The Tribune, Chandigarh, India

Maternal mortality: Gujarat shows the way
The Chiranjeevi experience is the best public-private-partnership model that holds unique lessons for other states, says Dr Amarjit Singh

Surviving child birth is a fundamental right of every woman. Yet more than 100,000 die every year due to pregnancy and child birth related causes. Clearly, most of these lives can be saved!

The UN Summit on the Millennium Development Goals (MDGs) in New York has focussed on this issue. Many new commitments were made for women’s and children’s health. More than $40 billion was pledged, over the next five years to save the lives of over 16 million women and children, preventing 33 million unwanted pregnancies and ensuring access for women and children to quality facilities and skilled health workers.

India has to play a pivotal role if MDG 5 for reduction of maternal mortality ratio (MMR) by three quarters is to be achieved. Put simply, it implies a reduction of MMR from 301 to 75 per 100,000 live births. This is difficult. Out-of-the-box solutions will have to be found and synergistic partnerships developed with the private sector to prevent these deaths.

India accounts for the largest number of births (27 million) worldwide, every year. A large majority of these are in the rural areas and take place at home without the presence of skilled birth attendants. There are trained nurse/midwife in 30 per cent of the villages, but they are not skilled to handle even ordinary deliveries, not to speak of complicated cases.

The lack of availability and access to essential health services results in the death of 1,17,100 mothers and more than a million infants within critical 28 days of birth. Ironically, trained obstetricians are available mostly in the private sector. For reasons such as lack of amenities, poor salaries and government policies, only a few work in the government in the rural areas. For example, of the 2000 obstetricians in Gujarat, only seven were practicing in the block level hospitals which serve the poorest population.

A similar situation exists in UP, Bihar, Rajasthan, Chhattisgarh and Jharkhand. Consequently, the MMR in the rural areas worsened during the Nineties from 448 to 619 per 100,000 live births. Those lucky to survive, may, in many cases, suffer from incontinence, chronic pelvic pain, dismennorrehea and other complications of a badly handled delivery.

The Gujarat government’s innovative Chiranjeevi scheme has ensured safe deliveries for Below Poverty Line (BPL) population. Under it, for long life of mothers and children, the private obstetricians were contracted to provide skilled birth attendance and emergency obstetric care free of charge to poor rural women. In return, the government paid the obstetricians Rs 1,79,500 for a package of 100 deliveries including treatment of complications. The average price per delivery came to Rs.1795.

The criterion for selection of private obstetricians was kept simple to get good representation. The scheme was developed in consultation with IIM, Ahmedabad; Sewa Rural, Jhagaria and the Federation of Gynaecological Societies of India (FOGSI). The doctors are paid, in consultation with FOGSI, on the basis of the actual cost in a rural setting for Sewa Rural, a reputed non-government hospital in a tribal area of the state.

The Chiranjeevi scheme was started as a pilot in 2005-06 in Gujarat’s five districts. The response was phenomenal: 75 per cent of the private obstetricians in those districts joined the scheme willingly. From January, 2006 to March 2008, around 97,000 poor women delivered in private hospitals under the scheme. Each obstetrician did an average of 500 deliveries and earned up to Rs 9 lakh from the scheme. The scheme turned out to be a win-win situation for poor women, private doctors and District Health Authorities.

The government bagged the Asian Innovation Award for its initial efforts. Soon the scheme was extended to the whole state. Over 800 private obstetricians are currently working with the government; they have carried out 5.35 lakh BPL deliveries in the last four years. The coverage of deliveries under the scheme averaged 53 per cent of the total BPL deliveries.

The beneficiaries include 38,812 women who underwent caesarian deliveries and 26,730 women who had complicated deliveries free of cost. This prevented destitution and misery as many rural families go bankrupt for undergoing complicated deliveries. The scheme saved many lives. In the normal course, 1611 women may have lost their lives during these deliveries. However, due to skilled birth attendance, only 87 maternal deaths were reported under the scheme. Similarly, a large number of early neo-natal deaths were prevented because of skilled care during birth. The total cost to the state for the 5.35 lakh deliveries has been Rs 960 million or Rs 240 million annually.

The Chiranjeevi Yojna is only one of the components of the strategy for improving maternal health. Simultaneously, steps were taken to upgrade peripheral health infrastructure, effectively implement the Janani Surakasha Yojna, train MBBS doctors in emergency obstetric care and auxiliary-nurse-cum-midwives as skilled birth attendants.

Consequently, the institutional delivery rate, the best proxy indicator for a safe delivery, which was increasing at the rate of 1 to 2 per cent every year, increased from 55 per cent in 2005 to 90% in 2009. In all, 108 Emergency Trauma Care Service vehicles ferried the poor expectant mothers to safe delivery centres in the public or private sector.

