All of the obstetricians who participated in the study were owners of small private health facilities where they, as owner-doctors, made all decisions relating to clinical, technical, financial and administrative activities. Most practices we visited had 10–15 beds, and the main obstetrician employed both qualified and unqualified staff to work at the facility. More obstetricians were interviewed in district 1 due to the larger size of that district’s sampling frame and larger numbers of practising private obstetricians. The total number of obstetricians in district 1 was 55 compared with 21 in district 2, as mapped by the MATIND study team. Only two providers in our sample had ‘never participated’ in the scheme, and this could be due to the intense enrolment campaign across the state and political support the scheme enjoyed at the time it was launched. The gender distribution of our participants reflects the gender composition of obstetricians in Gujarat; there are fewer women obstetricians in the state (Table 1).
We identified six main themes that help to explain private practitioner decisions to participate in the CY scheme, the important influences on their decision making, and their experiences of participating in the scheme.
Why should I participate? Tension between doing good for the public and making a profit
Private practitioners discussed at length the competing demands of providing a ‘public service’ to poor women, while at the same time needing to run a practice to make a profit. All the private practitioners we interviewed referred to making a significant initial investment in their practice and the expectation that this would translate into a reasonable profit:
“Private [practice] is totally different. When someone has invested Rs. 7 million, he will try to make more money instead of getting involved in a loss making proposition. It is a business for him.” (Past participant, rural, male)
At the same time many respondents, both currently participating and past participant groups, recognised and expressed the moral responsibility of a doctor to serve the poor. Private sector obstetricians claimed to work to their own kind of moral code, one which they believed would operate even in the absence of such schemes. They said it was common for them to treat poor patients and charge them less. As one doctor from an urban area who had discontinued participating in the scheme, claimed, ‘even when this scheme did not exist, almost every one of us was considering poor people’.
Some of the obstetricians, mostly in rural areas and currently participating in the scheme, commented that they were pleased that they could provide services free of charge to poor women while they themselves received reasonable fees through the scheme. A typical comment was that through the scheme doctors get paid by the government, but also get satisfaction of serving ‘poor people free of cost’.
Younger obstetricians observed a clear economic benefit to their participation in the scheme, particularly in the early stages of establishing their practice. One urban doctor who no longer participated in the scheme was certain that ‘new practitioners should definitely take [up] the scheme’. Others described how the scheme allowed them to launch their practices:
“As a new comer I had enrolled into the scheme, and it helped me in my practice in the initial stage.” (Current participant, urban, male)
“We were struggling hard in our private practice and we got the chance, and it was the good chance to join the practice and to highlight ourselves […] Definitely benefited us to get name and fame.” (Current participant, rural, female)
Private doctors from smaller towns felt that CY made more business sense in provincial or remote locations than in bigger cities:
“The payment (Rs 2,800) what we get in CY is sufficient as the usual charge for normal delivery here is similar. In bigger cities, charges are around Rs10,000, so Rs 2,800 is very less for them.” (Current participant, rural, male)
In spite of the scheme’s popularity among some younger practitioners, the majority of private obstetricians we talked to said the scheme was not economically viable, as the remuneration was inadequate, and it did not increase the volume of patients sufficiently to reap the benefits of ‘economy of scale’. One current participant in an urban area described his disappointment at the lack of new work the scheme brought, as initially he had thought that the ‘flow of patients would increase’. Other past participants also thought the scheme would ‘increase in the number of deliveries, patients will come to a private set up (facility), and we will get more work’.
In addition to disappointment over the volume of new patients the scheme would bring, a common concern was inadequate remuneration for complicated deliveries, such as those requiring blood transfusion or Caesarean section:
“From this amount of Rs 2,800, medicines will cost us 1,000, anaesthesia cost 1,500. Hence doctor doesn’t get a single penny. That is why C.S. [Caesarean section] is not preferable to the doctor.” (Current participant, rural, female)
Providers suggested that the cost of blood transfusion should be reimbursed separately, and that the Caesarean section rate calculated in the package should comprise at least 15–25% of total deliveries:
“Amount of Rs 2,800 for normal [delivery] is alright but for C-Section it is quite less. Moreover C-Section rate is much higher [than 7% as calculated in CY] in private practice - around 20-30%.” (Current participant, urban, male)
The disappointing volume of patients and the bundled remuneration for Caesarean sections and vaginal deliveries together meant that many obstetricians struggled with their (purported) desire to deliver a public good and their profit-making motives. As a consequence, a number of currently participating obstetricians’ spoke of this unresolved tension; those who had left the scheme cited it as a key reason why they were no longer participating in the scheme.
