Maternal health econimics will we achieve millineum goals
NARENDRA MALHOTRAM.D., F.I.C.O.G., F.I.C.M.C.H• Prof. Dubrovick International university,croatia• Indian FOGSI representative to FIGO• President FOGSI (2008)• Dean of I.C.M.U. (2008)• Director Ian Donald School of Ultrasound• National Tech. Advisor for FOGSI-G.O.I.—Mc Arthur Foundation EOC Course• Hon Prof Ob Gyn at DMIMS,Sawangi,Advisor ART unit at MAMC & SMS Jaipur• Editor od SAFOG journal• Chairman publication committee of AOFOG• Practicing Obstetrician Gynecologist at Agra. Special Interest in High Risk Obs., Ultrasound, Laparoscopyand Infertility, ART & Genetics• Member and Fellow of many Indian and international organisations• FOGSI Imaging Science Chairman (1996-2000)• Awarded best paper and best poster at FOGSI : 5 times, Ethicon fellowship, AOFOG young gyn. award,Corion award, Man of the year award, Best Citizens of India award• Over 30 published and 100 presented papers• Over 50 guest lectures given in India & Abroad.Presented 10 orations.• Organised many workshops, training programmes, travel seminars and conferences• Editor 8 books, many chapters, on editorial board of many journals• Editor of series of STEP by STEP books• Revising editor for Jeatcoate’s Textbook of Gynaecology (2007) and DONALD OBS MANNUAL(2012)• Very active Sports man, Rotarian and Social workerMALHOTRA HOSPITALS & RAINBOW HOSPITALS,Agra-282 010Phone : (O) 0562-2260275/2260276/2260277, (R) 0562-2260279, (M) 98370-33335; Fax : email@example.com;firstname.lastname@example.org;email@example.com;www.rainbowhospitals.orgjallandhar,ludhiana,ambala,bhiwani,gwalior,allahabad,gorakhpur,kolkata,bariely,jaipur,delhi,sirsaNeapal & Bangladesh
MATERNAL HEALTH ECONOMICS INSOUTH ASIAWILL WE ACHIEVEMILLINIUM DEVELOPMENT GOALS 5 ?Narendra MalhotraJaideep MalhotraNeharika MalhotraKeshav Malhotrawww.rainbowhospitals.orgProf Alokendu ChatterjeeProf Rubina Sohailwww.safog.org“Small opportunities are often the beginnings of great enterprises”(Helen Keller)
"Children are ourfuture, and theirmothers are itsguardians.”Kofi Annan
• Each year more than half a million womendie from pregnancy related causes and10.6 million children die, 40% of them inthe first month of life.• Almost all of these deaths are indeveloping countries. Many could be pre-vented with well-known interventions, ifonly they were more widely available.• In establishing the Millenniumgoals,years ago, the internationalcommunity made a commitment toreducing maternal deaths by threequarters, and reducing child mortality bytwo thirds by the year 2015.
EVERY DAY A JUMBO JET FULL OFPREGNANT WOMEN CRASHES IN THEWORLD DAILY,KILLING OVER 400 WOMENDURING PREGNANCY AND CHILDBIRTHTHIS NEWS NEVER MAKES DAILY HEADLINESWHY ??
