Feb 9, 2004 ... We are also grateful to all people of 30 clusters, beneficiaries of the Vande.
Mataram Scheme and registered Vande Mataram Doctors for ...
A study on Vande Mataram Scheme in Ahmedabad District
By Indian Association of Preventive & Social Medicine (Gujarat Chapter) With Support of
Commisionerate of Health (Health, Medical Services & Medical Education)
ACKNOWLEDGEMENT Before starting this study is teamwork, and contributed by numerous people at one or another point of time. Inputs from each are very important and vital however more little it may be. We would first of all like to acknowledge Dr. Dhananjay Bhatt, Additional Director, Family Welfare, Gujarat State for inviting the organising and providing an opportunity to observe and study one of the important health activities of the Government. We are also grateful to all people of 30 clusters, beneficiaries of the Vande Mataram Scheme and registered Vande Mataram Doctors for sparing their valuable time and providing information to our investigators. We also extend our gratitude of thanks to Dr. Desai, Chief District Health Officer, Ahmedabad and his office staffs for making the baseline information on the scheme available to us. We also thank interns doctors, B. J. Medical College, Ahmedabad for enthusiastically participate in the study and collecting information without tiredness. We thank all staff member of Community Medicine Department, B.J.Medical College, Ahmedabad who have provided the base and extended support at every juncture of study. Finally, we extend our feeling of gratitude to all members of the team who have worked hard on the behalf of the organization to make it reality to put this report in your hand.
Dr. B. S. Bhavsar, President
Dr. K. N. Sonaliya, Secretary
Sr.
Content
Page no 1
A.
Executive Summary
B.
Vande Mataram Scheme
1.
Introduction
6
2.
Genesis & Rationale of the Scheme
7
3.
Initiation & Launching of scheme
7
4.
Objectives
8
5.
Operationalisation of scheme & Strategies
8
6.
Role of Government
8
7.
Role of Private Practitioners
8
8.
Responsibility of Government
9
a. Government of India b. Government of Gujarat 9.
Responsibility of FOGSI
10
10.
Expected outcomes
10
C
Material and Methodology
12
D
Observation & Discussion
1
Part : A – Community Survey
14
2
Part : B – Interview of Doctors
19
3
Part : C – Interview with Beneficiaries
23
E
Conclusion
33
F
Recommendation
33 ANNEXURE
Vande Mataram Study Team
Executive Summary Introduction Vande Mataram “a programme dedicated” to mothers was launched on 9 th February 2004 with the objective to improve the access of safe motherhood services and to reduce the maternal and neonatal deaths significantly. To fulfill these objectives, Obstetricians and Gynecologists of public and private facilities and NGOs are included. This programme was started with the objectives to bring the change in health seeking behavior utilizing resources/trained workforce available in private sector, improving the acceptance and access to family planning methods, detection and management of RTI/STI cases in pregnant women, improving institutional delivery and strengthen public private partnership. The Vande Mataram Scheme envisages….. a.
Provision of free OPD services including ante natal check up to all pregnant women and
b.
Family planning counseling to new mothers on the 9th of every month
………by private obstetricians and gynecologists Thus, aims to reduce maternal deaths significantly. In addition, the public facilities of Government will also observe 9th of every month as Vande Mataram Day and render special priority to expectant mothers in public sector, Government facilities. The scheme, which is a step towards public-private and civil society partnership, will be a voluntary scheme under the auspicious of the FOGSI, eventually such gynecologists / Lady doctors who are not members of FOGSI will also be able to participate
Material and Methods :The study was conducted in Ahmedabad district (city area + Rural area ) in December 2004 in two phases and three parts. Phase I :A : Community Survey
30 cluster sampling technique (Ward / PHC is cluste unit taken)
Probable / prospective beneficiaries women (360) and women of reproductive age group (600) were interviewed.
Phase II :B : Vande Mataram Doctor’s Interview
30 doctors were randomly selected (33% of total registration) and interviewed.
C : Beneficiary’s interview :
90 beneficiaries (10% of cumulative beneficiaries) randomly selected and interviewed.
1
Analysis : Data was entered in Microsoft Access and analysis was done in SPSS.
Salient observations : A. Community Survey
Total 960 women (360 pregnant / postnatal and 600 non pregnant women) of reproductive age group were studied out of 30 clusters. 71 % of the women were from 21 – 30 years age group.
Only 3.2 % were aware about the Vande Mataram Scheme.
Health workers were the source of information in most of the cases.
6.67 % was the utilization rate of Vande Mataram scheme.
Most of the beneficiaries had undergone ante-natal check-ups.
Almost 90 % underwent urine, Hemoglobin, B.P. examination and taken T.T and IFA tablets.
Out of 60 postnatal women 16.67 % underwent postnatal check-ups.
Note : Out of total women who were aware about scheme 93 % and 100% who had utilisized were reported from the one cluster in community survey.
2
Part B: Doctor’s Interview :
Average service utilization is 5.1 beneficiaries per doctor for last 11 months (i.e. since inception of the scheme.
Monthly average of service utilization is 0.47 beneficiaries /per doctor i.e.around one patient per two months.
93 % of the doctors believes the scheme is not adequately utilized by the
66.6% doctors have received “Vande Matamram LOGO Board’ and all of them have displayed it.
Most of the doctors (>80%) were satisfied with the regularity and adequacy of the supply of ANC cards and IFA tablets and FP devices.
60 % doctors felt that the scheme is good.
70 % of the doctors were of the opinion that more awareness should be generated to improve the scheme.
Part C: Beneficiary’s Interview
Among the registered beneficiaries almost half were in 25-29 years of age group.
99 % of the beneficiaries were housewives.
71 % of the beneficiaries were educated upto or beyond higher secondary level.
66.66% of the beneficiaries belonged to Class II or class III socio economical status.
Doctors were the source of information for the 90 % of the beneficiaries.
39 % of the beneficiaries were primi-gravida.
Almost 92 % of the beneficiaries availed the antenatal services of the scheme rest has utilized for Family Planning consultation.
All of them were given the ANC card by doctor but only 10 % of the beneficiaries showed the card to the card to the investigators at the time of visit.
32.7% had expressed satisfaction with the service while Majority 66.7% found the programme to be O.K i.e. average.
