.2 Decentralization funds have been used for repairing the aanganwadi, getting furniture Gujarat is a large state, with an area of 196 for the subcentre, emergency 024 square km. Successful implementation transportation or purchase of of the public health system requires that the powder for chlorination.” districts and block offices have a fair degree of Dr N.N. Damod, Block Health autonomy. To this end, the state has introduced Officer, Panchmahal District initiatives to give greater authority to local offices, recognizing that local officers and staff are in the best position to know local priorities District and block Programme Management Units and use for resources. “The medical officer can bring about a sea change, if they are As a step towards decentralization, the supported satisfactorily,” according to Dr State Programme Management Unit Vaidya, CDHO, . He (SPMU) was set up in 2005–2006 to has taken the initiative to provide free weekly provide technical support to the public transportation to the PHC for antenatal check- health system. The SPMU is staffed by ups. This facility has been made available trained managers. Each district has for rural residents living in distant and poorly a District Programme Management connected talukas Unit headed by a District Programme Coordinator, who is a trained manager.

40 IMPROVING MATERNAL AND CHILD HEALTH IN GUJARAT : Initiatives for Achieving MDGs 4 and 5 Dr P. Vaghela, CDHO, Panchmahal Office; often the PHCs are located at District comments, “The setting-up of a great distance from the Office, and Programme Management Units has satisfactory review and supervision of helped us in many ways. The quality the PHC becomes difficult. To provide of our data has improved significantly, better support to the PHCs, the GoG and we are able to validate and verify created Block Health Offices, which assist the data that comes from the PHCs. the District Health Office in planning We are now able to use this data for and review of PHC activities and flow of monitoring and planning purposes, and data from the field to the district, and for conducting training of our teams.” generally improve the communication flow between the community and the District Health Societies District Health Office. This initiative has been implemented on a pilot basis in In 2006, District Health Societies (DHS) Surat. were instituted to plan district-level activities, make budgetary allocations 4.4.3 Community participation and monitor the progress on stated objectives. Each DHS is chaired by the Rogi Kalyan Samiti (Patient Welfare District Collector (the chief government Societies) administrive officer of the district), and the six-monthly meetings are attended A Rogi Kalyan Samiti (RKS) is a local by the District Collector, the CDHO and voluntary civic body that oversees the block-level health officers. the functioning of the health facility and devises strategies to improve its functioning. The RKS is made up of 11 to In Panchmahal District, the 15 local elected leaders and community District Health Society decided to representatives. RKSs have been use some funds from the Rashtriya established in 916 PHCs, 273 CHCs and Sam Vikas Yojana to procure 23 District Hospitals. weekly services of a gynaecologist and a paediatrician at the Vejalpur Each RKS is funded by the state. For PHC. example, an RKS at a PHC receives Rs.10 000 per annum for each revenue village Block health offices that falls under the PHC. In addition, the RKS can raise funds through user fees Each district has around 60 PHCs which and donations. The RKS utilizes these are supervised by the District Health funds as it deems fit.

INITIATIVES TO IMPROVE MATERNAL AND CHILD HEALTH IN GUJARAT 41 The flexibility of RKS funds means to review the patient’s history and provide they can be used for a variety of appropriate treatment. This system has purposes to enable better health resulted in reduced waiting time for patients services. For example, in the Aakhaj and improved continuity of care. This initiative PHC in Mehsana, the discretionary was awarded the e-governance award by the funds are used to bring in a Computer Society of India in 2007 and the gynaecologist and a paediatrician SKOCH Challenger award in 2008. once a week. The specialist doctors 4.4.5 Safe motherhood monitoring are paid Rs.1000 or Rs.1500 per system visit. The funds are also used to provide free transportation from An initiative to monitor maternal deaths the village to the block level health was begun in July 2009 on a pilot basis in facility, to hold health camps (such three districts (Vadodara, Sabarkantha and as IUD camps held on the day of Mehsana). Under this system, each pregnant our visit on August 17, 2009) and to woman is listed in an online database by provide nutritious food to pregnant name and location. Her progress during the women and lactating mothers. course of her pregnancy is monitored and the information is entered in the database for An evaluation of the performance of transparency and easier supervision. Other NRHM in Gujarat reported that the State districts such as Panchmahal have also has “…attempted to promote a flexible adopted this monitoring system. decentralized participatory structure with reasonable levels of efficiency” 4.5 Physical infrastructure: quality (Srinivasan et al., 2007). improvement and accreditation 4.4.4 Management information systems Gujarat was the first state in the country to introduce National Accreditation Board for Health Management Information Hospitals and Healthcare Providers (NABH) Systems (HMIS) are being implemented standards in public hospitals, including CHCs in all hospitals with support from Tata and PHCs. Between 2003 and 2007, CHCs Consultancy Services (TCS), a noted and PHCs were evaluated and brought software development organization. up to standard for RCH services. Quality This has enabled the creation of a database improvement in the PHCs and CHCs aims with details of each patient who registers at achieving Indian Public Health Standards at a government hospital. The data can be (IPHS) and focuses mainly on reproductive accessed and updated on subsequent visits health care. by the patient, which enables the doctor

