By Debjani Barman, FHS Researcher, India
Worldwide, 830 women die daily from preventable causes related to pregnancy and childbirth, and unfortunately one fifth of these women reside in India (UNICEF). Maternal death accounts for highest share of Disability-Adjusted Life Year (DALY) and is more prevalent in rural areas as compared to urban ones. This is demonstrated in areas such as the Sundarbans, where geographically inaccessible terrain makes maternal health service delivery challenging.
How difficult it is to provide basic obstetric care in Sundarbans?
The Sundarbans - a UNESCO world heritage site - is famous for its Royal Bengal Tiger. People often jokingly say that in Sundarbans, Tiger is the first citizen whereas human interests take the back seat. This unique biosphere is home to 4.5 million people and is intersected by numerous tidal creeks and estuaries. This region is comprised of a group of 104 islands, with only 54 islands inhabited by people. Being situated in the southernmost part of Gnaga-Megna-Bramhapurta basin, this region is prone to sudden climatic shocks and climate change.
When seeking health care, the people of Sundarbans mostly depend on nearby Rural Medical Practitioners (RMPs), who practice modern medicine without any formal training. Formal health service delivery is available at village levels, but its role is limited up to preventive health care. For formal delivery care, one needs to come to the block level, which is, on average, a one to four hour journey, depending up on village location. Both the journey time and travel cost differs over a day and can take much longer if travelling overnight. As a result, most women in the Sundarbans deliver their baby at home with assistance from a RMP or traditional birth attendant. An earlier FHS India study found that in 55% of cases, the child is delivered at home and among them only 5% of births were assisted by formal health service providers.
In the near absence of formal delivery care at the grassroots level, Community Delivery Centers (CDCs) bring basic obstetric care to the doorsteps of hard-to-reach regions of Indian Sundarbans. In this public private partnership (PPP), the private partners – a Non Government Organization (NGO) - provide basic obstetric care, while government provides financial support as per the total number of deliveries. The contract between these two parties is renewable on a yearly basis.
What is the USP for a CDC?
The question is: how can the NGO reach this pocket when the government fails to do so? A recent piece of implementation research by IIHMR University and Sarvik Vivekananda Gram SevaSanstha (SVGSS), funded by theAlliance for Health Policy and Systems Research (AHPSR), tried to find a reply. SVGSS has been running CDCs in Sundarbans since the inception of this program.
The answer lies in the NGO’s usage of local human resources for managing a CDC and their link-up with frontline health workers. India launched a human cadre of Accredited Social Health Activists (ASHA)who are in their early 20s. This cadre is from the same locality and plays a pivotal role in ensuring antenatal check-ups and institutional delivery, in addition to the standard public health services. They receive financial incentives for ensuring institutional delivery of a mother in their service area, and CDCs arrange for additional incentives once an ASHA brings a mother to the CDC.
In a CDC, the medical staff, such as doctors and nurses, are from outside, while all other staff are from local areas with strong social networks with neighboring villages. This makes the job of the CDC easier in gaining acceptance of their service among the beneficiaries. In addition, it provides a 24 hour ambulance service, solving the issue of non-accessibility. While Government facilities do not provide an ambulance service, its availability at the time of actual need is questionable and, most importantly, CDCs are nearer than Government health facilities with basic obstetric care. All these factors bring a pregnant women to CDC.
What are the challenges of running a CDC?
The grass is greener on the other side, but only in perception. CDCs also face many challenges and those mainly stem from managerial issues. This PPP initiative is contractual in nature and often there is a delay in renewing the contract, with renewal processes or steps differing across CDCs. This often results in the service delivery coming to a halt. If the NGO is financially strong, sometimes it continues service delivery, but at their own risk.
Changing behavior is the toughest thing. If, once a CDC successfully generates demand for institutional delivery, they suddenly discontinue service for few months, this raises uncertainty among its beneficiaries. NGOs face the biggest challenge in this sphere and often they lose their medical doctors or staff nurse following a delay in their contract renewal.
What can be done to make this PPP initiative sustainable?
The main initiative needs to be taken at policy level. Maybe a long-term contract will solve uncertainty, but this requires strong monitoring on quality of care.
Additionally, it is crucial that NGOs collaborate. During our field work, we came across many defunct CDCs, where another NGO opened a new CDC in a neighboring village. Why can’t they provide the service from same facility, when it already had the required infrastructure? This demonstrates the current competitive relationship among NGOs. This not only puts them at the receiving end in front of government, but results in huge spending on infrastructural development. Once NGOs form a cartel and run the CDCs across Sundarbans this would minimize the risk without any disruption in service delivery.
This innovative service delivery model aims to achieve third Sustainable Development Goal (SDG) of ensuring healthy life and promoting well-being via seventeenth SDG of revitalizing the partnership for sustainable development. The CDCs role in ensuring safe delivery in hard–to-reach islands of Sundarbans is indispensible. So it is the need of the hour to ensure they remain reliably functional.
Find out more at HSR2018
You can find out more about this research at the Fifth Global Symposium on Health Systems Research, where I will be presenting. Join me on Friday 12 October from 9:00 – 10:30 in ACC room 4A -‘Community Delivery Center is our First Priority for Child Delivery’: A PPP Initiative for Basic Obstetric Care among Islanders of Indian Sundarbans