All the beneficiaries were willing to motivate other females to avail the services
82 % of the beneficiaries wanted that their delivery should be conducted at private hospital.
3
Discussion and derivations : 1. It was perceived as a good scheme by both, provider i.e. volunteered doctors and beneficiaries and adequately support in terms of the supply from the government sector, very poor awareness and utilization rate of the scheme was noted. 2. For gross inadequate utilization two key reasons can be traced. a. Lack of awareness about existence of the scheme. b. Not practicing the key principle of the scheme by Vande Mataram Doctor i.e. free consultation for Antenatal care and family planning services to all the eligible mothers on 9th of each month in their private practice. 3. More than 80% of doctors has expressed satisfaction about regularity and adequacy of the supply. Regularity shows the better fulfillment of the responsibility by the Government but adequacy should be viewed under the light of low utilisation of the services.
4
Recommendations: 1. It is required to reimbibe the key concept of providing free of cost consultation and family planning services to all eligible mothers coming on 9th of the months, In the registered doctors by health officials, since it has got tremendous implications on success. For that regular meetings with private practitioners should be carried out by them. 2. FOGSI is the key organisation in institution of this scheme, their interest, involvement, and active participation should be revived to strengthen the Private sector’s contribution. 3. Lack of awareness is the presently first and foremost bottleneck observed in the implementation of the programme and which needs to be taken up vigorously. 4. As it was envisages under the scheme that District collector should give advertisements on every 9th of month in local newspapers highlighting the features and name of the doctors registered under. This operational guidelines was also seems to be not in practice and need to be initiated and make it regular. 5. As it was suggested in the operational guidelines, practice of regular review at the end of three months should be reinstituted at State, district level together by both partners.
********
5
VANDE MATRAMA SCHEME Introduction : In any community, mothers and children constitute a “priority group” and are considered as “special risk group”. From a study carried out jointly by WHO and UNICEF on maternal mortality, it is estimated that 99 % of maternal deaths occur in developing countries. India is among those countries, which have very high maternal mortality. High maternal mortality reflects inadequacy of health care services for mothers. Maternal Mortality in India is estimated to be 407 in 1998 (SRS-RGI). This is significantly higher compared to even the countries like Sri Lanka where it is about 60. The tenth Plan target is to bring it down to less than 200 by the year 2007.
In the world as a whole, the problem of maternal mortality is principally one of applying existing obstetric knowledge through Antenatal, Intra-natal and post-natal services rather than developing new skills. Antenatal care is the care of woman during pregnancy. The primary aim of antenatal care is to achieve at the end of pregnancy a healthy mother and a healthy baby. For achieving this outcome, Government has introduced several health programmes time and again. Child Survival and Safe Motherhood programme was started in August 1992. With additional components this programme was renamed as Reproductive and Child Health programme in 1997. Thus Maternal mortality in India is unacceptably high and is one of the main concerns of the Deptt. of Family Welfare. Availability and accessabily to the antenatal, natal and postnatal care to all mothers is the major approch and key bottneck for reducing the the maternal mortality in India.
Their are multitude of health care providers such as Ministry of Health, Municipality, Private Sector, NGOs etc. with ill defined roles and poor coordination. A well coordinated effort involving both public sector and the NGOs can help address a number of crucial issues for effective functioning of reproductive and child health programme. NGOs can play an important role in identifying the neediest hidden pockets. National Health Policy 2002 welcomes the participation of private sector in all areas of health activities whether primary, secondary or tertiary.
6
Genesis of Vande Matram Scheme Currently, the Government health care system have only limited numbers of gynecologists. Against the 3043 CHCs in the country there are only 780 Obstetricians and Gynecologists for providing safe motherhood services. With a view to obviate the problem of lack of Gynecologists, it is proposed to take up the scheme titled “Vande Matram” for providing free safe motherhood services including immediate post natal care on a fixed date of every month by all Gynecologist both in public and private facilities including NGOs. Federation of Obstetrics and Gynecological Society of India (FOGSI) which has 18,000 Obstetricians and Gynecologists on its roll as its members has responded to the call of Smt. Sushma Swaraj, then Minister of Health and Family Welfare of India to come forward and render antenatal/ postnatal service on the 9th of every month free of cost. Thus, the concept of Public Private Partnership is actualised in the area of Maternal Care.
Rationale of the scheme : Data on major causes of maternal mortality is available from the SRS of the registrar General of India. The major causes of maternal mortality are ante and Postpartum hemorrhage, anaemia, Obstructed labour, hypertensive disorders, post partum sepsis and unsafe abortions and quick repeated pregnancies. Deaths due to anaemia, obstructed labour, Hypertensive disorders and sepsis are preventable with provision of adequate antenatal care, referral and timely treatment of complications of pregnancy. District household survey (1998 – 99) shows that about 33% pregnant women avail of even a single antenatal check up. Thus the need to find an alternative measure to provide safe motherhood service to all, pregnant women is sought, through the Vande Mataram Scheme by involving the private practitioners and making their experties and services accessuble free of cost to the mothers on a specific identified day of a month.
Initiation of the scheme : Immediately meetings with local members of FOGSI and also other obstetricians and gynaccologists from the private and public sector working in your district, and below levels was called. They were informed about the Vande Mataram Scheme and persuaded to participate in the scheme. Number of the copies on the detail of scheme were printed and distribute to Doctors, NGOs and others In order to ensure that all probable benificiaries do come to know who the volunteer Vande Mataram doctors are, the District IEC fund was utilized for appropriate insertions/advertisements highlighting the scheme in local hews papers most popularly read in your district on 9 th of February, 2004 i.e. day the scheme come into existence.
Launching of the shceme : The Vande Mataram Scheme was formally launched on 9th of February, 2004 at Ahmedabad by then Cetral Health Minisiter and several public functions were also organised at different district head quarters in the state and thoughout country.
7
Objectives of the scheme: 1.
To bring about the change in health seeking behaviour of and for expectant and new mothers and to creat awareness in the family and community the need for safe motherhood.
