Initiatives to address shortage of specialists for EmOC in  Maharashtra Dr.Sarika Chaturvedi  Dr.Bharat Randive Foundation...
<ul><li>Strategies:   </li></ul><ul><li>Utilise private sector:  PPPs - Contracting In </li></ul><ul><li>Task Shifting –  ...
Methodology <ul><li>Mix of qualitative & quantitative methods </li></ul><ul><li>Provisioning :  </li></ul><ul><li>Health f...
Study Area Source: Human Development Report Maharashtra 2002; DLHS-3 63.6 54 MH 32 25.3 16.5 Nandurbar 15 63.6 50.5 Amrava...
Data collection <ul><li>Provisioning </li></ul><ul><li>Health Facility Survey :  n=44 </li></ul><ul><li>Rural Hospitals, S...
Specialists availability at sub district level Potential for contracting in / Task shifting in 83% facilities 20 3 11 7(17...
Utilisation of public Obstetricians  (Apr-Sept 09) <ul><li>Under utilization: 25 Ob/Gyn - 34 C sections </li></ul><ul><li>...
Distribution of obstetricians Distribution  of private obstetricians 8 times more Ob/Gyn in private sector  5 (26) 14 (74)...
<ul><li>Contracting in at 7 of 34  facilities with  such potential </li></ul><ul><li>Task shifting- placement with no skil...
Distance of private specialist for contracting in Pvt. Specialist > 30kms for 50% facilities
Contracting in   <ul><li>Feasibility :  Contracting in  feasible only at CHCs in towns with private specialist </li></ul><...
Task Shifting   <ul><li>No buy-in for task shifting :  Senior practitioners disbelieve it builds skills/confidence </li></...
HR issues <ul><li>Specialists posted as generalists  </li></ul><ul><li>Specialists in public health department underpaid t...
Availability of CS services   57% women had CS in private hospitals CS at  sub district level: Public-5%, Pvt.- 51%
Govt. hospital with CS facility  ≥ 50km  from most non functional CHCs
Cost of CS in Private hospitals n = 80 For 78% users CS cost ranges Rs.10000-20000
Summary Findings <ul><li>Shortage of EmOC specialists limited to public sector in Maharashtra </li></ul><ul><li>Low utilis...
Recommendations <ul><li>Performance measurement to improve utilization of Govt. specialists </li></ul><ul><li>EmOC special...
Acknowledgements John D. & Catherine T. Mac Arthur Foundation IIM, Ahmedabad  THANK YOU ! Technical Advisors: Dr. Dileep M...
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Study of initiatives for addressing shortage of specialists for Emergency Obstetric care in Maharashtra -Sarika Chaturvedi

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Study of initiatives for addressing shortage of specialists for Emergency Obstetric care in Maharashtra -Sarika Chaturvedi

