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Speeding Up Reduction in Maternal Mortality

The recently launched Janani Suraksha Yojana of the government of India to speed up the reduction of maternal mortality should focus more on the creation of health infrastructure and ensuring road connectivity in the rural areas rather than merely doling out money to poor families. This article critically analyses the various aspects of the scheme.

Speeding Up Reductionin Maternal Mortality

Chasing a Mirage?

The recently launched Janani Suraksha Yojana of the government ofIndia to speed up the reduction of maternal mortality should focusmore on the creation of health infrastructure and ensuring roadconnectivity in the rural areas rather than merely doling out moneyto poor families. This article critically analyses the various aspects

of the scheme.

ASHISH BOSE

A
new scheme for the protection of women from the risk of maternal mortality called Janani Suraksha Yojana (JSY) was launched by the prime minister, along with the National Rural Health Mission (NRHM) in April 2005. The expected outcome of NRHM covering the period 2005-2012 is spelt out in the mission document. The first outcome is to reduce the infant mortality rate (IMR) to 30 per 1,000 live births and the second outcome is to reduce maternal mortality ratio(MMR) to 100 per 1,00,000 live births [GoI 2005].

According to the latest Sample Registration System (SRS) data of the registrar general, the IMR in 2004 was 64 per 1,000 in rural areas and 40 in urban areas. The overall figure was 58. It ranged from 84 in rural Madhya Pradesh, 80 in rural Orissa, 75 in rural Uttar Pradesh and 74 in rural Rajasthan. In rural Bihar it was 63. The lowest figure was in Kerala: 13 in rural areas and nine in urban areas [SRS 2006].

According to SRS data, the MMR was estimated to be 407 per 1,00,000 births in 1998. The SRS data for MMR were not considered reliable for individual states. However, the National Commission on Macroeconomics and Health in its background papers on Burden of Disease gives data for individual states from SRS (1998). It ranges from 707 in Uttar Pradesh, 670 in Rajasthan, to 28 in Gujarat which I consider to be quite absurd on statistical grounds. Apart from Gujarat, the lowest figures were as follows: Tamil Nadu 79, Haryana 103 and Kerala 198 [GoI 2005a].

A recent welcome development is a comprehensive sample survey on maternal mortality conducted by the registrar general in collaboration with the Centre for Global Health Research, University of Toronto, Canada. The report was released by the registrar general in October 2006 and is also available on the web site. For the first time, we have the estimates of MMR for the period 1997-2003 based on a fairly large sample size which gives an estimate at the state level. In the table we have summarised the result according to three types of estimation techniques.

Maternal Mortality

In the map on MMR given in the report the figures used are in accordance with the Routine Household Interview of Mortality with Medical Evaluation method given in column 4 of the table. It will be seen that the MMR ranges from 517 in Uttar Pradesh to 110 in Kerala. The conclusion one can draw that the MMR in India is at unacceptable levels in the modern world and it is very unlikely in the near future that we will be able to bring it down to a respectable figure. Even the registrar general concludes: “Based on the conservative estimates, it has been projected that the MMR would be 195 by 2012. However, using the Log-linear model, the projected MMR would be 231 by 2012. A stronger programme to increase institutional delivery in low performing states and in communities having high MMR can, however, make a difference” [RGI 2006]. As things are, in my view, if a stronger programme means only more investment of money, it will be a waste of our resources if the quality of health delivery system in the rural areas remains what it is. The Planning Commission should not be made to earmark more funds in the name of increasing institutional delivery.

For an international comparability, let me quote a few figures from the United Nations Fund for Population (UNFPA’s)

Economic and Political Weekly January 20, 2007

latest, State of World Population 2006. The MMR in Japan is 10, in the Republic of Korea 20, in Singapore 30, and in Thailand 44, in China 36 and in Sri Lanka it is 92. In Sweden the MMR is only two, while in Spain and Austria it is four. The UNFPA report gives a figure of 540 for India.

The international comparisons of IMR are equally shocking. India’s IMR as quoted in the UNFPA report is 62 while it is 32 in China, 18 in Thailand, 15 in Sri Lanka, nine in Malaysia and it is three in Japan and Singapore. It is also three in Norway and Sweden.

Against this statistical backdrop, I decided to study in detail the Guidelines for Implementation of Janani Suraksha Yojana and more importantly, do some field visits to the villages in Orissa, Madhya Pradesh and Rajasthan. Let me give the highlights of my findings in brief.