2. To involve and utilize the vast resourccs and specialist/trained workforce available in the private sector and the private sector infrastructure for providing obstetric care on the 9 th of every month. 3. To improve the acceptance and access to family planning methods through improved family planning counseling during both antenatal and postnatal period. 4. To detect for management of RTI/STI cases in pregnant women. 5. To improve institutional delivery. 6. To reduce the incidence and prevalence of nutritional anaemia in pregnant women. 7. To strengthen public, private and civil society partnership. Strategy & Operational Guidelines:
The scheme is in the pursuance of public-private and civil society partnership. It is a voluntary scheme under the auspicious of the FOGSI, eventually such gynecologists/Lady doctors who are not members of FOGSI will also be able to participate. It proposes to involve practicing Obstetricians and Gynecologists from the Government sector, the private sector including NGOs for providing the free Services at their clinics or by visiting the nearest CHC/ Public hospital.
The Scheme envisages…. Role of Private Obstetrician & Gynecologist …. 1.
Gynecologists /Lady doctors will provide
a). free antenatal/post natal services for pregnant women/new mothers and b) family planning services to new mothers……… ………on the 9 of every month. 2. Refer such women which is requiring treatment for complications if necessary, to pre identified and designated centres. Role of Government…… 1.
Public facilities of Government will also observe 9 th of every month as Vande Mataram Day and render special priority to expectant mothers in public sector, Government facilities.
2. In case some Gynecologists/lady doctors in private sector volunteer, they may be permitted to visit nearby CHC/FRU/Sub-district hospital for this purpose.
8
Operationalisation of the scheme : Responsibility of Government : The Government of India 1
To develop a suitable communication package for creating awareness amongst the people about the scheme.
3. To give a LOGO BOARD to identified volunteer doctors through district from the fund of the Department of Family Welfare or any other fund at district disposal. 4. To supply IFA Tablets to Vande Matram doctor for distribution to pregnant Women. 5. To supply Contraceptives including IUD to Vande Matram doctor for free distribution. 6. To provide Vande Mataram enrollment cards to registered doctors so that antenatal cases may be issued the same. 7. To ensure availability of supplly to the enrolled Vande Mataram doctors through local health authroity. 8. To recognize the participating gynecologists/Lady doctors by giving a certificate recognizing their participation and permitting them to display that they are providing free/voluntary services as part of RCH programme.
Extension of responsibity in future : 9. Government has proposed to extend legal and insurance /indemnity protection to the participatingng doctors to ensure that they do not face any adverse consequence due to Consumer Protection Act while delivering the service under scheme. 10. To devlop and implement a scheme whereby compensations/ transaction costs permitted for family planning procedures like Tubectomy, vasectomy and insertion of IUD currently available at Govermnent, institutions will be available for Vande Mataram Doctors also. State Governments 1.
State Governments and FOGSI will identify State and District coordinators for this scheme.
2. All hospitals/FRUs in the Government sector will be issued instructions to give priority to Vande Mataram card holders. 3. District Collectors to give advertisement every month in the local newspapers highlighting the Scheme and giving the names of newly enrolled Vande Mataram Doctors. 4. Adequate number of iron folic acid tablets will be provided to the hospitals and clinics by the State/Districts. 5. Contraceptives for free distribution, IUD for birth spacing and sterilization for permanent methods. 6. To ensure that the supplies are sent to the Vande Mataram Doctors and the Doctor is not made to waste his time by being asked to come to the Govt. supply points.
9
7. To hold fortnight motivational enrollment meetings in the districts till 8th of April, 2004 so that maximirn participation can is secured. Thereafter, Chief Medical Officer and district authority cn cominue to propagate the scheme and enroll more doctors. 8. District Collector to publish periodic small advertisements on 9h of every month in local newspapers, informing about the newly enrolled doctors to the public and also the main message of the scheme. 9. To invite local NGOs to locate and motivate private doctors to enroll.
FOGSI 1.
The FOGSI will involve all the 167 local societies in each of which they will initially identify at least two volunteer specialists.
2. Such identified volunteer specialists will provide free services on the 9th of every month to all antenatal cases. 3. Initially the free service will include only antenatal / post natal examination and counseling/ advice regarding contraceptive, diet, immunization, delivery etc. 4. Complicated cases will be suitably advised regarding further management and institutional delivery.
Expected Outcome of the scheme : Public Private and civil society partnership will improve, improvement in acceptance of spacing and family planning methods leading to reduction in unwanted pregnancy, Reduction of maternal and nenatal deaths and wide recognition that safe motherhood needs medical care and antenatal checkup.
Review : The scheme will be reviewed every three months with objective to further improvement.
10
Objectives : 1.
Assessing among
the the
awareness
of
scheme
prospective/probable
beneficiaries, 2.
Knowing the utilization rate.
3.
To
find
out
bottlenecks
in
the
implementation of the scheme. 4.
Satisfaction level among beneficiaries.
11
Materials and Method The study was conducted in the Ahmedabad district (city area + Rural area), covering a population of 50,00,000. In rural areas, PHC areas where doctors are registered were included for the study. Study Period :- The study was carried out in December 2005.
Sampling Methodology :- The study was carried out in two phases.
Part I :- Community Survey (Probable/eligible prospective beneficiaries)
30 cluster sampling was used. Ward / PHC were used as a cluster unit. Their population were listed and 30 clusters were selected from them.
360 i.e. eligible mothers (pregnant / mother with child of two months age) and 600 women of reproductive age. The 360 women was calculated out by considering 50% utilisation rate and 10% allowable error. Total 960 (360 pregnant / postnatal + 600
non-pregnant women) were
interviewed. 32 women (12 pregnant / postnatal women + 20 nonpregnant) were taken up from each of the cluster. (Annexure : II)
Part II :- Interview of doctors registered under scheme
30% of the total registered i.e. 30 doctors were randomly selected and interviewed. (Annexure : II)
Part III :- Interview of beneficiaries Approximately 900 beneficiaries have been registered in
Ahmedabad
district since its inception i.e Feb 2004. 10 % (90) of the total registered beneficiaries
were
interviewed
at
their
residence.
3
beneficiaries
registered under 30 doctors were selected for the interview. (Annexure : III)
12
Study instrument :A pre-designed and pre-tested proforma was used. Separate proformas were used for probable beneficiaries, Doctors and registered beneficiaries.
Analysis : Data was entered in Microsoft Access and analysis was done in SPSS.
13
OBSERVATIONS & FINDINGS Part A : Community Survey Total 960 women (360 eligible beneficiaries and 600 non pregnant women of reproductive age group) were studied from 3697 households of 30 clusters. To get 360 eligible beneficiaries 4763 women of reproductive age group were contacted. Table : 1. Age group of studied women
Sr.
