maternal mortality Govt. of Gujarat launched scheme called Chiranjeevi Yojana ( CY) in Dec. Shortage of obstetricians in rural areas of India. The research. Background The Chiranjeevi Yojana (CY) is a Public-Private-Partnership between the state and private obstetricians in Gujarat, India, since. Effect of Chiranjeevi Yojana on institutional deliveries and neonatal and maternal outcomes in Gujarat, India: a difference-in-differences analysis.
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Chiranjeevi Yojana Home Chiranjeevi Yojana. Nov 5, – state launched a public-private partnership PPP programme, Chiranjeevi Yojana CY ykjana, under which the state pays accredited private Uterotonics, Injectable Anticonvulsants, Manual removal of placenta, Removal chiraanjeevi retained products, Assisted Vaginal delivery, Neonatal resuscitati. Has Chiranjeevi Yojana changed the geographic availability of free Oct 6, – emergency obstetric care EmOC within reasonable geographic proximity.
The financial reimbursement package chiranjeevl private obstetricians under CY was However, a decline in Manual exploration of uterus was routine. Assessing Gujarat’s ‘Chiranjeevi’ Scheme – India Environment Portal Nov 28, – infection, hypertensive disease of pregnancy and eclampsia. EmOC is required to tackle such compli- cations Does the Janani Suraksha Yojana cash transfer Jul 7, – care for normal deliveries to ensure timely detection of complications that India’s Janani Suraksha Yojana, a conditional cash Andaman and Nicobar Islands.
BMC Pregnancy and Childbirth In India a lack of access to emergency obstetric care contributes to maternal deaths.
In Gujarat state launched a public-private partnership PPP programme, Chiranjeevi Yojana CYunder which the state pays accredited private obstetricians a fixed fee for providing free intrapartum care to poor and tribal women. A million women have delivered under CY so far.
We explored with private obstetricians the reasons and experiences that influenced their decisions to participate in the CY programme. In this qualitative study we interviewed 24 purposefully selected private obstetricians in Gujarat. We analysed data using the Framework approach. Participants expressed a tension between doing public good and making a profit. Bureaucratic procedures and perceptions of programme misuse seemed to influence providers to withdraw from the programme or not participate at all.
Providers feared that chiranieevi in CY would lower the status of their practices and some were deterred by the likelihood of more clinically difficult cases among eligible CY beneficiaries. Some cniranjeevi resented taking on what they saw as a state responsibility to provide safe maternity services to poor women.
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Some doctors had reservations over the quality of care that doctors could provide given the financial constraints of the scheme. While some private obstetricians willingly participate in CY and are satisfied with its functioning, a larger number shared concerns about participation. Operational difficulties and a trust deficit between the public and private health sectors affect chiranjeeci of private providers in the scheme.
Further refinement of the scheme, in consultation with private partners, and trust building initiatives could strengthen the programme. These findings offer lessons to those developing public-private partnerships to widen access to health services for underprivileged groups.
Collaborative partnerships, in which public authorities contract out services to the private sector, have been promoted as a ciranjeevi response to resource scarcity in the public sector in some contexts.
In countries like India, where health care users face a choice between overstretched public chiranjeebi or expensive and unregulated private services, successful public-private partnerships could harness the strengths and mitigate deficiencies of each sector.
In India, public-private partnerships are seen as a pragmatic response to one of the most highly privatised healthcare systems in the world. Over two chiranjedvi of all health care expenditure is made in the private sector, mostly out-of-pocket [2,3]. However, the evidence suggests that while some state partnerships with non-governmental yojna, voluntary organisations or the private for-profit sector have been successful, evidence remains mixed .
But owing to its widespread presence across the country, involvement of this sector is critical for implementation of Universal Health Care as declared by the Government of India .
Twenty percent of all global maternal deaths occur in India, and mostly among poor women .
Because most maternal deaths occur in the peripartum period, there is an assumption that a strategy based on birth in a facility equipped to provide skilled birth attendance and emergency obstetric care will lead to a reduction in maternal deaths . In India, the main barrier to giving birth infacility among poor women is financial access .
Removing financial barriers to facility birth and improving access to emergency obstetric care EmOC is imperative to reducing maternal deaths.
Health care provision in Gujarat is dominated by the for-profit private sector which provides most birthing facilities in the state, usually on a fee-for-service basis, paid out-of-pocket by the user. Weak obstetric care provision in the public sector  and wide availability of obstetric care in the private sector led the state Government to implement a public-private partnership to encourage poor women to give births in private obstetric care facilities.
CY is a performancebased financing scheme, where maternity services are contracted out by the state to private obstetricians accredited on proof of certain criteria, such as providing a minimum of 15 beds and ready access to anaesthetic and blood transfusion facilities. The state pays accredited private obstetricians a pre-determined sum to perform facility births among poor women targeted by the scheme .
Recent evidence suggests Chiranjeevi Yojana is failing to attract and retain private doctors, with increasing attrition of obstetricians from the scheme.
Understanding this could lead to improvements in CY and better design and implementation of future public-private partnerships for widening access to services for underprivileged groups. Methods Study setting Gujarat is a state in the western part of India with a population of about 60 million.