42 IMPROVING MATERNAL AND CHILD HEALTH IN GUJARAT : Initiatives for Achieving MDGs 4 and 5 In district hospitals and medical college and groups as defined by Quality hospitals, the emphasis is on the total quality Steering Committee management system, in accordance with • NABH lead assessor training of 32 NABH and National Accreditation Board for administrators, clinicians and staff Testing and Calibration Laboratories (NABL) nurses at state level standards. • NABL internal audit training of 25 heads of the departments of medical In July 2007, a memorandum of understanding college laboratories (MOU) was signed between the GoG and At the Vibrant Gujarat Summit in 2009, the the Quality Council of India (QCI) to begin state signed MOUs with QCI for accreditation the process of accreditation of public health of further CHCs and PHCs. It is planned that all facilities in Gujarat. This process was launched government hospitals will be accredited in eight district hospitals and one medical by the end of 2009 (Government of college in Phase I. In Phase II, all five medical Gujarat, 2008a). All accredited hospitals college hospitals, eight district hospitals two are being linked with state-of-the art dental college hospitals, two mental health HMIS. The department expects to have college hospitals and one paraplegic hospital completed the accreditation process for all were taken up under the scheme. In 2007, public health facilities in the state by 2012. the state also initiated the process of getting accreditation for its laboratories by the NABL. District Quality Assurance Officers have been The laboratories of six medical colleges in the appointed to maintain the improved quality state have initiated the certification process. of the health facilities. The best-performing medical officers from the PHCs and CHCs The state department empanelled NABH have been identified and selected for these and NABL consultants in coordination positions. The Quality Assurance Officers with QCI New Delhi to assist in this task. have also been trained as assessors for A set of strategies was adopted for quality NABH. improvement. These included:

• Appointment of assistant hospital Health facilities at all levels are administrators for government being upgraded, strengthened and hospitals/medical colleges in a improved with the help of the Project phased manner Implementation Unit set up for this • Development of quality steering purpose. For instance, starting in 2006, committee for the state at all levels each PHC has been equipped with a • Nomination of district quality computer which is used to maintain all assurance officers the data of the population covered by the • Objective-oriented roles and PHC. To facilitate timely maintenance of responsibilities for all committees health infrastructure, medical officers

INITIATIVES TO IMPROVE MATERNAL AND CHILD HEALTH IN GUJARAT 43 have the authority to commission civil This requires not just infrastructure but improvement and repair works of up to also human resources to staff the PHC. Rs.25 000 per annum. Under NRHM guidelines, each 24X7 PHC should have three staff nurses 4.5.1 24 X 7 PHCs to provide round-the-clock service. Gujarat is in the process of upgrading Bringing the infrastructure up to required 253 of its PHCs into 24X7 facilities that standards is the smaller challenge; the meet IPHS standards (Government of larger one is to meet the human resource Gujarat, 2008b). In July 2009, the PHC requirements for these facilities. To at Naswadi taluka of promote improved health services, was the first PHC in the country to be including basic emergency obstetric care accredited under NABH guidelines. and institutional deliveries, the state is However, there is a severe shortage of in the process of upgrading its PHCs. staff nurses to fill the positions needed to The objective is that all PHCs function make PHCs functional 24X7 (Srinivasan 24 hours a days, seven days a week. et al., 2007).