Procedural burden discourages participation
Most doctors (current and former participants) complained of the scheme presenting a procedural burden to their daily practice. Past participants commented on the opportunity cost of engaging in the ‘considerable amount of paperwork involved to secure reimbursement’ and described long delays in getting the reimbursement. Both these factors appeared to be major reasons why some respondents discontinued their participation in CY:
“Initially there was no problem, but later on the clerical work started increasing, so it was difficult to perform.” (Past participant, urban, male)
“When a pregnant lady comes to me for delivery, should I focus on saving the mother [and the baby] or on completing the form [documents]?” (Past participant, rural, male)
A mistrust of the government health sector was evident in the way practitioners described their experiences of dealing with the local government authorities for reimbursement under CY. For example:
“We have to give so many calls to them to get the payment. We have to meet them 2 to 3 times and I should go by myself to get the payment.” (Current participant, urban, male)
“When we go to the block office to get our payment, then the clerk behaves in such a way that [as if] he himself has to arrange payment from his pocket. They start picking up mistakes.” (Past participant, rural, male)
For one doctor, a past participant working in an urban area, payment received for his services provided under CY came very late. On the day we interviewed him he remarked: ‘I got last year's payment [the] day before yesterday only’. When doctors sense such risks to their income, they may be tempted to compromise quality when treating CY patients as compensation. As an obstetrician who has never participated in the scheme remarked:
“If the payment is less, quality gets compromised; disposables [may not be] used, low quality sutures used.” (Never participated, urban, male)
One formerly participating obstetrician spoke of the positive outcome for his practice after discontinuing from CY:
“Paperwork got reduced and income also [no longer] affected.” (Past participant, rural, male)
Overall, perceived procedural burdens and delays were a considerable disincentive to continue or embark on participation in the scheme.
Misuse of the scheme
The perceived misuse of CY by patients, health workers, government figures and other obstetricians alike was cited as a significant deterrent to private practitioners’ willingness to participate in the scheme. Almost all the obstetricians interviewed in both districts expressed their concern over misuse of the scheme by families they perceived as non-poor. According to the private obstetricians, many families who are not eligible manage to inappropriately procure a certificate of BPL (below poverty line) status from certifying authorities:
“Many people who can afford the cost come as ‘BPL’ , but they have mobile, bikes, cars and everything […] All such persons are bringing [poverty] certificates from Talati [revenue office].” (Current participant, rural, male)
“People come in their Toyota car and show BPL cards.” (Past participant, rural, male)
Moreover, many practitioners who had dropped out of the scheme told us that as misuse of CY by non-BPL women increased, they started to face a loss of revenue. This situation arose when the same clients who used to pay fees came in with appropriate BPL certification allowing them to access care for free:
“Yes, as I have told you, the ones who were well off, started coming in the private hospitals pretending to be BPL […]”
[Interviewer] “The same people who used to come and used to make a payment?”
“Yes, and now they bring the BPL card and we started facing a loss.” (Past participant, rural, male)
Another doctor concurred that the same was happening in urban facilities:
“Same people who paid for first delivery now comes as BPL […] We lose earning. So you know when you feel that you are being cheated.” (Past participant, urban, male)
Obstetricians were concerned about this ‘unfair procedure’ and considered it wasteful expenditure of government funds, diverting services from eligible families who actually need it.
Another source of discontent among the private obstetricians was what they considered the unfair means adopted by some of their fellow colleagues to profit personally from the scheme. A number of respondents described obstetricians paying community healthworkers to bring more patients to their hospitals. Respondents claimed that this included both ambulance drivers (of the state-supported 108 service) and Accredited Social Health Activists (ASHAs - voluntary community health workers paid an incentive to accompany poor women to facilities for hospital births). Conversely, providers gave examples of how some community health workers expected payment or favours from private practitioners for bringing women to the clinic. Providers we interviewed claimed:
“Then Government promoted 108 [the ambulance service], and they [some private obstetricians] started pampering [bribing] 108 people.” (Past participant, rural, male)
“One ASHA offered me a CY form and said, ‘This lady has undergone home delivery, can you include her in your CY list [as institutional delivery for getting the payment]?” (Past participant, urban, female)
“ASHAs bring patients and expect some amount in return from us. I don’t entertain, so they send patients to other doctors who may do so.” (Current participant, urban, male)
There was also evidence that some providers registered with CY exploit the scheme by accepting uncomplicated obstetric cases only. Practitioners located in rural as well as urban areas admitted that they tend to avoid accepting women who arrive late and with complications under CY, choosing instead to ‘push’ or ‘shift’ (i.e. refer) these cases to hospitals run by the government or charitable trusts. The reason commonly given for referring these women was that remuneration under CY is insufficient to cover the cost of blood transfusions or anaesthetist charges:
“A CY patient comes to me with complication which needs C-Section. I am paid only Rs 2,800. You just tell me, can I manage it with this amount? No. So – there is a trend to…‘shift’. I will push that patient to somewhere else.” (Past participant, rural, male)
“Now as both types of delivery [normal and Caesarean section] have the same [remuneration] rate in the scheme, all the doctors try to go for normal delivery. Hence, neo-natal deaths are occurring more because of the long trial for normal delivery resulting in delay and foetal distress. This is a routine.” (Current participant, rural, female)
Practitioners we interviewed also referred to misuse of the scheme by government workers. Private practitioners in urban and rural areas (both currently enrolled in CY and those who had dropped out), expressed displeasure at being placed under pressure from ‘influential (public) persons’ to accept their family members under the CY scheme. In most cases these requests were for individuals who were not eligible for CY, or who were not able to produce the necessary documents. Typically, practitioners explained they would receive a phone call to accept a particular woman and conduct the birth for free, and if they did not accept the woman, the influential caller ‘may create some problem’. Others believed they should not be ‘pressurised’ by the government authorities to accept their relatives under CY.
