#India – Chhattisgarh Diagnostics Privatisation Cancelled #goodnews #healthcare


The plan for privatisation of diagnostics services in Chhattisgarh has been cancelled. The RFP and tenders which had come in are no longer valid. This is a victory for  Jan Swasthya Abhiyan in Chattisgarh , The most heartening part of the struggle was the overwhelming support that this issue got from varied quarters.
indiahealth

Chhattisgarh diagnostic project on hold

SUVOJIT BAGCHI, The HINDU

State government says the policy requires a “fresh look”

The Chhattisgarh and Union governments have decided to halt the prestigious public-private partnership (PPP) project in diagnostic services in the State.

While Chhattisgarh’s Principal Health Secretary M.K. Raut said privatisation of diagnostic services was rolled back “for the time being,” the National Rural Health Mission (NRHM) refused to partially fund the outsourcing of diagnostic services. Last February, the State government invited private players to “set up shops” in the health facilities sector. Defending the programme on the government’s behalf, the Health Department’s technical assistance body, the State Health Resource Centre (SHRC), said that “outsourcing of health services” to private laboratories would enhance efficiency and facilitate delivery of services.

Mr. Raut, however, denounced the flagship privatisation project, which required a “fresh look.”

“In [the] near future we will take a fresh look at the project and decide a course of action,” he told The Hindu . A “revised PPP model” would be in place “in the coming months.”

Chhattisgarh has 154 community health centres (CHC) and 756 primary health centres (PHC). The government, Mr. Raut said, may consider implementing the PPP model in “a few” remote CHC and PHCs. “It would depend on whether it is possible for us to reach those areas or not. The PPP in diagnostic services will not be implemented in the district hospitals or 5,211 sub health centres.”

The government had issued request for proposals (RFP) from private health service providers to set up diagnostic services at public hospitals and health facilities, paid for by the taxpayer. The proposal was severely criticised by health activists and Mr. Raut said the “RFP and the floated tenders are closed chapters now.”

Explaining what compelled the government to retract a project floated only few months back, he said the “gaps need more scrutiny.” “We have to figure out a mechanism to monitor private players in remote areas.”

The Health Department is also not sure how the private players can be regulated. “A diagnostic chain may use government premises to market its services to the outpatients. We need to ask, why the government should provide incentive to a private player to do business using public facility,” said Mr Raut. He clarified that the government would not dismantle its “existing infrastructure and retrench staffs” to create space for the private players.

Owing to inadequate and chaotic public health care services in India, patients turn to private facilities, which are mostly unregulated and where quality is a concern. With the Union Health Ministry’s growing focus on more privatisation in health care, it was clear decades back that the health budget would not get the necessary boost. Rather, in view of the growing flow of private finance in health sector a National Health Policy was formulated in 2002 and the PPP model was suggested.

Chhattisgarh, known for abysmal health care in remote regions, has followed that model as it could not fill the post of 965 radiographers and laboratory technicians over the last several years. To fill those vacancies and provide necessary equipment to the health centres, the State health budget needed an additional funding of at least Rs. 30 crores, which was not available. Besides, trained technicians are generally reluctant to work in remote areas. In this context, the government opted for the PPP model.

However, in a span of four months the policy changed and Mr. Raut said the government had a “new PPP policy” in place and the “diagnostic sector policy has to fall in line with the new one.”

The NRHM has also refused to partially fund the present model and asked the State to “revise the proposal based on the Government of India recommendation” and submit a supplementary programme implementation plan.


  • Private players were invited to “set up shops” in the health facilities sector last February.
  • The Chhattisgarh Government has put the scheme on hold pending a “fresh look”.

 

NRHM -Removal of conditionalities for institutional deliveries underJanani Suraksha Yogana #Womenrights #Goodnews


Access the G.O. No. Z.14018/1/2012- JSY  relating to Removal of conditionalities associated with parity and minimum age of mother for institutional deliveries in High Performing States and for home deliveries in all the States/UTs under Janani Suraksha Yojana 

 

English: National Rural Health Mission of India

 

 

 

No. Z.14018/1/2012-JSY
Government of India
Ministry of Health & Family Welfare
(JSY Section)
Nirman Bhawan, New Delhi
Dated: 13.05.2013
To,
The Mission Director-NRHM,
All States/UTs
Subject: Removal of conditionalities associated with parity and minimum age of mother
for institutional deliveries in High Performing States and for home deliveries in
all the States/UTs under Janani Suraksha Yojana-Approval of Mission Steering
Group (MSG) –in continuation of letter dated 8.5.2013 regarding
Madam/Sir,
As you are aware, Janani Suraksha Yojana (JSY) is under implementation
throughout the country since 2005. The scheme encourages institutional delivery
among pregnant women by providing conditional cash assistance. In Low Performing
States, the financial assistance for institutional delivery is available to all pregnant
women regardless of age and parity who give birth in a government or private
accredited health facility. However, in High Performing States, financial assistance for
institutional delivery has only been available to women from BPL/SC/ST households,
aged 19 years or above and upto two live births for giving birth in a government or
private accredited health facility. Further, in all the States/UTs, the scheme provides Rs.
500/- to BPL women, aged 19 years or above and upto two live births, who prefer to
deliver at home.
Despite the fact that Janani Suraksha Yojana has contributed in increasing the
institutional deliveries in the public health facilities, recent evaluation conducted by
National Health Systems Resource Centre (NHSRC) and study report on Maternity
Protection in India by Ministry of Labour and Employment/International Labour
Organization noted with concern that JSY excludes a significant proportion of women by
virtue of exclusion criteria/ conditionalities of minimum age of mother and parity. These
women who are excluded include adolescents below the age of 19 years and
multiparous women who are at higher risk of maternal and perinatal outcomes.
Considering the above, a proposal to remove conditionalities associated with
minimum age of mother and parity was placed before Empowered Programme
Committee (EPC) which recommended the proposal for consideration of Mission
Steering Group (MSG) of National Rural Health Mission. The proposal has now been

approved by Hon’ble Health & Family Welfare Minister and Chairman of the Mission
Steering Group of NRHM as under:
 Removal of conditionalities associated with parity and minimum age of the
mother for institutional deliveries in the High Performing States.
 Removal of conditionalities associated with parity and minimum age of the
mother for home deliveries in all States/UTs.
In view of the recent decision approved by competent authority (mentioned
above) and the decisions of the competent authority taken at different times earlier,
comprehensive entitlements of beneficiaries covered and ASHA incentives, under
Janani Suraksha Yojana beyond 7th May 2013 are given below:

 

JSY

 

* Rs. 600/ per delivery in rural area includes Rs. 300 for antenatal component and Rs. 300 for
facilitating institutional delivery

 

** Rs. 400/ per delivery in urban area includes Rs. 200 for antenatal component and Rs. 200 for
facilitating institutional delivery

You are, therefore, €quesied to issue necessary instructions lo sll concem€d
field level officers lo ensu€ implementaiion of Janani Su€ksha Yojana in acmdance
with the abovo decision we.i 8.5,2013, the daie on which the decision has been
communicated (copy enclosed).
Yours sinceely,
Kr’t'(
(D.. Rak€sh Kumar)
Joint Secretary (RCH)

 

 

NRHM website at  http://www.nrhm.gov.in/images/pdf/programmes/jsy/imp-govt-orders/JSY_removal_of_conditionalities_13.5.13.pdf

 

 

 

 

 

Maternal Health Activist Madhuri of JADS arrested #Vaw #Tribalrights


 

English: National Rural Health Mission of India

English: National Rural Health Mission of India (Photo credit: Wikipedia)

 