“mothers are not dying because of disease we cannottreat.They are dying because society has to decidewhether their lives are worth saving”-Prof Fathalla
MAJORITY SOUTH ASIAN WOMENAREPOOR ,POWERLESS&PREGNANT
It is a call for radical progress in ensuringthe health of women and their children.These members of society are oftenneglected because they are vulnerable. Butwherever that happens the whole societyis harmed.Today we want to make it absolutely clearto everyone that the health of women,the newborn and children are a priorityfor our world as a whole, and for everysociety, every community, and everyfamily."Make every mother and child count"
ASSESMENT OF HEALTH OF A COUNTRY____• Adolescent health care – routinely practiced ornot• Pre-conception care – routinely practiced ornot• Ante Natal Care % -- 1 visit, 3 /4 visits & by whom• Skilled Birth Attendance – % delivered by SBA• Institutional Delivery -- % of Inst delivery• Post natal care -- % of PN care & when• Functional referral system -- how muchfunctional & how quick; who pays for it• MMR – current estimate i.e. for 2011
Maternal health care scenario is dismal inall South Asian countries (except Sri Lanka)the reasons in Bangladesh• Political will• Infrastructural issues, including basics• Dr/Nurse strength—human resources• Organisational failures• Social evils –female education (%), early marriage(age & %), domestic violence (%) &attitude of your society, particularlyattitude of men, on women’s health
Maternal health scenario- BangladeshPolitical will -very much positive in improving MCHInfrastructural issues- CMOC services in:• Community clinic• Upazilla health complex-132 (BMOC in rest UHC)• General hospitals-3 District hospitals - 59• MCWC-under DG family planning -63• All medical colleges & specialized hospitals-95
Human Resources in Health in Bangladesh• Doctor : Patient – 1:4000• Nurse : Patient - 1:8000• Nurse : Dr – 1 : 4• Private Dr : Pt at rural area – 1: 29000• Health care provider : Population -1:10000• 5 physicians & 2 nurses /10000 population
Organizational failure• Failure to increase the budget for MOHFW• Health Workers shortage (specially in rural areas)• Unable to retain trained HWs at EmONC centers• Hard to reach areas ; Logistic ; scarcity• Failure of monitoring• Failure to co-ordinate between H & FP of MOHFW
Social evilsFemale education-• Primary education (complete)-14.3%• Secondary education (complete) or higher-9%• No education-27.7% Rest ???Early marriage-• At 13-14 yrs - 4%• At 15-19 yrs -10.6%• 25% become mothers before 20 years Source-(BDHS 2011)Domestic violence- high ,mainly unrecorded.Attitude of society towards women’s health - Unsatisfactory• women has No decision making power -so repeated child birth.• No regular ANC, under nutrition, anemia• women not allowed to attend hosp even during emergency
Health economicsNational health expenses as % of GDP- 1.03%• Health budget - 5.4% total budget in 2011-12 & 4.9% in 2012- 2013 .$ 16 per capita for health/yr• Maternal health budget- 15% of total health budget• Public expenditure as % of total health exp. 33.59%• Private expenditure as % of total health exp. 2.29%• External support as % of total health exp 30%• Health insurance in Preg & child birth No provision
Strategies to improve Maternal healthscenario in Bangladesh• Strengthen health facilities for EmONC services (1994)• Demand Side Financing: Maternal Health Voucher Scheme(DSF:2006)• Maternal & neonatal health (MNHI) program 2007• Free Tetanus Toxoid for women of child bearing age:2008• Community based SBA (C-SBA) Program 2003(Target 13,500)• Nurse midwifery training :2010 (Target 3,000)
Regular financial flow is maintained by• Government’s own fund• Aids from Donor agencies• Development partners (USAID,DFID,CIDA,WHO,UNFPA)• Partial cost recovery• GOB finances 70% (93.55 billion for this fiscal year) and parallelfunders contribute remaining 30%, including 15% loans by WorldBank
