|Year : 2017 | Volume
| Issue : 3 | Page : 163-168
A study on implementation and factors affecting functioning of Chiranjeevi Yojna in Ahmedabad district of Gujarat
Rajendrasinh Bhikhuji Chauhan1, Rohit Vasabhai Ram2, Bhagyalaxmi B Aroor3
1 Department of Community Medicine, P. D. U. Medical College, Rajkot, Gujarat, India
2 Department of Community Medicine, M. P. Shah Government Medical College, Jamnagar, Gujarat, India
3 Department of Community Medicine, B. J. Medical College, Ahmedabad, Gujarat, India
|Date of Web Publication||9-Aug-2017|
Rohit Vasabhai Ram
Block No. 805, “King Palace” Apartment, Opposite Mehul Nagar Telephone Exchange, Mehul Nagar, Jamnagar - 361 006, Gujarat
Source of Support: None, Conflict of Interest: None
Aim: The aim is to study the bottlenecks and factors affecting the implementation of Chiranjeevi Yojna (CY) in Ahmedabad district.
Setting And Design: A cross-sectional study was conducted in six blocks of Ahmedabad district from April 2010 to June 2010.
Materials And Methods: We conducted detail interview of 50 beneficiaries of CY, 50 nonbeneficiaries of CY, 24 health workers and 13 doctors with pretested questionnaires after taking informed verbal consent. Data entry and analysis was performed using Microsoft Excel 2007 and Epi Info 3.5.1 software package.
Statistical Analysis: Percentages, Chi-square test, Wilcoxon matched – pair test were used.
Results: In more than 80% of the cases, place of delivery was decided by mother in law and husband, in both groups. It was seen that main motivator to join the scheme were Auxiliary Nurse Midwife (ANM) and Accredited Social Health Activist (ASHA) workers in 86% of the beneficiaries. In this study, beneficiaries were started antenatal visit early and taken more antenatal visits as compared to nonbeneficiaries and the difference is statistically significant. In this study, most of the beneficiaries were satisfied with the service but unsatisfied with the payment modalities. Very few beneficiaries have received cash assistance, and full payment (Rs. 200 + Rs. 50) was only given in around 10.53% of cases.
Conclusion: ANMs and ASHAs have been found effective in building awareness and guiding the clients to utilize the services. The level of education and awareness about CY was very low among the beneficiaries and nonbeneficiaries. Satisfaction with the service among client was quite good.
Keywords: Chiranjeevi Yojna, Gujarat, maternal mortality ratio
|How to cite this article:|
Chauhan RB, Ram RV, Aroor BB. A study on implementation and factors affecting functioning of Chiranjeevi Yojna in Ahmedabad district of Gujarat. Int J Health Allied Sci 2017;6:163-8
|How to cite this URL:|
Chauhan RB, Ram RV, Aroor BB. A study on implementation and factors affecting functioning of Chiranjeevi Yojna in Ahmedabad district of Gujarat. Int J Health Allied Sci [serial online] 2017 [cited 2020 Jul 10];6:163-8. Available from: http://www.ijhas.in/text.asp?2017/6/3/163/212600
| Introduction|| |
India has the second largest population in the world, also the largest number of births (27 million) and maternal deaths (117,100/year); it contributes 22% of all maternal death in the world and 62% of all maternal death in South Asia., Maternal mortality ratio (MMR) of India has decline from 301 per lake live birth in 2001–2003, to 230 per lake live birth in 2008, to 174 per lake live birth in 2015. However, the decline was not adequate to achieve the millennium development goals. MMR of Gujarat is 112 per lake live birth in 2015. It is argued that most of these maternal deaths are avoidable if adequate interventions are undertaken. A recent review of evidence recommends health center based intra-partum care mainly emergency obstetric care as the key strategy and most cost effective to reduce MMR. Another key constraint was nonavailability of obstetrics and gynecology specialists in the government sector in rural areas. Gujarat state has an estimated 17,738 registered doctors (with 2000 gynecologists) of which three-fourth are working in private health facilities.