Five Years of NRHM-JSY and more than a decade of RCH: continuing maternal deaths in Barwani and MP
Background
Janani Suraksha Yojana (JSY) was launched under the National Rural Health Mission (NRHM) in
April 2005 as a safe motherhood intervention, with the specific objective of reducing maternal and
neo-natal mortality by relying on institutional delivery as the primary strategy for making available
medical care during pregnancy, delivery and post delivery period, and thus promoting safe
motherhood. All women are encouraged to avail institutional care during pregnancy and delivery,
and through ASHAs recruited specifically for this purpose institutional delivery is being promoted
among poor pregnant women. JSY is a 100 % centrally sponsored scheme, and it links cash
incentives to pregnant women with hospital delivery and post-delivery care. Reproductive and
Child Health (RCH-I) has been operational since 1997 as a project to provide a variety of
reproductive and child health services in rural areas to bring down maternal and infant mortality, in
order to reduce fertility rates and achieve population control. The second phase of the program
(RCH-II) also commenced in 2005. NRHM itself was launched with the promise to improve
availability and accessibility to health care services to the rural population, especially the
disadvantaged groups including women and children, by strengthening public health systems for
efficient service delivery, improving access, enabling community ownership and demand for
services, enhancing accountability and promoting decentralization.
It is against this context of programmes and interventions and associated fund flows from
the central government and several international agencies that one needs to view the status of
public health services, of maternal and child health in the country in general and specifically in the
high-focus states like MP, and the developments in Badwani that is the focus of this report.
Mass protest against maternal deaths in District Hospital, Barwani
On 28th December 2010 a rally was held in Barwani town, the headquarters of a predominantly
adivasi district in south-western MP. Nearly a thousand people gathered under the banner of
Jagrit Adivasi Dalit Sangathan (JADS), a mass organisation, to protest against extremely
negligent treatment of women in pregnancy and labour, particularly the death on 29th November
2010 of Vypari bai, an 8-months’ pregnant woman admitted in the District Hospital.
The people had come for this rally
from far-flung adivasi villages of the
district, and sought to draw attention to and
to protest against extreme callousness and
ill-treatment regularly meted out to women
in pregnancy and labour by the public
health system, particularly the District
Hospital (DH). A quick perusal of the DH
records indicated that between April-
November 2010 there had been 25 maternal
deaths, and 9 maternal deaths had been
recorded in this hospital in the month of
November 2010 alone. In addition, deaths
of 21 neonates (within 24 hours of birth) had been recorded, related to 511 deliveries conducted
in the hospital during November 2010. People complained that women with problems during
pregnancy and labour were frequently referred to Indore Medical College Hospital, located 150
kms away, despite the DH being supposed to deal with such cases.
The tragic story of Vypari bai – ‘institutional death’ instead of ‘institutional delivery’
Vypari bai, a 22 year old woman had travelled over 55 kms from her village Ban since the
morning of 27th November 2010 to reach the District Hospital, having been referred from the
PHC at Bokrata, and then from the CHC at Pati. She had been carried in a `jhuli’ (cloth sling)
over the first 10 kms from her village to Bokrata, from where the family managed to get the
Janani Express ambulance. She had experienced a convulsion that morning, and had high blood
pressure (BP) and eclampsia at the time of admission in the DH around 1.30 pm on 27th
November.
Following her examination by a gynaecologist at the time of admission in the DH on 27th
Nov., she was visited only once by another doctor during the entire day on 28th Nov. She had been
prescribed medicines after admission to control her BP, but her treatment sheets show only two
measurements of BP during the entire stay from 27th to 29th Nov. No attempt seems to have been
made to deliver the baby, by either induction or cesarean, as is the standard procedure in such
cases. An ultrasound scan on 28th November (for which the woman was taken by auto-rickshaw to
a private centre even though the hospital has this facility) showed the presence of live foetus.
Both the mother and mother-in-law of Vyparibai are trained health workers, presently
working as ASHAs in the NRHM. The mother-in-law Dunabai in desperation attempted to contact
the gynaecologist, who never turned up to see the patient in spite of repeated pleas from the
patient’s family. Moreover the doctor on duty, after checking the patient only once on 28th, was
also absent from the hospital premises. After repeated efforts to contact her, at late night at around
11 pm on 28th November, she instructed the nurse on duty that the relatives could take the patient to
Indore, but did not bother to examine the patient or modify the treatment. When the family went to
the doctor’s residence (which is within the hospital premise at a stone’s throw from the ward) on
28th night to ask her to attend to the woman as she was in great pain, the doctor refused to go,
saying she would phone the instructions to the nurse. The young woman finally breathed her last at
5 am on 29th November 2010, without medical attention despite being admitted in the District
Hospital.
Both the block CHC and Barwani DH are CEMONC (Comprehensive Emergency Obstetric
Neonatal Care) centres, and the DH is equipped with a Blood Bank. Such centres are supposed
to provide emergency services related to pregnancy/ delivery round the clock and 365 days a year.
In any case, a hospital at the level of district hospital is supposed to provide emergency services at
all times, whether or not it is a CEMONC. Further, there is provision that in case of complications,
CEMONC centers can contract-in services of private medical practitioners. So she could have been
referred under the ‘Janani Sahayogi Yojana’ to one of the two local private hospitals. The DH has
four gynaecologists and two anaesthetists, who could have ensured Vypari bai’s delivery. However,
the case paper shows that nearly 35 hours after admission, the patient had been referred to the
medical college hospital in Indore at around 11 PM on 28th. Further, the family was asked to sign
an undertaking, stating that they were refusing to take her to Indore and they took responsibility for
the consequences. It has been repeatedly experienced that, rather than using the institutional
provisions, patients are generally referred to Indore. And are also made to sign such undertakings.
Several other cases of denial of services leading to complications and ill-treatment at all
levels of health services have been documented by JADS. Few illustrative ones are described
below.
District Hospital, Barwani – Baltabai, 20 years, Village- Ubadagad, Pati Block,
On 6th June 2010, 9-months’ pregnant Baltabai was taken to Pati CHC with labour pains, by bus at around 12
o’clock in the afternoon. There was no doctor in the CHC. When the family contacted the BMO and
requested him to see Baltabai, the BMO did not do so, but simply arranged for the Janani Express
Ambulance and referred the patient to the District Hospital. Around 3 PM Baltabai was admitted in the
female ward of the DH. Not a single doctor was present in the female ward, ostensibly because `it was
Sunday’. The nurse on duty informed the doctor who was supposed to be on duty, but was not physically
present in the hospital premises, about the serious condition of Baltabai. She was advised some blood test,
and after the blood report was available, referred by the doctor to M.Y. Hospital, Indore. During this period
the relatives were not adequately informed about the condition of the patient and need for referral. What is
more serious is that the family was not informed about intrauterine foetal death. Following the nurse’s
advice to go to the local hospital instead of Indore, the family took Baltabai to the private trust hospital in
the Barwani town, where the doctor examined Baltabai and informed them that the foetus was dead. She
recommended an emergency operation to remove the dead foetus and save the mother. The family had no
option but to go ahead with this surgery. They incurred a cost of around Rs 10,000/- and an additional Rs.
7000/- were spent on medicine. The family, dependent on daily-wages, had to borrow money from local
money lenders at very high interest rate.
On 14th June Baltabai was discharged from the trust hospital. However, her agony was not
over yet. On reaching home that evening she complained of abdominal distension and pain. On 15th
June, at 4 am she was taken to a private practitioner, where she was cathetarised, and again referred
to the DH, where she was treated till 21st June. On 21st June Baltabai was referred to M. Y. Hospital
Indore for treatment of paraplegia. What exactly happened to Baltabai from15th – 21st June is not
very clear, largely because there are no trustworthy clinical records. Why and how Baltabai
developed paraplegia was never explained to the family members and other concerned people.
Fortunately Baltabai’s condition improved in the M.Y. Hospital and she was subsequently
discharged on 1st July. The ordeal of Baltabai lasted for 24 days (6th June to 30th June), and has left
the family severely indebted.
In September 2008 a woman in labour at the District Hospital was referred by the attending
doctor to Indore as a case of obstructed labour. The family took her to the local Trust hospital,
where a caesarean operation was performed and the child delivered safely. However, due to the
delay the child developed complications and had to be admitted in the neo-natal intensive care unit
(NICU) in the DH.
CHC-Pati block – Meera, Patel phaliya , Pati
Meera had symptoms of threatened abortion since the second month of pregnancy; and was treated
at CHC, Pati. However, the doctor advised her that she should not rely on the medicines available
in the hospital, and made the family purchase injections and medicines from outside the hospital,
worth about Rs 1000-1200. Meera followed all the instructions given by the doctor, as she was told
that she would have a difficult labour. Despite this treatment Meera had intrauterine bleeding one
morning. When she called up the CHC for the Janani Express ambulance she was told that since
she was from Pati itself, she should go to the hospital by herself, and would not be provided the
ambulance. The lady walked over 5-8 km, for almost 2 hours, bleeding and in terrible pain, to reach
the CHC. At the CHC, she was informed that the baby had died in the womb. The family was
forced to purchase few special medicines from outside for the operation to remove the dead foetus.
