Providing universal maternal and child health care has not been an easy task to achieve in India. Hindustan Latex Limited has pioneered through Uttar Pradesh the ‘service model’ based on Public private Partnership (PPP) that has created an impact across its 70 districts. Over the last few years the dusty by lanes of the sub urban and rural UP has a health infrastructure taking care of ante natal, post natal and institutional deliveries.
Uttar Pradesh the state which is home to largest number of mal nourished children and has one of the highest number of maternal mortality rate, despite governments presence in the sector, things on ground do not seem to be any better. It called for a unique enterprise from stakeholders across sections in the society to create an affordable and economically viable health Infrastructure.
Sharad Agarwal, the Chief Executive Officer, Hindustan Latex Family Planning Promotion Trust strongly believes that a serious effort on the part of both public and private sectors can change the fate of health infrastructure across the nation. The CEO said “in Uttar Pradesh we are a success story through our MerryGold Health Network. We have attained a targeted 66,000 institutional deliveries in one year and hope to expand the network across India”
Merrygold Health Network (MGHN) is a flagship program of Hindustan Latex Family Planning and Promotion Trust (HLFPPT) which runs on a social franchisee model under Public Private Partnership. MGHN, work on a strategic business model, that has showcased that providing credible maternal child health care infrastructure for the people at the margins can be sustainable.
“The approach involves engagement with private sector using a franchising approach for delivering good quality maternal care services at affordable prices to the middle and poorer sections of society” added a senior official from MerryGold. This is further facilitated through the setting up of effective framework ensuring achievements of highest standards of healthcare of mothers and newborns. The MGHN has the mandate to contribute to the reduction of maternal mortality ratio in Uttar Pradesh through promotion of safe motherhood, institutional deliveries, timely referral and family planning by engaging with private sector providers using social franchising model. The’ network’ seeks to create demand for the need of maternal healthcare and institutional deliveries; demand created are met by increasing access to quality and affordable maternal health services for marginalised communities of the rural and semi urban areas focusing on the women of reproductive age by Merrygold Health Network.
Rationalising health Infrastructure
As the country accounts for about one-quarter of maternal deaths worldwide with the highest Maternal Mortality Ratio (MMR) 359 in the most populous (186.7 million) state of Uttar Pradesh, HLFPPT initiated its network in the state. According to a report more than half of the women in U. P. report one or more maternal complications and around 80 percent of maternal deaths is attributable to complications of pregnancy and childbirth, or are caused by interventions, omissions, incorrect treatment or events that result from these complications. As per a government data 24.6% of women have had institutional deliveries, and only 30% of safe deliveries (including institutional deliveries and deliveries at home assisted by skilled health personnel) have been reported. MGHN is an intervention strategy under PPP of the GOI that has created a network of 70 units offering MCH services in 35 districts also has contributed in reducing MMR.
The Pre intervention study reveals that as the intensity of ANC increases, women’s likelihood of suffering from maternal complications decreases. A woman having an institutional delivery has less likelihood to go through maternal difficulties than a woman who has a home delivery. A woman whose delivery is conducted by a skilled birth attendant is less likely to suffer delivery and post delivery complications than a woman whose delivery is conducted by either a traditional dai (trained or untrained) or a relative non-professionals.
The ‘network’ seems to have acquired some place between the government and private sector health infrastructure in the state. Realising the huge gaps between the claims and ground reality the HLL came up with a unique solution to the old delivery practices under the touts and Jhola chhap doctors in the interiors of the state.
Structurally, the MGHN is comprised of a referral system that runs bottoms up from village level till the district level. According to the CEO, the efforts on part of the governments in India have not been translated in to action in totality. “we provide affordable MCH through our professional network that guarantee quality service and care” added he.
MerryGold hospitals, also called L1 hospitals, are based at district level. L1 hospitals are owned by the franchisee. A hospital with 20-25 beds and OT facility qualifies to become L1 hospital. There are qualified Obstetrician (M.S/M.D. or DGO) who is trained in performing caesarean section. Associated Pediatricians and Anesthetists are available on call. Besides, qualified providers, the hospitals adhere to specific building norms, separate wards for maternity, labour rooms, Operation Theater, Autoclave area and wash area etc. A standard architectural design is shared with franchisees and modifications are also suggested for improving the hospital spaces prior to branding.
Capable of management of complicated or high risk pregnancies Merrygold hospitals or L1 receive referrals from the Merrysilver clinics (L2), located at the block level, other nearby facilities, as well as direct flow from Village level volunteers ( L3 ). L1 forms apex of the pyramidal structure of the MerryGold Health Network. At present, Uttar Pradesh chapter has 70 Merry gold hospitals in 35 districts. As demonstration sites, 2 LO hospitals have been developed at Agra and Kanpur and these are under HLFPPT’s direct administrative control.
However, the second line of facilities that engage with the people at tahsil and block levels are called the Merrysilver clinics or L2. They are 5 bedded hospitals with capacity of providing basic Ante Natal Cares (ANC), Normal deliveries and Post Natal Care (PNC). Any entrepreneur who wishes to run a hospital at block level can apply to become a Merrysilver L2 Clinic, provided there is a full time trained MBBS doctor or AYUSH practitioner who has undergone training in the labour room for six months and handles normal delivery. This practice has widened the scope for both MBBS and AYUSH to be part of mainstream maternal healthcare after appropriate capacity building by HLFPPT. In addition to this, it has also increased number of facilities on a block level where pregnant mothers seek quality maternal health care.
Bonding at the Bottom
Bottom of the pyramidal structure is occupied by the motivated community outreach workers called Merrytarang members. They are the community mobilisers selected from the local villages for educating eligible couples, pregnant mothers, their families and caretakers about the need of maternal healthcare and institutional delivery. Coming from rural communities, L3 workers have high credibility in the villages. They advocate family planning, refer pregnant mothers to the nearest L2 facility and do necessary follow-ups for ensuring high compliance for ANC. L3 workers can also refer to L1 in case of high risk and symptoms or emergencies.
This democratisation of private health care has been based on an innovative idea to leverage existing private healthcare infrastructure for delivering high quality maternal healthcare services. It is first of its kind in India which has effectively offered maternal healthcare services notably at a pre-defined price. At present, prices of services offered by private healthcare providers are not regulated by the government in India especially for maternal healthcare. A pregnant female from a low-middle income group faces dilemma of choosing private healthcare provider for delivery as the prices can vary significantly.
Secondly, innovation within the model is the constant evolution through learning. Several research, evaluation study and midterm impact assessments take place to understand the gaps. Implementation team constantly incorporates the recommendations and learning to make the network, suitable for the need of the target communities. “Key achievement of the efforts made over last 4 years, is an innovative maternal health network that is financially sustainable, culturally acceptable, economically affordable and scalable to other geographies” added the official.
The MGHN through it’s ‘Tarang’ initiative seems to have created an impact as it has been successful in attaining 66,000 institutional deliveries in Uttar Pradesh in a year. This amounts to almost 40 per cent of the total institutional deliveries across the state. It’s ‘Tarang’ volunteers engage the pregnant mothers at the margins of society and motivate them to get the services of MGHN. The network is all set to fill the gaps in the sector in states like Bihar, Orissa, Rajasthan and Chhattisgarh.