Related to their interactions with government officials, many practitioners in both districts, including current participants and those who had dropped out, described what they perceived sometimes as rude, uncooperative behaviour. Some of them also mentioned wilful delay at block level to make payments. One obstetrician said that some doctors are ‘giving [a] cut [a proportion of the payment to local officials] […] this should never happen’. Another went so far as to argue that without ‘some gratification’ to the system, working in the programme could be difficult. Officials could ‘pick up on mistakes’ for example, where forms were not filled out completely, and use this as a reason for delaying payment to the obstetrician.
Going downmarket: participation in CY is perceived to lower private facilities’ status
In general, obstetricians who had a higher professional status (senior and established), social status (located in bigger cities than in remote areas) or financial status (charging higher fees) were less keen to participate in this scheme, which they felt was primarily a ‘poor people’s scheme’. As one senior obstetrician, a former participant from a rural area explained:
“My charges are on higher side; Rs 4,000 in normal [delivery] and 8,000-10,000 for C-S [Caesarean section]. So CY is difficult for me.” (Past participant, rural, male)
By drawing attention to his high fees, this obstetrician hints at what he sees as the incompatibility of his practice’s clientele with CY. Another former participant in an urban area seemed pleased that the status of his patients has changed since leaving CY:
“Now, I am getting good socio-economically upper class people; when I was in CY, I used to get a lot of poor and village people.” (Past participant, urban, male)
A younger, rural doctor explained that doctors in bigger cities were concerned about having to serve a poorer socioeconomic class of clients of CY as they thought that this might downgrade the image of their facility and deter ‘higher class’ patients who the providers said were the main source of income for them:
“In bigger cities, certain hospitals have a stigma that they will not take this type of patient as they think that if such patients [CY beneficiaries] come to their hospital, the crowd of higher status patients will get [negatively] affected.” (Current participant, rural, male)
The significance of status to doctors’ participation is also linked to peer decision-making. We observed that the decision of private obstetricians to either continue or discontinue their enrolment in the CY was greatly influenced by decisions taken by their peer group through the local branch of their professional body FOGSI (Federation of Obstetric and Gynaecological Society of India). In some towns, where the local branch of FOGSI had decided not to support the scheme, we found that almost all obstetricians had discontinued participation, whereas in other towns, almost all were continuing their participation:
“Yes, I also think at times to leave this scheme but I am in this scheme just because of the competition, otherwise I would have left it because I have lost interest in it.”
[Interviewer]: “Competition means which type of competition?”