PHC Menimata – Baniya Bai
On the night of 11th November 2008 Baniya bai went to the PHC Menimata for delivery. The
compounder and nurse asked her family for Rs 100, which the family did not give. The next
morning she was forced to leave the hospital on grounds of being anaemic. Baniya Bai, in
labour pain, managed to crawl out to the road outside the PHC, where she delivered with the help
on the local dai. She was then sent by members of JADS to CHC Silawad by the Janani
ambulance.
These are not isolated cases; there are reports of similar incidents of maternal deaths and
denial of treatment at the health centres, including the DH in Barwani.
Demanding Accountability for Negligence
We were visiting Barwani to get a firsthand
account of the situation there
concerning health services, particularly
in the District hospital. On the morning
of 28th December when we tried to meet
the CMHO and the concerned lady duty
doctor (who happens to be the CMHO’s
daughter) we were told that they were
out of town. The gynaecologist who had
admitted Vypari bai on 27th November
said she had anemia and eclampsia and
was not in a condition to be operated
upon; and that they did not have a
ventilator in the hospital. This
gynaecologist was not around the day
after admission (28th November) to monitor the progress; she is usually out of the hospital four
days of the week performing sterilization operations in family planning camps.
We observed the rally taking place outside the DH on 28th December. About 500 people
(nearly half of them women) had gathered at the entrance of the DH at around 12 noon, by which
time the OPD was almost over. The 2-3 doctors present there left when they heard the rally
approaching. The police tried to snatch away from the rallyists their microphone and the cart on
which it was placed; however the rallyists managed to convince them that they would leave very
soon. About fifteen minutes later the people moved away from the hospital premises and
continued their dharna on the road in front of the Collectorate office, well away from the DH.
Several activists and ordinary village women, including the mother-in-law of the deceased
Vyaparibai spoke of their travails at the DH. A set of 22 issues concerning the District hospital,
which were mentioned in the memorandum of demands, were read out to the assembled people.
The Civil Surgeon was asked for, but he refused to come out to receive the petition; finally the
ADM came and just gave a brief assurance that the issues would be responded to in writing in 15
days time. By around 4 PM the rally had dispersed.
Response by the administration – ‘the message is secondary, crack down on the messenger’
We met the Collector on 28th December evening after the rally and apprised him of the state of
affairs in the DH. It emerged that the process of carrying out maternal death reviews had not
been carried out in case of any of the 25 maternal deaths. During our meeting with the Collector,
the CMHO and CS came when they were summoned. According to the CMHO such maternal
deaths keep occurring, that women here were very anaemic, and it was ‘not possible to bring
them down to zero’. When pointed out that the DH was a CEMONC centre, that there were 4
serving gynaecologists and 2 anaesthetists, and it was enquired why such institutional deaths
were still taking place, there was no satisfactory response. The Collector appreciated our
bringing things to his notice, and said he would initiate
the task of Maternal Death Reviews. At the same time,
he also hinted at linkages of the mass organisation with
‘Bastar’ and ‘Andhra Pradesh’, thereby seeking to
discredit the people’s organisation as being associated
with the ‘Naxalites’, who have been outlawed by the
central government.
We are now extremely shocked and dismayed
that two days after this rally (on 30th Dec.) as per local
press reports, the police has foisted several charges on
the leaders of JADS and 200 people who participated
in the protest. They have been charged with Sec 146 of
IPC (unlawful assembly, rioting, armed with deadly weapon which when used is likely to cause
death), Sec 186 IPC (obstructing public servant in discharge of public functions), and Sec 16(3)
of MP Kolahal Rules. On 31st December one of the activists of the organisation, Bachhiya bhai,
was arrested and sent to jail on charges that were slapped on him and others in 2008, when they
had protested against the denial of services in PHC Menimata (described above).
It needs to be mentioned that the pilot phase of community-based monitoring of rural
health services in MP under NRHM had been implemented in Barwani during 2007-08. Even
prior to this the mass organisation JADS had been actively addressing the health problems in the
area in several ways. In May 2008 a three-day programme of monitoring of services at the CHC
Pati and dialogue with health officials (with the intention to improve them), was followed up
with a rally at Barwani town on the dismal state of health services in the DH. So the area has a
history of peaceful rallying for improvement of rural health services. However, there seems to
have been hardly any concerted response from the administration to address the genuine
problems faced by and raised by the people.
Is the situation restricted to Badwani?
The situation regarding maternal deaths seems to be similar in many other districts of MP. The
audit report of NRHM in MP by the CAG gives an idea of the serious situation in the state.
According to the CAG audit report for the period 2005-06 to 2008-09 incidences of maternal and
infant deaths in MP remained high. In the 12 districts surveyed for the audit there had been 1377
maternal deaths in all in the four-year period – Betul recorded 152, Bhopal 269, Indore 162,
Shahdol recorded 393, Dhar recorded 125, Ujjain 124, and so on. Shahdol district reported 55
maternal deaths in 2008-09. The audit report also points out that despite increase in number of
institutional deliveries, post-delivery mortality remained alarmingly high. The Maternal Mortality
Rate remained high at 379 per lakh live births. Interestingly, the state government has fixed a
lower target than that of the central government for reduction of MMR and IMR. While NRHM
envisages MMR of less than 100 per lakh live births and IMR of 30 per 1000 live births by 2012,
the MP government has set these at less than 220 and 60 respectively. It has said that due to
shortage of manpower it was not possible to achieve the NRHM targets! The audit also found that
Maternal Death Review Committees were to be constituted at each district, but had not been done.
A large number of neo-natal deaths also seem to be occuring: according to figures (collected by
RCH – NRHM for monitoring and evaluation) between April-November 2010, there were 154 neonatal
deaths in the entire district of Badwani, of which 133 have been recorded at the District
Hospital (3879 deliveries recorded at the DH in the same period).
Some other findings of the CAG audit indicate that even after four years of NRHM the
state government was not taking adequate measures to address the long-standing problems of
lack of basic medical facilities, lack of physical infrastructure, and of doctors and other staff.
For instance: the number of health centres fell short of the prescribed norms; several centres,
particularly sub-centres were functioning without buildings; none of the institutions had been
upgraded to Indian Public Health Standards (IPHS); of the 82 CHCs designated as first referral
units (FRUs) 80 percent were non-functional and the rest were only partially functional. The
state government itself acknowledged that the health centres are non-functional due to shortage
of man-power. 101 out of 297 PHCs in the 12 districts studied were running without doctors,
despite the provision for hiring contractual staff under NRHM. Monitoring Committees too at
state and at lower levels to review the activities under NRHM had not been formed till 2009.
One also finds that several hundreds of crores of rupees have been spent over the past few
years under RCH-JSY. Government reports show that the allocations for RCH-JSY had increased
since 2005, and expenditure too had increased from Rs 26.29 crores in 2005-06 to Rs 344.87
crores in 2008-09. By 2009-10 Rs 797.65 crores from NRHM funds had been spent on activities
to improve maternal and child health.
Issues and Concerns
We wish to draw attention to the grave situation that seems to be building up in places like
Barwani. It is now more than a decade of RCH and five years since NRHM, RCH-II, JSY etc,
were launched as flagship programmes. On one hand, the government is spending several
hundreds of crores of rupees annually, is vigorously promoting institutional deliveries as a
panacea for high maternal and infant mortality, and talks of safe and guaranteed health services;
through processes such as community monitoring it is promoting the idea of demanding
accountability from the public health machinery. On the other hand, the ground reality in places
like Barwani shows little change. And when people get organized to demand accountability
through peaceful actions, attempts are made to discredit and ‘brand’ their leaders, to intimidate
and repress them, and to shield the responsible officials who seem to be to completely indifferent
to the plight of the patients.
One finds that in spite of several interventions and expenses of crores of rupees, women
continue to die in large numbers. Majority of these deaths are avoidable and completely
unacceptable. It is precisely these preventable deaths that JSY claims to address, right from
ante-natal care (ANC) to post-delivery care of mother and new-born, by getting the pregnant
women to register soon after pregnancy and `motivating’ them to go to a hospital for delivery.
However, the ground reality indicates that the government is not improving the `health’ of the
health facilities in order that they treat satisfactorily women in labour, especially those with
complications. This is corroborated by the findings of the audit of the performance of NRHM in
MP. The experiences of ill-treatment narrated by the rural women also point to the apathy of the
doctors and the poor quality of care they receive when they come in pain and suffering.
How many more such `institutional deaths’, complications and denial of services, are to
occur before the hospital doctors become responsible and accountable; before the state health
department, the health ministry, the rogi kalyan samitis, the district health societies, the
numerous managers, planners, consultants, and international agencies look beyond their
ritualistic exercises of working on technical assistance, planning, evaluating, re-evaluating, replanning,
merely recording numbers of pregnant women registered, of institutional deliveries and
of beneficiaries etc., in the name of safe motherhood and child health, and seriously take note of
the reality of the deaths of women and infants?
Dr Abhay Shukla – National Joint Convenor, Jan Swasthya Abhiyan
Dr Indira Chakravarthi – Public Health Researcher, Delhi
Rinchin – Bhopal
8.1.2011