  • (i) The JSY smacks of charity for the poor. In “the high focus” states as listed by the NRHM document (Bihar, Madhya Pradesh, Rajasthan, Uttar Pradesh, etc), the MMR is high because there are not enough rural hospitals and road connectivity is poor. If the objective is to reduce MMR in these states, an all-out effort has to be made to work on both these fronts: creating the health infrastructure in rural areas which is truly functional and ensuring road connectivity. Merely doling out money to BPL families will do very little to reduce the MMR.
  • (ii) In order to ensure that pregnant women get the much needed nutrition, 50 per cent of the incentive money should be given at least three months before delivery to the BPL families. But there is no such provision as of now.
  • (iii) There is no attempt in JSY to incorporate any element of insurance. In the rural health centre (‘Gonosasthya Kendra’) run by Zafrullah Choudhury of Bangladesh, there is a graded insurance scheme according to income levels and it is working very well [Bose 2004].

  • (iv) The JSY as it is popularly known in villages (the Hindi name has yet to take off in most states).
  • (v) Several states had ongoing maternity benefit schemes like Janani Kalyan Bima Yojana in Madhya Pradesh, the Delivery Hut Scheme in Haryana and several such schemes in other states. No note has been taken of this.
  • (vi) ‘Babus’ in the central ministry of health and family welfare seem to have conceptualised a scheme where accountancy dominates healthcare: basically, it is a scheme for distribution of incentives and
  • conveyance money to the below the poverty line families.

    (vii) The nutrition component is altogether missing as other schemes are supposed to take care of nutrition for pregnant women and mothers. The JSY scheme blatantly announces in the very first paragraph: “JSY …is being proposed by way of modifying the existing National Maternal Benefit Scheme (NMBS). While NMBS is linked to provision of better diet for pregnantwomen from BPL families, JSY integrates the cash assistance with antenatal care during the pregnancy period …’’[GoI 2005b] This is precisely our objection: Cash assistance given after delivery (and that is also doubtful because the frequent excuse given by the hospital/community health centre (CHC) is that “government funds have not arrived”) takes no note of antenatal care, particularly, nutrition of pregnant women. My fieldwork leaves me in no doubt that healthcare has been abandoned and a scheme of distribution of money has been devised with the usual frills of complicated administrative procedures.

    (viii) There is no thought given to the safe return of mother and child from the hospital/CHC after delivery and elimination of avoidable risk of infection both at the hospital and during the journey back home in the village.

  • (ix) There seems to be an overenthusiasm to increase the figures for institutional delivery to show progress on the health front, regardless of what happens to maternal and infant mortality. The message is: somehow bring the pregnant women to the hospital and things will be all right. This is a mirage.
  • (x) It seems to me that the new scheme is going the way of India’s family planning
  • (unnecessarily called welfare) programme which for a long time was centred around setting targets and fulfilling these, very often on paper. It is difficult no doubt to jack up figures for the number of women who came for institutional delivery but it is easy to ignore figures for maternal mortality or not even record maternal mortality. International funding agencies are happy to look at the rising figures for institutional delivery.

    (xi) Is there a hidden agenda in the wellmeaning JSY? Why is the scheme tagged to sterilisation of women after delivery (of course, it is optional). To quote the JSY guidelines: “If hospitalisation for delivery is followed by tubectomy/laparoscopy, money available under the family welfare scheme would also be paid to JSY beneficiary in the health centre as per the existing procedure followed for payment of compensation money”. One would concede that sometimes a sterilisation operation, soon after delivery, may be sound medical advice but my question is : Why can’t JSY stand on its own without being tagged to family planning? Don’t our women in rural areas deserve better healthcare, whether or not they are sterilised after delivery?

    (xii) The dominant theme of JSY seems to be the disbursement of money and not quality healthcare for pregnant women of BPL families. Let me quote from the JSY guidelines to give a glimpse of the accountancy approach: “As the scheme is targeting the poor women who would generally be short of cash it is essential that the cash assistance provided under the scheme is made available to her in the shortest possible time. With a view to quicken the process of disbursement, the

    Table: Maternal Mortality Ratio in India and States, 1997-2003

    State Retrospective Survey Prospective Household RHIME (Representative Re-sampled, Routine
    (1997-98) Reports Household Interview of
    Method (1999-01) Mortality with Medical Evaluation) (2001-03)
    1 2 3 4
    India 39 8 32 7 30 1
    Uttar Pradesh/Uttaranchal 606 539 517
    Assam 568 398 490
    Bihar/Jharkhand Rajasthan 531 508 400 501 371 445
    Madhya Pradesh/Chhattisgarh 441 407 379
    Orissa 346 424 358
    West Bengal 303 218 194
    Punjab 280 177 178
    Karnataka 245 266 228
    Andhra Pradesh 197 220 195
    Maharashtra 166 169 149
    Kerala 150 149 110
    Haryana 136 176 162
    Tamil Nadu 131 167 134
    Gujarat 4 6 202 172

    Source: Registrar General, India, Maternal Mortality in India: 1997-2003 Trends, Causes and Risk Factors, New Delhi, October 2006, pp 19-21.