NURSES AT A 24X7 PHC

44 IMPROVING MATERNAL AND CHILD HEALTH IN GUJARAT : Initiatives for Achieving MDGs 4 and 5 5 PROMOTING UPTAKE

The success of government initiatives schools. As the CDHO of Ahmedabad depend upon the uptake of these district, Dr Vaidya, said, “The State services among the target communities. Government has taken on maternal The supply of services by the state and child health as a top priority. The government needs to be matched with objective of celebrating 2008 as the a demand from the communities. In Nirogi Bal Varsh was to highlight the this section we describe two initiatives issue and give a jumpstart to a whole taken by the government to promote host of activities which are to continue awareness and use a delivery mechanism on a regular basis.” that is effective in reaching the target communities. We also discuss the Some key components of the Nirogi Bal creation of village-level functionaries Varsh were: to promote the uptake of public health • Care of the mother services. • Right of the girl child to be born • Unmet need for family planning 5.1 Nirogi Bal Varsh (Child • Addressing malnutrition Health Year) • Care of the neonates • School health To highlight the importance of child • Care of special children health, the GoG marked the year 2008- • Clean drinking water and sanitation 2009 as the Child Health Year (Nirogi Bal Varsh). The focus of activities was The activities of Nirogi Bal Varsh relied on reduction of child mortality through on interdepartmental coordination increasing institutional deliveries, taking in the government for successful care of neonates, reducing malnutrition implementation. Some key departments among mothers and children, and delivering services for this campaign increasing enrolment and retention in were the Department of Women and

PROMOTING UPTAKE 45 Child Development, the Department 5.2 Beti Bachao Abhiyan of Education and the Water Supply (Save the Girl Child cam- Department. Important programmes paign) involved were the Mamta Abhiyan and IMNCI. According to the Indian Census of 2001, there was a drastic fall in the sex ratio As an incentive to local in Gujarat from 10 years previously, governments, the state government and especially in the child sex ratio. The awarded recognition and a cash overall sex ratio dropped from 934 to award to village panchayats 920 per 1000 males, while the child sex (councils) that met the following ratio fell from 928 to 883. criteria in the course of the year: In response to this finding, the state • Complete birth and death launched a “Save the Girl Child records Campaign” (Beti Bachao Abhiyan) and • 75% or more children 3 years ordered stricter enforcement of the and younger healthy and not Prenatal Diagnostic Technique (PNDT) malnourished Act. Forty-three most adversely affected • 80% or more pregnant women talukas (with a sex ratio below 850 in and children under five registered the 0–6) were identified for focused under Mamta Abhiyan attention. • 80% or more institutional deliveries The Beti Bachao Abhiyan campaign was • 60% couples with two or more initiated on the occasion of International children accessed family planning Women’s Day in 2005. Under the services/using contraception campaign, there was widespread • 85% or more children under awareness-raising about the equality of one year with complete girl children and the problem of gender immunizations imbalance. A series of activities was • All children 6–14 years of age in organized to create awareness among school with zero dropout rate, different stakeholders and community • All anganwadi centres, health members. centres and primary schools have iodized salt, clean drinking The PNDT Act prohibits sex selection water and clean toilets before and after conception. It also • Newborn sex ratio of 925 or regulates prenatal diagnostic techniques above for detection of genetic abnormalities, • No child marriage in the village.

46 IMPROVING MATERNAL AND CHILD HEALTH IN GUJARAT : Initiatives for Achieving MDGs 4 and 5 restricting their use to registered As many as 137 ultrasound institutions and registering all clinics have been confiscated by the possessing ultrasound machines. The government, and legal action initiated government stepped up enforcement against 89 defaulting practitioners and of the Act and appointed District clinics. A high-level conference was Appropriate Authorities in all districts to organized with the higher judiciary to oversee its strict implementation. create greater awareness of the Act’s requirements. To check misuse of the technology, the government also set up a State Advocacy workshops have also been Inspection and Monitoring Committee organized by professional bodies and to undertake field visits, monitor the NGOs to sensitize medical practitioners implementation of the Act and initiate about the legal aspects of the PNDT Act action against unregistered institutions and the need for strictly adhering to and those violating the law. the law. The High Court of Gujarat and Gujarat State Judicial Academy have contributed to this effort.

Translation of text in poster: Stop female foeticide—save the girl child… The girl child also has a right to be born. In Indian culture, women’s strength is considered divine. Do not commit the sin of killing the girl child.

POSTER FOR SAVE THE GIRL CHILD CAMPAIGN AT KHAIRVA PHC

PROMOTING UPTAKE 47 We held meetings with the local religious leaders (Dharma Gurus) to bring them on board for the Beti Bacho Andolan. These leaders are powerful voices in the community and their word carries a lot of weight in the community. We thought we should try and convey the issue to them so that they could carry it into the community. We also held plays on the theme of the girl child using the traditional theatre form of bhavai.