Despite progress since —, maternal health indicators in Gujarat still lag behind some states in the south of the country, for example Kerala where the MMR was 81 perfor . In Gujarat, as in other states in India, there is a chronic shortage of obstetricians in the public sector, and particularly in rural areas of the state .
Many factors influence the persistence of this gap, including low salaries, poor infrastructure, and few incentives for obstetricians to join government services in rural areas. Gujarat is more economically developed than other states, and three quarters of the registered obstetricians in the state work in the for-profit private sector Ganguly et al.
Under these circumstances, where the state has a large and growing private health sector, a poorly functioning government sector, and a substantial proportion of the population eligible for social welfare programmes, an innovative scheme to co-opt the private sector to provide delivery care and access to emergency care seemed like a reasonable approach .
Table 1 Participant characteristics Participants Gender The study was carried out in two purposively selected districts of Gujarat which were part of a larger parent study MATINDwhich recorded every facility conducting births in the two districts using GPS mapping.
From this wider study, we had access to a comprehensive sampling frame of private practitioners. Each district is an independent administrative unit within the state, with an average population of two million.
The proportion of population without any work is marginally higher in district 2 . From our comprehensive sampling frame, we selected facilities offering childbirth services within the two districts . Study participants were qualified obstetricians whose facilities were eligible to participate in the CY scheme able to perform Caesarean sections and transfuse blood.
Panchayat Department | Chiranjivi yojana
We selected obstetricians to capture variation in age, sex, location and their CY participation status practitioners currently participating in the CY scheme, those who had discontinued their participation, and those who had never participated at all. Efforts were made to obtain a sample with a wide range of practitioner characteristics in order to identify what central, shared experiences around participation are common to each group, as well as areas of difference.
Shortlisted private practicing obstetricians were identified and invited for interview by phone; they were informed of the purpose of the interview and estimated time required. Permission was sought to audio record the interviews and confidentiality was assured. Only three of those invited could not give us a suitable time for interview. We continued to interview until no new information was forthcoming, and reached saturation at 24 participants.
This number represents about a third of the total eligible participants in these two districts Table 1. We piloted the interview with three doctors and made minor modifications to the topic guides. The first author of this paper PG conducted all interviews in a combination of the three languages commonly in use in Gujarat — Gujarati, Hindi, or English. On average the interviews took 40 minutes each, and were audio recorded; four interviewees did not wish to have their interviews recorded, so detailed notes were taken.
Data analysis A research assistant, present at each interview, transcribed all interview data and translated it into English for uniformity and the first author PG cross-checked a sample for accuracy.
We used the Framework approach, a matrix-based method for ordering and synthesising data, to analyse the qualitative data . Framework analysis is best suited to applied qualitative research, where the intention is to present themes identified in the data rather than develop or contribute to theory.
PG coded all transcripts using a coding index based on concepts identified after reading and re-reading the transcripts. We frequently referred back to the raw data and used matrices containing data for each theme to help us identify similarities and differences across the different types of providers, age groups and gender.
Written informed consent was obtained from those who agreed to be interviewed. Participant responses were anonymised during the analysis. Results All of the obstetricians who participated in the study were owners of small private health facilities where they, as owner-doctors, made all decisions relating to clinical, technical, financial and administrative activities.
Most practices we visited had 10—15 beds, and the main obstetrician employed both qualified and unqualified staff to work at the facility. The total number of obstetricians in district 1 was 55 compared with 21 in district 2, as mapped by the MATIND study team. The gender distribution of our participants reflects the gender composition of obstetricians in Gujarat; there are fewer women obstetricians in the state Table 1.
We identified six main themes that help to explain private practitioner decisions to participate in the CY scheme, the important influences on their decision making, and their experiences of participating in the scheme. Why should I participate? All the private practitioners we interviewed referred to making a significant initial investment in their practice and the expectation that this would translate into a reasonable profit: When someone has invested Rs.
It is a business for him. Private sector obstetricians claimed to work to their own kind of moral code, one which they believed would operate even in the absence of such schemes. They said it was common for them to treat poor patients and charge them less.
Some of the obstetricians, mostly in rural areas and currently participating in the scheme, commented that they were pleased that they could provide services free of charge chiramjeevi poor women while they themselves received reasonable fees through the scheme. Younger obstetricians observed a clear economic benefit to their participation in the scheme, particularly in the early stages of establishing their practice.
Others described how the scheme allowed them to launch their practices: In bigger cities, charges are around Rs10, so Rs 2, is very less for them. One current participant in an urban area described his disappointment at Ganguly et al. In addition to disappointment over the volume of new chiranjdevi the scheme would bring, a common concern was inadequate remuneration for chhiranjeevi deliveries, such as those requiring blood transfusion or Caesarean section: That is why C.
We have to meet them 2 to 3 times and I should go by myself to get the payment. They start picking up mistakes. On the day we interviewed him he remarked: When doctors sense such risks to their income, they may be yojaba to compromise quality when treating CY patients as compensation.
As an obstetrician who has never participated in the scheme remarked: Both these factors appeared to be major reasons why some respondents discontinued their participation in Chkranjeevi Almost all the obstetricians interviewed in both districts expressed their concern over misuse of the scheme by families they perceived as non-poor.
According to the private obstetricians, many families who are not eligible manage Ganguly et al.