Age group
No
%
(n=960)
(100%)
1
< 20
112
11.67%
2
21 to 30
684
71.25%
3
31 to 40
137
14.27%
4
> 41
27
2.81%
Majority of them were (71 % ) from 21-30 years age group, while 14.27% were from 31 to 40 years of age group and 11.67% were below the age of 20 years. Out of 360 eligible women 300 women were currently in antenatal period while 60 women were in their post natal period. (Table:1)
14
Table : 2. Knowledge regarding Vande Mataram Scheme Knowledge (n=960) Yes*
NO
No
31
929
%
3.20%
96.80%
Source of information Health worker
Neighbor
Others
No
29
1
1
%
93.55%
3.23%
3.23%
* Out of total 29 were reported from the one cluster only. Out of total 960 women studied, 96.80% women had denied the knowledge about the scheme. Only 3.20% had heard about the Vande Mataram scheme, out of them 93.55% got the knowledge through Health worker, and rest had got the information through neighbor or other source. (Table : 2) When the women who had who had knowledge about the scheme were asked about their willingness to avail the service, 93.55 % had expressed readiness to utilize/or had utilized services. 7% woman were not in favor of utilizing the scheme. Since the can afford the services the had denied to avail the service under the scheme (Table : 3)
15
Table : 3 : Like to avail/availed Vande Mataram scheme Sr.
Response*
1
Yes *
2
No Total
No
% 29
93.55%
2
6.45%
31
100%
* Out of total, 29 were reported from the one cluster only.
Out of the total 360 eligible prospective beneficiaries studied, only 11 mothers had taken the benefit of scheme. Rest had either availed services from private clinics (non vande matram), or municipal hospital. Few of them
Thus 6.67%
was the utilization rate of the Vande Mataram Scheme. Almost all of them had given the unawareness about the scheme as the reason for not availing the scheme. (Table : 4) Table : 4 : Utilization rate of Vande Mataram scheme.
Sr.
Registered No
1
Yes*
2
No Total
%
11
6.67%
349
93.33%
360
100%
* All of them were reported from one cluster only.
16
Table : 5 : Status of investigations in Antenatal Women.
Status of check-up Antenatal check-ups
IFA tablets
T.T.
Undergone urine examination
Undergone Hb. Estimation
Undergone TORCH examination
Weight checked
Undergone B.P. examination
No. (n =360)
%
Completed
317
88.06
Not completed
43
11.94
Taken
346
96.11
Not taken
14
3.89
Taken
306
85
Not taken
54
15
Yes
344
95.56
No
16
4.44
Yes
344
95.56
No
16
4.44
Yes
32
8.89
No
328
91.11
Yes
325
90.28
No
35
9.72
Yes
267
71.17
No
93
28.83
Majority (88.06 %) of the beneficiaries had undergone antenatal check-ups from either of the facilities. 96.11 % were given IFA tablets, 85 % have taken T.T, 95.56 % had undergone Urine and hemoglobin examination respectively. 8.89 % had undergone TORCH examination. 90.28 % beneficiaries got their weight check-up and 71.17 %had undergone B.P. examination. By and large it seems that majority of them had been investigated and prescribed as per the ANC norms. Majority of the beneficiaries had availed services from one or the other place. (Table:5)
17
Table : 6 : Status of check-up in postnatal women.
Undergone Postnatal check-up
No. (n = 60)
%
Yes
10
16.67
No
50
83.33
Sixty women were in their postnatal period. Out of the them women only 16.67 % had undergone postnatal check-ups and a huge portion (83.33 %)of the women had not undergone postnatal check-ups. This suggests that enough awareness about the importance of antenatal check is present and good practice is also existing but need and importance of examination are yet not realized in the community. (Table :6)
18
post natal
Part B : Survey of registered doctors. Total 154 women were registered with the 30 interviewed doctors since the initiation of the scheme. It comes around total average 5.1 beneficiaries last taken the services per doctor for last 11 months i.e. since inception of the scheme and one mother is taking the benefit of scheme in two months per doctor. (Monthly average per doctor is 0.47, i.e. nearly half-patient per doctor/month). As per the operational guidelines to all antenatal and postnatal mothers have be provided free of cost consultation on 9th of each month, but based on this figure, it seems that this practice is not followed at the clinics on designated date of month. Table : 7 : Doctor’s view on utilization of the Scheme
Utilization
No.
%
Adequate
2
6.67
Inadequate
28
93.33
Total
30
100
When asked about the their views on utilization of the scheme 93.37% had agreed about the low utilisation of the scheme, while 7 % of the doctors had expressed that the scheme is being utilized adequately. (Table :7)
19
Table : 8 : Doctor’s opinion for Inadequate utilization.
Reasons
No.
%
Inadequate publicity
27
90%
My clients preferred paid services
5
16.67%
When they were asked on the inadequate utilisation of the scheme, 90% of opinion were towards lack of knowledge because of inadequate publicity. 17 % of opinion were in the favour of the notion of the people that paid services offer more attention and care were of the doctors gave this reason for inadequate utilization of the services. (Table:8)
Table : 9 : Provision of board and display at clinic
FINDINGS
YES
NO
TOTAL
NO.
%
NO.
%
NO.
%
Provided
20
66.67
10
33.33
30
100
Board displayed
20
66.67
10
33.33
30
100
To provide the Vande Mataram logo board is the responsibility of the district health authority. Two third of the studied doctors were provided boards and all of them had displayed board in their clinic. (Table:9)
20
Table : 10 : Supply of FP devices /ANC card / IFA tablets Supply
REGULAR
IRREGULAR
TOTAL
NO.
%
NO.
%
NO.
%
FP devices
28
93.33
2
6.67
30
100
ANC card
24
80
6
20.00
30
100.
IFA tablets
26
86.67
4
13.33
30
100.
As per the operational guidelines district health officials have to provide FP devises, ANC card and Iron Folic Acid tables in order these can be supplied to Vande Mataram Beneficiaries free of cost. Most of doctors were satisfied with regularity and adequacy of supplies of Family Planning Devices, ANC card and IFA tablets. (Table : 10 & 11) Table : 11 : FP DEVICES / ANC CARD / IFA TABLETS Supply
ADEQUATE
INADEQUATE
NO.