  1. 1. Initiatives to address shortage of specialists for EmOC in Maharashtra Dr.Sarika Chaturvedi Dr.Bharat Randive Foundation for Research in Community Health (FRCH), Pune 2009-2010
  2. 2. <ul><li>Strategies: </li></ul><ul><li>Utilise private sector: PPPs - Contracting In </li></ul><ul><li>Task Shifting – Skill building of providers </li></ul><ul><li>EmOC & LSAS trainings </li></ul><ul><li>Study objectives : </li></ul><ul><li>Influence of PPP and Task shifting on </li></ul><ul><ul><li>size and distribution of EmOC providers </li></ul></ul><ul><ul><li>service uptake </li></ul></ul>
  3. 3. Methodology <ul><li>Mix of qualitative & quantitative methods </li></ul><ul><li>Provisioning : </li></ul><ul><li>Health facility survey, record review, interviews </li></ul><ul><li>Users : </li></ul><ul><li>Community level survey & interviews </li></ul>
  4. 4. Study Area Source: Human Development Report Maharashtra 2002; DLHS-3 63.6 54 MH 32 25.3 16.5 Nandurbar 15 63.6 50.5 Amravati 10 87.4 85.6 Satara Total(%) Rural(%) HDI Rank Institutional Deliveries Districts
  5. 5. Data collection <ul><li>Provisioning </li></ul><ul><li>Health Facility Survey : n=44 </li></ul><ul><li>Rural Hospitals, Sub District & District Hospitals </li></ul><ul><li>Interviews : n=40 </li></ul><ul><li>CS, DHO, DPM,BMO,MS,MO Obstetricians, Anaesthesists (Public & Private) </li></ul><ul><li>Mapping of private EmOC specialists </li></ul><ul><li>Users </li></ul><ul><li>Birth survey : </li></ul><ul><li>272 villages in 6 blocks (n=1833) </li></ul><ul><li>Identification of pregnancy /birth complications in JSY eligible women in recent one year </li></ul><ul><li>Interviews : n=120 </li></ul><ul><li>Women who had pregnancy/ birth complications </li></ul>
  6. 6. Specialists availability at sub district level Potential for contracting in / Task shifting in 83% facilities 20 3 11 7(17%) 41 Total 12 0 1 0 13 Amravati 6 0 2 3 11 Nandurbar 2 3 8 4 17 Satara Neither Anaesonly Ob/Gyn only Ob/Gyn & Anaes Facility District
  7. 7. Utilisation of public Obstetricians (Apr-Sept 09) <ul><li>Under utilization: 25 Ob/Gyn - 34 C sections </li></ul><ul><li>Placement: specialists at CHCs with no OT </li></ul>
  8. 8. Distribution of obstetricians Distribution of private obstetricians 8 times more Ob/Gyn in private sector 5 (26) 14 (74) 19 Nandurbar 97 (75) 33 (25) 130 Satara 25 (23) 86 (77) 111 Amravati Sub district(%) District HQ (%) Obst. District
  9. 9. <ul><li>Contracting in at 7 of 34 facilities with such potential </li></ul><ul><li>Task shifting- placement with no skill mix </li></ul><ul><li>Contracting in/ task shifting - hardly influenced service output </li></ul>0 1 11 157 10  0 10   0 1 9   62 1 8  78 1 7  1 1 6  0 1 5  4 1 4  0 1 3  6 1 2  6 1 1 Blood OT CS (Apr-Sep09) Anaes Obst Facility Regular Task shifting Contracting in
  10. 10. Distance of private specialist for contracting in Pvt. Specialist > 30kms for 50% facilities
  11. 11. Contracting in <ul><li>Feasibility : Contracting in feasible only at CHCs in towns with private specialist </li></ul><ul><li>Concerns : Private specialists concerned of post op management at CHCs </li></ul><ul><li>Used only for planned cases: “no complications have occured at the periphery because we select patients properly, we take only good, non risky cases there” </li></ul><ul><li>Contracted in Drs: Hidden motives - setting own clientele base, attend CHCs only in spare time </li></ul><ul><li>Financial issues : “ nobody will be willing to come in 1500 Rs. in the JSY, we are paying from IPHS funds,” </li></ul>
  12. 12. Task Shifting <ul><li>No buy-in for task shifting : Senior practitioners disbelieve it builds skills/confidence </li></ul><ul><li>Implementation issues: Wrong selection of trainees, improper postings, </li></ul><ul><li>Trainers views : Doubtful if trainees can perform independently in peripheral settings </li></ul><ul><li>Trained MOs views : Concerns of medico legal issues, demand for incentives, certification, more duration, proper postings, refresher courses </li></ul><ul><li>“ They send us for laproscopy (sterilization) camps at the periphery nothing else..” </li></ul><ul><li>“ This is additional load to me, what incentive I get is Rs.25 for a case of tubectomy.” </li></ul>
  13. 13. HR issues <ul><li>Specialists posted as generalists </li></ul><ul><li>Specialists in public health department underpaid than counterparts in medical education department </li></ul><ul><li>Non performance - Frustration with systems: “ The government does not even appreciate those who work, those who do not work make progress in the system </li></ul><ul><li>… The salary is going to be the same, whether I operate or not” </li></ul><ul><li>Suggest better salaries, no general duties, in service specialisation opportunities as solutions to curb specialists shortage </li></ul><ul><li>Job security and better pay attractive to young specialists : “ For people like me from middle class Govt jobs are good, only thing is there should be an assurance that we will not be expelled, otherwise it is not possible for one to start private practice after age of 35 years” </li></ul>
  14. 14. Availability of CS services 57% women had CS in private hospitals CS at sub district level: Public-5%, Pvt.- 51%
  15. 15. Govt. hospital with CS facility ≥ 50km from most non functional CHCs
  16. 16. Cost of CS in Private hospitals n = 80 For 78% users CS cost ranges Rs.10000-20000
  17. 17. Summary Findings <ul><li>Shortage of EmOC specialists limited to public sector in Maharashtra </li></ul><ul><li>Low utilisation of Govt. obstetricians for CS services. </li></ul><ul><li>Contracting in private specialists has limited feasibility and use in obstetric emergencies </li></ul><ul><li>Enabling conditions for success of Task Shifting for CS and obstetric anaesthesia have not been met </li></ul><ul><li>Availability of CS services in public hospitals scare at sub district level </li></ul>
  18. 18. Recommendations <ul><li>Performance measurement to improve utilization of Govt. specialists </li></ul><ul><li>EmOC specialists to be designated & paid as specialists and payments linked to performance </li></ul><ul><li>Contracting in to be considered as short term measure and not for emergency services </li></ul><ul><li>Choice of task shifting to be revisited in contexts with overall high density of specialists </li></ul><ul><li>Enablers for success of task shifting be met- training quality, licensing, posting and incentives </li></ul>
  19. 19. Acknowledgements John D. & Catherine T. Mac Arthur Foundation IIM, Ahmedabad THANK YOU ! Technical Advisors: Dr. Dileep Mavalankar, IIMA Dr.P.P.Doke,SHSRC,Maharashtra Dr.C A K Yesudian,TISS,Mumbai Dr.Nerges Mistry, Director, FRCH,Pune

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