 

 

Madhuri of JADS has been arrested for fighting against contnuing Maternal Deaths In Barwani #Vaw #Tribalrights


 

 

English: National Rural Health Mission of India

 

Five Years of NRHM-JSY and more than a decade of RCH: continuing maternal deaths in Barwani and MP

 
Background
Janani Suraksha Yojana (JSY) was launched under the National Rural Health Mission (NRHM) in
April 2005 as a safe motherhood intervention, with the specific objective of reducing maternal and
neo-natal mortality by relying on institutional delivery as the primary strategy for making available
medical care during pregnancy, delivery and post delivery period, and thus promoting safe
motherhood. All women are encouraged to avail institutional care during pregnancy and delivery,
and through ASHAs recruited specifically for this purpose institutional delivery is being promoted
among poor pregnant women. JSY is a 100 % centrally sponsored scheme, and it links cash
incentives to pregnant women with hospital delivery and post-delivery care. Reproductive and
Child Health (RCH-I) has been operational since 1997 as a project to provide a variety of
reproductive and child health services in rural areas to bring down maternal and infant mortality, in
order to reduce fertility rates and achieve population control. The second phase of the program
(RCH-II) also commenced in 2005. NRHM itself was launched with the promise to improve
availability and accessibility to health care services to the rural population, especially the
disadvantaged groups including women and children, by strengthening public health systems for
efficient service delivery, improving access, enabling community ownership and demand for
services, enhancing accountability and promoting decentralization.
It is against this context of programmes and interventions and associated fund flows from
the central government and several international agencies that one needs to view the status of
public health services, of maternal and child health in the country in general and specifically in the
high-focus states like MP, and the developments in Badwani that is the focus of this report.
Mass protest against maternal deaths in District Hospital, Barwani
On 28th December 2010 a rally was held in Barwani town, the headquarters of a predominantly
adivasi district in south-western MP. Nearly a thousand people gathered under the banner of
Jagrit Adivasi Dalit Sangathan (JADS), a mass organisation, to protest against extremely
negligent treatment of women in pregnancy and labour, particularly the death on 29th November
2010 of Vypari bai, an 8-months’ pregnant woman admitted in the District Hospital.
The people had come for this rally
from far-flung adivasi villages of the
district, and sought to draw attention to and
to protest against extreme callousness and
ill-treatment regularly meted out to women
in pregnancy and labour by the public
health system, particularly the District
Hospital (DH). A quick perusal of the DH
records indicated that between April-
November 2010 there had been 25 maternal
deaths, and 9 maternal deaths had been
recorded in this hospital in the month of
November 2010 alone. In addition, deaths
of 21 neonates (within 24 hours of birth) had been recorded, related to 511 deliveries conducted
in the hospital during November 2010. People complained that women with problems during
pregnancy and labour were frequently referred to Indore Medical College Hospital, located 150
kms away, despite the DH being supposed to deal with such cases.
The tragic story of Vypari bai – ‘institutional death’ instead of ‘institutional delivery’
Vypari bai, a 22 year old woman had travelled over 55 kms from her village Ban since the
morning of 27th November 2010 to reach the District Hospital, having been referred from the
PHC at Bokrata, and then from the CHC at Pati. She had been carried in a `jhuli’ (cloth sling)
over the first 10 kms from her village to Bokrata, from where the family managed to get the
Janani Express ambulance. She had experienced a convulsion that morning, and had high blood
pressure (BP) and eclampsia at the time of admission in the DH around 1.30 pm on 27th
November.
Following her examination by a gynaecologist at the time of admission in the DH on 27th
Nov., she was visited only once by another doctor during the entire day on 28th Nov. She had been
prescribed medicines after admission to control her BP, but her treatment sheets show only two
measurements of BP during the entire stay from 27th to 29th Nov. No attempt seems to have been
made to deliver the baby, by either induction or cesarean, as is the standard procedure in such
cases. An ultrasound scan on 28th November (for which the woman was taken by auto-rickshaw to
a private centre even though the hospital has this facility) showed the presence of live foetus.
Both the mother and mother-in-law of Vyparibai are trained health workers, presently
working as ASHAs in the NRHM. The mother-in-law Dunabai in desperation attempted to contact
the gynaecologist, who never turned up to see the patient in spite of repeated pleas from the
patient’s family. Moreover the doctor on duty, after checking the patient only once on 28th, was
also absent from the hospital premises. After repeated efforts to contact her, at late night at around
11 pm on 28th November, she instructed the nurse on duty that the relatives could take the patient to
Indore, but did not bother to examine the patient or modify the treatment. When the family went to
the doctor’s residence (which is within the hospital premise at a stone’s throw from the ward) on
28th night to ask her to attend to the woman as she was in great pain, the doctor refused to go,
saying she would phone the instructions to the nurse. The young woman finally breathed her last at
5 am on 29th November 2010, without medical attention despite being admitted in the District
Hospital.
Both the block CHC and Barwani DH are CEMONC (Comprehensive Emergency Obstetric
& Neonatal Care) centres, and the DH is equipped with a Blood Bank. Such centres are supposed
to provide emergency services related to pregnancy/ delivery round the clock and 365 days a year.
In any case, a hospital at the level of district hospital is supposed to provide emergency services at
all times, whether or not it is a CEMONC. Further, there is provision that in case of complications,
CEMONC centers can contract-in services of private medical practitioners. So she could have been
referred under the ‘Janani Sahayogi Yojana’ to one of the two local private hospitals. The DH has
four gynaecologists and two anaesthetists, who could have ensured Vypari bai’s delivery. However,
the case paper shows that nearly 35 hours after admission, the patient had been referred to the
medical college hospital in Indore at around 11 PM on 28th. Further, the family was asked to sign
an undertaking, stating that they were refusing to take her to Indore and they took responsibility for
the consequences. It has been repeatedly experienced that, rather than using the institutional
provisions, patients are generally referred to Indore. And are also made to sign such undertakings.
Several other cases of denial of services leading to complications and ill-treatment at all
levels of health services have been documented by JADS. Few illustrative ones are described
below.
District Hospital, Barwani – Baltabai, 20 years, Village- Ubadagad, Pati Block,
On 6th June 2010, 9-months’ pregnant Baltabai was taken to Pati CHC with labour pains, by bus at around 12
o’clock in the afternoon. There was no doctor in the CHC. When the family contacted the BMO and
requested him to see Baltabai, the BMO did not do so, but simply arranged for the Janani Express
Ambulance and referred the patient to the District Hospital. Around 3 PM Baltabai was admitted in the
female ward of the DH. Not a single doctor was present in the female ward, ostensibly because `it was
Sunday’. The nurse on duty informed the doctor who was supposed to be on duty, but was not physically
present in the hospital premises, about the serious condition of Baltabai. She was advised some blood test,
and after the blood report was available, referred by the doctor to M.Y. Hospital, Indore. During this period
the relatives were not adequately informed about the condition of the patient and need for referral. What is
more serious is that the family was not informed about intrauterine foetal death. Following the nurse’s
advice to go to the local hospital instead of Indore, the family took Baltabai to the private trust hospital in
the Barwani town, where the doctor examined Baltabai and informed them that the foetus was dead. She
recommended an emergency operation to remove the dead foetus and save the mother. The family had no
option but to go ahead with this surgery. They incurred a cost of around Rs 10,000/- and an additional Rs.
7000/- were spent on medicine. The family, dependent on daily-wages, had to borrow money from local
money lenders at very high interest rate.
On 14th June Baltabai was discharged from the trust hospital. However, her agony was not
over yet. On reaching home that evening she complained of abdominal distension and pain. On 15th
June, at 4 am she was taken to a private practitioner, where she was cathetarised, and again referred
to the DH, where she was treated till 21st June. On 21st June Baltabai was referred to M. Y. Hospital
Indore for treatment of paraplegia. What exactly happened to Baltabai from15th – 21st June is not
very clear, largely because there are no trustworthy clinical records. Why and how Baltabai
developed paraplegia was never explained to the family members and other concerned people.
Fortunately Baltabai’s condition improved in the M.Y. Hospital and she was subsequently
discharged on 1st July. The ordeal of Baltabai lasted for 24 days (6th June to 30th June), and has left
the family severely indebted.
In September 2008 a woman in labour at the District Hospital was referred by the attending
doctor to Indore as a case of obstructed labour. The family took her to the local Trust hospital,
where a caesarean operation was performed and the child delivered safely. However, due to the
delay the child developed complications and had to be admitted in the neo-natal intensive care unit
(NICU) in the DH.
CHC-Pati block – Meera, Patel phaliya , Pati
Meera had symptoms of threatened abortion since the second month of pregnancy; and was treated
at CHC, Pati. However, the doctor advised her that she should not rely on the medicines available
in the hospital, and made the family purchase injections and medicines from outside the hospital,
worth about Rs 1000-1200. Meera followed all the instructions given by the doctor, as she was told
that she would have a difficult labour. Despite this treatment Meera had intrauterine bleeding one
morning. When she called up the CHC for the Janani Express ambulance she was told that since
she was from Pati itself, she should go to the hospital by herself, and would not be provided the
ambulance. The lady walked over 5-8 km, for almost 2 hours, bleeding and in terrible pain, to reach
the CHC. At the CHC, she was informed that the baby had died in the womb. The family was
forced to purchase few special medicines from outside for the operation to remove the dead foetus.
PHC Menimata – Baniya Bai
On the night of 11th November 2008 Baniya bai went to the PHC Menimata for delivery. The
compounder and nurse asked her family for Rs 100, which the family did not give. The next
morning she was forced to leave the hospital on grounds of being anaemic. Baniya Bai, in
labour pain, managed to crawl out to the road outside the PHC, where she delivered with the help
on the local dai. She was then sent by members of JADS to CHC Silawad by the Janani
ambulance.
These are not isolated cases; there are reports of similar incidents of maternal deaths and
denial of treatment at the health centres, including the DH in Barwani.