To overcome this problem Gujarat government in collaboration with academic Institute (IIM Ahmedabad) and NGO (Sewa Rural-Jhagadia) implemented a public-private partnership scheme named “Chiranjeevi Yojna” (CY) – local name meaning “long life” (of mothers and babies) in April – 2005 on a pilot basis in five remote districts of state to provide delivery care to the poor and underprivileged in rural areas. Considering the success of the pilot project this scheme was scaled up to the entire state since October 2006. In CY government contracting with private obstetricians, to provide institutional services which include both normal and complicated delivery including C-sections operation and blood transfusion to target group which include below poverty line (BPL), schedule caste, schedule tribe, and above poverty line nontaxpaying families. The package of 100 deliveries for private practitioners who provide services at his/her nursing homes is Rs. 380,000. The private practitioner also has to give Rs. 200 as a transportation charges to beneficiaries.
It is necessary to study the bottlenecks and factors affecting the implementation of the scheme. Such operational study will support the effective implementation of the scheme. With this aim, present study conducted to assess the implementation of CY and associated factors in Ahmedabad district.
To study and compare service utilization factors among CY beneficiaries and nonbeneficiaries, to review the utilization pattern of services and reasons for nonutilization, to find the level of awareness about scheme among the beneficiaries and nonbeneficiaries, to obtain the views of service providers and field workers on administering the scheme.
| Materials and Methods|| |
A cross-sectional study was conducted from April 2010 to June 2010 in Ahmedabad district. Ahmedabad district has ten talukas (excluding Corporation area) but for implementation of CY district is divided into six blocks, namely, Sanand, Viramgam, Bavala, Dholaka, Dhandhuka, and Dascroi. The village representing the block (village with the same name as the block name) was selected for the study. As Dacroi is not representing the village with the same name, three villages in the block, namely, Bareja, Aslali, and Jetalpur were selected, and hence, total eight villages were selected. Permission was taken from the Ethical Committee of the Institute before caring out the study.
The scheme has involved different stakeholders in the process of implementation and therefore, it was decided to cover beneficiaries and nonbeneficiaries of the scheme and service provider like contracted private doctors and field health functionaries such as Accredited Social Health Activist (ASHA) worker, Female Health Worker (FHW), anganwadi worker, and Auxiliary Nurse Midwife (ANM). For this study, beneficiary was defined as women from BPL family who delivered within the past 4 months of starting the study and joined the scheme, and nonbeneficiary was defined as a woman from BPL family who delivered within the past 4 months of starting the study but not joined the scheme.
List of beneficiaries who had availed the services of the scheme was procured from the Block Health Officer (BHO) of respective block and also from the register of ANM of that area. Nonbeneficiaries of the scheme were selected from the same area as that of beneficiaries. A detailed interview was conducted with pretested pro forma. The field health workers who were working in the beneficiaries' area were also interviewed. The list of enrolled private doctors in each block was obtained from Chief District Health Officer, Ahmedabad and interviewed individually. Totally 50 beneficiaries, 50 nonbeneficiaries, 24 health workers and 13 doctors were selected from 8 villages by purposive sampling method. For qualitative data collection personal in-depth interviews were conducted. All the data were collected after taking informed verbal consent of the individual. Data entry and analysis was performed using Microsoft Excel 2007 and Epi Info 3.5.1 software package, to meet the study objectives, both quantitative and qualitative analysis were carried out.
| Results|| |
It was observed that in both the groups most of the mothers (74% in beneficiaries and 62% in nonbeneficiaries) were young and in the age group of 20–24 years. In both the groups, most of the mothers (64% in beneficiaries and 72% nonbeneficiaries) were from the joint family. Many mothers were illiterate (40% in beneficiaries and 52% in nonbeneficiaries). Almost all mothers (90% in beneficiaries and 76% in nonbeneficiaries) were housewives. However, the differences between two groups were not statistically significant [Table 1].
|Table 1: Sociodemographic characteristics of Chiranjeevi Yojna beneficiaries and Chiranjeevi Yojna nonbeneficiaries|
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It was observed that regarding the age of CY beneficiaries, they were young (mean age 23.56) and married at an early age (mean 21.34), but the difference with nonbeneficiaries group was not statistically significant. The CY beneficiaries had more average family members, less average per capita income and the more average number of living children as compared to nonbeneficiaries, but the observed difference was not statistically significant. While comparing the median cost of delivery, by applying the Wilcoxon matched – pairs test (or signed rank test), it was observed that amount spent for delivery was high in CY beneficiaries as compared to CY nonbeneficiaries which were statistically significant (Z = 3.96, P< 0.05) [Table 2]. In more than 80% of the cases, place of delivery was decided by the mother in law and husband, in both groups. It was seen that main motivator to join the scheme was the ANM/ASHA worker in 86% of the beneficiaries, whereas only 10% were suggested by the beneficiaries.