There is significant improvement in institutional deliveries among the BPL population with high level of client satisfaction. An evaluation by Indian Institute of Ahmedabad shows that most Chiranjeevi users have an income of less than Rs 12,000 per annum, indicating that the scheme is able to target the poor families. The users are relatively younger mothers and having lesser number of children. ANMs, Anganwadi workers and female health workers provided information to 82 per cent Chiranjeevi clients.

The Chiranjeevi Yojna has obvious lessons for other states. Despite the tremendous success of Janani Surakasha Yojana (JSY), of the 55 lakh births in Uttar Pradesh annually, only 21 lakh take place in institutions today. Thirty four lakh births still take place in unsafe surroundings making the expectant mother and the neonate very vulnerable. It will be very difficult for the government to provide safe delivery facilities to the remaining 34 lakh expectant mothers as most hospitals are fully utilised.

There are 4,000 private obstetricians in UP. They could be involved to provide safe delivery facilities to the poor women. In states like Jharkhand, only 20 per cent have access to safe delivery facilities. In Delhi, 32 per cent women in the slums and other poor areas deliver in unsafe surroundings. There is need to involve the private sector in enhancing safe delivery facilities for the poor.

Fears that the private sector’s involvement would eat into the government’s work are unfounded. In the above illustration of UP, there is enough work for public and private sectors. Even the Gujarat experience shows that after four years of an active partnership with the private sector, the public sector deliveries have increased both in percentage and absolute terms.

The Chiranjeevi experience has been profiled in the UNICEF’s State of the World’s Children Report 2009, as a unique initiative to improve maternal and child health. The South East Asia Region of World Health Organisation invited 11 countries in the region for a workshop in Ahmedabad to visit the private partners and learn about the scheme.

The Chiranjeevi scheme provides the first practical experience of involving private obstetricians on a large scale to deliver skilled birth attendance and emergency obstetric care to poor women in Gujarat. It demonstrates the possibility to contract private sector to increase rapidly, availability and utilisation of skilled birth attendants for the poor at a reasonable price. It appears to be a viable strategy for other states of the country to achieve the UN millennium development goals pertaining to mother and child health.

There is also a possibility of extending the scheme to cover screening for cervix cancer, HIV/AIDS and provision of high quality sterilisation services. In Gujarat, 258 private paediatricians are already working with the state government under the Bal Sakha scheme to provide expert care to critically ill neonates.

Such efforts, however, would require a proactive and a dynamic leadership from the top health managers at the state level and committed team work of peripheral health staff including nurses, health facilities, medical officers and private obstetricians. The returns, in terms of maternal and neonatal deaths averted, would be worthwhile.

The writer, a senior IAS officer, is Executive Director, National Population Stabilisation Fund, Government of India, New Delhi

Saving the mother and the child

l Annually, 78,000 women die from pregnancy and childbirth in India, which means one woman dies every seven minutes.

l In India, two-third mothers die within seven days after delivery. If we focus on these first seven days, we can reduce our infant mortality rate and maternal mortality rate.

l If women have access to essential maternity and basic health care services, up to 80 per cent of all maternal deaths and injuries could be avoided.

l Almost one in four women (23 per cent) receive no antenatal care, ranging from 1 per cent or less in Kerala and Tamil Nadu to 66 per cent in Bihar. At least 40 per cent of pregnant women did not get any antenatal care in Jharkhand, Arunachal Pradesh and Nagaland.

l There is need for increased investment in maternal and neonatal care in India which should be given priority in budget allocations.Funds must be used effectively to ensure that life-saving services reach all those who need them.

The broken line of road discipline
by Deepak Dasgupta

Lane discipline, to be successful, has to be universally observed as even an individual falling out of line will have a domino-like effect on the remaining traffic. Tribune photo: Mukesh Aggrawal

In the afterglow of the Commonwealth Games, Delhi citizens are in a self-adulatory mood. This is particularly so after all the talk about the delays in the setting up of the facilities for the Games and the myriad of corruption charges being thrown about. While the corruption charges are now being inquired into, it is believed that the conduct of the Games was exemplary.

One aspect of public behaviour that has come in for praise from Union Home Minister P. Chidambaram, was the observance of traffic rules during the Games that facilitated a smooth flow of road traffic. Though a dedicated lane was provided for the Games traffic, the other traffic movement remained unaffected, and, in the view of many, moved better because of observance of lane discipline and traffic regulation. Mr Chidambaram has expressed the hope that the change witnessed during the Games of following lane discipline would now remain forever.