 
Demanding Accountability for Negligence
We were visiting Barwani to get a firsthand
account of the situation there
concerning health services, particularly
in the District hospital. On the morning
of 28th December when we tried to meet
the CMHO and the concerned lady duty
doctor (who happens to be the CMHO’s
daughter) we were told that they were
out of town. The gynaecologist who had
admitted Vypari bai on 27th November
said she had anemia and eclampsia and
was not in a condition to be operated
upon; and that they did not have a
ventilator in the hospital. This
gynaecologist was not around the day
after admission (28th November) to monitor the progress; she is usually out of the hospital four
days of the week performing sterilization operations in family planning camps.
We observed the rally taking place outside the DH on 28th December. About 500 people
(nearly half of them women) had gathered at the entrance of the DH at around 12 noon, by which
time the OPD was almost over. The 2-3 doctors present there left when they heard the rally
approaching. The police tried to snatch away from the rallyists their microphone and the cart on
which it was placed; however the rallyists managed to convince them that they would leave very
soon. About fifteen minutes later the people moved away from the hospital premises and
continued their dharna on the road in front of the Collectorate office, well away from the DH.
Several activists and ordinary village women, including the mother-in-law of the deceased
Vyaparibai spoke of their travails at the DH. A set of 22 issues concerning the District hospital,
which were mentioned in the memorandum of demands, were read out to the assembled people.
The Civil Surgeon was asked for, but he refused to come out to receive the petition; finally the
ADM came and just gave a brief assurance that the issues would be responded to in writing in 15
days time. By around 4 PM the rally had dispersed.
Response by the administration – ‘the message is secondary, crack down on the messenger’
We met the Collector on 28th December evening after the rally and apprised him of the state of
affairs in the DH. It emerged that the process of carrying out maternal death reviews had not
been carried out in case of any of the 25 maternal deaths. During our meeting with the Collector,
the CMHO and CS came when they were summoned. According to the CMHO such maternal
deaths keep occurring, that women here were very anaemic, and it was ‘not possible to bring
them down to zero’. When pointed out that the DH was a CEMONC centre, that there were 4
serving gynaecologists and 2 anaesthetists, and it was enquired why such institutional deaths
were still taking place, there was no satisfactory response. The Collector appreciated our
bringing things to his notice, and said he would initiate
the task of Maternal Death Reviews. At the same time,
he also hinted at linkages of the mass organisation with
‘Bastar’ and ‘Andhra Pradesh’, thereby seeking to
discredit the people’s organisation as being associated
with the ‘Naxalites’, who have been outlawed by the
central government.