|Table 2: Comparative analysis of Chiranjeevi Yojna beneficiaries and Chiranjeevi Yojna nonbeneficiaries (n=50)|
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About 23.40% in nonbeneficiaries had initiated antenatal care (ANC) visits in the first trimester, whereas it was 48% in the beneficiaries group, which was very high as compared to nonbeneficiaries and the difference was statistically significant (P < 0.01). While comparing a total number of ANC visits, three or more than three ANC visits were taken by 76.60% of the nonbeneficiaries and 94% of the beneficiaries, the difference was statistically significant (P < 0.01). In both the groups, private vehicles were more used for transport compared to Emergency Management and Research Institute 108 ambulances which are free of cost service provided by the government of Gujarat. There were normal deliveries in most of the mothers in both the groups (76% in beneficiaries and 90% in nonbeneficiaries). As there were more numbers of normal deliveries, the timing of discharge from the hospital was within 24 h in most of the mothers in both groups [Table 3]. Most of CY beneficiaries were satisfied with services [Table 4]. Most common reasons for not joining the scheme among nonbeneficiaries were mainly unawareness about the scheme and charging of fees by some of the Chiranjeevi doctors [Table 5].
|Table 3: Utilization of maternal health services by Chiranjeevi Yojna beneficiaries and Chiranjeevi Yojna nonbeneficiaries|
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|Table 4: Satisfaction of the Chiranjeevi Yojna beneficiaries with services|
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|Table 5: Reason for not joining the scheme among non-Chiranjeevi Yojna beneficiaries|
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In most of the cases (62%), cash assistance was not given to beneficiaries. In case who received cash assistance (38%), it was given very late in most of the cases (68.41%). The amount decided in the guideline of Rs. 250 (200 + 50) was only given to 10.53% of the beneficiaries. Remaining beneficiaries received less than allotted amount [Figure 1].
To determine the various factors which affect the implementation at private practitioner level, in-depth interview with the doctors was made. Following is the summary of most common opinions of private doctors who are involved in the CY.
Skilled delivery care is provided to mother, especially in rural area free of cost and cash assistance is also given, and hence it is very useful to BPL families. There is an extra load due to lengthy documentation procedure and extra deliveries every month. There should be separate payment modalities for normal delivery and cesarian section. Extra payment should be made for complicated delivery, blood transfusion, Intensive Care Unit support, anesthesia, and medicines. As the payment is already very less, it should be tax-free. The timing of payment is not regular in most of the cases.
After taking personal interview of field health workers, we get following most common opinions.
There are no any incentives for FHW for motivating the beneficiaries to join the scheme. Many workers feel overburden due to the scheme as they have to look after many other programs. It is a very useful program for the poor people. Many doctors prescribing medicines from outside which cost a lot to the patient.
After taking personal interview of beneficiaries, following were the most common answers.
It is a very good initiative from the government for us (BPL families). We saved a lot of money and on the other hand also got free care from the private doctors. We did not get cash assistance from the doctors and even we paid charges for the delivery. We did not know that there is provision for free care and cash assistance for transport and attendants.
| Discussion|| |
The scheme mainly focuses on the underserved and poor families (BPL) in the remote areas where these families cannot afford specialist care. There are various factors which affect the implementation and proper functioning of CY. All the level stakeholders are responsible for it which includes (1) service provider (contracted doctors) (2) field health functionaries (3) beneficiaries. The present study is carried out to identify various factors responsible at each level.
To reduce the MMR, our major focus is to motivate the younger mother for institutional delivery because complications in first delivery will have deleterious effects on subsequent pregnancy. In the present study, the scheme is being used more by the younger mother. In rural areas, literacy level of the mother is very low, which is an important factor for nonutilization of the services. In this study, most of the mothers were illiterate and educated up to primary level in both groups.
One of the big hurdles for utilizing specialized care for delivery is a financial problem. Due to low-income level people in the rural area cannot utilize the specialized services which can be solved by Chiranjeevi scheme, but in this study, the average total expenditure incurred on delivery by beneficiaries was higher as compared to nonbeneficiaries due to various reasons like most of the nonbeneficiaries visited government health facilities for ANC and delivery services, whereas many of the beneficiaries were charged by some Chiranjeevi doctors for delivery care, investigations, anesthesia, and blood transfusion.