District Police Commissioner, Panchmahal District

Figure 5.1 shows the improvement in sex ratio at birth registration between 2001 and 2007.

Figure 5.1: Sex ratio in Gujarat

Source: Annual Administrative Report, Commissionerate of Health, Medical Services and Medical Education, GoG, 2007–2008

48 IMPROVING MATERNAL AND CHILD HEALTH IN GUJARAT : Initiatives for Achieving MDGs 4 and 5 6 DISCUSSION

Since 2005, the GoG has taken several determinants of poor health, especially initiatives taken for achieving MDGs among women. The health interventions 4 and 5. Some, like the Chiranjeevi therefore focus on rural areas which are and Bal Sakha schemes, have been poorly serviced and contain a higher new initiatives. In other instances, the proportion of poor families. The schemes state has taken a lead in implementing are especially targeted at BPL families initiatives promoted under the and tribal families. The initiatives also NRHM. The new initiatives have been aim to address gender disparities complemented by the strengthening through campaigns like ”Save the Girl of existing systems. However, there Child”. are few formal evaluations of these recent initiatives. The government’s Two factors that have contributed significantly own management information systems to the effective implementation of the initiatives indicate that these initiatives have are the intersectoral linkages that have been been successful in reducing maternal developed, and the leadership and political mortality, increasing institutional support these have received. We discuss deliveries and increasing the proportion each of these below. of children who are fully immunized. 6.1 Intersectoral linkages The initiatives taken by the Government are multi-pronged. The attempt is to 6.1.1 Linkages between strengthen the public health delivery government departments system, and in the meantime to use resources in the private domain. The Two government departments directly initiatives aim at improving direct associated with maternal and child health medical care, preventive health care are the Department of Health and Family and also the socio-economic and cultural Welfare (DHFW) and the Department of

DISCUSSION 49 Women and Child Development (DWCD). The various activities under the Nirogi DHFW aims to ensure universal access Bal Varsh also depend upon linkages to quality health care. All programmes and cooperation between various state of the DHFW are channelled through the departments. three-tier system of primary, secondary and tertiary care, described in Section In some districts, such as the all-tribal 2.1 above. Narbada district, the health department has linked up with the tribal welfare DWCD is the repository of national department. The latter funded the programmes for the holistic development purchase of nine vehicles which are of women and children. These include the kept available in interior locations to Integrated Child Development Services transport pregnant women to health (ICDS), which provides supplementary facilities for delivery. This scheme nutrition for pregnant and lactating was started in 2007, and according to mothers and children under six and anecdotal evidence, there has been a a variety of other programmes for 25% increase in institutional deliveries. social and economic development of women through collectivization, welfare The Adolescent Anemia Control and support services, employment Programme is carried out jointly by the related trainings and gender DHFW and the Education Department. sensitization. DWCD appoints an AWW and an Anganwadi helper in each village 6.1.2 Engagement with local of a stipulated size. bodies/voluntary agencies/ NGOs The DHFW and DWCD have overlapping objectives and the functionaries of The GoG works closely with local organizations the two work closely together at the to strengthen health services. community level. Public-private partnerships for managing health facilities The AWWs and helpers from the ICDS programme work closely with the ANMs The CHC in Unhja () is and other health workers for preventive managed by a committee of retired residents and primary health care at the village in the area. The Jeera Processers’ Association level. To ensure smooth functioning of in the region supplements the state’s funding workers from the two departments, the for running the CHC. These additional funds state has instituted a common chain of have been used to purchase medicines, pay command at the PHC level for effective for specialist services, and for improving the monitoring and supervision. services in the eye department.

50 IMPROVING MATERNAL AND CHILD HEALTH IN GUJARAT : Initiatives for Achieving MDGs 4 and 5 In the Aakhaj PHC in Mehsana district, the Linkages with NGOs for service land has been obtained and construction delivery undertaken with funds from the panchayat. The government bears the running expenses In certain prosperous districts the of the PHC. The local sarpanch takes an local residents have the resources to active interest in the running of the PHC. contribute towards health services. However, the GoG has also made There are other examples of local businesses effective linkages with NGOs for delivery like milk cooperatives or marketing yard of maternal and child health services committees becoming involved in the running where needed. Deepak Foundation of PHCs and CHCs. They support both the works in the tribal areas of Vadodara management of the facilities and some district. In 2004, the Foundation began funding requirements. promoting institutional deliveries among the tribal population. In each village, In some instances, the state government a female health worker was identified has entered into public private partnerships and given responsibility for referring to achieve effective health care delivery. pregnant women to institutions for The Shamlaji PHC in Sabarkantha is one institutional deliveries. Emergency successful example of such a public-private transportation services were begun in partnership. four talukas using vehicles provided