 
We are now extremely shocked and dismayed
that two days after this rally (on 30th Dec.) as per local
press reports, the police has foisted several charges on
the leaders of JADS and 200 people who participated
in the protest. They have been charged with Sec 146 of
IPC (unlawful assembly, rioting, armed with deadly weapon which when used is likely to cause
death), Sec 186 IPC (obstructing public servant in discharge of public functions), and Sec 16(3)
of MP Kolahal Rules. On 31st December one of the activists of the organisation, Bachhiya bhai,
was arrested and sent to jail on charges that were slapped on him and others in 2008, when they
had protested against the denial of services in PHC Menimata (described above).
It needs to be mentioned that the pilot phase of community-based monitoring of rural
health services in MP under NRHM had been implemented in Barwani during 2007-08. Even
prior to this the mass organisation JADS had been actively addressing the health problems in the
area in several ways. In May 2008 a three-day programme of monitoring of services at the CHC
Pati and dialogue with health officials (with the intention to improve them), was followed up
with a rally at Barwani town on the dismal state of health services in the DH. So the area has a
history of peaceful rallying for improvement of rural health services. However, there seems to
have been hardly any concerted response from the administration to address the genuine
problems faced by and raised by the people.
Is the situation restricted to Badwani?
The situation regarding maternal deaths seems to be similar in many other districts of MP. The
audit report of NRHM in MP by the CAG gives an idea of the serious situation in the state.
According to the CAG audit report for the period 2005-06 to 2008-09 incidences of maternal and
infant deaths in MP remained high. In the 12 districts surveyed for the audit there had been 1377
maternal deaths in all in the four-year period – Betul recorded 152, Bhopal 269, Indore 162,
Shahdol recorded 393, Dhar recorded 125, Ujjain 124, and so on. Shahdol district reported 55
maternal deaths in 2008-09. The audit report also points out that despite increase in number of
institutional deliveries, post-delivery mortality remained alarmingly high. The Maternal Mortality
Rate remained high at 379 per lakh live births. Interestingly, the state government has fixed a
lower target than that of the central government for reduction of MMR and IMR. While NRHM
envisages MMR of less than 100 per lakh live births and IMR of 30 per 1000 live births by 2012,
the MP government has set these at less than 220 and 60 respectively. It has said that due to
shortage of manpower it was not possible to achieve the NRHM targets! The audit also found that
Maternal Death Review Committees were to be constituted at each district, but had not been done.
A large number of neo-natal deaths also seem to be occuring: according to figures (collected by
RCH – NRHM for monitoring and evaluation) between April-November 2010, there were 154 neonatal
deaths in the entire district of Badwani, of which 133 have been recorded at the District
Hospital (3879 deliveries recorded at the DH in the same period).
Some other findings of the CAG audit indicate that even after four years of NRHM the
state government was not taking adequate measures to address the long-standing problems of
lack of basic medical facilities, lack of physical infrastructure, and of doctors and other staff.
For instance: the number of health centres fell short of the prescribed norms; several centres,
particularly sub-centres were functioning without buildings; none of the institutions had been
upgraded to Indian Public Health Standards (IPHS); of the 82 CHCs designated as first referral
units (FRUs) 80 percent were non-functional and the rest were only partially functional. The
state government itself acknowledged that the health centres are non-functional due to shortage
of man-power. 101 out of 297 PHCs in the 12 districts studied were running without doctors,
despite the provision for hiring contractual staff under NRHM. Monitoring Committees too at
state and at lower levels to review the activities under NRHM had not been formed till 2009.
One also finds that several hundreds of crores of rupees have been spent over the past few
years under RCH-JSY. Government reports show that the allocations for RCH-JSY had increased
since 2005, and expenditure too had increased from Rs 26.29 crores in 2005-06 to Rs 344.87
crores in 2008-09. By 2009-10 Rs 797.65 crores from NRHM funds had been spent on activities
to improve maternal and child health.
Issues and Concerns
We wish to draw attention to the grave situation that seems to be building up in places like
Barwani. It is now more than a decade of RCH and five years since NRHM, RCH-II, JSY etc,
were launched as flagship programmes. On one hand, the government is spending several
hundreds of crores of rupees annually, is vigorously promoting institutional deliveries as a
panacea for high maternal and infant mortality, and talks of safe and guaranteed health services;
through processes such as community monitoring it is promoting the idea of demanding
accountability from the public health machinery. On the other hand, the ground reality in places
like Barwani shows little change. And when people get organized to demand accountability
through peaceful actions, attempts are made to discredit and ‘brand’ their leaders, to intimidate
and repress them, and to shield the responsible officials who seem to be to completely indifferent
to the plight of the patients.
One finds that in spite of several interventions and expenses of crores of rupees, women
continue to die in large numbers. Majority of these deaths are avoidable and completely
unacceptable. It is precisely these preventable deaths that JSY claims to address, right from
ante-natal care (ANC) to post-delivery care of mother and new-born, by getting the pregnant
women to register soon after pregnancy and `motivating’ them to go to a hospital for delivery.
However, the ground reality indicates that the government is not improving the `health’ of the
health facilities in order that they treat satisfactorily women in labour, especially those with
complications. This is corroborated by the findings of the audit of the performance of NRHM in
MP. The experiences of ill-treatment narrated by the rural women also point to the apathy of the
doctors and the poor quality of care they receive when they come in pain and suffering.
How many more such `institutional deaths’, complications and denial of services, are to
occur before the hospital doctors become responsible and accountable; before the state health
department, the health ministry, the rogi kalyan samitis, the district health societies, the
numerous managers, planners, consultants, and international agencies look beyond their
ritualistic exercises of working on technical assistance, planning, evaluating, re-evaluating, replanning,
merely recording numbers of pregnant women registered, of institutional deliveries and
of beneficiaries etc., in the name of safe motherhood and child health, and seriously take note of
the reality of the deaths of women and infants?
Dr Abhay Shukla – National Joint Convenor, Jan Swasthya Abhiyan
Dr Indira Chakravarthi – Public Health Researcher, Delhi
Rinchin – Bhopal
8.1.2011

 

 

 

 

 

Uttar Pradesh forms spl court for all health scams #MUSTSHARE


 

English: National Rural Health Mission of India

English: National Rural Health Mission of India (Photo credit: Wikipedia)

 

Neeraj Chauhan | TNN

New Delhi:Criticized for tardy probe progress coupled with acute shortage of officers to investigate cases, the CBI got a relief in National Rural Health Mission (NRHM) scam investigations as the Uttar Pradesh government has constituted a special court for all the health scheme fraud cases.

 

The UP government issued anotification on August 28, constituting a special court especially for NRHM cases in Ghaziabad. The court of Session Judge Shyam Lal, where the Aarushi-Hemraj murder trial is going on, has been designated as the NRHM court. CBI has registered 18 cases so far in the Rs 5,700-crore NRHM scam that has been unearthed in various districts of the state.

 

 

 

 

 

 

NRHM financial wrongdoings reflect systemic irregularities


Prioritizing healthcare for India's rural poor

Prioritizing healthcare for India’s rural poor (Photo credit: Gates Foundation)


It turns out that some state officials were using NRHM to enrich themselves
Vidya Krishnan

New Delhi: The National Rural Health Mission (NRHM) was launched seven years ago with the goal of improving healthcare delivery to people in villages, especially the poor, through a generous infusion of federal funds. Local authorities were given a relatively free hand in deciding how to spend the money, with the Centre promising funds with no strings attached for the first seven years.

It turns out that some state officials were using NRHM to enrich themselves instead, raising questions about oversight, governance and accountability at the government’s marquee public health programme, which has won a five-year extension because many of its goals, such as significantly reducing child mortality and improving maternal health, haven’t been met.

Last month, several senior officials of Madhya Pradesh’s health department came under investigation for allegedly siphoning off Rs800 crore from the programme’s budget.
That follows a corruption scandal surrounding NRHM in Uttar Pradesh after allegations that Rs5,700 crore was embezzled from the scheme by health department officials during the regime of Mayawati’s Bahujan Samaj Party, which was ousted from power in the February-March assembly elections.

Six officials directly associated with the scheme in India’s most populous state died in controversial circumstances, one of them in police custody.

In Madhya Pradesh, health director Amarnath Mittal, who was overseeing NRHM’s implementation in the state, was suspended after income-tax (I-T) raids led to the recovery of evidence that he possessed unaccounted property worth Rs100 crore, according to Siddharth Chaudhary, superintendent of police, Lokayukta, an independent anti-corruption body that holds oversight of the state government.

Some Rs38 lakh in cash, 2.5kg of gold, jewellery worth Rs.72 lakh, foreign currency (€3,000 and 1,080 Australian dollars) and documents claiming titles for 50 acres of land were seized in the raids, Chaudhary said.

Public health experts say the case illustrates the larger malaise of corruption in India rather than fault lines in the programme that allowed flexible spending at the grassroots level.

“There is a need to delink the scheme from the system. The problem is not with NRHM’s design, but with governance,” said Amit Sengupta, co-convenor of the People’s Health Movement. “NRHM has been implemented efficiently in many states. Corruption at this level and of this kind—where bureaucrats are amassing Rs100 crore—does not happen without the connivance of elected representatives.”