    Economic and Political Weekly January 20, 2007 disbursing authority would arrange to provide an imprest money of Rs 5,000 to every auxiliary nurse midwife healthworker and authorise her to make payment subject to the condition that the beneficiary concerned fulfils the eligibility condition and the ANM has completed the laid down procedure”.

    A Case Study

    Let me give a case study of my recent field trip to villages in Madhya Pradesh. At a CHC in a village, I talked to the husband of a woman (a poor adivasi) who had just delivered at the CHC. To get Rs 700 promised under JSY, the pregnant woman persuaded a young man (probably a relative) in the village who had a motorcycle to take her at the back of the motorcycle to a CHC. This was when she started getting labour pains, and it was, indeed, the last day of her pregnancy. The motorcycle man obliged, the pregnant woman sat at the back and held him tight around his chest (or stomach!) and managed to arrive at the CHC!

    Fortunately, both the mother and the baby survived. But the husband complained: “There is no food given to the mother and we have no money to buy food”. The woman who had delivered was expecting to get Rs 700 and the motorcycle man Rs 600. However, they got no money! The health authorities told me that money would be given after discharge from the hospital but very often people were told that “government funds have not arrived and money will be given later!” The tragedy as heightened by the fact that the husband who came by bus along with relatives had no money to buy food from dhabas (at home they would have cooked something). When I asked the doctor why no food was given to the woman who delivered, he shot back a question to me “In which rural CHC is there arrangement for food?”

    In Rajasthan during a field visit, I observed that neither the doctors nor the expected beneficiaries knew the details of JSY and the procedure for giving money nor did the funds arrive. Nobody was clear whether the money was only for transport or for nutrition or for both. All they know was that sarkar was giving money to pregnant women to come to the rural health centre. For the health ministry, things are clear: “Give a package of Rs 1,300 and get one institutional delivery”. When will we have a humane approach to healthcare for the millions?

    EPW

    Email: ashish@vsnl.com

    References

    Bose, Ashish (2004): Women’s Empowermentthrough Capacity Building: Enduring Effortsin Bangladesh, Samskriti, New Delhi.

    GoI (2005): National Rural Health Mission (2005-2012): Mission Document, Ministry ofHealth and Family Welfare, Government of India, New Delhi, April, p 28.

  • (2005a): Burden of Disease in India, National Commission on Macroeconomics and Health, Ministry of Health and Family Welfare, Government of India, New Delhi, p 88.
  • (2005b):Guidelines for Implementation of Janani Suraksha Yojana, Ministry of Health and Family Welfare, Government of India, New Delhi, April.
  • RGI (2006): Maternal Mortality in India: 19972003, Trends, Causes and Risk Factors, Registrar General, India, New Delhi, pp 19-21.

    SRS (2006): SRS Bulletin, Vol 40, No 1, Registrar General, India, New Delhi, April, p 1.

    STATE BANK OF INDIA LOCAL HEAD OFFICE 16, College Lane, Nungambakkam, Chennai – 600 006.

    SBI Announces

    Campus Recruitment of Micro Finance Marketing Officers (MFMO) for Tamil Nadu and Pondicherry

    No. of Posts: 2 (two) The posts are on contract basis for a period of two years. Nature of Job:

  • 1. Canvassing, Booking of Business and Recovery under Agriculture and Non Farm Sector.
  • 2. The MFMO directly recruited from the campus will be shortlised and selected on the basis of Group Discussion/
  • Interview. Essential requirements i) Educational Qualification: Graduate or Postgraduate in Social Work/Social Welfare from a recognized university

    (First Class with 60% marks for General/OBC and Second Class with 55% marks for SC/ST/PH Category

    Candidates). ii) Candidates with Micro Finance as one of the subjects of study in graduation will be an added advantage. iii) Candidates must have graduated in 2004 or thereafter. iv) Age: -Minimum 21 years

    Maximum 30 years as on 01.10.2006

    (Relaxation for SC/ST/PH as per Govt. guidelines) v) The candidates must be well conversant with the local language, geographic terrain, local customs and practices. vi) Compensation: Rs.1.50 lacs per annum on cost to Bank basis (with 80% fixed pay and 20% variable pay). vii) Candidates should have driving licence for two wheelers.

    Application can be collected within 10 days from the date of this publication in the following address:

    The Asst. General Manager (HR), State Bank of India, Human Resources Department, 5th Floor, Local Head Office, 16, College Lane, Nungambakkam, Chennai – 600 006. Phone : 044 – 2821 5360, 2823 3733. Mobile : 98416 40720 FAX : 044 – 2821 4316.

    Economic and Political Weekly January 20, 2007

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