Role of Bangladesh OBGY Society* OGSB working on Maternal health programs along with GOB,NGOs, UN agencies and development partners• EmoNC-training & monitoring of doctors , paramedics• C-SBA training and monitoring at govt .& private level• Treatment of Eclampsia at community level• Prevention of unsafe abortion –IPAS,FIGO• Human resource development - LSTM, UNICEF• F.P-Training on long acting contraceptions etc
Will MDG 5 targets be reached by BangladeshTargets & indicators Unlikely Potentially No data5A: Reduce MMR by 75%between 1990- 2015Maternal mortality ratio ✓most births attended by SBA ✓5B: Achieve universal access toreproductive health by 2015Contraceptive prevalence rate ✓Adolescent birth rate ✓ANC (one/ four visits) ✓Unmet need or family planning ✓Achieving Millennium Development Goals 4 and 5 in BangladeshS Chowdhury,LA Banu,TA Chowdhury, S Rubayet, S Khatoon BJOG Sep, 2011
Per100000livebirthsCHANGING TRENDS IN MMR IN INDIA (1950-2011)Target- M M R 109 by 2015Source- RGI, Lancet, vol 378 ; sept, 2011
Unfavorable maternal health in IndiaReasons ---Political Will• Not a priority agenda for any political party• National opinion has never focused onmaternal health as a burning issue• We need to decide to save women’s lives
Unfavorable maternal health in IndiaReasons -- Infrastructure• Nearly 80% of Mat Health care provided by private sectors in India• Dr :Pt 1:1953 or 0.5 Dr /1000 Indian (WHO-- 1/ 1000)• Only 0.86 hospital beds per 1000 people• Health facilities maldistributed & mostly in urban areas• Transport & connectivity need vast improvementTimes of India, March 6, 2012 Financial Express, July 8, 2009
Unfavorable maternal health in IndiaReasons-- Organisation• No central theme• Diffusion of focus from EmOC and SBA cares• Lack of integration• Inadequate monitoring and evaluation
Unfavorable maternal health in IndiaReasons -- Social IssuesFemale Education - Adult literacy rate: females as a % ofmales, 2005-2010, is 68%• Age at Marriage – 18% by age 15, 47% by age 18• Domestic violence – ‘Wife beating’ justified by 51% ofmen and 54% of women. violence by husband on > 40%married Indian women• Sexual violence -- 1 in 2 women suffer in IndiaNFHS III, 20005 – 6http://www.unicef.org/infobycountry/india_statistics.html
Health Economics -- lop sidedState health exp as % of GDP: 1. 4%(2011)-- 3%(2022)Public expenditure on health: 20. 3% **Private expenditure on health: 77.4% mostly own/family expExternal Support: 2.3%Source : National Health Accounts India (2001 – 2002), NHA Cell, MoHFW, GOIEffect of hospitalisation – 35% pt drop to BPL , 40% borrow/sale assets,20% (U) 28%(R)- no funds for health care. Insurance coverage -just 1%** USA Public health exp. 50% ; West European states > 80%(Scieber & Poullier, 1988)
Health Economics - Insurance• Chiranjeevi Scheme of GOI--PPP model, where feespaid to Drs. For Obst & other RH services• In private insurance, most policies excludepregnancy and childbirth related expenses• Corporate employees & members of certain largegroups, health policies cover pregnancy
Strategies to improve Maternal Health & itsfinancing, in IndiaJanani Suraksha Yojana--Encourages Inst.delivery through cashincentives by central Govt, to Pt.& female community healthworkers• Chiranjeevi scheme – PPP model; Govt pay Private empanelled Drsfor every delivery in their hospital to encourage institutionaldelivery• Benefits from other schemes aimed at population stabilization,reducing neonatal & infant mortality
Strategies to improve Maternal Healthin India• Upgradation of physical facilities at all PHCs• Skills upgradation of PHC workers• Training in obst. & anesthesia skills• Over 35000 personnel trained as health workers