“Besides, there are vested interests that want NRHM-like schemes to fail so that the argument in favour of outsourcing services to the private sector is strengthened,” Sengupta added. “There is a lot of evidence that there is connivance between government officials and private sector.”

The alleged financial wrongdoing in NRHM reflects the systemic irregularities that plague centrally funded schemes, including the Mahatma Gandhi National Rural Employment Guarantee Scheme and the Jawaharlal Nehru National Urban Renewal Mission, said Sidharth Sonawat, assistant director and healthcare analyst at industry lobby group Federation of Indian Chambers of Commerce and Industry.

“This is a result of giving large amounts of funds, poor administering at state-level organizations and even worse monitoring from the Centre,” Sonawat said. “In the case of NRHM, district-level officials to elected representatives seem to be aware of the irregularities; otherwise such blatant, systemic corruption cannot exist in isolation.”

According to officials in the Madhya Pradesh Lokayukta, recent raids have established a payoff between the state’s health department and the procurement cell, Laghu Udyog Nigam. These officials didn’t want to be identified because they are not authorized to speak to the media.

An audit by the Accountant General of Madhya Pradesh, the apex body for compiling and preparing state-level accounts of public spending, has revealed that the health department incurred expenditures worth Rs67 crore without having budgetary provisions or approvals from the Union government.

In a letter dated 7 May, the audit officer sought a response from Ravindra Pastore, NRHM mission director for Madhya Pradesh.

The investigative arm of the Lokayukta is currently probing 13 cases of misuse of office against health commissioner Manohar Agnani and nine cases against Mittal, but is yet to link them to NRHM.

“As of now, Mittal’s raid is being treated as a case of disproportionate assets and we have not yet linked it to NRHM even though he was heading the department that rolled out the health scheme,” said Chaudhary.

“Besides disproportionate assets case, we received complaints alleging irregularities under various NRHM schemes in March and we have started our investigations,” he added.

While Mittal declined to comment, Agnani maintained that the cases of irregularities have been exaggerated and that he was “unaware that contracts had been given to blacklisted firms, substandard material procured at inflated rates, and unqualified officials had been employed”.

“My director (Mittal) would be best placed to answer these queries,” he said.

The department’s previous commissioner, Rajesh Rajora, is currently under suspension for irregularities to the tune of Rs11 crore, according to official data. Previous mission director Ashok Sharma was suspended in 2008 after Rs130 crore was allegedly recovered from his residence by I-T officials in a raid. Sharma was reinstated in 2010 and is currently director, health services.

“They (I-T officials) recovered only Rs27,000 from the raid at my residence. Subsequently, judicial inquiries were conducted in nine cases in which no irregularity was found,” Sharma said. “All those cases have been closed.”

Madhya Pradesh health minister Ajay Vishnoi resigned in 2008 on moral grounds after I-T officials raided 56 places in the state and unearthed evidence of a nexus between politicians, bureaucrats and suppliers.

This time, cases being investigated by the state’s Lokayukta include procurement of an insecticide under the anti-malaria programme, causing the exchequer a loss of approximately Rs70 crore; imposing monopolies in the purchase of ingredient used for analysis of blood samples that caused a loss of Rs20 crore; appointments in the health department that did not follow prescribed procedures; and favouring of two companies—Nitapol Industries and Kilpest India Ltd—that were blacklisted by the Gujarat government for supplying substandard insecticides.

Both the companies declined to comment on the matter.

NRHM was launched with a budget of Rs6,730 crore; the outlay swelled to Rs20,822 crore in the latest budget. It aimed at improving health indicators in rural areas, with a special focus on 18 states that lagged behind the rest on key health parameters.

It aimed at reducing the infant mortality rate (IMR) to 30 per thousand live births and the maternal mortality rate (MMR) to 100 per 100,000 live births and the total fertility rate (TFR) to 2.1 nationally, in line with the millennium development goals.

At the time of launch, Madhya Pradesh’s TFR was 3.6 while, MMR and IMR stood at 335 and 76, respectively. Seven years and Rs3,381.93 crore of spending later, the health indicators remain below target at 3.3, 269 and 67, respectively.

Still, the improvement is commendable given the backdrop of leakages, some public health experts say.

“If these figures are to be trusted, the drop in maternal mortality rate is impressive,” said Sakthivel Selvaraj, health economist at the Public Health Foundation of India. “The nine-point drop in infant mortality is also not bad. Overall, it is evident that NRHM has made a dent in these figures despite leakages in the system.”

Last month, the Comptroller and Auditor General (CAG) said it found large-scale financial irregularities in the NRHM scheme during Mayawati’s reign over Uttar Pradesh.

According to CAG’s audit report, funds worth Rs1,768.12 crore were received from the Centre but never shown in state government accounts. The report revealed that the government had not maintained accounts for advances worth Rs4,938.74 crore.

The Central Bureau of Investigation is investigating at least two ministers in Mayawati’s government and several bureaucrats in connection with financial irregularities.

Union health secretary P.K. Pradhan said NRHM could not be faulted because of Uttar Pradesh; anyway, only a portion of the scheme allowed flexible use of funds, he said.

“Because of UP (Uttar Pradesh), everyone is faulting NRHM without seeing how well it is implemented in southern states,” Pradhan said. “The government will never be able to implement any scheme if we start faulting in on this basis. Procurement and construction, etc., are the state government’s prerogative and states with better governance have done well under NRHM. Since funds were easily available in large amounts, a portion was flexible; states which lacked transparency took advantage of this.”

“It is vacuous to blame the system when the issue is individual intention and integrity of state-level bureaucracy and politicians,” Pradhan added.

vidya.krishnan@livemint.com

Most pregnancy-related deaths occur in transit’


A map of the world showing country-level mater...

A map of the world showing country-level maternal mortality rates. (Photo credit: Wikipedia)

AARTI DHAR, The Hindu

Maternal Death Reviews reveals many facilities show mothers the door soon after delivery

According to a study conducted on pregnancy-related deaths, a large number of women die during transit to a health facility or returning home after a delivery. ‘Maternal Death Reviews — Implications for Quality of Care,’ (MDR) a review of maternal deaths done by the Federation of Obstetric and Gynaecological Societies of India (FOGSI) in Jhunjhunu and Sikar districts of Rajasthan between November 2010 and March 2012 has revealed that 90 per cent of these deaths had occurred during transit to a higher health centre.

The study, conducted on 819 deaths of a total of 1,065 probably maternal deaths reported in Madhya Pradesh between April 2011 and January 2012, suggests 132 women died on their way home or to a health facility. A similar analysis done in 69 health facilities in Karnataka has revealed that 20 per cent women die during transit.

Experts believe such deaths could possibly have increased because of an emphasis on institutional deliveries and a lack of corresponding clinical infrastructure — the Janani Suraksha Yojana gives women financial incentives for delivering at a health facility, but are often taken to the health facility as a mere formality and often asked to go home immediately after delivery because of lack of infrastructure to deal with the heavy patient load, which puts the life of the child and mother at huge risk.

This reality came across during a daylong conference to mark the Safe Motherhood Day last week, where participants from several States shared their experiences and progress on maternal death reviews.

The MDR was rolled out in 2010 under the Reproductive and Child Health programme as an important strategy to improve the quality of obstetric care and to reduce maternal mortality and morbidity.

It provides detailed information on various factors at the facility, district, community, regional and national levels that need to be addressed to reduce maternal deaths. Analysis of these deaths can identify the delays that contribute to maternal deaths at various levels and the information can be used to adopt measures to fill the gaps in service.

While haemorrhage, sepsis, abortion, obstructed labour and hypertensive disorders are the major medical causes of maternal deaths in the country, delay in initiating treatment, substandard care in hospital, lack of blood, equipment and drugs in hospitals coupled with lack of staff at health facility are other factors that often lead to the death of a young woman.

