Contracting in specialists for emergency obstetric care- does it work in rural India?

Abstract

BackgroundContracting in private sector is promoted in developing countries facing human resources shortages as a challenge to reduce maternal mortality. This study explored provision, practice, performance, barriers to execution and views about contracting in specialists for emergency obstetric care (EmOC) in rural India.MethodsFacility survey was conducted in all secondary and tertiary public health facilities (44) in three heterogeneous districts in Maharashtra state of India. Interviews (42) were conducted with programme managers and district and block level officials and with public and private EmOC specialists. Locations of private obstetricians in the study districts were identified and mapped.ResultsTwo schemes, namely Janani Suraksha Yojana and Indian Public Health standards (IPHS) provided for contracting in EmOC specialists. The IPHS provision was chosen for use mainly due to greater sum for contracting in (US $ 30/service episode vs.300 US$/month). The positions of EmOC specialists were vacant in 83% of all facilities that hence had a potential for contracting in EmOC specialists. Private specialists were contracted in at 20% such facilities. The contracting in of specialists did not greatly increase EmOC service outputs at facilities, except in facilities with determined leadership. Contracting in specialists was useful for non emergency conditions, but not for obstetric emergencies. The contracts were more of a relational nature with poor monitoring structures. Inadequate infrastructure, longer distance to private specialists, insufficient financial provision for contracting in, and poor management capacities were barriers to effective implementation of contracting in. Dependency on the private sector was a concern among public partners while the private partners viewed contracting in as an opportunity to gain experience and credibility.ConclusionsDensity and geographic distribution of private specialists are important influencing factors in determining feasibility and use of contracting in for EmOC. Local circumstances dictate balance between introduction or expansion of contracts with private sector and strengthening public provisions and that neither of these disregard the need to strengthen public systems. Sustainability of contracting in arrangements, their effect on increasing coverage of EmOC services in rural areas and overlapping provisions for contracting in EmOC specialists are issues for future consideration.

Assessing geographical inequity in availability of hospital services under the state-funded universal health insurance scheme in Chhattisgarh state, India, using a composite vulnerability index

“…The findings suggest that, in the more vulnerable areas, this ‘choice’ was limited. The findings on the concentration of hospitals, especially private hospitals in less vulnerable and more urbanized areas, is corroborated by studies in India and other LMICs [8,17,19,21]. …”

Administrative reform and pay‐for‐performance methods of primary health service delivery: A comparison of 3 health districts in Cambodia, 2006‐2012

“…SOA directors are given increased autonomy in using the SDG. This arrangement is consistent with performance‐based financing (PBF) or pay‐for‐performance (P4P) approaches used in other countries, such as Afghanistan, Bangladesh, India, and Pakistan but is based more firmly on the use of the “internal contracting” approach within a broader government administration reform.…”

Successes, Challenges and Opportunities Towards Universal Health Coverage for Maternal and Child Health in South East Asian Countries: A Systematic Review

“…These programmes provide improvements in maternal health care in India 14,18,27,34,37,40 . They further provide contracting in EmOC specialists in private sector as a measure to reduce maternal mortality 29 . In Nepal, Bangladesh and Indonesia, there are similar programmes to facilitate maternal care including institutional delivery 42,43,52,57,59,63,64,66,67 .…”

“…The health facilities are in poor quality and provide suboptimal bene ts due to lack of resources and various interactions, which lead to poor utilization of facilities 18 . Identi ed challenges for low participation of private practitioners in government-funded programmes are low and delayed reimbursements, poor infrastructure and administrative issues 29,41 . Despite the government's efforts at increasing access to delivery services for poor women in the private sector with programmes, uptake was low 34 .…”

“…Inadequate healthcare workers including specialists was identi ed as a challenge for provision of better maternal and neonatal care in India, Nepal, Bangladesh, Indonesia, Timor-Leste and Myanmar 12,22,24,26,29,8,45,47,49,51,56,61,63,69,73 . Shortage of staff is widespread in rural areas.…”