Ayesha de Costa is an associate professor of Global Health and Senior Lecturer at the Karolinska Institutet, Stockholm. She begins this lecture by noting the increasing importance of emergency obstetric care (EmOC) which can only work if it is of a high quality. EmOC should be able to provide: injectable antibiotics, injectable anticonvulsants, injectable oxytocics, manual removal of the placenta, manual removal of retained products of conception, assisted vaginal delivery, Caesarean section (CS), and blood transfusion. These require staff in place in an environment to support them. Staff need to be skilled in identifying complications which can occur suddenly and progress rapidly. They need to know how to deal with these and have access to resources required. These need to be 24/7 services. Referral capacity is also required.
The challenge of good quality EmOC is that good quality care is underfunded and understaffed. Ayesha de Costa looks into bringing in the private sector to improve provision. She presents a case study: The Public Private Chiranjeevi Yojana (CY) to support institutional delivery in Gujarat, India. The programme was largely designed to provide access for vulnerable women but also to ensure the care is of good quality. India is dominated by private health care and most qualified obstetrician/gynaecologists (OB/GYNs) practice in the private sector. Public sector EmOC is largely inadequate and this was recognised by the State. In CY the State pays private obstetricians to care for vulnerable women. The aim of the project is to harness the private sector resource for vulnerable women rather than move towards privatisation.
CY have performed one million deliveries for women below the poverty line and tribal women since its inception in 2007. Ayesha further describes the rationale for the programme, the programme contribution to institutional delivery, uptake, and quality of care. Quality of care is assessed by looking at outputs: EmOC services, skilled staff, facilities, drugs equipment, transport and outcomes; facility deliveries, skilled birth attendants, critical clinical interventions. Criteria to ensure quality of care were for facilities to have: at least ten beds, full-time OB/GYN, operating theatres for CS’s, and access to an anaesthetist. CY facilities were found to be significantly better staffed and equipped than government facilities.
Some CY obstetricians have left the scheme, due to difficulties in interfacing with the State. There is often mistrust regarding payments. Private obstetricians were finding payments not remunerative enough, the State have now raised payments.
To deter induced demand (unnecessary CS’s) CY facilities were paid per 100 deliveries irrespective of whether they were CS or not. Accountability to the user is also important in maintaining quality. Quality in the processes of care is difficult to assess in the CY programme because they are private facilities. Inability to monitor is a drawback. Impact indicators, particularly maternal mortality, are not used as they are so few and they are not disaggregated by programme and non-programme.
The programme has not been found to weaken the public sector.