%
NO.
%
NO.
%
FP devices
27
90
3
10
30
100
ANC card
24
80
6
20
30
100
IFA tablets
25
83.33
5
16.67
30
100
21
TOTAL
Majorities of the doctors were of expressed that it is a good scheme but only 35.48 % were feeling that it is not adequately utilized. Only 3.23 % doctors were having dissatisfaction with the scheme due to poor supply of the logistics. (Table : 12) Table : 12 : Experience of Doctors regarding the Scheme .
Experience/opinion*
NO.
%
Good scheme
19
61.29
Not properly utilized by beneficiaries
11
35.48
Poor supply
1
3.23
Total
30
100.00
* Multiple answers. Table : 13 : Suggestions by the Doctors to improve the scheme. Suggestions to improve
NO.
%
Publicity / awareness
16
69.57%
Supply of logistic
3
13.04%
Regular follow up by government
2
8.70%
Day should be changed
1
4.35%
Involvement of more doctors
1
4.35%
*Multiple answers.
Majority (70 %) of the suggestion were in favour of increasing awareness while 13 % suggestion were towards ensuring adequate supply of logistics to improve the utilization of the scheme. 8.7% suggestion do asked the greater involvement of Government and rest suggestions were in foavour of changing the day and increasing the involvement of doctor. (Table:13)
22
Part C : Interview of registered Beneficiaries. Three beneficiaries from the list of each selected doctors were chosen randomly. They were visited and their place and detail interview were taken. All the beneficiaries availed the services at the private hospital of the registered doctors and all were examined by the specialists. Table : 14 : Age – Group of the registered beneficiaries. AGE – GROUP
NO.
%
20-24
35
38.9
25-29
50
55.6
30-34
5
5.6
Total
90
100.0
(IN YEARS)
Almost half of the beneficiaries were in 25 – 29 years age-group while around 39 % of the beneficiaries were in 20-24 years age-group and only 5.6% were 30 or above the 30 years of their age. (Table : 14) Table : 15 : Occupation of the registered beneficiaries.
Occupation
NO.
%
Housewife
89
98.9
Labourer
1
1.1
Total
90
100.0
Most (99 %) of the beneficiaries were housewives. Only 1 % of the beneficiaries were labourers. Not a single woman was reported professional/employed. (Table : 15)
23
Table : 16 : Literacy Status of the registered beneficiaries.
Literacy Status
NO.
%
Illiterate
4
4.4
Primary
6
6.7
Secondary
16
17.8
Higher secondary
30
33.3
Graduate
34
37.8
Total
90
100
Majority (71.1 %) of the beneficiaries were educated up to or beyond higher secondary level. Only 4.4 % beneficiaries were illiterates. Education is related to the utilization of services and this may be the reason for availing the health service. (Table : 16) Table : 17 : Literacy Status of the husband of the beneficiaries. Literacy status
No.
%
Illiterate
2
2.2
Primary
1
1.1
Higher Secondary
15
16.7
Graduate
62
68.9
Post graduate
4
4.4
Professional
6
6.7
Total
90
100.0
Almost 70 % of the beneficiaries’ husband were graduates. This may be the motivating factor for their wives for availing the health services. Also, education of husband is linked with income generation which is anther factor for choosing type of the facility and availing the services. (Table: 17)
24
Table : 18 : Socioeconomic status of the beneficiaries. Socioeconomic status
No.
%
Class I
26
28.90
Class II
48
53.33
Class III
12
13.33
Class IV
4
4.44
Total
90
100.00
Almost half of the beneficiaries belonged to Class II socioeconomic status and 13.33% were from the belonging to the Class III. These are the middle and lower middle class people. Together they constitute 66.66% of the total. One third of the beneficiaries belonged to Class I socioeconomic status. Only 4 % beneficiaries were from Class IV socioeconomic status. These is the group which was targeted to take maximum benefit of the scheme but found very small proportion of the beneficiaries. (Table : 18)
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Table : 19 : Source of information regarding Vande Mataram Scheme Source of information
NO.
%
Doctors
80
88.9
Pamphlets – Posters
3
3.3
Beneficiaries
7
7.8
Total
90
100.0
Majority (88.9 % ) of the beneficiaries came to know about the scheme through Doctors. Only few (7 %) beneficiaries got the information through already registered beneficiaries. Thus mouth to mouth publicity was noted weak in the spreading the words about the scheme, while other mass media had non-significant role. (Table : 19)
Table : 20 : Order of pregnancy Order of pregnancy
NO.
%
1
35
38.9
2
33
36.7
3
18
20.0
4
4
4.4
Total
90
100.0
39 % of the beneficiaries were primigravida. The reason may be that those females who became pregnant for the first time may be more conscious regarding their child and were availing the services provided by the specialists. (Table : 20)
26
Table : 21 : Family size (No of living children) of the beneficiaries. Family Size
NO.
%
0
36
40.0
1
32
35.6
2
18
20.0
3
3
3.3
4
1
1.1
Total
90
100.00
Majority (95.6 %) of the beneficiaries had children ranging from nil to two. Only few (1.1 %) of the beneficiaries had four children. (Table:21)
Table : 22 : Bad obstetric history Bad obstetric history
Yes
NO.
%
Caesarian section
1
1.1
Spontaneous abortion
1
1.1
No
88
97.8
Total
90
100.0
Only 2 % of the beneficiaries had bad obstetric history. One beneficiary had past history of spontaneous abortion and one had past history of Caesarian section. (Table : 22)
27
Table : 23 : Services availed by the beneficiaries. Services
NO.
Antenatal Family Planning Total
% 83
92.2
7
7.8
90
100.0
Most (92.2 %) of the beneficiaries availed the Antenatal services. 8 % beneficiaries availed the Family Planning services. (Table : 23) Table : 24 : ANC Cards with Beneficiaries. ANC card
NO.
%
Present
9
10.00
Lost
58
64.40
Could not find
23
25.60
90
100.00
Not Present
Total
When beneficiaries were asked for the availability of the ANC card, only 10 % reproduced the card to the investigators. Majority (64.4 %) of them lost the ANC Card while 25.6% were unable to find the card at the time of study. It showed that the importance of ANC card was realised by very few. (Table : 24)
28
Table : 25 : Charges paid by the beneficiaries. Charges paid
NO.