AAKHAJ PHC

DISCUSSION 51 by the State Health Department. The any OPD patients, the increase in institutional village health worker accompanies the deliveries has been notable. In 2008–2009 pregnant woman to the hospital. The the CHC conducted 1700 deliveries; in 2010 Foundation also set up a help desk at the number is expected to exceed 2000. Baroda Medical College Hospital to guide the women coming in for deliveries and Gujarat has an active civil society and the other services. Currently the Foundation state’s health department has engaged with is implementing an anaemia control civil society organizations to ensure that its programme in coordination with the services reach the poorest and remotest areas state government. in the State. The state government’s Health Department and seven NGOs promoted an At Jabugam CHC (Jetpur Pavi), EmOC association of traditional birth attendants services have been provided since 2006 (TBAs), which was launched in April 2005. using the PPP model. The CHC is located on Together with Jan Swasthya Abhiyan (JSA), the outskirts of the town of Bodeli and was not a collective of NGOs in the state that are being used by the local communities. Deepak active in the field of health, the government is Foundation constructed facilities for EmOC trying to develop a mechanism whereby civil in this CHC and retained specialists to carry society can participate in ensuring that health out deliveries. In a facility which saw hardly services reach all (Government of Gujarat, 2008a).

TRUSTEES AT PALIAD GRANT-IN-AID HOSPITAL IN PALIAD VILLAGE, MEHSANA DISTRICT

52 IMPROVING MATERNAL AND CHILD HEALTH IN GUJARAT : Initiatives for Achieving MDGs 4 and 5 6.2 Political support and Gujarat has been proactive in leadership implementing initiatives recommended under NRHM and has added its own According to the State Health innovations. Commissioner, the initiatives for achieving MDGs 4 and 5 have The leadership in the state and its widespread political support, starting Health Department has played a critical with the Chief Minister of the state. role in energizing the public health Elected state representatives also follow system. The success of Gujarat is in part this example and exhibit their support driven by the commitment of the Health at various forums. For example, local Commissioner, who has an education­ in MLAs (elected members of the State public health has occupied his position Legislative Assembly) in Ahmedabad for the last four years (Vora et al., 2009). district came to inaugurate trainings The senior team comprises qualified for ASHAs and discussed issues such as persons who are willing to take risks. the importance of early breast feeding, Personnel at all levels are given power institutional deliveries, antenatal care along with responsibility and the space and polio drops. They also participate to take decisions. in the activities of Mamta Diwas. Such support from the political leadership 6.3 Factors that have plays an important role in motivating contributed to the successes the team members implementing the in Gujarat programmes. Undoubtedly the leadership provided Gujarat has successfully instituted by the state’s chief executive and innovative programmes such as the the Department of Health and Family Chiranjeevi Scheme and the Emergency Welfare has been the driver for the Ambulance Service. These schemes recent initiatives. The State has been were debated extensively by senior innovative in adopting strategies that politicians and bureaucrats before they work around the constraints of the public were begun. According to Dr Ajesh health system. There is recognition of Desai, a positive consequence of these the importance of good management discussions was an increased level of practices, and persons and systems awareness about these issues among have been aligned accordingly. the state’s leadership. This has also led to increased recognition of the need for The umbrella of NRHM has also facilitated social sector funding in the state. many positive changes in the public health delivery system. There is increased

