Assessing the Regional and District Capacity for Operationalizing Emergency Obstetric Care through First Referral Units in Gujarat

Maternal mortality remains to be one of the very important public health problems in India. The maternal mortality estimates, is about (300-400/100,000 live births). There are diverse management issues, policy barriers to be overcome for improving maternal health. Especially, the operationalization of Emergency Obstetric Care (EmOC) and access to skilled care attendance during delivery. This study focuses on understanding the regional and district level capacity of the state government to operationalize First Referral Units for providing Emergency Obstetric care. This study is a part of a larger project for strengthening midwifery and Emergency Obstetric Care in India. The study apart from giving an in-depth insight into the functioning of various health facilities highlights the results from the basic to the more comprehensive level of EmOC services. It gives recommendation on various measures to rectify shortcomings noticed and make EmOC a more effective at different levels in the State of Gujarat. The study uses both primary and secondary data collection. The study was conducted in six regions of Gujarat -one district from each of these regions was selected. Out of these districts 27 health facilities were examined, which consists of seven district hospitals, eight designated as first referral units (FRU), four community health centers (CHC) and eight 24/7 primary health centers (PHC). Detailed field notes for individual facilities were prepared and analyzed subsequently for all facilities together. A common feature among all health centres were issues related to general infrastructure. Many times infrastructure planning (location, layout and maintenance) is left to engineers, who have limited knowledge about proper EmOC services. Poor infrastructure leads to poor quality of health services and wastage of resources. Through National Rural Health Mission (NRHM) and Rogi Kalyan Samiti funds major and minor repair/renovations are taking place to improve hospital buildings. In some health facilities from poor resource setting with high demand from patients were still able to deliver services. Human resources analysis suggests that there is shortage of specialists at FRUs, and committed nursing staff in labor room. As result of the Chiranjeevi initiative, the Below Poverty Line (BPL) population who earlier used to public health facilities are now accessing private facilities for delivery, and this has affected and decreased the workload of the public health facilities. Furthermore, there is lack of managerial skills at senior level hospital staff. Registers like birth, drug, Medical Termination of Pregnancy are maintained but not in standard format. Since complicated cases are not registered properly, maternal deaths are not reported. Even though the system of monitoring is well established at the state and district level, they are not properly followed. The funds for operationalization of First Referral Units come from department of family welfare. However, the administrative control is in the hands of department of medical services. Due to this factor monitoring system has become weak. The weak link between these two departments is the Regional Deputy Director who has only one administrative staff to take care of the issues in their region. The problem of monitoring the Primary Health Centres has become smooth with the appointment of new District Project Coordinators. Some facilities especially in district hospital reported that internal meetings and monitoring are happening because of the special interest of facility managers and newly appointed assistant hospitals administrators. In lower facilities this type of internal monitoring exists in a weak form. Underutilization of government facilities is a result of poor quality of services provided. In spite of reasonably developed health system, several problems of infrastructure, staffing, accountability and management capacity contribute to the poor functioning of facilities to act as an EmOC service delivery center. Some of the major bottlenecks in improving EmOC services are limited management capacity, lack of availability of blood in rural areas and poor registration of births and deaths and no monitoring of EmOC. District hospitals, FRUs, CHCs and Sub district hospitals come under the administrative control of the department of medical services. The clinical monitoring of these facilities lies with the department of health and family welfare. At the district level monitoring of these facilities are not properly done, therefore it effects directly the operationalization of the facilities. In the absence of adequate management capacity, the operationalization of EmOC is not well planned, executed or monitored, which results in delays in implementation and poor quality of care.