The traffic path on a road is delineated with the help of appropriate road markings which are expected to perform the function of guiding and controlling traffic on the road. These markings are either in the form of broken lines which allow for crossing with discretion or in the form of unbroken white or yellow solid line which restricts any crossing except in exceptional circumstances. Traffic is expected to drive within the lanes and observe the discipline stipulated by the form of the road marking on the road.

In normal times, Delhi traffic observes none of these rules pertaining to lane driving. It is common place to see four or greater number of lanes of traffic on a two-lane road, vehicles being driven astride the road marking with impunity or darting from lane to lane, quite often crossing over the solid unbroken line, and generally behaving as if the markings were of no particular significance apart from providing some kind of adornment to the road. For two wheelers, the entire road width is one big lane notwithstanding the markings that may exist. Such driving behaviour is a principal cause of traffic snarls on Delhi roads leading to delays and wasteful fuel consumption.

Even the authorities appear generally unconcerned and large length of roads, including national and state highways, are bereft of any road markings. In their effort to save expenditure on maintenance, the item of road marking is often left out by them. Alternatively, low quality cheap material is used that wears off in a few days. While the situation has improved in recent years with the use of thermo-plastic reflective paints, particularly on national highways and urban centres like Delhi, the awareness that proper marking of the road is an essential requirement is still lacking.

For the CWG, the Games lane was distinctly marked by a solid unbroken line that was broken only when traffic had to cross over from one road to another. The Traffic Police was out in a large number to enforce the lane discipline with any infringement inviting a stiff fine of Rs 2,000. Not only did this allow the Games traffic to move very smoothly, but also resulted in unhindered movement of the other traffic as in the balance available space, people were virtually forced to move in lanes.

The question now is whether Delhi traffic will allow Mr Chidambaram’s hope to be realised or the traffic mess will reappear without the level of enforcement used during the Games. Delhi roads are now well marked and, following the Games, there is greater level of awareness. However, lane discipline, to be successful, has to be universally observed as even an individual falling out of line will tend to have a domino-like effect on the remaining traffic.

Thus, a certain level of enforcement will be necessary if the lessons learnt during the Games have to be fully imbibed. The beginning could be selective and initially cover enforcement of the bus lane discipline and the non-crossing of the solid unbroken line. On roads with clearly marked bus lanes, no other traffic should be allowed except at points clearly identified with broken lines.

Similarly, the casual and careless crossing of the solid line should be severely dealt with. Implementation of these small measures with due publicity and accompanied by a salutary fine as imposed for the CWG may go some way towards making the hope expressed by Mr Chidambaram come true. Otherwise, the broken line on the roads will continue to remind us of the state of our traffic discipline.

The writer, a 1966 batch IAS officer of Haryana cadre, is a former Chairman, National Highways Authority of India

OPED

Impact of UK visa curbs
Our skilled professionals should look inwards
by Ranjit Malhotra

The new measures announced by British Home Secretary Theresa May on November 23 will strictly control the number of non-European workers that can come to the UK and work from outside Europe. The new rules, effective from April 2011, will impact on the highly skilled professionals from India who want to work in the UK.

The new rules will limit the number of skilled non-European Union workers which businesses can bring into the UK. The Home Office is tightening the intra-company transfer route which will be out of the purview of the annual limit. It will also restrict Tier 1 of the Points Based System (PBS) introduced in 2008 to all high end applicants except entrepreneurs and investors. The new rules are likely to be framed for the entrepreneur and investor categories.

To control those coming to the UK, the British government has decided to introduce a composite annual limit of 21,700 under the skilled and highly skilled routes as carved out under Tiers 1 and 2 of the present British immigration rules. While the allocated number under the skilled and highly skilled route is 20,700, it is 1,000 under the new ‘exceptional talent’ route only for scientists, academics and artists.

Coming to income benchmarks, the new rules raise to £40,000 the minimum salary for those coming through the intra-company transfer route for more than 12 months. The rules also seek to restrict the highly skilled tier of the PBS (Tier 1) to all except entrepreneurs and investors. The rules further mandate occupations in Tier 2 to be at the graduate level.

The British government’s reasoning is that it was determined to make changes to Tier 1 — the ‘highly skilled’ tier — when it was revealed that approximately a third of those coming through this route were actually doing low skilled jobs once in the UK. Business houses have made it clear that their priority is to fill their specific vacancies through Tier 2.

The applicants under Tier 2 will still be required to apply for a visa from the UK Border Agency through the PBS, will have to be of graduate level, be sponsored by an employer and will be awarded points based on scarcity of skills and salary. However, they will compete against other applicants for a visa to enter the UK and in months when the limit is oversubscribed those with the most points will qualify for one of the certificates of sponsorship available each month.