At the community level, absence of ante-natal check ups, delay in seeking care, referral, getting transport, mobilising funds and not reaching the appropriate facility in time are some other factors of maternal deaths, besides prevailing beliefs and customs that prevent women from going to a health facility at the appropriate time.

In a presentation on maternal death reviews in Madhya Pradesh, Apurva Chaturvedi, State Consultant, National Rural Health Mission, and Archana Mishra, Deputy Director (NRHM), explained that 32 per cent of the reviewed deaths had occurred in district hospitals, 25 per cent in maternity centres, 13 per cent in sub-centres and 6 per cent in private facilities. “Only 17.7 per cent of the expected maternal deaths are being reported and analysed while the remaining go unreported. Worse, in 37 per cent of the cases the cause of maternal deaths is registered as ‘other’,” they said.

“Maternal death review is a good thing and not some kind of a blame game. It aims to look into where and how maternal deaths are happening and how these cane be prevented,” says Aparajita Gogoi of the White Ribbon Alliance, working in the field of maternal health and rights.

“The government has given cash incentives to promote institutional deliveries but the communities should also be able to identify signs of emergency and understand the importance of regular ante-natal and post-natal check-ups for safe delivery. The focus should also be on the quality of care,” she said.

According to T.P. Jayanthi, Department of Community Medicine at Kilpauk Medical College (Chennai), in addition to medical causes, maternal death reviews also help us to identify the various contributory factors leading to maternal deaths. It is an important quality indicator to identify our system gaps and community barriers, including some problems that are area specific.

In her analysis of maternal death review process in 10 States between April and December 2011, Himachal Pradesh had reviewed 92 per cent of the reported maternal deaths, Uttar Pradesh 90 per cent, Orissa (79 per cent), Rajasthan (69 per cent), Assam (56 per cent), Uttarakhand (53 per cent), Bihar (38 per cent), Madhya Pradesh (39 per cent) and Chhattisgarh only 18 per cent.

In Tamil Nadu, all the 18 government medical college hospitals are being reviewed under the facility-based MDR programme. The review is being conducted by the Mission Director, State Health society through videoconferencing on the fourth Thursday of every month.

The MDR, even deaths occurring in other departments like Medicine, and Intensive Care Unit which would come under the criteria of maternal deaths are discussed along with the concerned specialist.

 


  • Communities should identify signs of emergency to make use of State incentives: NRHM official
  • MDR came out in 2010 to improve quality of obstetric care, reduce maternal mortality, morbidity

For Immediate Release- Division Bench at Patna Underscores Importance of Maternal Mortality


Division Bench at Patna Underscores Importance of Maternal Mortality and Orders State of Bihar to Account for Every NRHM Rupee Spent

20 March 2012

PATNA- The Division Bench of Patna’s recent order in Centre for Health and Resource Management (CHARM) v. The State of Bihar and Others (W.P. 7650/2011) asks the State Health Secretary to account for NRHM spending and unequivocally holds the State responsible for failures to protect, respect, and fulfill the rights of pregnant women under the National Rural Health Mission (NRHM).

At about 300 maternal deaths per 1 lakh births, Bihar has the fourth-highest Maternal Mortality Rate (MMR) in India and one of the highest MMRs in the world. Almost all of these deaths are completely preventable where the government provides adequate antenatal, delivery, and post-natal care. Despite significant financial support under the NRHM, sub centres and hospitals in Bihar do not have adequate supplies of iron, folic acid, blood, or basic equipment for checking blood pressure or hemoglobin levels. The state does not have adequate staff or infrastructure and reports an institutional birth rate of just 27%.

The Fifth Common Review Mission of the National Rural Health Mission found that state mismanagement of NRHM funds and inadequate implementation “prevented women from receiving these crucial benefits and services and contributed to the high incidence of preventable maternal deaths.” (p.203). In light of these facts, this Public Interest Litigation (PIL) was filed by CHARM through its executive director, Dr. Shakeelue Rahman and the Humlog Trust through its Secretary Parveen Amanullah as a part of Human Rights Law Network’s strategy to use litigation to address India’s high maternal mortality and morbidity rates. Advocate Ms. Anubha Rastogi argued the case.

On 6th February a Division Bench of the Patna Court led by Justice (Smt) T Meena Kumari expanded the scope of the PIL to cover NRHM implementation in all districts of Bihar. The Health Secretary, Bihar was expected to file a district-by-district status report by 19th March 2012. In an unusual move, the State filed its report, but through a private advocate and not through government counsel. The case came up for hearing again on 20th March where the Division Bench of Justice T Meena Kumari and Justice Jyoti Saran took objection to the fact that a government official filed an affidavit through a private lawyer. The Division Bench has since ruled that this status report is unsatisfactory.

On 20 March, the Division Bench also ordered the Health Secretary to account for each and every Rupee released by the Central Government under NRHM and spent by the State Government for the implementation of NRHM. The total sum amounts to nearly Rs. 3500 crores. The State Government must file their response in an affidavit and should produce the bills for every Rupee spent. The report will highlight key gaps between Central Government disbursement and state level implementation. The State must submit its expense report by 9 April 2012.

The High Court of Madhya Pradesh recently held that the state has a duty to ensure that every woman survives pregnancy and childbirth. Today, the Patna Court underscored the state’s obligation to effectively implement the NRHM and to protect pregnant women.and Orders State of Bihar to Account for Every NRHM Rupee Spent

March 22
PATNA- The Division Bench of Patna’s recent order in Centre for Health and Resource Management (CHARM) v. The State of Bihar and Others (W.P. 7650/2011) asks the State Health Secretary to account for NRHM spending and unequivocally holds the State responsible for failures to protect, respect, and fulfill the rights of pregnant women under the National Rural Health Mission (NRHM).

At about 300 maternal deaths per 1 lakh births, Bihar has the fourth-highest Maternal Mortality Rate (MMR) in India and one of the highest MMRs in the world. Almost all of these deaths are completely preventable where the government provides adequate antenatal, delivery, and post-natal care. Despite significant financial support under the NRHM, sub centres and hospitals in Bihar do not have adequate supplies of iron, folic acid, blood, or basic equipment for checking blood pressure or hemoglobin levels. The state does not have adequate staff or infrastructure and reports an institutional birth rate of just 27%.

The Fifth Common Review Mission of the National Rural Health Mission found that state mismanagement of NRHM funds and inadequate implementation “prevented women from receiving these crucial benefits and services and contributed to the high incidence of preventable maternal deaths.” (p.203). In light of these facts, this Public Interest Litigation (PIL) was filed by CHARM through its executive director, Dr. Shakeelue Rahman and the Humlog Trust through its Secretary Parveen Amanullah as a part of Human Rights Law Network’s strategy to use litigation to address India’s high maternal mortality and morbidity rates. Advocate Ms. Anubha Rastogi argued the case.

On 6th February a Division Bench of the Patna Court led by Justice (Smt) T Meena Kumari expanded the scope of the PIL to cover NRHM implementation in all districts of Bihar. The Health Secretary, Bihar was expected to file a district-by-district status report by 19th March 2012. In an unusual move, the State filed its report, but through a private advocate and not through government counsel. The case came up for hearing again on 20th March where the Division Bench of Justice T Meena Kumari and Justice Jyoti Saran took objection to the fact that a government official filed an affidavit through a private lawyer. The Division Bench has since ruled that this status report is unsatisfactory.

On 20 March, the Division Bench also ordered the Health Secretary to account for each and every Rupee released by the Central Government under NRHM and spent by the State Government for the implementation of NRHM. The total sum amounts to nearly Rs. 3500 crores. The State Government must file their response in an affidavit and should produce the bills for every Rupee spent. The report will highlight key gaps between Central Government disbursement and state level implementation. The State must submit its expense report by 9 April 2012.

The High Court of Madhya Pradesh recently held that the state has a duty to ensure that every woman survives pregnancy and childbirth. Today, the Patna Court underscored the state’s obligation to effectively implement the NRHM and to protect pregnant women.

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