FOGSI and maternal health• To built a bridge between private Drs & Govt• Catalyst to bring about changes• Opinion creator and the leader• Advocacy-Advocate Central & state govts for changes to policies,laws, rules, regulations & practices to increase access to safeabortion services in public & private sectors
FOGSI & Maternal Health …contd• Emergency Obstetric Care ( EmOC )Objective -- develop skills of non-specialist Drs.(GPs & MO), to providehigh quality EmOC services in underserved areas to preventmaternal mortality & morbidity• Comprehensive Abortion Care( CAC )District level model, to deliver safe abortion services,through public health system & expand use of MVA & MA
Will MDG 5 targets be reached by India ?Target 5A Unlikely Potentially No dataReduce MMR by 75% ✓ possiblebetween 1990 to 2015Most births by SBA ✓ possibleTarget 5BIncrease CPR ✓ PossibleReduce Adolescent birth rate UnlikelyANC 4visits ✓ 1 visit PossibleUnmet need for FP ✓ PossibleSource :--Chatterjee A, Paily VP. Achieving MDG 4 and 5 in India. BJOG 2011;118 (Suppl. 2):47–59
Maternal health care scenario in Nepal –reasons• Total Hospital Beds 6944Community Hospital- 10-15 bedsDistrict Hospital 50 beds2349 person for a single bed• Organizational failures –Availability of electricity, drinking water ,emergency medicines etc -- are available butsometimes there is shortage of medicine• Social evilsFemale education (%): 52% LiterateEarly marriage (age & %) Median age 17.5yrs;< 17 yrs-- 5% ; Domestic violence (15-49) (%) = 22%• Attitude of men on women’s health --in 35% cases men decides forwomen and in 65% cases she decides
CEOC/BEOC/BC-making it functionalHuman resources-train/in place/transferTertiary Level hospitals are too busyEquity access/demand/need Flow and monitoring of fundSustainability-tapping local resourcesInvolvement of private/medical colleges health facilities33 CEOC functioning-HR/qualityPoor Monitoring and EvaluationPoor reporting and recordingHow to reach special groupsIntegration with SRH/FPReferral mechanismsPolicyProgramMajor Challenges in Ama Surachha Program
NESOG ROLEAdvocacyWork with Ministry of Health, Govt of NepalIdentify short comings & Propose for changesPrepare Guide books for training purposesTo cope with the demands & support Ministry of Health’s initiative
Will MDG 5 targets be reached by Nepal?Target Unlikely Potentially No data5A: Reduce MMR by 75%between 1990 & 2015Maternal mortality ratio ✓most births attended by SBA ✓5B: Achieve universal access to reproductive health by 2015Contraceptive prevalence rate ✓Adolescent birth rate ✓ANC (one/ four visits) ✓Unmet need or family planning ✓Achieving Millennium Development Goals 4 and 5 in Nepal-- D S Malla, K Giri, C Karki, P ChaudharyBJOG Sep, 2011
Present scenario of maternal health in Pakistan• Adolescent health care – patchy• Pre-conception care – not routinely practiced•ANC by health prof. – 1 ANC -- 61% ; 4 & more ANC --28% ;Urban: Rural = 48%: 20%• Delivered by SBA --39% ; urban : rural = 60% : 30%• Institutional delivery– 35 % ; Public 11%, Private 24%,• Home delivery --65% ; urban : rural = 56% : 25%•Postnatal check up -- 43%• Referral system – informal, paid by patient’s relatives[2006-7 PDHS,NIPS, Macro international ]
MMR By ProvincePunjab227Sindh314Balochistan785NWFP275MMR for 3 yrs prior to survey .MMR 260 in 2010MMR is significantly higher in the RURAL areas and in BALOCHISTAN province2006-07 PDHS, NIPS and Macro InternationalPresent scenario of maternal health inPakistan ……contd
Poor Maternal Health Care in Pakistan- ReasonsPolitical Will In theory onlyInfra structure Exists, not utilised. Inadequateequipment;lack of staff & quality training;lack of public confidencedoes not operate 24X7Drs : nurses 1 : 1.4OrganisationalfailureInferior health care in rural & urbanareas, lack of adequate community & Pvtsector involvement, lack of strong DHS &implementation of short / long term policymeasures.