Separately, businesses can bring in their own employees through the intra-company transfer route (ICT). But the employees must earn more than £40,000 to stay beyond 12 months, and their stay will be restricted to five years. Those earning under £40,000 will find their visas limited to 12 months. It is very important to clarify that Tier 2 (ICT) will not lead to settlement.

In line with the coalition government’s commitment to reduce inward migration, a consultation will be launched before the end of the year focusing on Tier 4 of the PBS — the student route — which currently accounts for two thirds of migrants entering the UK each year. The government aims to prevent abuse while continuing to attract the top students to our top universities. Last year, the student application process in Punjab got a notorious reputation on account of the gaps existing in the student immigration rules at that point of time.

Locally, the Punjab government needs to be lauded for pushing the prevention of human smuggling legislation which is currently awaiting the assent of the President of India. When the Punjab government embarks upon the process of framing of the rules under the said legislation, sufficient care should be taken to ensure that gullible youth from Punjab are not duped in the student category.

More to the point, the rules should strictly prohibit payment of the handsome commission paid to the local agents and franchisees in India, by low level foreign universities from the tuition fees paid by the students in India. Over the years, this has promoted a different type of an industry giving fillip to lot of illegal activities on the side to exploit the student avenue.

Coming to the converse side of the agenda of managed migration, in June this year, the British Home Secretary commissioned the Migration Advisory Committee (MAC) on the changes which are now reflected in the latest announcement. The MAC received over 400 written submissions and has published a 324 page report on November 19, 2010.

The first annual limit for Non-European workers with effect from April 2011 again reiterates the British government’s mandate to promote managed migration. There are two important reasons for the same: First, to protect the domestic employment market for their own nationals commensurate with changing market conditions which would be the obvious concern and priority of any nation. And secondly, to convey a message to the highly qualified and talented professionals from India and other nations that employment avenues befitting their qualifications are not easily available in the UK.

Certainly, such forward advance policy planning will curb inflow at the entry point and at the end of the day to avoid frustration and disappointment of highly skilled manpower once actually on a foreign soil.

As for the direct impact of the numbers cap on the highly skilled individuals from India on companies from India established and operating in the UK, they would potentially also have to downsize their European operations also as the UK traditionally is viewed as a gateway to the European Union.

Clearly, the highly skilled professionals in India in different streams need to seriously introspect and ponder that the opportunities lie within India and not outside India.

The writer, a Felix Scholar with an LL.M degree from the University of London, specialises in areas of immigration and private international law in Chandigarh

On Record
Give environment its due: Seechewal
by Sarbjit Dhaliwal

Sant Balbir Singh Seechewal

Sant Balbir Singh Seechewal is a noted environmentalist. His name figured among the world’s 30 heroes of environment selected by Time magazine. Punjab Chief Minister Parkash Singh Badal made the 48-year-old Sant a member of the Punjab Pollution Control Board (PPCB).

He continues to pursue his agenda to clean up Punjab’s polluted rivers and other water bodies, its highly polluted air and soil. Impressed by his work, eminent persons from India and abroad have visited his religious headquarters along the bank of the holy Bein nadi (formerly Kali Bein), which was cleansed by him, at Sultanpur Lodhi in Kapurthala district. He speaks to The Tribune on various issues related to environment.

Excerpts:

Q: What motivated you to become an environmentalist?

A: I became a disciple of Sant Avtar Singh 1981.That turned me towards spiritualism. Divine verses of Guru Nanak Devji uttered about 500 years ago made me an activist on environment. Guru Nanak Devji has called air the Guru, water the father and earth the mother. Gurbani has played a crucial role in changing my life.

Q: What is the status of environment in Punjab?

A: Punjab is one of the highly polluted areas in the world. Its rivers are filled with filth, toxic chemicals and metals. At one stage water used to be worshiped in the state. It was known as amrit. But now it has virtually become poison in some parts of the state. Some people drinking this water have fallen ill. Sometimes it is difficult to even breath.

Q: What are your experiences as a member of the PPCB?

A: My experiences are sweet and sour. Sweet because had I not become the PPCB member, I would have not able to understand the hollowness of such institutions. Sour because the PPCB seems unable to play the role of a guardian to the environment. It is just another institution pushing papers and files from one place to the other and doing little to address the people’s concerns regarding the pollution of rivers, air, subsoil water, etc.

Q: Do you repent your decision to join the PPCB?

A: No. I am trying my best to help PPCB change its attitude and take decisive steps to address peoples’ concerns about the polluted environment. I point out the weaknesses in the decision-making process and tell the authorities concerned to take corrective steps to remove deficiencies.