“Competition in the sense, see we have 10 to 12 gynaecologists in the same area, and three to four doctors have continued this scheme and other four have discontinued. So just to get more patients [not losing patients to them who continue enrolment in CY] we have continued to participate in this scheme.” (Current participant, urban, male)
Participating unwillingly: private sector perception of being coerced into taking on state responsibility
We found that private practitioners’ lack of trust in the government system adversely influenced the principle of partnership between government and private sector in CY. It was apparent in almost all the interviews across the three categories of respondents (those who were currently participants, past participants and had never participated). The providers were united in their opinion that rather than making government health staff and facilities accountable for maternal health services, the CY scheme ‘tends to pass on this responsibility to the private sector’. In addition, it was their view that private practitioners ‘shoulder the risk of providing these services’ with no additional legal protection provided by the government in case they are faced with maternal deaths or severe complications. This seemed to influence participation in the scheme, with some doctors dropping out and others avoiding complicated cases, because they felt they would expose themselves to potential litigation without any government support:
“Complicated cases are avoided by us because if there is any mortality then it becomes very difficult for any doctor. Government has told us that it is our responsibility to tackle those matters; whether it is criminal, civil or consumer. Only the burden is on doctors, no protection at all.” (Current participant, rural, female)
“I don’t take complicated CY cases because of fear that I will be held responsible if any unwanted things happen. Whole responsibility comes on us only. Government should give full protection in case of complications.” (Past participant, rural, male)
Older practitioners and those who had dropped out of the scheme were critical of what they perceived as unwarranted government enquiries into private practices under the CY scheme, and the negative publicity this could involve. They commented that the government seemed ‘suspicious’ of private practices, and were quick to report any malpractice or misconduct, yet ignored the irregularities in government hospitals:
“Government does not bother for mistakes done by Government staff but in case of private doctors they are very strict. They are always suspicious about private doctors.” (Past participant, urban, female)
“Some colleagues faced enquiries - demoralising and bad for social and professional reputation.” (Never participated, urban, male)
Many practitioners perceived there to be an association between participation in CY and their vulnerability under the Pre-Natal Sex Determination Techniques (PNDT) Act. The act is in place to prevent female foeticide which is a major social problem leading to a disproportionate sex ratio in the population. Under the act, obstetricians are forbidden to tell parents the sex of the child during an ultrasound examination. Obstetricians feared that if they did not participate in CY, government officials would accuse them of violating the PNDT Act, or not grant them registration to carry out ultrasound examinations. Not surprisingly, practitioners who had dropped out of the scheme were more willing to talk about this, whereas those remaining in the scheme raised the same issues but were more guarded in their descriptions:
“They told, ‘You have to join otherwise we will not give you registration for sonography’…yes it was [a] threat, by the Collector.” (Past participant, rural, male)
“Government people keep us threatened that action may be taken against us in the pretext of some irregularity in PNDT.” (Past Participant, urban, male)
Participation in CY perceived as a risk by the private sector
Another theme we identified in the data, which is closely linked to other risks raised by the participants, is their perception of the clinical risks associated with participating in the scheme. There was a clear sense that clinically difficult cases cluster in CY because of the socioeconomic background of the beneficiaries, and this deterred providers from participating. Private practitioners in rural areas in particular felt that CY beneficiaries as a group are at much higher risk of complications, as they are often highly anaemic, malnourished and multiparous. For example, this urban practitioner, a past participant, explained:
“There are differences between BPL and APL [Above Poverty Line] patients. Complications are high among BPL patients - anaemia, sepsis, unhygienic conditions. Anaemia is a big problem indeed.” (Past participant, urban, female)
Obstetricians commented that CY beneficiaries often arrive late to the facility, already in established labour. At the same time, few BPL patients attend free antenatal care. Without knowing the detailed history of the pregnant women, practitioners were of the view that they are unable to anticipate complications, or prevent them by treating underlying causes such as anaemia or malnutrition. As two past participants from rural areas stated:
“Three to four ANC [antenatal care visits] is a must, but most patients don't come for ANC; [they] directly come for delivery.” (Past participant, rural, male)
“Here people receive two TT [Tetanus Toxoid] from the sister (community worker) and think their ANC is finished.” (Past participant, rural, female)
The pressures placed by a large volume of high risk patients led some obstetricians to question the ability of doctors to offer sufficient quality care. Several practitioners raised concerns about the quality of care for women during delivery at private facilities participating in the scheme, with one provider confident that, under such circumstances ‘there are some people who compromise quality’. Some of the older practitioners we interviewed (those who had dropped out or had never participated), suggested that many clinical procedures including delivery were conducted not by the doctor, but by ‘unqualified staff’ in many private hospitals. This was perceived not as a deliberate misuse of the scheme, but as a response to resource shortages:
“How a private practitioner can manage himself to see 100 patients, do 5–7 deliveries with 1–2 C-Sections in a day? In reality, s/he entrusts 5–6 nonqualified person (trained by him/her) to do a lot of things, including deliveries. So, where is the quality?” (Past participant, rural, male)
Many practitioners, old and young and across all categories (participating, dropped out and never participated in CY) stated that the Caesarean section rate is relatively high in private practice because it is the preference of the practitioner to do elective surgery in cases with complications. Private obstetricians said that they usually avoid a trial of normal labour and delivery as it increases the chance of emergency Caesarean delivery, which is always challenging in single doctor practices without ready availability of blood and an anaesthetist:
“Now here we are, single handed practitioner, and without teamwork; to tackle such emergency is difficult.” (Past participant, urban, male)
“In private practice it is difficult to tackle emergency C-section as blood, and an anaesthetist may not be readily available.” (Past participant, urban, male)