Poor Maternal Health Care in Pakistan - ReasonsSocial issues Poverty, rapid urbanization, sizeableyoung population, large refugeepopulation, Male gender preferenceFemale education Female 46%, Total 58%. (2011)Early marriage Age of marriage - 21.8 years. 74% girlsbelow 16 married in Charsadda & MardanDomestic violence VAW – 8539, DV - 610 cases (2011)Better gender equality. Protection againstHarassment of Women at Workplace Bill2009’adopted in 2010Attitude of societyto womens healthLow status, not enough emphasis, not thedecision makers
Maternal Health Economics PakistanState health expenses % of GDP 3.2% of GDPShare of maternal health 0.67% of GDPPublic expenditure 33.32%Private expenditure 57.33%External Support 4-16%Health insurance for Preg &child birth1.64%Employers contribution Socialsecurity5.07%Philanthropy 0.92%Population not fully covered forhealth care costs73.38 %
Maternal Health Economics PakistanOther Issues• Limited commitment within system to generateresources for intended purpose•Poor correlation between spending & outcomes• Lack of efficient & equitable use of finances• Leakage of funds•Inequitable allocation of revenue-- 26.81% spent on 13%of population
Strategies to Improve Maternal Health Scenarioin PakistanKey working areas• Strengthening health systems & promotinginterventions focusing on pro-poor policies• Monitoring and evaluating the burden of maternal &newborn ill-health and its socio-economic impact• Building effective partnerships to use scarceresources & minimize duplication in efforts.
Strategies to Improve Maternal Health ScenarioPakistan• Strengthening of MNCH, LHW and SBA programs• Strengthening contraceptive services• Management of unsafe abortions• Creating awareness amongst women• Opportunities for earning for women
Role of SOGP –Supportive Corporate Capacity• Leadership role• Advocacy– Dissemination among faculty and students in medical and publichealth institutions, information about:• Maternal mortality, Gyn oncology. Abortion DATA• PDHS and status of health indicators• MDGs and way forward, emphasizing their roles• Impart competency-based training to Drs.& Midwives• Support research to update clinical practice
Role of SOGP – Supportive Corporate Capacity• Practice best practices in clinical OB/GYN• Collaborate with Govt to develop health care policies• Collaborate with agencies & development partners• Support efforts to ensure quality
Will MDG 5 targets be reached by Pakistan ?Target Unlikely Potentially No data5A: Reduce MMR by 75%between 1990 & 2015MMR ✓Most births attended by SBA ✓5B: Achieve universal access to reproductive health by 2015Contraceptive prevalence rate ✓Adolescent birth rate ✓ANC (one/ four visits) ✓Unmet need or family planning ✓source :--Mahmud G, Zaman F, Jafarey S, Khan RL, Sohail R, Fatima S.AchievingMillennium Development Goals 4 and 5 in Pakistan. BJOG2011;118 (Supp. 2):69–77.
1.Geographical variations : North & East-21% & Estate -18%of NMM2. Poverty – 30% Estate, 28% Rural3. Septic abortions- increasing (10-15%); PPH commonest4. Contraceptive compliance - Poor5. Inadequate health facilities few areas-EMOC, staff ,finance6. Aftermath of ethnic conflict- IDP, single mother7. Emerging communicable diseases- Dengue, H1N1, HIV8. Increase Maternal mortality & morbidity due to NCD, Mentalillnesses and Suicides9. Domestic Violence – Incidence varied 5-47% during Preg; Highestamong unmarried ,extremes of age. Adverse pregnancyoutcome 3 times high.MMR is low in Sri Lanka but stagnant for last half decade
factors in Sri Lanka• Political willGood Political commitment to MDG 5 through Presidential task force,Health master plan and “Mahinda Chinthanya”• Infrastructural issues, including basicsExcept north & east most people live within 5km of health facility, butin some areas transport & road access are major problem.Estate & some rural areas – poor social indicators like sanitation ,safedrinking water and housingNorth & East- Disruption of homes( IDP) , roads , health facilities, localeconomy and community network• Dr/Nurse strengthMedical Officers 49, Obstetrician 3, Nurses 87 & Midwifes 26 /100,000 popAcute shortage of HR & EMOC in some rural areas, estates & north and east