DISCUSSION 53 availability of funds. In addition, there some sanctioned positions do not get is an emphasis on decentralization and filled (Desai & Bhavsar, 2007). This is engagement of client communities. especially a problem in health care facilities The empowerment of grassroots-level in remote and sparsely populated areas. workers like the ANMs has made a big There has been a decrease in doctors and difference. The district health societies nurses living near PHCs, and a sharp drop in have enabled decision making at the numbers of deliveries conducted at PHCs district level. In addition, the shortage (Mavalankar & Vora, 2008). of human resources can be partially addressed through hiring staff such as The shortage of technical staff, especially ANMs on contract, without waiting for MBBS doctors and trained nurses, puts the more lengthy bureaucratic process additional burdens on the existing doctors and of a formal appointment. There is a lot paramedical staff and constrains their ability of emphasis on capacity building at all to carry out their routine duties satisfactorily. levels, and on ongoing monitoring of When the researchers asked the staff of four programmes. PHCs about their level of work satisfaction, they found that staff from well-staffed PHCs Linkages with other government expressed greater levels of satisfaction than departments, civic bodies and NGOs have those where the staffing was inadequate made it possible to maximize resources (Desai & Bhavsar, 2007). and build ownership of the programmes among a wider constituency. One challenge is that specialists are reluctant to work in rural FRUs, as these 6.4 Challenges areas lack the basic amenities of urban living. Doctors trained by the government The primary challenge the system faces are required to serve for three years is a shortage of trained human resources in a public facility. However, once this for delivery of public health services. term is completed it can be difficult to Although the reduction in the MMR is keep them in the government system; a key health policy objective, Gujarat their entry into private practice after the does not have a separate director in mandatory government service cannot charge of maternal health (Mavalankar be ruled out. The leadership feels that et al., 2009). In addition, the state this is not entirely negative. While the lacks adequate human resources, trained doctor may not be in a public organizational and supervisory health facility, she/he will continue to structures and systems. practice in the rural sector and thus continue to provide safe deliveries. Obtaining adequate staff for health care facilities continues to be difficult, and

54 IMPROVING MATERNAL AND CHILD HEALTH IN GUJARAT : Initiatives for Achieving MDGs 4 and 5 Training of medical officers in CEmOC In addition to strengthening the public and anaesthesia is constrained by the health systems, there is a need to shortage of MOs in rural areas. According address the root causes of maternal to Dr Ajesh Desai, there are not enough and child mortality and morbidity such doctors in the public health system that as poverty and the lack of education can benefit from this training. and general development in the region.

Another challenge is to ensure that An important reason for the rapid field workers are not overloaded with strides being made in the initiatives multiple tasks. Each village has a cadre for maternal and child health is the of workers such as ASHAs for delivery personal commitment and motivation of MCH services. There is the risk that of the leadership in the state and the additional responsibilities may be given Department of Health and Family to these workers that are technically Welfare. Undoubtedly this vision has outside their purview, e.g. water testing. reached all levels of the department, Overloading these workers can dilute and led to a motivated team. For these their efforts vis-à-vis their primary efforts to continue, it is important that responsibilities for MCH. leadership remains motivated and committed.

DISCUSSION 55 56 IMPROVING MATERNAL AND CHILD HEALTH IN GUJARAT : Initiatives for Achieving MDGs 4 and 5 APPENDICES

Appendix - I

Chiranjeevi Scheme

Under the Chiranjeevi Scheme, obstetricians are paid Rs.179 500 for a package of 100 deliveries (Rs.1795 per delivery). This package includes normal and complicated deliveries as well as caesarean section operations. The beneficiary does not pay any type of charges related to delivery, medicine, anaesthesia, laboratory investigations or the operation. The package also includes Rs.200 for transportation of the pregnant woman and Rs.50 for the TBA or other person escorting her. If the enrolled private gynaecologist offers his/her services at a government hospital, Rs.65 900 (Rs.659 per delivery) is receivable for 100 deliveries (normal and/or complicated) performed. Payment to the doctors is made through the District Project Management Unit in each district.

Selection criteria for private Ob/Gyns for enrolment in the PPP scheme

• Doctor must have postgraduate qualification in Ob/Gyn • Must have his/her own hospital—preferably minimum of 15 beds • Must have labour room and operating room • Must be able to access blood in emergency situation • Must be able to arrange for anaesthetists and do emergency surgery • Facility should preferably be accredited for sterilization procedures for FP by the government. • Norm would be to select 2–3 private Ob/Gyns per subdistrict. All available and willing Ob/Gyns were contacted.