Q: There has been a lot of debate on organic farming in the state. People are sharply divided about it. What is your take on it?

A: I am all for organic farming. Excessive use of pesticides, fertilisers and other chemicals has played havoc with Punjab’s sub-soil water, soil and air. Drinking water has become undrinkable in many parts of the state and a source of many diseases. Indiscreet use of pesticides is being blamed for the high incidence of cancer in Punjab’s Malwa region. Organic farming is natural farming. Pesticides, chemical fertilizers etc. are not very old. Our forefathers used to do organic farming which is natural farming. We must revert to natural farming.

Q: What role do you expect from politicians regarding the cleaning up of the
environment?

A: I have been emphasising that the mainstream political parties must make environment part of their political agenda. During elections, they must make it a part of their manifesto and must tell people that what they would do to improve the state’s environment. During the last Assembly and Lok Sabha elections, I had written about this to all main political parties. However, there was no encouraging response though some parties took notice of my letters.

Q: Could you throw some light on your viits to developed countries?

A: In developed countries, people work hard to keep their countries clean. They scrupulously follow the rules to keep the environment clean. In our country, people are not so sensitive to environment. Ironically, literate people create more problems than the illiterate. Our urban settlements, vastly inhabited by literate people are dirtier than those in rural areas.

Profile
Rita, Shilpi spread the message of ecological balance
by Harihar Swarup

Rita Banerji and Shilpi Sharma

When Delhi-based film makers — Rita Banerji and Shilpi Sharma — embarked upon on a trip to understand the hunting practices in the North-east, little did they know that it would bag them the prestigious Green Oscar, also known as Panda Award. Their 28-minute film — The Wild Meat Trail — won them a Panda in the category to promote filmmakers from developing countries at Wild Screen Film Festival in Bristol recently. The Green Oscar had received as many as 446 entries.

The Wild Meat Trail explores the hunting practices of the north-east and its role in society. While travelling in the North-east, the two-member team of Rita and Shilpi gained an insight into the region’s hunting practices and its place in the current cultural contest. The film also looks at the attempts by a few villagers communities to ban hunting and conserve their natural resources. The film was shot in Arunachal Pradesh, Mizoram and Nagaland.

Travelling to the remote areas of North-east was not an easy task. It was challenging initially and Rita and Shilpi had to manage the logistics and travel a lost. They spoke to villagers, the sellers and consumers of the wild meat. After some time, people became friendly so much so that the two filmmakers stayed with them and this enabled them to study the habits of the people of North-east.

About three-fourth of the North-east forests are owned by tribal communities. Rita says, “When everything you own and use and eat comes from the forest, you became part of the ecology and the forest becomes a very powerful metaphor. But that ecological balance is now threatened”.

The villages have no other sources for cash. Wild meant is considered tasty and medicinal also, so it is in great demand. Over the years, it has also become commercial, fetching good prices in cities. In the film, a hunter says he earns Rs 15,000 a month selling wild meat as compared to Rs 2,000 selling vegetables.

While modernity has brought tough challenges, it also holds the seeds of future resolutions. A reassuring strand in the film is the figure of Taran Rachi, the village’s first college graduate, who has returned to the community with a job in the forest department. Taran understands that the forest is peoples’ most precious resources and if old ways continue both the forest and the people will be destitutes. Urging his elders to mould tradition to accommodate new realities is by no means an easy task.

The elders are incredulous at the suggestion that they give up hunting. But in a touching irony, Tarang’s father, once deemed the best hunter in the village, speaks of how some animals have become difficult to find. Others speak of animals of their childhood that are not seen anymore. Slowly, the mood shifts. Everyone is agreed that they will observe a three-year hunting ban so that the forest can get back on its feet, claws and wings.

The filmmakers see this as the most hopeful answer. The North-east forests are in capable hands — the tribal communities. More important, they recognise the importance of forests. Their strong participatory democracy and knowledge of the forests can shift them from their unintended role of destruction to their traditional role of keepers of the forest.

They are slowly learning about the alternative sources for cash through preserving natural resources, ethical eco-tourism, the sale of organic products and handicrafts. Tarang’s is an inspiring story of a catalyst. Others will surely emerge. If they do, the traditional relationship between the forest and the tribals might just successfully persist.

Rita has been a core team member of several award winning films. Among these have been The Last Migration — the first film from Asia to win the Green Oscar at Wild Screen Festival, 1994, and Shores of Silence: Whale Sharks in India, which not only won the Green Oscar in Wild Screen 2000, but also went to put the whale shark in the Wildlife Protection Act of India.