factors in Sri Lanka• Organizational failureDecentralisation of health system slow and uneven. Reorganisation of hosp &referral system has not achieved good results. Existing health information system isoutdated .. Social evilsFemale literacy -89% Female literacy (15-24y) 99%Female life expectancy -76yrsMarriage by age 15 - 2% Marriage by age 18 - 12%Poverty > 30% of estate pop & 28% rural pop are BPL18% maternal deaths occur in Estates. Attitude of men GBV not uncommon but generally men respect women duereligious and socio-cultural reasons
010000200003000040000500006000070000800001999 2000 2001 2002 2003 2004 2005 2006 2007 2008Total Health Expenditure (SLR Million)Increase government spending on health at least 2.5-3.0 % of GDP.Private spending would continue to be about 1.5-2.0 GDP so that the total expenditure wouldbe 4.5- 5.0 of GDP ---2011Government to maintain health care expenses at 8% --10% of total public outlays.Only 9% of the health budget allocated to preventive sector.No National data available for health budget allocation for Maternal Health
Role of SLCOGAdvocacy and help in policy makingTraining and Education ; Service providerBy 2013 all maternal death inquiries & by 2015 all severe acute maternalmorbidity audit – SLCOG to audit in the internationally accepted standardof confidential reportingBy 2014, SLCOG aims to set standard on :--ANC, IPC,PNC ,EmOC, Post abortion care & Contraceptive services for allsexually capable people irrespective of age, parity & marital status
Will MDG 5 targets be reached in Sri Lanka ?Target Unlikely Potentially No data5A: Reduce MMR by 75%between 1990 and 2015Maternal mortality ratio ✓Most births attended by SBA ✓5B: Achieve universal access to reproductive health by 2015Contraceptive prevalence rate ✓Adolescent birth rate ✓ANC ( 1 & 4 visits) ✓Unmet need or family planning ✓Senanayake H, Goonewardene M, Ranatunga A, Hattotuwa R, Amarasekera S, Amarasinghe I.Achieving Millennium Development Goals 4 and 5 in Sri Lanka. BJOG 2011;118 (Suppl. 2):78–87.
All the SAFOG countries, except Sri Lanka, urgently need to expeditetheir efforts many folds, to reach their MDG targets, sooner than later.Need of the hour -- each constituent country of the South Asia, MUSTpolitically, financially & sincerely, work hand in hand, with theObstetricians of this region, to improve the health of their mothers.More Public expenditure needed on maternal health with all roundInfrastructural improvements in health sector and more communityinvolvement. we need ---POLITICAL WILL AT THE HIGHEST LEVELSAFOG is ready to be the most important stake holder
Maternal health care strategiesImproved Indirectly – by• Improvement of FP services• Free female education upto 12thstandard• Safe menstrual regulation services• Maternal nutrition project• Increase of Maternity leave upto 6 months• Day care center in public & private sectors
A strong Political will and society isneeded to put the simple measure inplace to save lives of women dieing inchildbirth.We are not attempting to do theimpossible. On the contrary, our aim isto do what is well known to be entirelypossible. This approach has thepotential to transform the lives ofmillions.Giving mothers, babies and children thecare they need is an absoluteimperative.PRIVATE SECTOR HAS A MAJOR C.S.Rfor this cause
how can we private sector help• Understand that this is our problem tooo??• Keeping mothers alive and healthy is ourresponsibility to(cannot blame govt.for all ills)• Enroll in PPP janani suraksha yojanas• Form our own programmes to help BPL• Charity• Free camps and check ups and immunizations• Awareness• Save girl child programmes,walks,rally etc etc
how we are helping ..the 9th campspregnancy ….nines
Its time for society to decide whether theywantTAJ MAHALSor mothers and neonatesAND IT IS TIME THAT SUMMITS LIKE THISDISCUSS MATERNAL HEALTH IN ALLMEETINGSif we could have saved this beautiful queen during her 14th childbirth….therewould have been no tajmahal……………….
“mothers are not dying because of disease we cannottreat.They are dying because society has to decidewhether their lives are worth saving”-Prof Fathalla