Staying Alive Gujarat Program Saves Mothers and Their Infants
This year's silver winner is unusual in that no fancy technology is involved at all. But the innovation is definitely a noteworthy one, and has already saved hundreds of lives. It wrestles with the age-old problem for health officials: How to get care to the people who need it most?
Gujarat, nestling at the western edge of the subcontinent, is one of India's most prosperous states but, like the rest of the country, it struggles to provide proper care to pregnant mothers and new-born infants. India accounts for a quarter of the world's maternal deaths -- the largest number of any country, according to the latest World Health Organization survey. This is perhaps unsurprising, given that nearly three-quarters of babies are delivered in the home or at poorly equipped facilities. It's a blight that India is tackling, pledging to reduce maternal mortality from 389 per 100,000 births to 100 by the year 2010. But that's easier said than done.
It's not because of a lack of doctors -- nearly 18,000 are registered in the state -- but a lack of doctors available to treat the people who most need help: the rural poor. Three-quarters of these doctors work in private practice, while vacancies at state hospitals remain unfilled: the Gujarat government Web site lists 17 of 48 gynecologists' positions at district hospitals filled; at rural community health centers only eight out of 34 such posts are occupied.
Clearly the state's poor either weren't getting the treatment they needed because the state wasn't providing it, or else they were further impoverishing themselves by buying it in the private sector.
For Gujarat's health officials, the problem was how to get the private sector to start treating the people who couldn't afford their services, in a way that gave everyone involved an incentive to make the system work. Their answer: Bundling deliveries into packages and farming them out to the private sector under a program called Chiranjeevi Yojana, or Long Life. Or, as Mona Khandhar, joint secretary at the state Health Department and one of those involved in arranging the scheme, puts it: "We are short of specialists so why not outsource it to the social sector?"
Health officials had a cooperative relationship with private-sector doctors and nongovernment groups, so they had little problem persuading them to play ball. And public-private partnership is not new in India. But they also knew that some similar approaches didn't work. One government scheme, for example, provided benefits to pregnant women, but was limited only to medicine. "It wasn't comprehensive enough," says Ms. Khandhar. "This scheme provides a whole package."
The deal was this: Families below the poverty line in five trial districts would be given vouchers that would entitle them to a full range of services covering the whole period of pregnancy, childbirth and postnatal care. They would even get a cash sum to cover travel expenses -- no small deal for families that have to travel significant distances to get medical care.
Private gynecologists would be given a fixed fee per 100 deliveries, designed to cover all eventualities, including complicated pregnancies and births. (This figure was based on the national average of complicated cases per 100 deliveries.) Their incentive was to expand their patient base, confident in the knowledge that so long as their patient roster remains close to the national average their costs will be covered.
Patients, of course, needed little encouragement, while the voucher system prevented earmarked funds from being spent on other family necessities. But to provide further incentives for doctors to provide the best care they could, patients are allowed to choose their provider, based on a list of recommended nursing homes.
The result: nearly three-quarters of private gynecologists are actively participating in the scheme. In districts where none was practicing before, there are now nearly 60 available for consultation. Most important: following previous patterns, in the five months the project has been active, 88 mothers should have died in or after childbirth: only one has, says Ms. Khandhar. More than 1,000 babies should have died; only 109 have. "We have saved around 1,000 babies," she says. y
印度古吉拉特邦：生命长青
今年的银奖得主非同寻常，因为他们根本没有使用任何复杂的新技术。但是他们的创新却相当引人注目，并且已拯救了数百人的生命。它解决了卫生官员们多年面临的难题：如何将医疗服务送到那些最需要的人身边？
相关报导
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? 深圳赛百诺：基因治疗
古吉拉特邦位于印度次大陆的西边，它是印度最繁荣的省份之一。但是和印度的其他地区一样，它为如何向孕妇及新生儿提供必要的医疗护理而大伤脑筋。根据世界卫生组织(World Health Organization)的最新调查，印度的孕产妇死亡人数约占全球此类死亡总数的四分之一（孕产妇死亡率是全球各类死亡率中最高的）。考虑到约有四分之三的印度婴儿是在家中或医疗设施匮乏的诊所内出生的，这个现实或许就不那么令人惊讶了。印度政府一直努力应对这个问题，它宣称要在2010年前把孕产妇死亡率从每10万新生儿389例降至100例。但是，实现这个目标远比设定目标要困难。
这种情况并不是由于缺乏医生造成的，古吉拉特邦有将近18,000名注册医生。问题在于贫穷的农村地区最需要帮助的人们无法获得医生的治疗。注册的医生中大约有四分之三在私人诊所工作，而邦立医院中的职位空缺却一直都没有人填补：古吉拉特邦政府网站上显示，地区医院48个空缺的妇科医生职位只有17人填补；农村社区医疗中心的34个此类空缺职位只有7人担当。
很显然，古吉拉特邦的贫民们无法获得必要的治疗，这或是因为政府没有提供此类服务，或是因为他们承担不起私人诊所的高昂费用。
对于古吉拉特邦的卫生官员来说，需要解决的问题是如何让私人诊所的医生为无法承担医疗费用的贫民进行治疗，解决问题的方法还得使参与其中的医生有动力将这个系统一直运行下去。他们找到的解决方法是：通过一个名为“生命长青”(Chiranjeevi Yojana)的项目将分娩医疗服务打包，外包给私人诊所。正如古吉拉特邦卫生局(Health Department)联合秘书、此项目的设计者之一莫纳?坎哈尔(Mona Khandhar)的解释：“我们缺乏专业人士，为什么不把这个服务外包给社会呢？”
卫生官员与私人诊所医生及一些非政府团体有着合作关系，因此他们毫不费力的说服了后者参与这个项目。在印度，政府与私人的合作也不是什么新鲜事了。但是他们同样明白，以前一些类似的方法并不奏效。比如，一个政府项目为孕妇提供仅限于药物方面的福利。“这个项目不够全面，”坎哈尔说。“这个新项目将提供全面的服务。”
新项目是这样开展的：在五个试验地区内，生活在贫困线以下的家庭将获得证明凭证，获认证家庭的孕妇将有权在怀孕、分娩和产后阶段获得全面的医疗服务。这些家庭甚至可以获得一笔支付路费的现金──路费对那些需要长途跋涉才能获得医疗服务的家庭可不是个小问题。
私人妇科医生每为100名孕妇提供服务就能获得一笔固定的资金，用来应付所有可能发生的情况，包括情况复杂的妊娠及分娩。（这笔费用的金额是根据印度每100个分娩案例中棘手案例的平均数量来确定的）。医生的动力就是不断扩大病人基数，因为他们明白只要病人情况接近全国的平均水平，政府付费就足以支付医疗成本了。
病人当然不需要动员，尽管这个认证系统使这笔专项资金不能够被用于其他家用必备品的消费。为了进一步刺激医生尽其所能提供最好的医疗服务，病人被允许根据推荐名单自行选择诊所。
这个项目带来的结果是：近四分之三的私人妇科医生积极地参与其中。在那些以前根本没有医生的地区，现在有近60人提供咨询服务。坎哈尔说，最重要的是：在项目启动的五个月中，根据以前模式的估算，应该有88名产妇会在分娩中或分娩后死亡，但现在仅有一名不幸死亡。约有1,000多名婴儿会死亡，但事实上这个数字仅为109名。她说：“我们挽救了大约1,000名婴儿。”
Jeremy Wagstaff