In rural India, the mothers have very limited decision power to seek health care. Mostly, elder female family member takes the decision about care during pregnancy. In this study, there was major influence of the mother in law and husband in deciding the place of delivery in both groups. The field health workers play a major role in explaining and motivating the people about various schemes and help them to utilize the services. In this study, ANM and ASHA have been the source of information to 86% of the beneficiaries.
The major determinants of the outcome of the pregnancy in terms of survival of the mother and child are antenatal care, timely transport to the health facility and type of delivery. ANC must be started early and taken regularly by all the pregnant mothers. In the present study, beneficiaries were started ante natal visit early and taken more antenatal visits as compared to nonbeneficiaries. Most of the mothers in both the group had normal delivery and were discharged within 24 h. Complicated cases were referred to the higher center. The private vehicle was more used for transport which is not equipped but easily available.
For the successful implementation and utilization of any scheme, it is very necessary to create awareness and to maintain satisfaction among the beneficiaries by providing quality services. In the present study, most of the beneficiaries were satisfied with the service but unsatisfied with the payment modalities. Very few beneficiaries have received cash assistance, and full payment (Rs. 200 + Rs. 50) was only given in around 10.53% of cases. The behavior of the staff and attention by the doctor were satisfactory in most of the cases. While most of the BPL nonbeneficiaries were not aware about the scheme and remaining, have various reasons not to join the scheme like money charged by private doctors for delivery care, the suggestion by relatives/friends.
The strength of the study is that this type of evaluation study was not done before and we collected not only quantitative but qualitative data from an open interview of participants. Limitations of the study are that in conducted only in six blocks of Ahmedabad district and among relatively small sample size, this type of study should be conducted in the whole state to evaluate the implementation of CY.
| Conclusion|| |
The scheme has not only provided linkage between the BPL community and the institution but also provided financial protection to marginalized section of the population. Large numbers of the clients using the scheme are young; therefore, this has implications for improving the health seeking behavior for future health needs. ANMs and ASHAs have been found effective in building awareness and guiding the clients to utilize the services. Their role in the process has been found quite important and needs to be strengthened. The level of education and awareness was very low among the beneficiaries and nonbeneficiaries. Satisfaction with the service among client was quite good.
The scheme needs to be specified care protocol to be followed by service providers. Issues related to use of drugs for the patients, standardized case reporting, duration of hospitalization following delivery, etc., need to be specified. There should be regular and tax-free payment to the provider. There should be strengthening the antenatal and postnatal care component and improving the package by adding the neonatal care component. Awareness should be generated in service providers, beneficiaries, and health functionaries for better implementation of the scheme. There should be strict monitoring system for the BPL certification to reduce fake BPL cards. Cash assistance to the beneficiaries should be directly from the block authority instead of from the provider to make it more transparent.
We would like to thank Block Health Officers of all the six blocks for giving us permission to do study in their area. Authors also thankful to all subjects who participated in the study and all the health workers, without their kind support and active participation this study was nearly impossible.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Progress for Children. A Report Card on Maternal Mortality. Vol. 7. UNICEF; September, 2008. p. 6.
Government of India, Maternal Mortality in India: 1997-2003 Trends, Causes and Risk Factors, Sample Registration System, Registrar General of India, New Delhi; October, 2006.
Trends in Maternal Mortality: 1990 to 2008, Estimates Developed by WHO, UNICEF, UNFPA and THE World Bank; 2010. p. 1.
Tyagi U, Pattabi K, Kaur P. Utilization of services under Janani Shishu Suraksha Karyakram for institutional deliveries in the public sector facilities, Sirmaur district, Himachal Pradesh, India. Indian J Community Med 2016;41:65-8.
] [Full text]
Bhalwar R, Vaidya R, Tilak R, Gupta RK, Kunte R. Textbook of Public Health and Community Medicine. Vol. 10. New Delhi, Pune, India: Department of Community Medicine, AFMC in Collaberation with WHO India Office; 2009. p. 816-21.
Koblinsky M, Matthews Z, Hussein J, Mavalankar D, Mridha MK, Anwar I, et al.
Going to scale with professional skilled care. Lancet 2006;368:1377-86.
Ramesh B, Verma BB, Elan R. Hospital efficiency: Analysis of district and grant-in-aid hospitals in Gujarat. J Health Manage 2001;3:167-97.
Kothari CR. Research Methodology Methods & Techniques. Revised 2nd
ed. Vol. 12. New Delhi: New Age International Publisher; 1990. p. 291-2.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]