%
Yes
6
6.67
No
84
93.33
Total
90
100.0
93.33 % of beneficiaries had availed free of cost laboratory services. 7 % of the beneficiaries paid for the investigations. (Table : 25) Table : 26 : Advise given to the beneficiaries. Advise given regarding*
No.
%
Family planning
63
70.00
Diet
83
92.22
Rest
77
85.56
Breast feeding
19
21.11
Danger signs
17
18.89
Follow – up
75
83.33
*Multiple answers expected. Most of the beneficiaries (92%) were given the advice regarding the diet while 86 % and 83 % of the beneficiaries were advised for the rest and follow-up respectively and 70 % were advised regarding the Family Planning. Only 19 % of them were advised regarding the timely advise on appearance of danger signs. (Table : 26) Only two patients were referred to other hospital. One was referred for L.S.C.S. and other for the Pre-eclampsia. (Table : 26)
29
Table : 27 : Satisfaction among the beneficiaries Experience
No
Satisfied* Check-up done nicely
27
Check-up done by the specialist
26
%
Total 32.2
15
Check-up done free of cost
4
Check-up done regularly
8
Advise regarding F.P. Programme is given Not satisfied
1
1.1
O.K.
60
66.7
Total
90
100.0
*Multiple answers. Out of the total surveyed beneficiaries one third of the beneficiaries were satisfied with the programme. Most (66.7 %) of the beneficiaries found the programme to be O.K. i.e. average. Only 1.1 % were not satisfied with the programme that too because of inconvenient timings to them. (Table : 27) Table : 28 : Recommendation to other females to avail the services. Recommendation
NO.
%
Yes
89
98.89
No
1
1.11
Total
90
100.0
Almost all of the beneficiaries replied that they will motivate other females to take the benefit of Vande Mataram Scheme. Surprisingly one beneficiary replied that she will not motivate other females to avail the services under this scheme. (Table : 28)
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Table : 29 : Preference for place of delivery. Place of delivery
NO.
%
Private Hospital
74
82.22
PHC
8
8.89
Not applicable (postnatal women)
6
6.67
At home
2
2.22
Total
90
100.0
Majority (82.22 %) of beneficiaries replied that they will give preference to the private hospital for their delivery while 9 % gave PHC as their preference for the delivery. Surprisingly 2 % of the beneficiaries were interested in the home delivery. (Table : 29) Several important suggestions given by beneficiaries to improve the scheme were :1. Adequate and appropriate publicity of the programme should be done through print and press media. 2. There should be involvement of more doctors. 3. The programme should be properly implemented. 4. Adequate and appropriate advice should be given to the patients by the Doctors.
31
SUMMARY
A cross-sectional study was carried out in December 2004 to study the Vande Mataram Health Scheme. The study was carried out in 3 phases. In the first phase the probable / prospective beneficiaries were interviewed to know the utilization rate of beneficiaries. In second phase doctors registered in the scheme were interviewed. In the third phase beneficiaries registered in the scheme were interviewed. Total 960 women (360 pregnant / postnatal and 600 non pregnant women) of reproductive age group were studied. 71 % of the women were from 21 – 30 years age group. Only 3.2 % were aware about the Vande Mataram Health Scheme. Health workers were the source of information in most of the cases. 6.67 % was the utilization rate of Vande Mataram Health scheme. Most of the beneficiaries had undergone ante-natal check-ups. Almost 90 % underwent urine, Hemoglobin, B.P. examination and taken T.T and IFA tablets. Out of 60 postnatal women 16.67 % underwent postnatal check-ups. Average registration of the beneficiaries came out to be 5.1 since last 11 months of the starting of the scheme. According to 93 % of the doctors, the scheme is not adequately utilized by the beneficiaries, reason being the inadequate publicity. Board for the awareness of the scheme was displayed by those doctors who were provided with the board. Majority of the doctors were satisfied with the regularity and adequacy of the supply of FP devices, ANC cards and IFA tablets. 60 % doctors felt that the scheme is good. 70 % of the doctors were of the opinion that more awareness should be generated to improve the scheme. Among the registered beneficiaries almost half were in 25-29 years of age group. 99 % of the beneficiaries were housewives. 71 % of the beneficiaries were educated up to or beyond higher secondary level. Almost 70 % beneficiaries’ husbands were graduates. Doctors were the source of information for the 90 % of the beneficiaries. 39 % of the beneficiaries were primigravida. 2 % of the beneficiaries were having bad obstetric history. Almost 90 % of the beneficiaries availed the antenatal services of the scheme. Only 10 % of the beneficiaries showed the card to the card to the investigators at the time of visit. All the beneficiaries availed the services at the private hospital of the registered doctors. Majority of the beneficiaries found the programme to be O.K. All the beneficiaries were willing to motivate other females to avail the services. 82 % of the beneficiaries wanted that their delivery should be conducted at private hospital.
32
CONCLUSION & RECOMMENDATIONS
As any new programme takes time for fulfilling its objectives, this scheme will also take time for its effective utilization. According to the survey, the scheme was perceived as a good scheme by both providers i.e. volunteered doctors and beneficiaries. 1. It is required to reimbibe the key concept of providing free of cost consultation and family planning services to all eligible mothers coming on 9th of the months, In the registered doctors by health officials, since it has got tremendous implications on success. For that regular meetings with private practitioners should be carried out by them. 2. FOGSI is the key organisation in institution of this scheme, their interest, involvement, and active participation should be revived to strengthen the Private sector’s contribution. 3. Lack of awareness is the presently first and foremost bottleneck observed in the implementation of the programme and which needs to be taken up vigorously. 4. As it was envisages under the scheme that District collector should give advertisements on every 9th of month in local newspapers highlighting the features and name of the doctors registered under. This operational guideline was also seems to be not in practice and need to be initiated and make it regular. 5. As it was suggested in the operational guidelines, practice of regular review at the end of three months should be reinstituted at State, district level together by both partners. 6. Thus lack of awareness is the presently first and foremost bottleneck observed in the implementation of the programme and which need to be taken up vigorously. Also it is observed that the all patients coming on 9th of the months are not consulted free of cost which was the key guidelines under the scheme with tremendous implications on success. It is required to re-imbibe this concept in the registered doctors for improving the utilization of scheme.
