A note prepared by a top advocacy group, Jan Swasthya Abhiyan (JSA), Gujarat, ahead of crucial public hearing on right to health before the National Human Rights Commission in Mumbai next monthy, has found major issues with maternal healthcare system in the state, especially among the vulnerable communities. Excerpts:
The Maternal Mortality Ratio in Gujarat has decreased to 122/100,000 live births, but who are the women who are dying? The Gujarat Jan Swasthya Abhiyan (JSA) report (46 deaths reviewed between 2012 and 2013) shows that it is women with multiple vulnerabilities who died – young, SC/ST, low education, wage labourers, migrants. About 41% of the maternal deaths occurred among very young women, below the age of 25 years – seven were between 16 and 20 years, more than half i.e. 27, of the 46 deaths were of scheduled caste (SC) and scheduled tribe (ST) women. This is a higher proportion than the state’s SC-ST population of around 22 % (2011 Census). Almost half of the women, who died – 46 % — were illiterate in comparison to 37% female illiteracy in Gujarat.
Most of the women who died had multiple occupations/responsibilities – in addition to domestic work, 25 of them were involved in either agricultural work or/and wage labour. Nine of the women who died migrated for longer than 2-3 months without safety of home and other basic amenities or any social security.
The need to pay special attention to vulnerable groups is reinforced by Deepak Saxena in his book Inequity in Maternal Health in Gujarat- DLHS in their study on Inequities in Maternal Health in Gujarat. They found that the poor, regardless of caste, are almost six times less likely to access antenatal care services in Gujarat. And, amongst non-poor, women from scheduled tribes, scheduled castes and socio-economic backward castes were two times less likely to use antenatal care services.
A review of maternal deaths also found:
- Poor quality of ante natal care
- Social determinants interact with antenatal conditions, especially for vulnerable women, to accentuate their risks for maternal deaths and morbidities. Anaemia in women is very high increasing their maternal health risks
- Absence of post natal care
- Weak reporting and recording of maternal deaths
- Multiple referrals and issues with transport
- Out of pocket expenditure – despite Janani Shishu Suraksha Yojna (JSSY) and Chiranjeevi, denial of services because of lack of money with the family
- Poor blood availability even in emergencies
- Weak role of public health facilities in emergency obstetric care
Issues with Janani Shishu Suraksha Yojana
The JSSY is a Government of India initiative to assure free and cashless services to pregnant women for deliveries in public health facilities. The scheme includes: free antenatal care, deliveries (normal and Caesarians) and care up to 42 days after delivery, care for sick newborns up to 30 days after birth and for infants up to one year of age.
In a study done by Sahaj and Anandi in three districts of Gujarat (January to June 2015 covering 500 women) we found that despite JSSY more than half the women (51.4%) incurred expenditure for ante natal care, and 48% for deliveries. Another major finding was that most healthcare seeking happens from the private sector, where JSSY is not operational. There are various and paradoxical reasons for care seeking from the private sector. In Anand district, which is economically developed, although the public health system is relatively better functioning, the unregulated private sector has managed to capture much of health service provision. In contrast, the backward tribal Panchmahals and Dahod, although supposedly high priority districts, the government health system is weak and under resourced/staffed.
The impoverished and already vulnerable women are pushed to the private sector. Around 75% of those who went to the private sector incurred expenditures for delivery up to Rs 5,000. In Anand district’s Pansora primary health centre (PHC), 80% of the women incurred out of pocket expenditure (OOPE) even for antenatal care which is supposed to be provided by the public health system. Even in public facilities, up to 53.4% women (Rasnol PHC) incurred OOPE of up to Rs 6,000.
To improve the situation, we feel, JSSY should be expanded to cover maternal healthcare through the private sector till such time that quality of care is assured in public facilities. Private sector regulation is urgently required. Grievance redressal mechanisms are required and should be implemented in public and private facilities.
Blood Availability in Gujarat
Blood availability is a serious issue when it comes to maternal deaths. The most frequent cause of maternal deaths is post partum and ante partum hemorrhage. Given high levels of anemia among women in Gujarat, the risk of hemorrhage increases. From the field experience of JSA members and maternal deaths’ study, we find many preventable deaths due to lack of availability of blood. Many stories from the field reflect how harassed family members are because of non-availability of blood.
According to the Government of India’s Indian Public Health Standards (IPHS 2012), every district should have a blood bank (BB). According to the NACO guidelines (2007) and IPHS standards (2012), there should be a blood storage unit (BSU) in each CHC. These standards are not met in Gujarat.
In this context, it is necessary to know what the Comptroller and Auditor General (CAG) Report on BBs in Gujarat.
As of March 2014, 136 BBs were functioning in the state. Many of them were managed by the State government – at 12 Medical College Hospitals, nine District Hospitals, two Special Hospitals, one Taluka Hospital, four Municipal Hospitals, one Military Hospital and one Private Medical College; 82 BBs were managed by Charitable Trusts (Charitable BBs), and 24 BBs are being run by private bodies (private BBs).
Eight districts did not have a Government BB. In Narmada district, there was no BB, either Government or Charitable/Private.
According to IPHS guidelines, each district hospital should have a BB. However, Audit observed (July 2014) that out of 18 district hospitals, nine district hospitals (50 per cent) did not have a BB. Five were in tribal districts – Bharuch, Dahod, Narmada, Navsari and Tapi. This is where the most marginalised people live.
Twelve districts (population ranging between 2.28 lakh and 31.16 lakh) have only one government BB each, while six districts have between two and seven government BBs.
Only 34 BBs were available in 30 Talukas (out of 224 talukas) and no BB was available below taluka level in Gujarat.
NACO guidelines (2007) and IPHS standards (2012) state that there should be a Blood Storage Unit (BSU) in each CHC. While 126 CHCs were identified for BSU between 2006-13, in July 2014 only 43/300 CHCs had a BSU. Seventy seven of the remaining 83 had been supplied with equipment which was lying unused.
The mandated computer network was not set up resulting in 73,000 units of blood being discarded in 2012-14, because they couldn’t be used within the stipulated 35 days. On the other hand, we have many cases of women dying because of lack of blood.
In 2011-14, 10 BBs sold 52,000 litres of “fresh frozen plasma” to pharmaceutical companies for Rs 6.17 crore in contravention of the national blood policy.
Out of the 32 blood banks in the CAG sample, seven overcharged HIV patients, even though the National AIDS Control Organisation instructs not to do so. Together, these banks collected “excess… service charge of Rs 4.82 crore for 3.14 lakh units of blood or blood components” from HIV patients during 2011-14.
We think that blood should be considered as an essential life-saving item and it should be the responsibility of the health system to ensure availability in an emergency and without any cost. And, there should be a speedy implementation of the BB policy.