APPENDIX 57 58 IMPROVING MATERNAL AND CHILD HEALTH IN GUJARAT : Initiatives for Achieving MDGs 4 and 5 Appendix - II

Guidelines for Bal Sakha Schemes

Bal Sakha Scheme 1

• Chiranjeevi doctors will contact private paediatricians to provide services to newborns in their hospitals/nursing homes. • The mother and newborn baby will stay in the Chiranjeevi doctor’s nursing home for a minimum of 48 hours after the delivery for postnatal care. • They will be given preventive care such as such as Vitamin K injections, BCG vaccine and polio drops and guidance on breast feeding, kangaroo care of the infant, etc. • The Chiranjeevi doctors will maintain a register of data on all cases, using a prescribed format. These records should be available to any officials from the Department of Health and Family Welfare. • The Chiranjeevi doctors will make their hospitals into “mother and child friendly hospitals” in accordance with government guidelines and become accredited as such. • After discharge from the nursing home, the family will be given the contact information of the paediatrician who examined the newborn. The paediatrician must also record all the newborn care provided to the infant during its first 30 days. • A Chiranjeevi doctor will receive Rs.30 000 additional monies per 100 cases for keeping the mother and child for 48 hours after the delivery. • A private paediatrician will receive Rs.30 000 for providing neonatal care to 100 newborns, including admitting them to her/his hospital if necessary. The paediatrician should conduct investigations and provide the treatment required to the newborns. • A private paediatrician will receive Rs. 5000 per newborn for providing treatment to the newborn, including admitting them to her/his hospital if necessary. (Assuming 20% of newborns will need this care.) • A Chiranjeevi doctor will receive actual transportation costs incurred for transporting a child from a Chiranjeevi doctor’s hospital to the paediatrician’s hospital. (Assuming 20% of newborns will need this care.)

APPENDIX 59 • A Chiranjeevi doctor or private paediatrician will receive actual transportation costs incurred for transporting a newborn to a medical college hospital. (Assuming 20% of newborns will need this care.)

Bal Sakha Scheme 2 (For infants not born in Chiranjeevi/government hos- pitals)

• Rs. 20 000 for 100 newborns for consultation with a private paediatrician. • Transportation costs of Rs.200 for transporting a newborn from a rural area to a paediatrician’s hospital. (Assuming 20% of newborns will need this care.) • Incentive of Rs.50 to the ASHA/Health worker/AWW for accompanying a sick newborn to a paediatrician. • Treatment costs of Rs.5000 per newborn that needs to be admitted to the paediatrician’s hospital. • Transportation costs of Rs.1000 for transporting a newborn to a medical college hospital. (Assuming 20% of newborns will need this care.)

60 IMPROVING MATERNAL AND CHILD HEALTH IN GUJARAT : Initiatives for Achieving MDGs 4 and 5 Appendix - III

Form completed by paramedic in the 108 ambulance en route to obstetrician’s hospital for delivery

APPENDIX 61 APPENDIX III (contd.)

62 IMPROVING MATERNAL AND CHILD HEALTH IN GUJARAT : Initiatives for Achieving MDGs 4 and 5 Appendix - IV

Persons interviewed for this report (Interviews took place between June and September 2009)

Department of Health and Family Welfare, Gandhinagar Dr Amarjit Singh, Commissioner, Health and Family Welfare Dr Vikasben Desai, Additional Director (Family Welfare) Dr S.R. Patel, Consultant, Maternal health (for maternal health initiatives) Dr Ranavat, Consultant, Maternal health Dr N.B. Dholakia, Joint Director, MCH Dr Ajesh Desai, Director, Gujarat State Institute of Health and Family Welfare Dr J.L. Meena, State Quality Assurance Officer Dr Kamlesh Parmar, Immunization Officer, DHFW Ahmedabad District Dr Vaidya, CDHO, Ahmedabad District Dr Parmar, District RCH Officer, Ahmedabad District Mehsana District Dr Harshad Vaidya, Chiranjeevi doctor Rogi Kalyan Samiti, Santokba PHC, Aakhaj, Mehsana District Trustees, S.J. Patel Sarvajanik Hospital, Paliad, Mehsana District Superintendant, District Hospital, Mehsana Godhra District Dr Prakash Vaghela, CDHO, Panchmahal District Dr N.N. Damod, Block level health officer Ms Nidhi Verma, Programme Management Unit Dr Aashish Jayswal, Chiranjeevi doctor, FHW Dr Mukesh Goswami, Medical Officer, Vejalpur PHC Kesarben, Female Health Worker, Subcentre Chalali Hetalben Atulkumar, AHSA worker Jashodaben Dilipbhai, AHSA worker Kesarben Ramubhai, AHSA worker Surajben Alpeshbhai Rawal, Chiranjeevi beneficiary Kantaben Channubhai, Chiranjeevi beneficiary

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66 IMPROVING MATERNAL AND CHILD HEALTH IN GUJARAT : Initiatives for Achieving MDGs 4 and 5