************
33
Annexure : I QUESTIONNAIRE FOR THE WOMEN OF REPRODUCTIVE AGE GROUP ( PROSPECTIVE BENEFICIARIES)
Cluster No. :-
Locality :-
Dist :- Ahmedabad
Details
Married women (18–45 yrs)
Women number in cluster (1). Age (in Years) (2). Knowledge regarding any programme for mothers Yes / No (3). Knowledge regarding Vande Mataram Scheme Yes / No (3) a. If Yes, (i) From where did you get the information ?Advertisement = 1, Neighbours = 2, Health workers = 3, From registered beneficiaries = 4, others = 5. (i) What is the Programme about ? Related to pregnant women = 1, Related to women of reproductive age group = 2, Related to children = 3, Others = 4. (ii) Programme is executed at :- Private Hospital (multi-speciality hospital) =1, Private Clinic = 2, CHC = 3, Sub-district hospital = 4, PHC : 5, Others = 6. (iii)Frequency of Check-up :- Weekly = 1, Fortnightly = 2, Monthly = 3, Others = 4. (iv)By whom check-up is done ? Private obstetrician = 1, Govt. Obstetrician = 2, Medical Officer = 3, General Practitioner = 4, Others = 5. (v) What investigations are carried out ? Hb. = 1, Urine Albumin & Sugar = 2, Blood grouping & Cross-matching = 3, Torch infections = 4, Weight = 5, B.P. = 6, Others =7. (vi) Is it free of cost ? Yes / No (vii) Are IFA tablets provided free of cost ? Yes / No (viii) Are FP services available free of cost ? Yes / No (ix) Are complicated cases referred ? Yes / No (x) Is treatment for RTI / STDs given ? Yes / No (xi) Would you like to avail the services provided in this programme ? Yes / No
34
1
2
3
4
5
Pregnant & women with child of 2 months 6 7 8
Women number in cluster (cont..) Further Questions applicable for pregnant women 6 , 7 & 8 (xi) Do you avail the services under the Vande Mataram Scheme ? Yes/No If No, Reasons :- Don’t Know = 1, It consumes lot of time = 2, Charges are taken = 3, Approach is not proper = 4, Behaviour is not good = 5, Timings are not convenient = 6, Place of check-up is too far = 7, others = 8 (4) Place of diagnosis of pregnancy :- At home by using kit = 1, Private Obstetrician = 2, Govt. Hospital = 3, Trust hospital = 4 , Vande Mataram Scheme = 4, PHC = 5, Municipal Hospital =6, Others = 7. (5) Place of registration : Private Obstetrician : 1, Govt. Hospital : 2, Trust hospital : 3, Vande Mataram Scheme : 4, PHC : 5, Municipal hospital = 6, Others = 7. (6) No. of Antenatal check-ups till now (7) Have you taken IFA tablets ? Yes / No (8) Have you taken T.T ? Yes / No (9) Which investigations have been carried out ? Hb. = 1, Urine Albumin & Sugar = 2, Blood grouping & Cross-matching = 3, Torch infections = 4, Weight = 5, B.P. = 6, Others =7. Questions for postnatal mothers (10) Have you undergone postnatal check-ups ? If Yes, how many times ? (11) Have you been given advise regarding FP ? Yes / No
1
2
3
4
No. of Household visited :-
Name of the Investigator :-
Sign of the Investigator :Date :Dec 2004
35
5
6
7
8
Annexure : II Interview with the Doctors volunteered in the scheme Sr. No. : -
__ __
Date of Interview :General Information of Doctor
Name of the Doctor :
Qualification :
Passed in (MD/DGO ) : ____________
Address :-
Ward/PHC area :
Date/month of registration to scheme :
Details Feb Mar Apr May June Jul Beneficiaries Days and Time of service:registered IFA used
Aug Sep
Services provide at: Own Clinic /Govt. hosp / Trust (NGOs) hosp. /
FP devices Referred
Other (Specify) ____________________
RTI / STDs * Write down the number or not applicable
36
Oct Nov Dec
Q-1. According to you whether scheme is utilized by beneficiaries adequately or not?
Yes / No
If not reasons: 1. Inadequate publicity by Govt. 2. My clients prefer paid services 3. Others (Specify): __________________________ Q-2. Doctor’s Experience and opinion about scheme: _____________________________________________________________ Q-3. Doctor’s Suggestion to improve the scheme: _____________________________________________________________ Q-4: Weather the board for the scheme is provided by the CDHO? Yes / No Q-5. Whether board of Vande Mataram Scheme displayed or not:Yes / No Q-6. What is the trend of supply of FP devices from CDHO :Regular / Irregular Adequate / Inadequate: Q-7. What is the trend of supply of ANC card from CDHO :Regular / Irregular, Adequate / Inadequate: Q-8. What is the trend of supply of IFA from CDHO:Regular / Irregular Adequate / Inadequate
Name & Sign of the investigator : ______________________________
37
Annexure : III PROFORMA FOR THE BENEFICIARIES Q-1. Profile of the beneficiaries :(i) Name : ________________________________________________________ (ii) (iii)
Address : ______________________________________________________ ______________________________________________________ Ward/PHC: _____
(iv)
Age : __ __ years
(v)
Occupation :Housewife = 1, Labourer = 2, Private employee = 3, Govt. employee = 4, Professional = 5, Business = 6, Skilled worker = 7, Others = 8 (Specify) _________________________________________ Education :Illiterate = 1, Primary = 2, Secondary = 3, Higher Secondary = 4, Graduate = 5, Post-graduate = 6, Professional = 7, Other = 8 (Specify) __________________
(vi)
(vii)
Education of the husband :Illiterate = 1, Primary = 2, Secondary = 3, Higher Secondary = 4, Graduate = 5, Post graduate = 6, Professional = 7, Other = 8 (Specify)__________________
(viii) Total Family Members :- __ __ (ix)
Total Family Income :- __ __ __ __ __ /month
(x)
Socioeconomic status :- Class I / II / III / IV / V
(xi)
Order of pregnancy : 1/ 2 / 3 / 4 / > 5
(xii)
Family size ( No. of living children) :- ___
(xiii) Past Obstetric history : Still Birth = 1, Caesarian Section = 2, Spontaneous abortion = 3, Hemorrhage = 4, Not Applicable = 5 (xiv)
In case of Second Gravida or more, Where she has availed the previous services :Private Hospital = 1, Private clinic = 2, Government Hospital = 3, Municipal Hospital = 4, Trust Hospital = 5, Others = 6 (Specify) _____________________
(xv)
Date of LMP : __ __ / __ __ / 2004
(xvi)
Due date of delivery : __ __ / __ __ / 2004
(xvii) No. of Ante natal check-ups undergone till now (Taken/Due) :- __ / __ 38
Q-2
Show the ANC Card given by practitioners? Shown / Not shown. If not shown, Reasons for non availability of the card :Lost = 1,could not, Find = 2, Others=3(specify)_________________________
(i)
From where did you get the information about Vande Mataram Scheme ? Newspapers = 1, Doctors = 2, TV = 3, Radio = 4, Pamplets-posters = 5, Beneficiaries = 6, Person other than beneficiaries = 6, Others = 7 (Specify) _____________________________________________
(ii)
Date on which the Services you have availed : : __ __ / __ __ / 2004
(iii)
Which Services did you avail ? Antenatal = 1, Postnatal =2, Family Planning = 3
(iv)
Where did you avail services? CHC = 1, Private hospital = 2, FRU = 3, Sub-district Hospital = 4, Others = 5.
