1

Health Minister’s DecisionHow to Save Women

Dr. Dileep Mavalankar

IIM Ahmedbad

Magdegene Rosenmoller

IESE Business School

2

Minister goes to address FOGSI Conference in Agra

• History of Taj - a maternal death

• Minister reminded of the fact that even today 100,000 women die in child-birth

• Minister promises to do something to improve MMR -

• Calls for a meeting in dept on return

3

India Basic Health and MM Data

• 1 billion people, 600 + districts…

• Large health infrastructure - DH, CHC, PHC, SC….

• Many public health programs - Family welfare, MCH,

• Substantial private sector health care

4

MM Rate data

• MMR estimate 400-500 per 100,000 LB

• Nationally 100,000 mothers die

• 20% of global maternal deaths.

• MMR has not declined in recent past - may have increased

• NFHS I & II data show rural MMR of 449 and 619 for 1992 and 1998

5

India’s policy commitment to MMR reduction

• MMR reduction is a health objective for many years

• Health policy 1983 - below 200 by yr 2000

• Nat Population Policy 2000 and Nat Health Policy 2002 - MMR of 100 by 2010

• Tenth five year plan: MMR 200 by 2007

6

Programs for Maternal Health

• Since 1960 MH programs

• MH important part of Primary Health Care

• Development of cadre of ANMs 130,000 for MH

• TBA training, antenatal care, TT immunization

• by mid 1980s program attention got diverted to immunization and child survival.

7

Change in Strategy

• International evidence and opinion changed - TBA training, ANC not effective in reducing MMR - Need Emergency Obstetric Care (EmOC).

• 1992 on wards some efforts to bring back attention to MH and add EmOC to strategy under CSSM , RCH program

• But programs for MH esp. EmOC not well implemented

8

Top Management structure of Health & FW dept for MH

• Dept of Health, Family Welfare, ISM, NACO …

• MH division has only 3 technical offices for the whole country - DDG, 2 AC

• All technical offices from CGHS

• Over-burdened with administrative work

• poor support services

• poor office infrastructure

9

Other relevant institutions• Planning commission: 1 health advisor

• NIHFW - not much work on MH

• State Health depts: weak• No state has technical offices solely for MH

• Most MCH directors are not trained or qualified in MH, Public Health, Obgyn ….

• Hardly any delegation of authority to technical offices

• No International Org has technical officer solely for MH.

10

World Bank’s and other studies on implementation capacity of MH

• Limited technical capacity in MH at central and state levels.

• Review of CSSM program showed that only 30% of FRUs are providing EmOC services - without blood transfusion

• Key problems - lack of obgyns and anesthetists

• Program monitoring poor - no data

• Lack of clarity of roles of staff - ANM

11

• Not much technical standards or protocols developed

• Technical managers so overburdened that they can not do much technical work.

12

What have other countries done

• Sri Lanka ( 18 m), Malaysia (23 m) have 2-3 technical offices for MH

• Offices take technical decisions

• Sri Lanka took lot of technical steps over last 40 years to develop maternal health services in rural areas - systematic identification of deficiency and addressing them.

• Close monitoring of the program

13

How expensive is technical top management capacity

• At central level 1 technical offices for MH for 100 million people

• At state level 1 technical office for MH for 10 million people

• Need 110 technical office for MH for the whole country -

• Annual cost 6.6 Crore - or 3 % of total RCH program budget.

14

Minister calls a meeting

• Joint secretary - lack of infrastructure and equipment - donor assistance possible

• DDG MH: shortage of specialists, 24 hours servics - posting and transfers, training of MBBS doctors to do EmOC.

• Secretary: cautions about training MBBS doc for EmOC, legal implications. Suggests TBA training based on NGO experience.

15

• Nutrition advisor: suggestions treatment of Anemia - special program

• Minister: met with private obgyns - – suggests increasing awareness among women– Free ANC through private obgyns once a month– dismisses other options of infrastructure up-

gradation and staffing improvement

16

• DDG does not agree but keeps quiet.

• Secretary supports the ministers idea of involving private obgyns giving free ANC

• Minister is happy: want a quick inauguration of the scheme by PM

• DDG is thinking - did the minister make a right decision?