(v)
How many times have you availed services? Once = 1,Twice = 2, Thrice = 3, More than three times = 4.
(vi)
By whom the check-up is done ? Specialist = 1, MBBS doctor = 2, Nurse = 3, Paramedical personnel = 4, Others = 5 (Specify)_________________________________________________
(vii)
Which investigations have been carried out ? Hb. = 1, Urine Albumin & Sugar = 2, Blood grouping & Cross-matching = 3, Torch infections = 4, Weight = 5, B.P. = 6, Others =7 (Specify) _______________________________
(viii)
Had you paid any charges ? Yes/ No
(ix)
How much you paid : ______________
(x)
Reasons for paying charges :For check-up = 1, For investigations = 2, for medicines = 3
(xi)
IFA tablets received? Yes/ No, If yes how many :
(xii)
What advices you have been given ? FP = 1, Diet = 2, Rest = 3, BF = 4, Danger signs = 5, Follow-up = 6, Others = 7 (Specify) ____________________________
39
Q-3. Your experience regarding the programme? Highly satisfied = 1, Satisfied = 2, Not satisfied = 3, OK = 4, Not replied = 5, Others = 6 (Specify) ___________________ (a) If Satisfied/highly satisfied reasons; (i) Check-up is done nicely (ii) Check-up is carried out by the specialist (iii) Is is free of cost (iv) It is done regularly (v) Advise regarding the selection of family planning devices is given (vi) Others (specify) ________________________ (b) If No, reasons (i) Place of check-up is too far ? (ii)It consumes lot of time ? (iii) Charges are taken ? (iv) Check-up is not done properly? (v) Behavior is not good ? (vi) Timings are not convenient ? (vii) Others (specify) ________________________ Q-4. Will you recommend other females to avail the services under this programme ? Yes / No Q-5. Where would you like your delivery to be conducted ? Home = 1, Private hospital = 2, CHC = 3, FRU = 4, PHC = 5, Not applicable in case of postnatal mothers = 6. Q-6. Are you been referred to any other hospital during pregnancy ? Yes / No Reason for referral : ____________________________________________________ Q-7. Are you been given treatment for any infection during pregnancy ? Yes / No Q-8. Your feed back on the Scheme : ____________________________________________ __________________________________________________________________________ ___________________________________________________________________________ Q-9. Your suggestion to improve the Scheme : -____________________________________ ___________________________________________________________________________ ___________________________________________________________________________
Name & Signature of investigator :
Date :- -- / -- / ----
40
Annexure : IV
Sr. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Clusters (Wards/PHC) Aamraivadi Behrampura Gomtipur Jamalpur Jetalpur Kaligam Khadia Khokhara Kubernagar Madhupura Maninagar
Memnagar Naranpura Naroda Naroda Muthiya Navrangpura Nikolgam Odav Ognaj Old Vadaj Rakhiyal Ranip Sabarmati Saraspur Sardarnagar Shahpur Thakorbapanagar Vasna Vatva Vejalpur
(Total population = 40,52,777, Cluster Interval 1,5,093/-)
Total 51 units (44 wards and 7 PHC areas. i.e. areas where Private Gynecologist have enrolled in Vande Mataram Scheme.) were considered for cluster selection.
41
TEAM* FOR VANDE MATARAM SCHEME STUDY Project Guide
Dr. B. S. Bhavsar,
Chief coordinator
Dr. K. N. Sonaliya
Principal Investigator
Dr. A. M. Kadri
Co-Investigator & Project Coordinator Co-Investigator & Co-Coordinator Asst project Coordinator Performa Design
Dr. Shikha Jain
President, IAPSM-GC & Professor & Head Secretary IAPSM-GC & Assistant Professor Joint secretary IAPSM-GC & Assistant professor Assistant professor
Dr. Sunil Nayak
Final Year Resident
Dr. Chintul Shah
Final Year Resident
Field Investigators
Data Entry Analysis & Report writing Finance
Dr. Dr. B. S. Bhavsar, Dr. G. K Kedia Dr. M. K. Lala Dr. A. Bhagyalaxmi Dr. A. M. Kadri Dr. Atul Trivedi Dr. Shikha Jain Dr. Sunil Nayak Dr. Chintul Shah Dr. Nital D. Patel Dr. Avni N. Suthar Dr. Kiran C. Patel Dr. Jayshree M. Patel Dr. Bhumi Meghpara Dr. Nisarg Patel Dr. Sapra Dalpat Dr. Arpit Sharma Dr. Rakesh Tank Dr. Nikhil Chaudhari Dr. Maulik Jethva Dr. Dipak G. Patel Mr. Narendra Parmar Ms. Finomina Dr. A. M. Kadri Dr. Shikha Jain Dr. Mitesh Patel Dr. Sunil Nayak Dr. Atul Trivedi
42
Faculties of Department of B.J.Medical College
All interns
Sanitary Inspector Laboratory Technician Assistant Professor Assistant Professor Assistant Professor Final Year Resident Treasure, IAPSM-GC & Assistant Professor
